Racial/Ethnic Disparities in Anticoagulation Persist in Hospitalized AF Patients

SAN FRANCISCO, CA—Among patients hospitalized with atrial fibrillation (AF), Black patients are less likely than their white counterparts to be discharged on oral anticoagulation, which appears to be worsening clinical outcomes, data from the American Heart Association’s Get With The Guidelines–AFib initiative shows.

Overall, 78.5% of patients were prescribed an oral anticoagulant when leaving the hospital, including 77.7% of Black patients and 81.8% of white patients, a significant difference after accounting for potential confounders (adjusted OR 0.75; 95% CI 0.67-0.84). Also, Black patients who were discharged on treatment were less likely to receive a direct oral anticoagulant (DOAC) versus warfarin (adjusted OR 0.82; 95% CI 0.65-0.96).

These disparities appear to have translated into worse outcomes, with Black patients having higher rates of bleeding, stroke, and mortality than their white peers at 1 year.

Utibe Essien, MD (University of Pittsburgh School of Medicine, PA), who is set to present the findings here at Heart Rhythm 2022 on Saturday, told TCTMD “this is yet another study that supports the fact that, unfortunately, we do need to emphasize this term of ‘pharmacoequity’ and really ensure that patients have access to the highest quality of medications to treat their health conditions regardless of race, ethnicity, and social class.”

And that goes for all conditions, not just AF, he added.

“I’m hopeful that these data help encourage the Get With The Guidelines registry developers to start to really take equity as a big goal within their initiatives and really think about how to not only collect race and ethnicity data, but also intervene in a way that helps to balance the inequities that we’re seeing here, both for the treatment as well as the outcomes,” said Essien.

‘Really Striking’ Difference in Outcomes

For Essien and his colleagues, this has been an area of focus for several years. In 2018, they showed that the quality of anticoagulation therapy—both receipt of DOACs and control of warfarin—was poorer in Black versus white patients, a difference that remained after accounting for socioeconomic factors. And last year, they reported that racial/ethnic disparities lingered even among patients who had dual coverage from the Veterans Health Administration and Medicare.

For the current study, they delved into data from the Get With The Guidelines–AFib national quality-improvement initiative. The analysis included 69,553 patients (mean age 68.6; 48.8% women) hospitalized with AF across 159 participating sites between 2014 and 2020. Most (85.6%) were white, and the rest were Black (7.3%), Hispanic (5.8%), and Asian (1.2%). Mean CHA₂DS₂-VASc score was 3.8.

After adjustment for demographics, medical history, year of admission, socioeconomic status, and hospital characteristics, Black patients were less likely than whites to receive oral anticoagulation at discharge but there were no differences between whites and Hispanics or Asians.

The investigators used linked Medicare data to assess clinical outcomes at 1 year, and found that Black patients had increased rates of the following events compared with white patients:

• Bleeding (adjusted OR 2.08; 95% CI 1.25-2.82)
• Stroke (adjusted OR 2.07; 95% CI 1.33-3.20)
• Mortality (adjusted OR 1.22; 95% CI 1.02-1.47)

“That was really striking for us and [we’re] really looking to future work to try and understand the ‘why’ there,” Essien said.

The other racial/ethnic groups generally fared as well as white patients, although Hispanics had a higher rate of stroke (adjusted OR 2.02; 95% CI 1.38-2.96).

A Call to Do Better

Fred Kusumoto, MD (Mayo Clinic, Jacksonville, FL), president of the Heart Rhythm Society, told TCTMD via email that he is not surprised by the findings because these types of disparities have been seen for all advanced AF therapies—catheter ablation, left atrial appendage occlusion, and DOACs—in multiple US-based registries.

The problem is related to multiple factors, he said, but the most important is probably access to care.

The first step toward making care more equitable, Kusumoto said, is “recognition among all that these disparities exist in medicine.” Then, the community needs to “collectively develop long-term strategies and design systems of care to address these inequities.”

And finally, he said that “each of us individually [must] make a real commitment to address this issue with our medical center or clinic, among our team members, and when we provide direct patient care.”

The bottom line, Kusumoto said, is that “we need to do better.”

The findings show that the aphorism “a rising tide lifts all boats” does not apply to this situation, when Black patients are still trailing their white peers in use of anticoagulation and outcomes within the Get With The Guidelines–AFib registry, Essien said. “That to me is suggesting, unfortunately, that that classic adage is not true in this case and that we do need equity-focused interventions along with quality-improvement registries.”

Essien said his prior work combined with this new analysis indicates that it’s not just socioeconomic factors or differences in access to care that are driving the observed disparities.

“It really is time for us to move beyond just social factors,” he said. “So how do we actually assess provider bias within care and how it influences prescribing? I think [that] is an important next step for this work. What is going on at the patient level in terms of their trust in the health system, their trust in their cardiologist or their electrophysiology doc, their trust in these medications, their education or knowledge around these medications?

“And then when we actually do prescribe these therapies, in terms of the long-term outcomes,” he continued, “how easy is it for patients to adhere to them?” Factors like copays and physical access to a pharmacy, which couldn’t be captured in the analysis, could be important, he suggested.

Future studies will dig into qualitative data locally and nationally to explore patient and physician beliefs around prescribing these medications, Essien said. “There’s got to be something more than what these bigger data studies are showing us.”