What Do Measures, Outpatient Care, Disposition, Engagement and Stroke Have in Common?

Dictionary.com defines a mode as “a way, or manner, in which something occurs or is experienced, expressed, or done.” ACC Accreditation Services offers Atrial Fibrillation version 3 (AF v3) Accreditation as the way, or manner, in which processes, policies and practices are examined and improved with the objective of providing the best possible care to patients with atrial fibrillation (AFib), both in the hospital and in the community. The acronym MODES is an easy way to summarize and remember the key areas in which AF v3 Accreditation partners with hospitals to accomplish these goals.


AF v3 Accreditation provides a mechanism to track important clinical quality measures. Entry of specific patient information into the Accreditation Conformance Database provides the data to automatically calculate quality measures to track and trend performance and outcomes. Measuring the quality of care in this way is an important tool to compare current clinical practice with evidence-based guidelines and established standards of care for patient assessment, treatment and management.

Reports are updated daily to display real-time performance and trends. Frequent evaluation of these data can be used to clearly demonstrate gaps in clinical practice. With the help of AF v3 Accreditation online tools and resources, unfavorable trends in performance can undergo scrutiny, strategies for process improvement can be implemented and measures once again re-evaluated over time to demonstrate more favorable outcomes.

The acronym MODES is an easy way to summarize and remember the key areas in which AF v3 Accreditation partners with hospitals to accomplish these goals.

The measures associated with AF v3 Accreditation align, in part, with clinical performance and quality measure sets established by the ACC and the American Heart Association (AHA).1 Most notable are measures designed to track the use of thromboembolic risk assessment tools with AFib patients and the guideline-directed assignment to a patient-specific anticoagulation protocol. Other outcome and performance measures in common with the ACC and AHA are tracking assessment and treatment parameters, follow-up with specialized physicians for medication adjustment and adherence, and providing consistent and patient-specific discharge education.

Detailed information for seventeen quality measures is provided with AF v3 Accreditation to define the numerator, denominator, inclusions and exclusions for each of the calculations. Recommended goals and a direct link to process improvement criteria statements and resources are provided for each measure. Functions are also provided to generate lists of patient records included in the calculation of the measures. These functions are helpful when correlating performance and outcome measures to specific patient-level data.

Outpatient Care

Historically, much of the assessment, treatment and management of AFib patients has occurred in the inpatient setting of the hospital. Some of the rationale has been associated with necessary time-related adjustments in prescribed oral anticoagulants (OAC) and antiarrhythmic medications. However, the lack of standardization by emergency physicians for early assessment and treatment can lead to unnecessary admissions.2 Treatment and management of AFib patients currently costs the U.S. health care system an estimated $26 billion annually, most of which is spent on hospitalizations.3 With the growing incidence and prevalence of AFib, staying the current course will increasingly burden the health care system. Actions to establish more efficient and effective treatment and management in an outpatient setting must be implemented.4

Outpatient AFib clinics are being “re-invented” to significantly reduce the use of acute care resources and improve quality of life.4,5 Beyond their traditional functions, outpatient AFib clinics have become centers for care and medication management, physician-patient decision making, and patient education and engagement. Additionally, they can be used to support behavior and risk modification programs, educate regarding treatment options, provide follow-up of treatment plan adjustments and monitor changes in quality of life.

Pursuing AF v3 Accreditation provides a roadmap to develop processes to direct patients toward discharge from the emergency department (ED) or observation and then to outpatient care. The processes and management philosophy will naturally reduce admissions, length of stay and re-presentation to the hospital. AF v3 Accreditation provides online tools and resources to help hospitals and health care systems develop focused pathways of treatment and management to provide outpatient services as an integrated part of the patient care continuum. Specific and efficient care pathways for the treatment of low-risk patients and guideline-driven direction to outpatient care will reduce the overall AFib economic burden.


Disposition is often used to describe the destination of the patient after hospital discharge. It can also describe the destination within the care pathway following early assessment and treatment in the ED. Destinations could include the observation unit, an inpatient unit or discharge to home or other care facility directly from the ED. The efficient use of the AFib patient care pathway from the ED to eventual discharge will translate into improved outcomes, shorter length of stay, decreased costs and increased patient satisfaction. The AF v3 Accreditation online tool has been designed to facilitate an efficient but thorough clinical care pathway for the AFib patient. Consecutive sections of the tool mimic the pathway from ED arrival to the observation unit or inpatient services as a destination and finally discharge from the hospital.

The online tool becomes a roadmap for improving the continuum of care. Accreditation criteria statements are carefully designed to prompt the development of care and management processes. Guidance and best practices are provided to help develop the most appropriate care processes for the patient. Statements include:

  • Triaging and early assessment
  • Establishing the presence of precipitating and predisposing factors related to the current AFib episode
  • Using an AFib-specific order set to direct care
  • Ensuring patient safety during cardioversion
  • Choosing rate-control or rhythm-control as a strategy for treatment
  • Consulting other members of the health care team
  • Admitting to observation or an inpatient unit
  • Discharging to home.


Engagement describes the unique and vital relationships that must be forged to develop an AFib program of care, including:

  • Cooperating as a multidisciplinary and multiskilled health care team to efficiently and effectively care for the AFib patient
  • Empowering the patient, with support from the health care team, to make quality of life decisions and assume a responsibility in the management of care
  • Connecting with the community to educate, raise awareness and provide resources to health care and emergency medical system providers who often are the front-line and back-end contact for the AF patient.

