Social drivers of health may hinder catheter ablation access for AF
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Use of catheter ablation after diagnosis of incident atrial fibrillation was low among Danish patients with low level of education, low income and those who lived alone, researchers reported.
Despite the Danish tax-financed social welfare system, individuals with poor levels of social determinants of health remained less likely to undergo AF ablation, according to the study published in the European Heart Journal – Quality of Care & Clinical Outcomes.
Catheter ablation was extended to first-line therapy in select patients with paroxysmal AF and no structural heart disease, according to the 2012 update of the European Society of Cardiology guidelines for the management of AF.
“In contemporary practice, patients with newly diagnosed AF lose 2 years of expected lifetime compared to AF-free individuals over 10 years of follow-up. Pharmacological rhythm control therapy is associated with side effects or turns out ineffective in many patients, and thus catheter ablation is an alternative and common strategy for symptomatic patients,” Nicklas Vinter, MD, PhD student in the diagnostic center at the University Clinic for Development of Innovative Patient Pathways at Silkeborg Regional Hospital, Denmark, and colleagues wrote. “The Danish welfare system is characterized by a principle of free and equal access to health care and education. However, socioeconomic inequity in access to and quality of care can still exist in universal health care systems.”
To better understand the effects of social determinants of health on use of ablation after incident AF, researchers in Denmark conducted a nationwide study using four nationwide registries.
Social determinants of health were attained at AF diagnosis: level of educational attainment, family income and whether the patient was living alone.
Researchers identified 122,276 men (mean age, 71 years) and 98,476 women (mean age, 76 years) with a diagnosis of AF from 2005 to 2018.
Comorbidities were more common among patients with lower education and income. For both men and women, age at diagnosis was greater if they lived alone.
The median follow-up was 3.2 years for men and 3.1 years for women.
The median time to ablation was 2.1 years and the frequency of AF ablation was 9.2 procedures per 1,000 person-years for men and 5.6 procedures per 1,000 person-years for women.
Odds of catheter ablation among men with incident AF
Researchers observed that men with lower education (HR = 0.49; 95% CI, 0.45-0.53), lower income (HR = 0.31; 95% CI, 0.27-0.34) and those who lived alone (HR = 0.6; 95% CI, 0.55-0.64) were less likely to receive AF ablation compared with those with higher education, higher income and cohabitated.
Men with medium levels of education (HR for upper secondary education = 0.72; 95% CI, 0.68-0.77) and medium income (HR = 0.56; 95% CI, 0.52-0.6) had better odds of undergoing ablation but remained less likely than those with high levels of education and income.
Odds of ablation among women with incident AF
Among women, those with lower education (HR = 0.45; 95% CI, 0.4-0.5), lower income (HR = 0.34; 95% CI, 0.28-0.4) and those who lived alone (HR = 0.67; 95% CI, 0.61-0.74) were less likely to receive AF ablation compared with women with higher education, higher income and cohabitated.
Similar to the cohort of men, women with medium levels of education (HR = 0.83; 95% CI, 0.75-0.91) and medium income (HR = 0.51; 95% CI, 0.46-0.58) had better odds of undergoing ablation but remained less likely than those with high levels of education and income.
“These results originated from the Danish tax-financed social welfare system, in which access to health care and education is free. The observed associations may be even more dominant in countries without similar social security,” the researchers wrote. “Even though equity in health care has been a health policy priority in Denmark for decades, inequity in the use of catheter ablation has persisted. Our results suggest a need for initiatives that address social determinants of health in the care of AF patients.”
Researchers included an interaction term between the exposure (education, income and living alone) and calendar years to evaluate temporal trends but observed none.
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