Division of General Internal Medicine, University of Pittsburgh School of Medicine, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
Department of Medicine, Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
J Natl Med Assoc. 2020 Feb;112(1):103-108. doi: 10.1016/j.jnma.2019.10.003. Epub 2020 Feb 6.
Atrial fibrillation (AF) is the most common heart rhythm disorder and is associated with a 5-fold increased risk of ischemic stroke. Racial/ethnic minorities and women with AF have higher rates of stroke compared to white individuals and men respectively. Oral anticoagulation reduces the risk of stroke, yet prior research has described racial/ethnic and sex-based variation in its use. We sought to examine the initiation of any oral anticoagulant (warfarin or direct-acting oral anticoagulants, DOACs) by race/ethnicity and sex in patients with incident, non-valvular AF. Further in those who initiated any anticoagulant, we examined DOAC vs. warfarin initiation by race/ethnicity and sex.
We used claims data from a 5% sample of Medicare beneficiaries to identify patients with incident AF from 2012 to 2014, excluding those without continuous Medicare enrollment. We used logistic regression to assess the association between race/ethnicity (white, black, Hispanic), sex, and oral anticoagulant initiation (any, warfarin vs. DOAC), adjusting for sociodemographics, medical comorbidities, stroke and bleeding risk.
The cohort of 42,952 patients with AF included 17,935 women, 3282 blacks, and 1958 Hispanics. Overall OAC initiation was low (49.2% whites, 48.1% blacks, 47.5% Hispanics, 48.1% men, and 51.5% women). After adjusting, blacks (odds ratio (OR) 0.84; 95% CI, 0.78-0.91) were less likely than whites to initiate any oral anticoagulant with no difference observed between Hispanics and whites (OR 0.92; 95% CI, 0.83-1.01). Women were less likely than men to initiate any oral anticoagulant, OR 0.59 (95% CI 0.55-0.64). Among initiators of oral anticoagulation, DOAC use was low (35.8% whites, 29.3% blacks, 40.0% Hispanics, 41.6% men, and 42.4% women). After adjusting, blacks were less likely to initiate DOACs than whites, OR 0.75 (95% CI 0.66-0.85); the odds of DOAC initiation did not differ between Hispanic and white patients or between men and women.
In a national cohort of Medicare beneficiaries with newly-diagnosed AF, overall oral anticoagulant initiation was lower in blacks and women, with no difference observed by Hispanic ethnicity. Among oral anticoagulant initiators, blacks were less likely to initiate novel DOACs, with no differences identified by Hispanic ethnicity or sex. Identifying modifiable causes of treatment disparities is needed to improve quality of care for all patients with AF.
心房颤动（AF）是最常见的心律失常，其缺血性中风风险增加 5 倍。与白种人和男性相比，非裔美国人和女性房颤患者中风的发生率更高。口服抗凝剂可降低中风风险，但先前的研究表明其使用存在种族/民族和性别差异。我们旨在研究非瓣膜性房颤患者中种族/民族和性别的起始任何口服抗凝剂（华法林或直接作用口服抗凝剂，DOACs）的情况。此外，在开始任何抗凝剂的患者中，我们根据种族/民族和性别检查了 DOAC 与华法林的起始情况。
我们使用来自 Medicare 受益人的 5%样本中的索赔数据，从 2012 年至 2014 年确定了患有非瓣膜性房颤的患者，排除了没有连续 Medicare 参保的患者。我们使用逻辑回归来评估种族/民族（白种人、黑种人、西班牙裔）、性别和口服抗凝剂起始（任何、华法林与 DOAC）之间的关联，调整了社会人口统计学、合并症、中风和出血风险。
42952 例房颤患者的队列包括 17935 名女性、3282 名黑人和 1958 名西班牙裔。总体而言，OAC 起始率较低（白人占 49.2%，黑人占 48.1%，西班牙裔占 47.5%，男性占 48.1%，女性占 51.5%）。调整后，黑人（比值比（OR）0.84；95%置信区间，0.78-0.91）比白人更不可能开始任何口服抗凝剂，而西班牙裔与白人之间无差异（OR 0.92；95%置信区间，0.83-1.01）。与男性相比，女性开始任何口服抗凝剂的可能性更低，OR 为 0.59（95%置信区间，0.55-0.64）。在开始口服抗凝剂的患者中，DOAC 的使用率较低（白人占 35.8%，黑人占 29.3%，西班牙裔占 40.0%，男性占 41.6%，女性占 42.4%）。调整后，黑人比白人更不可能开始 DOAC，OR 为 0.75（95%置信区间，0.66-0.85）；西班牙裔和白人患者或男性和女性患者之间开始 DOAC 的几率没有差异。需要确定可改变的治疗差异的原因，以提高所有房颤患者的护理质量。