Optimal management of patients with AFib requires input from a multidisciplinary team which includes ED physicians, hospitalists, cardiologists, internal medicine specialists, pharmacists, surgeons, advanced practice providers, nurses and allied healthcare professionals.6,7 Patients and caregivers must also join this team to ensure management becomes successful. Empowering the patient with education, a role in decision making and a responsibility in the care plan can significantly impact reducing readmission and improving quality of life. Education outreach to the community and building AFib awareness will directly affect behavior and reduce the incidence and risks associated with new and recurring AFib.

[I]mprovement in processes surrounding thromboembolic risk assessment and appropriate guideline-directed OAC prescription are perhaps the most vital and critical to our patients.

AF v3 Accreditation online tools and resources emphasize education at all levels of the health care team on aspects of AFib care. Early integration of the multidisciplinary team in the clinical pathway and the engagement of community primary and specialty health care providers are essential to success. These community providers often lack the education and resources required to assume responsibility for the care of the discharged AFib patient. AF v3 Accreditation provides guidance and shared practices to help meet the needs of the community, including awareness of the relationship between AFib and risk of stroke, opportunistic pulse checking, lifestyle and behavior modification, and options for the treatment of AFib.


AFib is a well-established risk factor for ischemic stroke and systemic thromboembolism. Published guidelines provide recommendations pertaining to the use and documentation of risk assessment tools, scores that identify patient risk, and anticoagulation regimens that reduce the risk for a thromboembolic event.8,9 Gaps in clinical practice related to stroke prevention in AFib have been identified, including:

  • Failure to use assessment tools appropriately to determine patient risk for a thromboembolic event
  • Failure to use assessment tools routinely with established AFib patients at potential increased risk
  • If risk is identified, failure to prescribe an OAC
  • If an OAC is prescribed, failure to achieve optimal anticoagulation, failure to monitor physiological changes that could impact its therapeutic level, and failure of patient adherence.

Get with the Guidelines stroke data from nearly 95,000 patients presenting with an acute ischemic stroke and a known history of AFib determined that only 30 percent received any form of anticoagulation before their stroke.10 Of those on warfarin, nearly two-thirds were not achieving therapeutic levels at the time of the stroke. Overall, 84 percent of these patients were not receiving guideline-recommended anticoagulation or had anticoagulation levels outside the therapeutic range, even among those at high thromboembolic risk. A review of NCDR PINNACLE data from 2008 through 2012 revealed that only 60 percent of outpatients at thromboembolic risk (CHA2DS2-VASc score ≥2) were treated with an OAC and less than half at the highest risk (CHA2DS2-VASc score >4) were receiving an OAC.11

Fewer than half of high-risk patients prescribed an OAC for AFib was taking it consistently at one year, whether it was warfarin or a direct acting oral anticoagulant, in an analysis of nearly 65,000 patients in a large U.S. commercial insurance database.12 In a similar study linking prescription data with hospital admissions for 26,000 patients, 36 percent receiving dabigatran and 32 percent receiving rivaroxaban were no longer taking their medication six months after it was first prescribed.13

Of all the features of AF v3 Accreditation, improvement in processes surrounding thromboembolic risk assessment and appropriate guideline-directed OAC prescription are perhaps the most vital and critical to our patients. AF v3 Accreditation will guide the development of protocols for assessing stroke risk, assigning guideline-recommended anticoagulation to minimize risk of thromboembolism and bleeding, tracking OAC education and monitoring adherence. Further, calculated measures are included to help track performance related to utilization of risk assessment tools, assigning anticoagulation to low- and high-risk patients and providing discharge education for those with an OAC prescription.


  1. Heidenreich PA, Solis P, Estes NA 3rd, et al. J Am Coll Cardiol 2016;68:525-68.
  2. Mansour M. Medscape Medical News from the Heart Rhythm Society (HRS) 36th Annual Scientific Sessions, May 5, 2017.
  3. Barrett TW, Storrow AB, Jenkins CA, et al. Am J Cardiol 2015;115:763-70.
  4. Minakakis T. Can J Cardiovasc Nurs 2016;26:15-21.
  5. Barnes GD, Nallamothu BK, Sales AE, et al. Circ Cardiovasc Qual Outcomes 2016;9:182-85.
  6. Kirchhof P. Heart 2017;103:729-31.
  7. Tran HN, Tafreshi J, Hernandez EA, et al. Current Cardiol Rev 2013;9:55-62.
  8. Culebras A, Messe SR, Chaturvedi S, et al. Neurology 2014;82:716-24.
  9. January CT, Wann LS, Alpert JS, et al. J Am Coll Cardiol 2014;64:e1-76.
  10. Xian Y, O’Brien EC, Liang L, et al. JAMA 2017;317:1057-67.
  11. Hsu JC, Maddox TM, Kennedy K, et al. J Am Coll Cardiol 2016;67:2913-23.
  12. Yao X, Abraham NS, Alexander GC, et al. J Am Heart Assoc 2016;5:e003074.
  13. Hendriks JM, Gallagher C, Sanders P. Heart 2017;April 7:[Epub ahead of print].
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Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Anticoagulation Management and Atrial Fibrillation, EP Basic Science, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: ACC Publications, Cardiology Magazine, Atrial Fibrillation, Risk Factors, Prevalence, Electric Countershock, Critical Pathways, Patient Safety, Pharmacists, Follow-Up Studies, Length of Stay, Patient Readmission, Power (Psychology), Quality of Life, Anti-Arrhythmia Agents, Ambulatory Care, Treatment Outcome, Stroke, Continuity of Patient Care, Risk Assessment, Patient Compliance, Thromboembolism, Patient Care Team, Anticoagulants, Accreditation, Behavior Therapy

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