Blog | Thursday, May 5, 2011

Cardiologists not needed: A nurse and a computer will do


Wait ...

Before reading any further, I would like to issue a warning. If your ideas about healthcare delivery are of an older ilk; if you cling white-knuckled to past dogma, please stop reading now. What follows may cause your atria to fibrillate.

Last month I wrote that the best tool for treating atrial fibrillation (AF) was to give patients information--to teach them about their AF, its complications, role of lifestyle factors and the many treatment options. I didn't say this was easy. In fact, thoroughly explaining AF takes nearly the same time it takes me to isolate the pulmonary veins--a lot longer than the 10 minutes allotted for a typical office visit. (Remember: of a 30 minute office visit, I have to review your chart, listen attentively to your story, examine you, and complete the e-record. That doesn't leave much time for teaching.)

I was serious about the role of education in AF therapy, but I didn't have any hard data to support such a bold claim. All I could offer was 15 years of experience on the front lines of treating AF--cardiology's most expensive and prevalent disease.

But now I have found some real-world data to support the thesis that good teaching translates to better AF outcomes.

I'd like to present a tremendously important abstract from last month's American College of Cardiology meeting. This study speaks not just to the AF community, but it also offers an optimistic view of health care delivery reform.

Dutch researchers reported that AF patients cared for in a specialized AF clinic featuring specialized nurses, aided by software programs designed to increase adherence to published guidelines, and adequate time to teach had drastically better outcomes than AF-patients treated in the usual way by a general cardiologist.

Here's how it works: (From a MedPage Today report.)

"When a patient first visits the clinic developed by Dr Tieleman's (lead researcher) team, he or she provides a detailed medical history and undergoes various tests, including an electrocardiogram. The information is entered into a custom computer program, which acts as an electronic patient record but also produces an individualized treatment plan for each patient based on practice guidelines.

"Nurses spend a lot of time with the patient at that first visit--much more time than the cardiologist would normally be able to, according to Tieleman--teaching them about atrial fibrillation, its various treatments, and the expected course of treatment.

"At the second visit, the patient sees the nurse and the cardiologist together to go over test results and the prescribed therapies, including oral anticoagulation, antiarrhythmic drugs, and others.

"Subsequent visits are with the nurse, not the cardiologist, Tieleman said. The nurse provides evidence-based care according to the plan derived by the computer program under the supervision of the cardiologist.

"Tieleman likened the arrangement to that of a pilot and a co-pilot, with each person serving as backup for the other."

The researchers followed 712 patients with varying types of AF for an average of 22 months. Patients were cared for in either an AF clinic model or in the usual way by a cardiologist. The primary outcome was a composite of adverse effects from AF. These include: heart-related death, heart-related hospitalization, stroke, major bleeding, or a life-threatening adverse effect from an AF drug.

Here's what they found:
--Significantly fewer patients in the AF-clinic group reached the primary endpoint: 51 (14.3%) versus 74 (20.8%) in the usual care group.
--Heart-related deaths were lower in the AF-clinic group: 1.1% versus 3.9%.
--Heart related hospitalizations were lower in the AF-clinic group: 13.5% versus 19.1%.
--7 patients in the trial died from blood clots. All were in the usual care group.

This kind of approach represents the "healthcare of the future," said the president of the ACC, Dr. David Holmes.

Dr. Gordon Tomaselli, from John's Hopkins University adds this, "I think with the increasing complexity of the therapeutic options available for [AF], this kind of clinic structure makes some sense."

See?

Maybe a blogger was right, and, maybe the new way of delivering care will actually yield better results.

The researchers commented that their next task will look into the cost-effectiveness of this approach. Any guesses on whether preventing expensive adverse outcomes like hospitalizations, stroke, and blood clots, with a team of specialized nurses will be cost-effective?

Reference:
Hendriks J, et al "Specialized atrial fibrillation clinic reduces cardiovascular morbidity and mortality in patients with atrial fibrillation" ACC 2011; Abstract 3016-12.

This post by John Mandrola, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.