同时参加退伍军人健康管理局和医疗保险的心房颤动患者的种族和民族与抗凝治疗的关联：医疗保险D部分对处方差异的影响。

Association of Race and Ethnicity and Anticoagulation in Patients With Atrial Fibrillation Dually Enrolled in Veterans Health Administration and Medicare: Effects of Medicare Part D on Prescribing Disparities.

作者信息

Essien Utibe R, Kim Nadejda, Magnani Jared W, Good Chester B, Litam Terrence M A, Hausmann Leslie R M, Mor Maria K, Gellad Walid F, Fine Michael J

机构信息

Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, PA (U.R.E., N.K., C.B.G., T.M.A.L., L.R.M.H., M.K.M., W.F.G., M.J.F.).

Division of General Internal Medicine (U.R.E., C.B.G., L.R.M.H., W.F.G., M.J.F.), University of Pittsburgh School of Medicine, PA.

出版信息

Circ Cardiovasc Qual Outcomes. 2022 Feb;15(2):e008389. doi: 10.1161/CIRCOUTCOMES.121.008389. Epub 2021 Nov 15.

DOI:10.1161/CIRCOUTCOMES.121.008389

PMID:34779655

Abstract

BACKGROUND

Racial and ethnic disparities in anticoagulation exist in atrial fibrillation management in Medicare and the Veterans Health Administration, but the influence of dual Veterans Health Administration and Medicare enrollment is unclear. We compared anticoagulant initiation by race and ethnicity in dually enrolled patients and assessed the role of Medicare part D enrollment on anticoagulation disparities.

METHODS

We identified patients with incident atrial fibrillation (2014-2018) dually enrolled in Veterans Health Administration and Medicare. We assessed any anticoagulant initiation (warfarin or direct-acting oral anticoagulants [DOACs]) within 90 days of atrial fibrillation diagnosis and DOAC use among anticoagulant initiators. We modeled anticoagulant initiation, adjusting for patient, provider, and facility factors, including main effects for race and ethnicity and Medicare part D enrollment and an interaction term for these variables.

RESULTS

In 43 789 patients, 8.9% were Black, 3.6% Hispanic, and 87.5% White; 10.9% participated in Medicare part D. Overall, 29 680 (67.8%) patients initiated any anticoagulant, of whom 17 568 (59.2%) initiated DOACs. Lower proportions of Black (65.2%) than Hispanic (67.6%) or White (68.0%) patients initiated any anticoagulant (=0.001) and, lower proportions of Black (56.3%) and Hispanic (55.9%) than White (59.6%) patients (=0.001) initiated DOACs. Compared with White patients, Black patients had significantly lower initiation of any anticoagulant (adjusted odds ratio, 0.89 [95% CI, 0.82-0.97]). The adjusted odds ratios for DOAC initiation were significantly lower for Black (0.72 [95% CI, 0.65-0.81]) and Hispanic (0.84 [95% CI, 0.70-1.00]) than White patients. The interaction between race and ethnicity and Medicare part D enrollment was nonsignificant for any anticoagulant (=0.99) and DOAC (=0.27) therapies.

CONCLUSIONS

In dually enrolled Veterans Health Administration and Medicare patients with atrial fibrillation, Black patients were less likely to initiate any anticoagulant, and Black and Hispanic patients were less likely to initiate DOACs. Medicare part D enrollment did not moderate the associations between race and ethnicity and anticoagulant therapies.

摘要

背景

在医疗保险（Medicare）和退伍军人健康管理局（Veterans Health Administration）的心房颤动管理中，抗凝治疗存在种族和民族差异，但退伍军人健康管理局和医疗保险双重参保的影响尚不清楚。我们比较了双重参保患者按种族和民族进行抗凝治疗起始情况，并评估了医疗保险D部分参保在抗凝差异中的作用。

方法

我们确定了2014 - 2018年期间同时参加退伍军人健康管理局和医疗保险的新发心房颤动患者。我们评估了心房颤动诊断后90天内的任何抗凝治疗起始情况（华法林或直接口服抗凝剂[DOACs]）以及抗凝治疗起始者中DOAC的使用情况。我们建立了抗凝治疗起始的模型，对患者、提供者和机构因素进行了调整，包括种族和民族的主效应、医疗保险D部分参保情况以及这些变量的交互项。

结果

在43789例患者中，8.9%为黑人，3.6%为西班牙裔，87.5%为白人；10.9%参加了医疗保险D部分。总体而言，29680例（67.8%）患者开始了任何抗凝治疗，其中17568例（59.2%）开始使用DOACs。开始任何抗凝治疗的黑人患者比例（65.2%）低于西班牙裔（67.6%）或白人（68.0%）患者（P = 0.001），开始使用DOACs的黑人（56.3%）和西班牙裔（55.9%）患者比例低于白人（59.6%）患者（P = 0.001）。与白人患者相比，黑人患者开始任何抗凝治疗的比例显著较低（调整后的优势比，0.89[95%CI，0.82 - 0.97]）。黑人（0.72[95%CI，0.65 - 0.81]）和西班牙裔（0.84[95%CI，0.70 - 1.00]）患者开始使用DOACs的调整后优势比显著低于白人患者。种族和民族与医疗保险D部分参保之间的交互作用在任何抗凝治疗（P = 0.99）和DOAC治疗（P = 0.27）中均无统计学意义。