Race- and sex-related differences in care for patients newly diagnosed with atrial fibrillation

doi:10.1016/j.hrthm.2015.03.031

Heart Rhythm

Volume 12, Issue 7, July 2015, Pages 1406-1412

https://doi.org/10.1016/j.hrthm.2015.03.031 Get rights and content

Background

Atrial fibrillation (AF) is associated with an increased risk of stroke and death. Uniform utilization of appropriate therapies for AF may help reduce those risks.

Objective

We sought to determine whether significant race and sex differences exist in the treatment of newly diagnosed AF in Medicare beneficiaries.

Methods

We used administrative encounter data for Medicare beneficiaries to identify patients with newly diagnosed AF during 2010–2011. Services received after initial AF diagnosis were cataloged, including visits with a cardiologist or electrophysiologist, catheter ablation procedures, and use of oral anticoagulants, rate control agents, and antiarrhythmic drugs.

Results

Overall, 517,941 patients met study criteria, of whom 452,986 (87%) were white, 36,425 (7%) black, and 28,530 (6%) Hispanic. Male patients comprised 209,788 (41%) of the cohort. In multivariate analysis, there were statistically significant differences in the use of AF-related services by both race and sex, with white patients and male patients receiving the most care. The most notable disparities were for catheter ablation (Hispanic vs white: adjusted hazard ratio [AHR] 0.70; 95% confidence interval [CI] 0.63–0.79; P < .001; female vs male: AHR 0.65; 95% CI 0.63–0.68; P < .001) and receipt of oral anticoagulation (black vs white: AHR 0.94; 95% CI 0.92–0.95; P < .001; Hispanic vs white: AHR 0.94; 95% CI 0.93–0.97; P < .001; female vs male: AHR 0.93; 95% CI 0.93–0.94; P < .001).

Conclusion

Race and sex appear to have a significant effect on the health care provided to this cohort of Medicare beneficiaries diagnosed with AF. Possible explanations include racial differences in access, patient preferences, treatment bias, and unmeasured clinical characteristics.

Introduction

Atrial fibrillation (AF) is a highly prevalent problem in the United States, affecting about 1% of the population and about 5% of the population aged 65 years and older.¹ The deleterious health effects of AF are protean and include a marked increase in embolic stroke risk and an association with higher mortality.²

For patients with AF, a few therapies are available to manage patient symptoms and decrease their long-term risk of major cardiovascular events. Oral anticoagulation has been shown to significantly decrease the frequency and severity of strokes.³ Rate- and rhythm-controlling medications may be prescribed to restore normal heart rate and sinus rhythm. In addition, catheter ablation for AF in properly chosen patients may improve outcomes—this has been demonstrated primarily in younger patients with antiarrhythmic drug refractory symptomatic paroxysmal AF.4, 5 Finally, access to specialist physicians with experience in managing AF has been correlated with improved management; for example, in one study⁶ of Medicare beneficiaries, the strongest predictors that a patient with AF receives oral anticoagulation are having a primary care provider and seeing a cardiology specialist.

Previous work7, 8 has suggested that race and sex disparities affect the treatment of patients with other cardiac conditions such as chest pain and coronary ischemia. More recently, studies have documented race and sex disparities in the likelihood of receiving certain AF-related therapies, including anticoagulation⁹ and cardiac ablation.10, 11 We sought to determine whether race- or sex-based inequalities exist in the overall care of patients with AF by examining the use of outpatient clinic visits to a general cardiologist or cardiac electrophysiologist, catheter ablation procedures, antiarrhythmic and rate-controlling medications, and oral anticoagulation in Medicare beneficiaries with new diagnoses of AF.

Section snippets

Methods

Data sources included the Centers for Medicare and Medicaid (CMS) Beneficiary Summary File Base and Chronic Conditions segments, Inpatient (Part A) and Carrier (Part B) Standard Analytic Files for 2009–2012, and CMS Pharmacy (Part D) Drug Events data for 2010–2012. Patient information in the data sources was de-identified. Patients were included in the study if they met the CMS chronic condition criteria for AF during 2010–2011 (defined as 1 inpatient or 2 outpatient encounters within 12 months

Baseline characteristics

Overall, 452,986 patients (87%) were white, 36,425 black (7%), and 28,530 Hispanic (6%); 308,153 patients (59%) were female patients (Table 1). Compared to white patients, black patients were significantly more likely to have several key comorbid conditions. While all differences in the prevalence in comorbid conditions were statistically significant (due to the large sample size), differences were notable for congestive heart failure, hypertension, diabetes mellitus, cerebrovascular disease,

Discussion

In our large cohort of Medicare beneficiaries diagnosed with AF, significant race- and sex-based differences in the patterns of treatment and care of AF were seen. Most of these differences remained significant after controlling for patient-level confounders. In particular, sizable differences were noted in the use of catheter ablation, with Hispanics and women being substantially less likely to undergo ablation compared to whites and male patients. While black and white patients were equally

Conclusion

As the prevalence of AF steadily rises, the appropriate management of this chronic disease becomes increasingly important. The severe adverse long-term sequelae of AF—stroke, heart failure, and increased mortality—suggest that specialist care for this dysrhythmia is warranted. This is borne out by published findings that specialist referral in patients with AF leads to higher rates of prescription of appropriate anticoagulant therapy,⁶ which has been shown to be a highly cost-effective

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: Abstract was presented at the Heart Rhythm Society Scientific Sessions, San Francisco, CA, May 9, 2014.

: Dr Kamel receives research funding from the National Institutes of Health (K23NS082367). Dr Vaughan Sarrazin receives support from a Mentored Career Enhancement Award for Mid-Career and Senior Investigators (5K18HS021992) provided by the Agency for Healthcare Research and Quality as well as from the Health Services Research and Development Service of the Department of Veterans Affairs. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. The funding sources played no role in the study design, data collection, data management, data analysis, data interpretation, manuscript preparation, manuscript review, or manuscript approval.

View full text

Race- and sex-related differences in care for patients newly diagnosed with atrial fibrillation

Background

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Baseline characteristics

Discussion

Conclusion

Womens Health Issues

Am J Prev Med

Am J Med

J Am Coll Cardiol

Heart Rhythm

Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study

JAMA

Risk of death and cardiovascular events in initially healthy women with new-onset atrial fibrillation

JAMA

Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation

N Engl J Med

Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial

JAMA

Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial

JAMA

National utilization patterns of warfarin use in older patients with atrial fibrillation: a population-based study of Medicare Part D beneficiaries

Ann Pharmacother

Racial variation in the use of coronary-revascularization procedures. Are the differences real? Do they matter?

N Engl J Med

The effect of race and sex on physicians’ recommendations for cardiac catheterization

N Engl J Med

Racial disparities in awareness and treatment of atrial fibrillation: the REasons for Geographic and Racial Differences in Stroke (REGARDS) study

Stroke

Demographic profile of patients undergoing catheter ablation of atrial fibrillation

J Cardiovasc Electrophysiol

Trends in catheter ablation for atrial fibrillation in the United States

J Hosp Med

Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data

Med Care

Comorbidity measures for use with administrative data

Med Care