Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System

Essien, Utibe R.; Kim, Nadejda; Hausmann, Leslie R. M.; Mor, Maria K.; Good, Chester B.; Magnani, Jared W.; Litam, Terrence M A; Gellad, Walid F.; Fine, Michael J.

doi:10.1001/jamanetworkopen.2021.14234

Cited by 57 publications

(96 citation statements)

References 63 publications

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“…Social and personal factors that are part of the eFI and we have captured in our prediction model may partially explain this, such as patients requiring additional care, being housebound, or being socially vulnerable. Previous work has examined the association between ethnicity and OAC prescribing in the US [ 44 , 45 ], but little is known in the UK. A local cross-sectional study found that there were no clear differences in warfarin prescribing by ethnic group, using data from general practice records from south and east London from 2008 to 2011 [ 46 ].…”

Section: Discussionmentioning

confidence: 99%

Incidence of nonvalvular atrial fibrillation and oral anticoagulant prescribing in England, 2009 to 2019: A cohort study

et al. 2022

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Background Atrial fibrillation (AF) is an important risk factor for ischaemic stroke, and AF incidence is expected to increase. Guidelines recommend using oral anticoagulants (OACs) to prevent the development of stroke. However, studies have reported the frequent underuse of OACs in AF patients. The objective of this study is to describe nonvalvular atrial fibrillation (NVAF) incidence in England and assess the clinical and socioeconomic factors associated with the underprescribing of OACs. Methods and findings We conducted a population-based retrospective cohort study using the UK Clinical Practice Research Datalink (CPRD) database to identify patients with NVAF aged ≥18 years and registered in English general practices between 2009 and 2019. Annual incidence rate of NVAF by age, deprivation quintile, and region was estimated. OAC prescribing status was explored for patients at risk for stroke and classified into the following: OAC, aspirin only, or no treatment. We used a multivariable multinomial logistic regression model to estimate relative risk ratios (RRRs) and 95% confidence intervals (CIs) of the factors associated with OAC or aspirin-only prescribing compared to no treatment in patients with NVAF who are recommended to take OAC. The multivariable regression was adjusted for age, sex, comorbidities, socioeconomic status, baseline treatment, frailty, bleeding risk factors, and takes into account clustering by general practice. Between 2009 and 2019, 12,517,191 patients met the criteria for being at risk of developing NVAF. After a median follow-up of 4.6 years, 192,265 patients had an incident NVAF contributing a total of 647,876 person-years (PYR) of follow-up. The overall age-adjusted incidence of NVAF per 10,000 PYR increased from 20.8 (95% CI: 20.4; 21.1) in 2009 to 25.5 (25.1; 25.9) in 2019. Higher incidence rates were observed for older ages and males. Among NVAF patients eligible for anticoagulation, OAC prescribing rose from 59.8% (95% CI: 59.0; 60.6) in 2009 to 83.2% (95% CI: 83.0; 83.4) in 2019. Several conditions were associated with lower risk of OAC prescribing: dementia [RRR 0.52 (0.47; 0.59)], liver disease 0.58 (0.50; 0.67), malignancy 0.74 (0.72; 0.77), and history of falls 0.82 (0.78; 0.85). Compared to white ethnicity, patients from black and other ethnic minorities were less likely to receive OAC; 0.78 (0.65; 0.94) and 0.76 (0.64; 0.91), respectively. Patients living in the most deprived areas were less likely to receive OAC 0.85 (0.79; 0.91) than patients living in the least deprived areas. Practices located in the East of England were associated with higher risk of prescribing aspirin only over no treatment than practices in London (RRR 1.22; 95% CI 1.02 to 1.45). The main limitation of this study is that these findings depends on accurate recording of conditions by health professionals and the inevitable residual confounding due to lack of data on certain factors that could be associated with under-prescribing of OACs. Conclusions The incidence of NVAF increased between 2009 and 2015, before plateauing. Underprescribing of OACs in NVAF is associated with a range of comorbidities, ethnicity, and socioeconomic factors, demonstrating the need for initiatives to reduce inequalities in the care for AF patients.

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Section: Discussionmentioning

confidence: 99%

Incidence of nonvalvular atrial fibrillation and oral anticoagulant prescribing in England, 2009 to 2019: A cohort study

et al. 2022

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“…This cohort study used data from the Race, Ethnicity, and Anticoagulation Choice in Atrial Fibrillation (REACH-AF) cohort to compare rates and types of anticoagulant therapy among PEH vs non-PEH. 4 Using administrative and clinical data from the Veterans Health Administration (VA), we defined the REACH-AF cohort as patients with a new AF diagnosis between January 1, 2010, and December 31, 2020, continuous VA enrollment for 2 years before diagnosis, and an outpatient confirmatory AF diagnosis within 180 days of the index diagnosis (eFigure in the Supplement ). We excluded patients with valvular heart disease, cardiac ablation, hyperthyroidism, an anticoagulant prescription in the 2 years before the index diagnosis, or death or hospice care in the 90 days after diagnosis.…”

Section: Methodsmentioning

confidence: 99%

Analysis of Initiating Anticoagulant Therapy for Atrial Fibrillation Among Persons Experiencing Homelessness in the Veterans Affairs Health System

et al. 2022

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“…In patients with AF, lower income and socioeconomic status have been associated with lower overall use of oral anticoagulant therapy and lower use of newer generation direct oral anticoagulants as well as with worse outcomes [16] , [17] , [18] , [19] . However, evidence on the association of income level with the utilization of AATs is limited.…”

Section: Introductionmentioning

confidence: 99%

Socioeconomic disparities in use of rhythm control therapies in patients with incident atrial fibrillation: A Finnish nationwide cohort study

Teppo

Jaakkola

Biancari

et al. 2022

IJC Heart & Vasculature

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Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System

Cited by 57 publications

References 63 publications

Incidence of nonvalvular atrial fibrillation and oral anticoagulant prescribing in England, 2009 to 2019: A cohort study

Incidence of nonvalvular atrial fibrillation and oral anticoagulant prescribing in England, 2009 to 2019: A cohort study

Analysis of Initiating Anticoagulant Therapy for Atrial Fibrillation Among Persons Experiencing Homelessness in the Veterans Affairs Health System

Socioeconomic disparities in use of rhythm control therapies in patients with incident atrial fibrillation: A Finnish nationwide cohort study

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