Black Patients Hospitalized for AF Less Likely to Receive DOACs at Discharge

Black and Hispanic patients are less likely than White patients to be prescribed anticoagulation therapy at discharge following hospitalization for AF.

In a national registry of patients hospitalized with atrial fibrillation (AF), Black and Hispanic individuals are less likely than White individuals to be prescribed anticoagulation, in particular direct-acting oral anticoagulants (DOACs), at hospital discharge according to the results of a retrospective analysis published in JAMA Cardiology.

Recognizing that little is known about how differential OAC prescribing habits relate to inequities in AF outcomes, researchers sought to compare OAC use at discharge, and AF-associated outcomes according to race and ethnicity, in the GWTG-AFIB (Get With the Guidelines-Atrial Fibrillation) registry. The GWTG-AFIB program is a national, voluntary quality improvement initiative that was started by the American Heart Association, in partnership with the Heart Rhythm Society, in January 2013. The goal of GWTG-AFIB is to improve cardiovascular health and outcomes in patients with AF, including in the use of class I recommended stroke reduction therapies.

The analysis used data from GWTG-AFIB registry patients who had been hospitalized with AF from 2014 to 2020. All of the data obtained were analyzed between November 2021 and July 2022. The primary study outcome was the prescription of a DOAC or warfarin at hospital discharge. Secondary outcomes were cumulative 1-year incidence of ischemic stroke, major bleeding, and mortality postdischarge. All outcomes were adjusted for patient demographic, clinical, and socioeconomic characteristics, as well as for hospital factors.

Among a total of 69,553 patients hospitalized with AF from 159 sites in the study cohort, 863 were Asian, 5062 were Black, 4058 were Hispanic, and 59,570 were White. The median patient age was 72 years (range, 63-80 years). Overall, 34,113 of the patients were women. The median CHA2DS2-VASc risk score was 4, with 61,523 of the participants having a CHA2DS2-VASc score of 2 or higher. In all, 29,845 patients had paroxysmal AF, 17,521 had persistent or permanent AF, and 14,545 were experiencing their first diagnosis of AF.

There is an urgent need for interventions to achieve pharmacoequity in guideline-directed AF management to improve overall outcomes.

At hospital discharge, 56,385 patients were prescribed OAC treatment, including 41,760 who received a DOAC. Receipt of an OAC prescription was the lowest among Hispanic patients (74.2%), which was followed by Black patients (77.7%), Asian patients (80.1%), and White patients (81.8%).

Results of the study showed that Black participants were less likely than White participants to be discharged while taking any anticoagulant (adjusted odds ratio [aOR], 0.75; 95% CI, 0.68-0.84) or a DOAC (aOR, 0.73; 95% CI, 0.65-0.82).

Further, among a total of 16,307 patients with 1-year follow-up data available, bleeding risk (adjusted hazard ratio [aHR], 2.08; 95% CI, 1.53-2.83), stroke risk (aHR, 2.07; 95% CI, 1.34-3.20), and mortality risk (aHR, 1.22; 95% CI, 1.02-1.47) were all higher in Black participants than White participants. Additionally, Hispanic participants had a higher risk for stroke (aHR, 2.02; 95% CI, 1.38-2.95).

Several limitations of the study should be noted. Since the data were collected by medical record review and claims data, they are dependent on the accuracy and completeness of the documentation and abstraction. Further, vital signs and laboratory values at hospital discharge are not evaluated. Additionally, because of the design of the registry, GWTG-AFIB attracts participating hospitals with an interest in quality improvement, which can potentially lead to selection bias.

“There is an urgent need for interventions to achieve pharmacoequity in guideline-directed AF management to improve overall outcomes,” the study authors wrote.

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

References:

Essien UR, Chiswell K, Kaltenbach LA, et al. Association of race and ethnicity with oral anticoagulation and associated outcomes in patients with atrial fibrillation: findings from the Get With The Guidelines-Atrial Fibrillation registry. JAMA Cardiol. Published online October 26, 2022. doi:10.1001/jamacardio.2022.3704