Racial and ethnic disparities in anticoagulation initiation for atrial fibrillation (AF) exist among patients dually enrolled in Medicare and the Veterans Health Administration (VHA), Department of Veterans Affairs (VA), according to study findingspresented at the American Heart Association (AHA) Scientific Sessions 2021, held virtually from November 13 to 15, 2021.
Researchers from the University of Pittsburgh School of Medicine sourced data from the “Race, Ethnicity and Anticoagulant CHoice in Atrial Fibrillation” (REACH-AF) cohort, which included national retrospective data. Patients (N=43,789) with incident, nonvalvular AF who had enrolled in VA or Medicare between 2010-2018 were evaluated for anticoagulant initiation.
The patient population had a mean age of 73.1±8.4 years; 98.2% were men; 87.5% were White; 8.9% Black; 3.6% Hispanic; and 10.9% were enrolled in Medicare Part D. All baseline characteristics differed significantly on the basis of ethnicity (all P <.05).
Overall, 67.8% of study participants initiated an oral anticoagulant (OAC), specifically 59.2% took a direct oral anticoagulant (DOAC) and 40.8% warfarin. Uptake overall was higher among the non-Medicare enrollees (68.1% vs 64.9%; P <.0001). Non-Medicare enrollees had a higher rate of warfarin (40.9% vs 39.7%) and lower rate of DOAC (59.1% vs 60.3%).
The uptake of OAC among the AF population increased from 59.0% in 2014 to 74.3% in 2018 (P <.0001). DOAC use increased from 31.1% to 84.2% (P <.0001) and warfarin decreased by a similar proportion during this time. These trends did not differ on the basis of ethnicity.
Stratified by ethnicity, 68.0% of White, 65.2% of Black, and 67.6% of Hispanic patients initiated any OAC (P <.001). DOAC use was significantly lower among Black (56.3%) and Hispanic (55.9%) populations than White (59.6%; P =.008). Conversely, Black (43.7%) and Hispanic (44.1%) patients tended to initiate warfarin more than White patients (40.4%).
After adjusting for clinical, facility, provider, and socioeconomic factors, compared with White patients, fewer Black patients initiated any OAC (adjusted odds ratio [aOR], 0.89; 95% CI, 0.82-0.97), and Hispanic patients did not differ significantly (aOR, 1.10; 95% CI, 0.96-1.27).
Among the subset of Medicare enrollees, any OAC initiation was decreased among both the Black (aOR, 0.72; 95% CI, 0.65-0.81) and Hispanic (aOR, 0.84; 95% CI, 0.70-1.00) populations compared with White patients.
The study data may not be generalizable, as the majority of information was sourced through the VA and was gender biased.
The findings suggest that there is a lower initiation of OAC among Black patients and DOAC use in Black and Hispanic patients with AF. Researchers also observed that Medicare Part D enrollment did not moderate the link between racial and ethnic differences and anticoagulant therapy.
“Understanding why anticoagulant disparities persist in a sample of patients with ample access to medical care is critical to ensuring equitable AF management in VA,” the study authors noted. “Such understanding will also guide the design and implementation of policy-level interventions to reduce disparities in anticoagulation for AF.”
Essien UR, Kim N, Magnani JW, et al. Association of race and ethnicity and anticoagulation in patients with atrial fibrillation dually enrolled in VA and Medicare: effects of Medicare Part D on prescribing disparities. Circ Cardiovasc Qual Outcomes. Published online November 15, 2021. doi:10.1161/CIRCOUTCOMES.121.008389