Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments

Cardiologists Not Needed: A Nurse And A Computer Will Do


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 healthcare 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; emphasis mine.)

“When a patient first visits the clinic eveloped 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.”


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?


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

*This blog post was originally published at Dr John M*

You may also like these posts

    None Found

Read comments »

Comments are closed.

Return to article »

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »

Commented - Most Popular Articles