Hi, my name is Eric Prystowski. Welcome to another episode of EP on EP. It's an absolute delight to have with me a friend for many years and the director of the, executive director, in fact, of the Kansas City Heart and Rhythm Institute. DJ, thank you and welcome to the show. Thank you, Eric. So, DJ and his group have just published an extraordinarily interesting paper. It's called ER to EP. I put a little twist on it when we did an editorial and I said, eliminating the middleman for AFib. And it's a great idea. And so, DJ, let's start with why you, tell us about the study and the design and why you did it. Well, Eric, that was actually a fantastic title for the editorial. Like my editorial, huh? Yes. I think, I think it was, it was so apt and it was actually rather clever. So this whole idea came about, right? So when you really look at the patient flow access to care, right? The biggest problem that the world faces today is appropriate access to care is a major problem, right? And over the last 20 years of me being involved in the atrial fibrillation care, we realized that the complexity of patient flow through healthcare institutions in the United States or for that matter, anywhere in the world is so complex, right? Initial diagnosis comes off when they have initial symptoms, they go to the emergency room and then what happens from that emergency room for this patient to receive appropriate medical care in a timely fashion is very convoluted and it's very twisted and it's very heterogeneous in so many ways, depending on the structure of the organization that they end up in and also the type of resources that this institution has, right? And so there is a significant amount of variation in how quickly a cardiologist can see them or how quickly would they get put on oral anticoagulation and how quickly they get put on anaerobic drugs or access to ablation. So when we really mapped this out as part of my MBA project, I found a significant amount of a problem with this, right? So this is where we thought, okay, how about we really simplify this whole process irrespective of where they come from, when a patient shows up in the emergency room with atrial fibrillation, if they have the criteria to be admitted to the inpatient, then there is an automatic inpatient consult to the EP service so that we expedite their care. It doesn't mean that we are eliminating the need for cardiologists or hospitalists or anybody else, but the specialist comes into the picture much faster. If they don't need an admission and they can go home, then we send this patient home with a directed consultation with the EP team within two weeks after they get home. So let's stop you there. For a lot of us, it's really hard to have an open slot in the office. So while that's an ideal situation, do you have like a designated hitter that can take these? Because let's say you're in an office and you're full, right? I mean, I'm sure your usual schedule, you may be three and four months out. So how do you get someone on this? How do you arrange that part? So I think what it is, is in our schedule, we have built in at least three to four open slots per physician. And if the physicians can't see them, we have open slots on our nurse practitioner schedule. So there are at any given point in time, there are three docs within the market that are in the clinics. So that's really what I'm saying. So you haven't scheduled your schedule so tight you can't take a new patient? We always have three to four open slots. You got rid of that problem. All right. I'm sorry, I interrupted you. Go ahead now. What happens next? So when you really do that, what this is doing is the patient, when they come in, they have early access to an electrophysiologist with a more definitive plan. As a result of which, the assessment of this clinical situation is much more faster, right? You essentially assist the general cardiologist or the hospitalist that's managing this patient's care on the inpatient side and making appropriate timely recommendations, right? So when we really instituted this path and then compared it to the traditional approach, we wanted to see how effective this particular pathway is. And so we had hard outcomes to measure. That means we looked at the time to initiation of anticoagulation, time to initiation of antirhythmic drugs, time to catheter ablations, and a lot more harder endpoints like repeated hospitalizations, strokes, TIAs, heart failure admissions, which oftentimes don't get taken into consideration, right? So we worry about improving the outcomes of atrial fibrillation by working on molecular genetics, drugs, catheter ablation, and the whole idea of that. What is really fascinating about this approach is how do you really change hard outcomes of a disease and its evolution by changing the workflow, by changing the process flow in how these patients are managed, right? So which is also an equally important part of the care continuum, which we as electrophysiologists oftentimes don't think about, right? Epidemiologists think about it. Hospital administrators may or may not think about it. But this is a part that I think we as electrophysiologists who are capable of delivering highest quality care to our patients, we should also be thinking about the process flow so that access to care becomes important. So you got this done in your Kansas City setup. What's the scalability of this? In other words... I think it's super easy, super scalable. Well, but before you start, I mean, you're making it sound more easy than it... And I say that only because I know over the years, I've tried to do some similar things, not quite as organized as yours, just trying to see if we get people, you know, preventing strokes and stuff. I enjoy it. Yeah. And often people would... They get busy in the ER and they don't send them and, you know... So you must have had some rigor to the system. Efficient use of electronic medical records is the easiest thing that you can do, right? I mean, especially in somebody like your situation, you have a singular electronic medical record for both outpatient and inpatient. Ours is worse than that. So what you do is there is an automatic order. When somebody comes in with atrial fibrillation, there's an inpatient admission. There is a clickable box which asks the ER admitting ER physician to say, do you want to consult electrophysiology? You click on it. It's an automatic consult. Okay. Right? So similar to what we do with the standardization of many of these orders. And then for those patients who get discharged from the hospital, from the ER, to be seen as an outpatient, there is a method for them to actually reach our scheduling team for that patient to be seen in the next two weeks. So we want to live up to our promise of seeing these patients within two weeks. But I mean, do we succeed 100% of the time? But I say we succeed about 80% of the time. Let me ask you one last thing. I think a major problem that I see is also admitting people who don't need to be admitted. And a lot of AFib people get admitted, as we both know. Why did you even bother, right? So have you been able to slick the system down in your own system where you can get someone down into the ER to help make that decision? Because some ER docs may just feel uncomfortable, and I can understand they don't want someone going out who's going 120 a minute. Well, we both know people are always going 120 a minute, right? So we have a different threshold. Has that part also taken place in your system? So we sort of looked at this a little bit differently because during the COVID, obviously, we really didn't have much of a choice. So we mentally prepared our ER docs, okay, you put them in the ER, observe them for four or five hours. You bring their rates down, put them on oral anticoagulation, right? Give them a DOAC, which kicks in within two hours. You put them on rate-controlling medications, and if you don't feel comfortable doing anything else for these patients, then send them to the clinic. We take care of them. So as a result of which, this strategy may even be very helpful in minimizing the number of hospitalizations that we end up seeing for AFib, because unlike the general mindset of many ER doctors, AFib is not a life-threatening disease that is going to be hurting people, right? You're absolutely right. If you have control over their stroke prophylaxis, if they have control over their rate control, most of these patients can be managed as an outpatient. Yep. No, I agree. That's why I said that. Well, I think your study is wonderful. I enjoyed writing the editorial. I'm glad you liked my title. Oh, it was fantastic. It was hilarious. Well, I was sitting there thinking about it, and I thought, all you really did was eliminate the middleman. Then I said, oh, that's a great title, the middleman. One of my general cardiology buddies came to me and said, so you're calling me the middleman now? So, by all means, I think patients with atrial fibrillation have enough comorbidities. I think they are best served by having a general cardiologist taking care of them. I think we are sort of helping them to tide over this access issue in a bigger way. No, I think you did a great job. And by the way, for the listening audience, a welcome to DJ. He is the incoming second vice president of HRS. Congratulations. Thank you for being here. Thanks for the opportunity.

Eric Prystowski

DJ

Kansas City Heart and Rhythm Institute

atrial fibrillation

patient care approach