Association of Race and Ethnicity With Oral Anticoagulation and Associated Outcomes in Patients With Atrial Fibrillation

Abstract

ImportanceOral anticoagulation (OAC) is underprescribed in underrepresented racial and ethnic group individuals with atrial fibrillation (AF). Little is known of how differential OAC prescribing relates to inequities in AF outcomes.ObjectiveTo compare OAC use at discharge and AF-related outcomes by race and ethnicity in the Get With The Guidelines–Atrial Fibrillation (GWTG-AFIB) registry.Design, Setting, and ParticipantsThis retrospective cohort analysis used data from the GWTG-AFIB registry, a national quality improvement initiative for hospitalized patients with AF. All registry patients hospitalized with AF from 2014 to 2020 were included in the study. Data were analyzed from November 2021 to July 2022.ExposuresSelf-reported race and ethnicity assessed in GWTG-AFIB registry.Main Outcomes and MeasuresThe primary outcome was prescription of direct-acting OAC (DOAC) or warfarin at discharge. Secondary outcomes included cumulative 1-year incidence of ischemic stroke, major bleeding, and mortality postdischarge. Outcomes adjusted for patient demographic, clinical, and socioeconomic characteristics as well as hospital factors.ResultsAmong 69 553 patients hospitalized with AF from 159 sites between 2014 and 2020, 863 (1.2%) were Asian, 5062 (7.3%) were Black, 4058 (5.8%) were Hispanic, and 59 570 (85.6%) were White. Overall, 34 113 (49.1%) were women; the median (IQR) age was 72 (63-80) years, and the median (IQR) CHA2DS2-VASc score (calculated as congestive heart failure, hypertension, age 75 years and older, diabetes, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, and sex category) was 4 (2-5). At discharge, 56 385 patients (81.1%) were prescribed OAC therapy, including 41 760 (74.1%) receiving DOAC. OAC prescription at discharge was lowest in Hispanic patients (3010 [74.2%]), followed by Black patients (3935 [77.7%]) Asian patients (691 [80.1%]), and White patients (48 749 [81.8%]). Black patients were less likely than White patients to be discharged while taking any anticoagulant (adjusted odds ratio, 0.75; 95% CI, 0.68-0.84) and DOACs (adjusted odds ratio, 0.73; 95% CI, 0.65-0.82). In 16 307 individuals with 1-year follow up data, bleeding risks (adjusted hazard ratio [aHR], 2.08; 95% CI, 1.53-2.83), stroke risks (aHR, 2.07; 95% CI, 1.34-3.20), and mortality risks (aHR, 1.22; 95% CI, 1.02-1.47) were higher in Black patients than White patients. Hispanic patients had higher stroke risk (aHR, 2.02; 95% CI, 1.38-2.95) than White patients.Conclusions and RelevanceIn a national registry of hospitalized patients with AF, compared with White patients, Black patients were less likely to be discharged while taking anticoagulant therapy and DOACs in particular. Black and Hispanic patients had higher risk of stroke compared with White patients; Black patients had a higher risk of bleeding and mortality. There is an urgent need for interventions to achieve pharmacoequity in guideline-directed AF management to improve overall outcomes.

Association of Direct Oral Anticoagulation Management Strategies With Clinical Outcomes for Adults With Atrial Fibrillation

“…A forthcoming cost-effectiveness analysis comparing the 3 DOAC management models will provide greater insight as to which model is most cost-effective, given the evidence from the current study that all 3 are similarly effective. Further research may also evaluate whether specific DOAC models could reduce health disparities in anticoagulation prescribing and outcomes, which persist in contemporary clinical care, as demonstrated by recent evidence from the Get With The Guidelines registry …”

“…We used administrative and clinical data to calculate the CHA 2 DS 2 -VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, stroke, vascular disease, age 65-74 years, female sex) score and ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) stroke and bleeding risk scores to summarize patients’ thromboembolic stroke and major bleeding risks (eMethods in Supplement 1). We collected data on race and ethnicity because patients who identify as races and ethnicities other than non-Hispanic White are less likely to be prescribed DOACs and have worse anticoagulation-related outcomes …”

Initiation of oral anticoagulation in US older adults newly diagnosed with atrial fibrillation during hospitalization

“…Prior studies have investigated anticoagulant prescribing patterns in the outpatient setting, but little is known about care patterns for hospitalized patients newly diagnosed with atrial fibrillation. 4,6,13,14 Moreover, hospitalized patients represent a high-risk group with greater medical comorbidity burden, and therefore increased stroke and bleeding risk, compared to healthy outpatients. Patients with frailty are also of particular interest, as the majority of older adults with atrial fibrillation have frailty or pre-frailty, and these states confer high risk of stroke but may have lower rates of anticoagulant prescribing.…”

Considering pharmacoequity when deprescribing potentially inappropriate medications

“…Pharmacoequity is a term that refers to equity in access to high‐quality pharmacotherapy, regardless of race, sex, age, and other socioeconomic factors 16 . The pharmacoequity literature so far has highlighted the importance of ensuring equitable access to guideline‐concordant therapies, lower cost equivalent medications when available, and clinical trials 16–18 . Pharmacoequity should also involve equity in access to interventions that aim to deprescribe PIMs, or avoid them altogether.…”

“…16 The pharmacoequity literature so far has highlighted the importance of ensuring equitable access to guidelineconcordant therapies, lower cost equivalent medications when available, and clinical trials. [16][17][18] Pharmacoequity should also involve equity in access to interventions that aim to deprescribe PIMs, or avoid them altogether.…”