Racial, Ethnic, and Socioeconomic Inequities in the Prescription of Direct Oral Anticoagulants in Patients With Venous Thromboembolism in the United States

Abstract

Background: Beginning in 2012, direct oral anticoagulants (DOACs) were approved for treatment and prevention of venous thromboembolism. Prior investigations have demonstrated slow rates of adoption of novel therapeutics for black patients. We assessed the association of racial/ethnic and socioeconomic factors with DOAC use among commercially insured venous thromboembolism patients. Methods and Results: We performed a retrospective cohort analysis of adult patients with an incident diagnosis of venous thromboembolism between January 2010 and December 2016 using OptumInsight’s Clinformatics Data Mart. We identified the first filled oral anticoagulant prescription within 30 days of discharge of an inpatient admission. We performed a multivariable logistic regression, adjusting for age, sex, race/ethnicity, region, zip code–linked household income, and clinical covariates to identify factors associated with the use of DOACs. Race and ethnicity were determined in this database through a combination of public records, self-report, and proprietary ethnicity code tables. There were 14 140 patients included in the analysis. Treatment with DOACs increased from <0.1% in 2010 to 65.6% in 2016. In multivariable analyses, black patients were less likely to receive a DOAC compared with white patients (odds ratio, 0.86; 95% CI, 0.77–0.97; P =0.02). There were no differences in DOAC utilization among Asian (odds ratio, 1.06; 95% CI, 0.75–1.49; P =0.74) or Hispanic patients (odds ratio, 1.04; 95% CI, 0.88–1.22; P =0.66) compared with whites. Patients with a household income over $100 000 per year were more likely to receive DOAC therapy compared with patients with a household income of <$40 000 per year (odds ratio, 1.50; 95% CI, 1.33–1.69; P <0.0001). Conclusions: Although DOAC adoption has increased steadily since 2012, among a commercially insured population, black race and low household income were associated with lower use of DOACs for incident venous thromboembolism despite controlling for other clinical and socioeconomic factors. These findings suggest the possibility of both racial and socioeconomic inequity in access to this novel pharmacotherapy.

Opportunity for Genotype‐Guided Prescribing Among Adult Patients in 11 US Health Systems

“…Also consistent with previous studies, 35,36 we observed that African Americans were less likely than Whites to be prescribed newer cardiovascular agents, although differences in the frequency of comorbidities that impact drug prescribing might partially account for our observations. African American race and lower household income have been associated with lower use of newer agents, suggesting that both race and socioeconomic status affect access to novel therapies.…”

Outpatient Treatment of Low‐risk Pulmonary Embolism in the Era of Direct Oral Anticoagulants: A Systematic Review

“…Direct oral anticoagulants have surpassed VKAs to become the leading outpatient therapy for VTE, with 65% to 82% of patients reportedly using DOACs instead of VKAs for VTE therapy during 2012 to 2017 26,27 . Early research suggests outpatient management of DVT in the United States has increased since the release of DOACs, 28 but similar research on management of PE is lacking.…”

Ethnoracial variations in venous thrombosis: Implications for management, and a call to action

“…Interestingly genotype‐guided warfarin dosing led to longer time to first therapeutic INR and overall, lower time in therapeutic range compared to a clinically guided algorithm in Black African patients requiring VKA 87 . Despite challenges with VKA management, DOACs remain under‐used in African Americans for VTE treatment in the United States, highlighting the need for improved access and affordability to cardiovascular therapeutics in an attempt to equalize outcomes after VTE among ethnoracial groups 88 …”