Study Shows Racial and Ethnic Disparities Persist in the Management of VA Patients with Atrial Fibrillation
BACKGROUND:
Atrial fibrillation (AF) is the most common cardiac rhythm disorder in the US, affecting up to 6 million adults. VA treats nearly 1 million Veterans with AF, which increases the risk of all-cause mortality and is associated with high rates of cardiovascular morbidity, including stroke. Oral anticoagulation (OAC) for non-valvular AF reduces stroke risk by up to 70%. Despite the effectiveness of OAC, there are racial/ethnic inequities in the initiation of such therapy. This retrospective cohort study compared the initiation of any anticoagulant therapy by race/ethnicity for Veterans with AF. Investigators also assessed patterns of OAC initiation by race/ethnicity over a time frame coinciding with the increased availability of a newer class of direct oral anticoagulants (DOACs). Using VA data, investigators identified 111,666 VA patients with atrial fibrillation from 2014-2018. The primary outcome was initiation of any form of OAC – defined as the first outpatient filled prescription for warfarin or DOACs (i.e., apixaban, dabigatran, edoxaban, or rivaroxaban) within 90 days of an initial AF diagnosis. Patient, provider, and facility-level characteristics were examined as potential drivers or confounders of the association between race/ethnicity and OAC initiation.
FINDINGS:
- A total of 69,590 Veterans (62%) initiated any anticoagulant therapy, varying 10.5 percentage points by race/ethnicity; initiation was lowest in Asian (52%[n = 676]) and Black (60%[n = 6177]) patients and highest in White patients (63%[n = 59 881]).
- After adjusting for clinical, sociodemographic, provider, and facility factors, Black and Asian patients were significantly less likely than White patients to initiate OAC, with 10-18% lower odds of such therapy. Also, among those who initiated OAC, Black, Hispanic, and American Indian/Alaska Native patients were significantly less likely to initiate DOACs, with 21-26% lower odds of such therapy.
- While overall OAC initiation and DOAC use increased significantly over time, there were no significant differences by race/ethnicity in the initiation of these treatments.
IMPLICATIONS:
- Understanding the reasons for these treatment disparities is essential to improving equitable atrial fibrillation management and outcomes among racial/ethnic minority patients managed in VA.
LIMITATIONS:
- Note: Use of odds ratios can exaggerate the magnitude of the difference between groups.
- The assessment of socioeconomic factors did not capture individual-level measures (i.e., income and education) or systemic factors (i.e., racism that perpetuates disparities in treatment).
- This analysis was limited regarding the capture of possible contraindications to OAC initiation or patient treatment preferences.
- Investigators were unable to determine whether disparities in the initiation of anticoagulation were related to differential provider prescribing or patient refusal of such therapy.
AUTHOR/FUNDING INFORMATION:
Dr. Essien is supported by an HSR&D Career Development Award (CDA 20-049). Drs. Essien and Hausmann and Ms. Kim are part of HSR&D’s Center for Health Equity, Research and Promotion (CHERP) located in Pittsburgh and Philadelphia, PA.
Essien U, Kim N, Hausmann L, et al. Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race-Ethnicity among Patients in the Veterans Health Administration System. JAMA Network Open. July 28, 2021;4(7): e2114234.
