Association of Race/Ethnicity With Oral Anticoagulant Use in Patients With Atrial Fibrillation

Abstract

IMPORTANCE Black and Hispanic patients are less likely than white patients to use oral anticoagulants for atrial fibrillation. Little is known about racial/ethnic differences in use of direct-acting oral anticoagulants (DOACs) for atrial fibrillation. OBJECTIVE To assess racial/ethnic differences in the use of oral anticoagulants, particularly DOACs, in patients with atrial fibrillation. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II, a prospective, US-based registry of outpatients with nontransient atrial fibrillation 21 years and older who were followed up from February 2013 to July 2016. Data were analyzed from February 2017 to February 2018. EXPOSURES Self-reported race/ethnicity as white, black, or Hispanic. MAIN OUTCOMES AND MEASURES The primary outcome was use of any oral anticoagulant, particularly DOACs. Secondary outcomes included the quality of anticoagulation received and oral anticoagulant discontinuation at 1 year. 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 atrial fibrillation. After adjusting for clinical features, black individuals were less likely to receive any oral anticoagulant than white individuals (adjusted odds ratio [aOR], 0.75 [95% 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, oral anticoagulant use was no longer significantly different in black individuals (aOR, 0.78 [95% CI, 0.59-1.04]); among patients using oral anticoagulants, 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 oral anticoagulants. Among patients receiving warfarin, the median time in therapeutic range was lower in black individuals (57.1% [IQR, 39.9%-72.5%]) and Hispanic individuals (51.7% [interquartile range {IQR}, 39.1%-66.7%]) than white individuals (67.1% [IQR, 51.8%-80.6%]; P < .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, 1003 of 7988 [12.6%]; P = .01). One-year persistence on oral anticoagulants was the same across groups. CONCLUSIONS AND RELEVANCE After controlling for clinical and socioeconomic factors, black individuals were less likely than white individuals to receive DOACs for atrial fibrillation, with no difference between white and Hispanic groups. When atrial fibrillation was treated, the quality of anticoagulant use was lower in black and Hispanic individuals. Identifying modifiable causes of these disparities could improve the quality of care in atrial fibrillation.

Racial disparities and cardiovascular disease: One size fits all approach?

“…46,49 A 2018 study comparing the rates of prescription of OACs among Black, White, and Hispanic AF patients calculated a 27% decrease in the likelihood of receiving NOACs in Black patients but deemed that figure insignificant after accounting for socioeconomic factors. 56 A recent 2020 study, however, found that Black, Asian, and other minority ethnics were in fact, significantly less likely to receive any OACs, the difference continuing to be significant even after accounting for socioeconomic factors. 57 The efficacy and required doses of OACs have not been performed in populations with adequate representation of ethnic minorities, and therefore cannot be commented on at this time.…”

“…Inconsistent results have been yielded from the various studies that have been performed evaluating the reduced prescription of non–vitamin K oral anticoagulants (NOACs) in minority ethnics 46,49 . A 2018 study comparing the rates of prescription of OACs among Black, White, and Hispanic AF patients calculated a 27% decrease in the likelihood of receiving NOACs in Black patients but deemed that figure insignificant after accounting for socioeconomic factors 56 . A recent 2020 study, however, found that Black, Asian, and other minority ethnics were in fact, significantly less likely to receive any OACs, the difference continuing to be significant even after accounting for socioeconomic factors 57 .…”

Association of Race/Ethnicity, Gender, and Socioeconomic Status With Sodium-Glucose Cotransporter 2 Inhibitor Use Among Patients With Diabetes in the US

“… 24 Historically, there has been decreased adoption of novel therapies among Black patients as well as among female patients and those with low socioeconomic status. 25 , 26 , 27 The objective of this study was to evaluate trends in SGLT2 inhibitor prescription by race/ethnicity, gender, and socioeconomic status between 2015 (the year of publication of EMPA-REG) and 2019. We also assessed the association of race/ethnicity, gender, and socioeconomic status with SGLT2 inhibitor use among commercially insured patients with type 2 diabetes in the US, including those with heart failure with reduced ejection fraction (HFrEF), CKD, and atherosclerotic cardiovascular disease (ASCVD); individuals with these comorbidities were evaluated because of the demonstrated benefit of SGLT2 inhibitor use in these particular subgroups.…”

Racial/Ethnic and Socioeconomic Disparities in Management of Incident Paroxysmal Atrial Fibrillation

“…11 There is decreased adoption of advanced cardiovascular therapeutics among Black, Latinx, and low-income patients. 12 , 13 , 14 , 15 Demographic studies have shown that patients with AF who underwent catheter ablation were mostly White and male. 16 Racial and sex inequities in receipt of certain AF-related therapies were demonstrated among Medicare patients.…”