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Publication Briefs

Study Shows Wide VA Facility-Level Variation in Anticoagulation for Veterans with Atrial Fibrillation, Including by Race

Atrial fibrillation (AF) is a common heart rhythm disorder and leading cause of stroke. Oral anti-coagulation significantly reduces stroke risk and is the standard of care in patients at risk of this AF complication. Studies from several healthcare systems, including VA, have demonstrated significantly lower anticoagulant prescribing rates in Black compared to White individuals. This retrospective cohort study sought to assess variation in anticoagulant initiation by race across 82 VA facilities. Using data from the Race, Ethnicity, and Anticoagulant CHoice in Atrial Fibrillation (REACH-AF) study cohort, investigators identified 26,832 Veterans (23,061 White and 3,771 Black) with incident AF and enrolled in the VA healthcare system from 2020 through 2021. The primary outcome was the rate of any anticoagulant initiation (i.e., warfarin or direct oral anticoagulant, direct oral anticoagulant [DOAC]) or any DOAC therapy within 90 days of an AF diagnosis, overall and for Black and White patients at each facility. Investigators also estimated the adjusted Black-White risk difference.


  • In 82 VA facilities serving Black Veterans (n = 3,771) and White Veterans (n = 23,061) with incident atrial fibrillation, there was large (>28 percentile point) facility-level variation in any anticoagulant and DOAC therapy initiation, overall and by race.
  • Overall unadjusted rates of any anticoagulant therapy ranged from 57% to 87% across facilities; corresponding rates for Black and White patients were 48% to 91% and 58% to 87%, respectively.
  • Racial disparities in anticoagulation in excess of 10 percentile points were found in nearly one-quarter of VA facilities, though most facilities did not demonstrate a statistically significant difference in prescribing between Black and White Veterans.


  • These findings may represent a target to reduce prescribing inequities and improve AF care.


  • This study excluded VA facilities serving fewer than 10 Black Veterans with AF.
  • Investigators used outpatient and not inpatient anticoagulant prescription data for this analysis, and they used VA data only for diagnoses and medications.

Dr. Essien and Dr. Washington are part of HSR’s Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP) located in Los Angeles, CA, and Drs. Hausmann, Mor, Gellad, and Fine are part of HSR’s Center for Health Equity Research and Promotion (CHERP) located in Pittsburgh and Philadelphia, PA.

Essien U, Kim N, Hausmann L, Washington D, Mor M, Gellad W, and Fine M. Facility Level Variation in Racial Disparities in Anticoagulation for Atrial Fibrillation: the REACH-AF Study. Journal of General Internal Medicine. February 2, 2024; online ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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