Division of General Internal Medicine, Massachusetts General Hospital, Boston.
Harvard Medical School, Boston, Massachusetts.
JAMA Cardiol. 2018 Dec 1;3(12):1174-1182. doi: 10.1001/jamacardio.2018.3945.
Black and Hispanic patients are less likely than white patients to use oral anticoagulants for atrial fibrillation. Little is known about racial/ethnic differences in use of direct-acting oral anticoagulants (DOACs) for atrial fibrillation.
To assess racial/ethnic differences in the use of oral anticoagulants, particularly DOACs, in patients with atrial fibrillation.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II, a prospective, US-based registry of outpatients with nontransient atrial fibrillation 21 years and older who were followed up from February 2013 to July 2016. Data were analyzed from February 2017 to February 2018.
Self-reported race/ethnicity as white, black, or Hispanic.
The primary outcome was use of any oral anticoagulant, particularly DOACs. Secondary outcomes included the quality of anticoagulation received and oral anticoagulant discontinuation at 1 year.
Of 12 417 patients, 11 100 were white individuals (88.6%), 646 were black individuals (5.2%), and 671 were Hispanic individuals (5.4%) with atrial fibrillation. After adjusting for clinical features, black individuals were less likely to receive any oral anticoagulant than white individuals (adjusted odds ratio [aOR], 0.75 [95% CI, 0.56, 0.99]) and less likely to receive DOACs if an anticoagulant was prescribed (aOR, 0.63 [95% CI, 0.49-0.83]). After further controlling for socioeconomic factors, oral anticoagulant use was no longer significantly different in black individuals (aOR, 0.78 [95% CI, 0.59-1.04]); among patients using oral anticoagulants, DOAC use remained significantly lower in black individuals (aOR, 0.73 [95% CI, 0.55-0.95]). There was no significant difference between white and Hispanic groups in use of oral anticoagulants. Among patients receiving warfarin, the median time in therapeutic range was lower in black individuals (57.1% [IQR, 39.9%-72.5%]) and Hispanic individuals (51.7% [interquartile range {IQR}, 39.1%-66.7%]) than white individuals (67.1% [IQR, 51.8%-80.6%]; P < .001). Black and Hispanic individuals treated with DOACs were more likely to receive inappropriate dosing than white individuals (black patients, 61 of 394 [15.5%]; Hispanic patients, 74 of 409 [18.1%]; white patients, 1003 of 7988 [12.6%]; P = .01). One-year persistence on oral anticoagulants was the same across groups.
After controlling for clinical and socioeconomic factors, black individuals were less likely than white individuals to receive DOACs for atrial fibrillation, with no difference between white and Hispanic groups. When atrial fibrillation was treated, the quality of anticoagulant use was lower in black and Hispanic individuals. Identifying modifiable causes of these disparities could improve the quality of care in atrial fibrillation.
与白人患者相比，黑人和西班牙裔患者使用华法林治疗心房颤动的可能性较低。对于使用直接作用的口服抗凝剂（DOAC）治疗心房颤动的种族/民族差异知之甚少。
评估种族/民族差异在使用口服抗凝剂，特别是 DOAC 治疗心房颤动患者中的作用。
设计、地点和参与者：这项队列研究使用了来自 Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II 的数据，这是一个针对年龄在 21 岁及以上且非一过性心房颤动的门诊患者的前瞻性、基于美国的登记处，从 2013 年 2 月至 2016 年 7 月进行随访。数据于 2017 年 2 月至 2018 年 2 月进行分析。
自我报告的种族/民族，分为白人、黑人或西班牙裔。
主要结局是使用任何口服抗凝剂，特别是 DOAC。次要结局包括接受的抗凝质量和口服抗凝剂在 1 年内停药。
在 12417 名患者中，11100 名是白人个体（88.6%），646 名是黑人个体（5.2%），671 名是西班牙裔个体（5.4%）患有心房颤动。在调整了临床特征后，与白人个体相比，黑人个体接受任何口服抗凝剂的可能性较低（调整后的优势比[OR]，0.75 [95%CI，0.56，0.99]），如果开了抗凝药，接受 DOAC 的可能性也较低（调整后的 OR，0.63 [95%CI，0.49-0.83]）。在进一步控制社会经济因素后，黑人个体的口服抗凝剂使用情况不再存在显著差异（调整后的 OR，0.78 [95%CI，0.59-1.04]）；在使用口服抗凝剂的患者中，黑人个体的 DOAC 使用仍然显著较低（调整后的 OR，0.73 [95%CI，0.55-0.95]）。白人个体和西班牙裔个体在使用口服抗凝剂方面没有显著差异。在接受华法林治疗的患者中，黑人个体（57.1%[IQR，39.9%-72.5%]）和西班牙裔个体（51.7%[IQR，39.1%-66.7%]）的治疗时间低于白人个体（67.1%[IQR，51.8%-80.6%]；P<0.001）。接受 DOAC 治疗的黑人和西班牙裔个体更有可能接受不适当的剂量，而不是白人个体（黑人患者，394 例中有 61 例[15.5%]；西班牙裔患者，409 例中有 74 例[18.1%]；白人患者，7988 例中有 1003 例[12.6%]；P=0.01）。口服抗凝剂的 1 年持续率在各组之间相同。
在控制了临床和社会经济因素后，与白人个体相比，黑人个体更不可能使用 DOAC 治疗心房颤动，而白人和西班牙裔个体之间没有差异。在治疗心房颤动时，黑人和西班牙裔个体的抗凝使用质量较低。确定这些差异的可改变原因可以改善心房颤动的护理质量。
