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Race/Ethnicity and Oral Anticoagulant Use in AF Patients
Study Questions:
What are the racial/ethnic differences in the use of oral anticoagulant (OAC) therapy, particularly direct-acting oral anticoagulants (DOACs), in patients with atrial fibrillation (AF)?
Methods:
The investigators used data from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II, a prospective, US-based registry of outpatients with nontransient AF 21 years and older who were followed up from February 2013 to July 2016. Data were analyzed from February 2017 to February 2018. Self-reported race/ethnicity was categorized as white, black, or Hispanic. The primary outcome was use of any OAC, particularly DOACs. Secondary outcomes included the quality of anticoagulation received and OAC discontinuation at 1 year. A multivariable logistic regression model with site as a random effect was used to evaluate the association between race/ethnicity and overall OAC use at baseline.
Results:
Of 12,417 patients, 11,100 were white individuals (88.6%), 646 were black individuals (5.2%), and 671 were Hispanic individuals (5.4%) with AF. After adjusting for clinical features, black individuals were less likely to receive any OAC than white individuals (adjusted odds ratio [aOR], 0.75; 95% confidence interval [CI], 0.56-0.99) and less likely to receive DOACs if an anticoagulant was prescribed (aOR, 0.63; 95% CI, 0.49-0.83). After further controlling for socioeconomic factors, OAC use was no longer significantly different in black individuals (aOR, 0.78; 95% CI, 0.59-1.04); among patients using OACs, DOAC use remained significantly lower in black individuals (aOR, 0.73; 95% CI, 0.55-0.95). There was no significant difference between white and Hispanic groups in use of OACs. Among patients receiving warfarin, the median time in therapeutic range was lower in black individuals (57.1%; interquartile range [IQR], 39.9%-72.5%) and Hispanic individuals (51.7%; IQR, 39.1%-66.7%) than white individuals (67.1%; IQR, 51.8%-80.6%; p < 0.001). Black and Hispanic individuals treated with DOACs were more likely to receive inappropriate dosing than white individuals (black patients, 61 of 394 [15.5%]; Hispanic patients, 74 of 409 [18.1%]; white patients, 1,003 of 7,988 [12.6%]; p = 0.01). One-year persistence on OACs was the same across groups.
Conclusions:
The authors concluded that after controlling for clinical and socioeconomic factors, black individuals were less likely than white individuals to receive DOACs for AF, with no difference between white and Hispanic groups.
Perspective:
This cohort study reports reduced use of OAC therapy, particularly DOACs in black patients compared with white and Hispanic patients, and these differences persisted after controlling for socioeconomic markers and region. Furthermore, anticoagulation quality in black and Hispanic patients was inferior to that that in white patients, with lower time in the therapeutic range values in those taking warfarin and modestly greater underdosing in patients taking DOACs. Additional studies are indicated to identify correctable causes of these disparities to improve overall quality of care and outcomes in AF.
Keywords: African Americans, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Ethnic Groups, Hispanic Americans, Outcome Assessment, Health Care, Secondary Prevention, Socioeconomic Factors, Quality of Health Care, Warfarin
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