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Treatment of AF varies by race, sex
Among Medicare beneficiaries with newly diagnosed atrial fibrillation, receipt of oral anticoagulation and catheter ablation was more common in men and white adults compared with women and Hispanic adults, according to study results published in Heart Rhythm.
A team of researchers analyzed administrative encounter data for 517,941 Medicare beneficiaries (41% men) in 2010-2011, cataloging services received after an initial diagnosis of AF, including visits with a cardiology or electrophysiologist, catheter ablation procedures, use of oral anticoagulants, use of rate control agents and use of antiarrhythmic drugs. The cohort was 87% white, 7% black and 6% Hispanic.
The researchers conducted multivariate analyses to determine disparities by race or sex in those services. The most notable disparities were in catheter ablation (Hispanic vs. white, adjusted HR = 0.7; 95% CI, 0.63-0.79; women vs. men, adjusted HR = 0.65; 95% CI, 0.63-0.68) and in receipt of oral anticoagulation (black vs. white, adjusted HR = 0.94; 95% CI, 0.92-0.95; Hispanic vs. white, adjusted HR = 0.94; 95% CI, 0.93-0.97; women vs. men, adjusted HR = 0.93; 95% CI, 0.93-0.94).
Anticoagulation disparities ‘troubling’
“What I thought was most interesting and probably the most troubling was the disparity in the blood thinners that were given,” Prashant D. Bhave, MD, FHRS, assistant professor of medicine at the University of Iowa Hospitals and Clinics, Iowa City, Iowa, told Cardiology Today. “Blood thinners are important for the prevention of stroke [in patients with AF]. We know that strokes that are associated with AF are much more severe and disabling than strokes from other causes.”
Prashant D. Bhave
Bhave noted that “while the numbers in the differences in the study may seem small, those small differences translate to huge numbers of people that are being treated suboptimally.”
Biases may exist
Access to care does not likely explain the whole story, according to Bhave.
“We looked at whether access to heart rhythm specialists was different because if patients are not seeing electrophysiologists or heart rhythm specialists, perhaps they would be less likely to get appropriate therapies, but it turns out the access to care didn’t seem terribly different,” Bhave said in an interview. “So there’s something about the interaction that’s different, whether it’s provider bias, potentially being less aggressive with certain subsets of the population, or whether it’s patient-related bias, [such as] women being less likely to want invasive procedures and less likely to agree to take medications that confer bleeding risk, or in the case of Hispanic patients, there being a language gap that precludes the most effective therapies. It’s impossible to know, but my strong suspicion is that there are certain subsets of the population that are not offered more aggressive therapies, whether consciously or unconsciously, by the provider.”
Determining why the disparities exist and how to fix them cannot be done via national administrative databases and will have to be done by local and regional projects, Bhave said.
“That may include community efforts to educate patients as well as to interview patients who have been diagnosed with AF to try to understand which were offered blood thinners and [declined], and which were never offered blood thinners,” he said. “The root causes may be different in different regions.” – by Erik Swain
For more information:
Prashant D. Bhave, MD, FHRS, can be reached at Cardiology Division/Electrophysiology Section, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, JCP 4426B, Iowa City, IA 52242; email: pdbhave@gmail.com.
Disclosure: The researchers report no relevant financial disclosures.