Race- and sex-related differences in care for patients newly diagnosed with atrial fibrillation
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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2023, Current Problems in CardiologyFrom the Heart Rhythm Society's Diversity, Equity and Inclusion Council
2023, Heart RhythmReview: Sex-related differences in the treatment of cardiac arrhythmia
2023, Pharmacology and Therapeutics
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.