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Racial, ethnic disparities exist in treatment of AF with oral anticoagulants
Black patients with atrial fibrillation were less likely to receive direct-acting oral anticoagulants than their white counterparts, whereas black and Hispanic patients were more likely to be given inappropriate dosing than white patients, according to a study published in JAMA Cardiology.
“Prior studies have shown that anticoagulation use in underrepresented ethnic groups with AF is lower than in white individuals, with some of this disparity explained by socioeconomic status,” Utibe R. Essien, MD, MPH, assistant professor from the division of general internal medicine at the University of Pittsburgh, and colleagues wrote. “Time in the therapeutic range of INR of 2 to 3 on warfarin, a measure of anticoagulation quality, has also been shown to be lower in black patients compared with white patients, as well as in patients with limited English proficiency, increasing the stroke risk in these populations. However, these studies did not examine whether these differences in AF care extended to the use of direct-acting oral anticoagulants.”
Researchers conducted a cohort study of 12,417 adults aged at least 21 years who, between February 2013 and July 2016, were enrolled in ORBIT-AF II, which is a prospective, multicenter, U.S.-based registry of outpatients with AF (88.6% white; 5.2% black; 5.4% Hispanic).
The primary outcome was the use of any oral anticoagulant, especially direct-acting oral anticoagulants, and secondary outcomes included the quality of anticoagulation received and the discontinuation of oral anticoagulants at 1 year.
Researchers compared the use of anticoagulants and other baseline characteristics across race/ethnicity at the index ORBIT-II enrollment visit and patients were then followed up at 6-month intervals, which lasted from 12 to 24 months.
Overall, 88.9% of white patients, 84.2% of black patients and 87.3% of Hispanic patients reported taking any oral anticoagulant.
Racial discrepancies
After adjusting for baseline clinical features, researchers found that black patients were still less likely to have received oral anticoagulants than white patients (adjusted OR = 0.75; 95% CI, 0.56-0.99) and that, if anticoagulants were prescribed, they were less likely to receive direct-acting oral anticoagulants (aOR = 0.63; 95% CI, 0.49-0.83).
After further controlling for socioeconomic factors, it was determined that oral anticoagulant use was not significantly different between black and white individuals (aOR = 0.78; 95% CI, 0.59-1.04), but direct-acting oral anticoagulant use remained lower in black patients (aOR = 0.73; 95% CI, 0.55-0.95).
Researchers found no significant difference between white and Hispanic patients in the use of oral anticoagulants but, compared with white individuals, black and Hispanic individuals treated with direct-acting oral coagulants were more likely to be given inappropriate dosing (15.5% of black patients; 18.1% of Hispanic patients; 12.6% of white patients).
Additionally, the median time in therapeutic range for patients receiving warfarin was lower in black patients (57.1%; interquartile range [IQR], 39.9-72.5) and Hispanic patients (51.7%; IQR, 39.1-66.7) than white patients (67.1%; IQR, 51.8-80.6; P < .001).
Researchers found no difference in 1-year persistence on oral anticoagulants between the groups.
“These results contribute toward understanding racial/ethnic differences in stroke-preventive treatment in patients with AF,” the researchers wrote. “Novel approaches are needed to address modifiable causes of racial/ethnic disparities in anticoagulant use, a central issue in improving the overall quality of care for patients with AF.”
Subconscious bias
In a related editorial, Clyde W. Yancy, MD, MSc, of the division of cardiology at Northwestern University Feinberg School of Medicine, wrote: “After adjusting for clinical variables, socioeconomic characteristics and acknowledging patient-level factors, what potentially remains is the subtle but pernicious influence of subconscious bias. ... All of us as physicians and all our patients engage the health care experience with biases that emanate from deep and firmly embedded life experiences. The goal is not to rewire culture but to change context. As evidence-based, quality-driven physicians, achieving the best care for all our patients is the only acceptable goal. We must continue to report performance as a function of race/ethnicity and seek actionable interventions. Falling short exposes our patients to untoward outcomes; in the case of those patients participating in the ORBIT-AF II trial, this is an unprotected vulnerability to stroke. This gap in cardiovascular care must be further addressed and eliminated.” – by Melissa J. Webb
Disclosures: Essien reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Yancy reports that his spouse is an employee of Abbott.