Racial/Ethnic and Socioeconomic Disparities in Management of Incident Paroxysmal Atrial Fibrillation

Importance: In patients with paroxysmal atrial fibrillation (AF), rhythm control with either antiarrhythmic drugs (AADs) or catheter ablation has been associated with decreased symptoms, prevention of adverse remodeling, and improved cardiovascular outcomes. Adoption of advanced cardiovascular therapeutics, however, is often slower among patients from racial/ethnic minority groups and those with lower income. Objective: To ascertain the cumulative rates of AAD and catheter ablation use for the management of paroxysmal AF and to investigate for the presence of inequities in AF management by evaluating the association of race/ethnicity and socioeconomic status with their use in the United States. Design, Setting, and Participants: This cohort study obtained inpatient, outpatient, and pharmacy claims data from the Optum Clinformatics Data Mart between October 1, 2015, and June 30, 2019. Adult patients (aged ≥18 years) in the database with a diagnosis of incident paroxysmal AF were identified. Patients were excluded if they did not have continuous insurance enrollment for at least 1 year before and at least 6 months after study entry. Exposures: Race/ethnicity and zip code-linked median household income. Main Outcomes and Measures: Treatment with a rhythm control strategy, and catheter ablation specifically, among those who received rhythm control. Multivariable logistic regression models were used to assess the association of race/ethnicity and zip code-linked median household income with a rhythm control strategy (AADs or catheter ablation) vs a rate control strategy as well as with catheter ablation vs AADs among those receiving rhythm control. Results: Of the 109 221 patients who met the inclusion criteria, 55 185 were men (50. 5%) and 73 523 were White (67. 3%), with a median (interquartile range) age of 75 (68-82) years. A total of 86 359 patients (79. 1%) were treated with rate control, 19 362 patients (17. 7%) with AADs, and 3500 (3. 2%) with catheter ablation. Between 2016 and 2019, the cumulative percentage of patients treated with catheter ablation increased from 1. 6% to 3. 8%. In multivariable analyses, Black race (adjusted odds ratio aOR, 0. 89; 95% CI, 0. 83-0. 94; P <. 001) and lower zip code-linked median household income (aOR for <50 000: 0. 83 95% CI, 0. 79-0. 87; P <. 001; aOR for 50 000-99 999: 0. 92 95% CI, 0. 88-0. 96; P = <. 001 compared with ≥100 000) were independently associated with lower use of rhythm control. Latinx ethnicity (aOR, 0. 73; 95% CI, 0. 60-0. 89; P =. 002) and lower zip code-linked median household income (aOR for <50 000: 0. 61 95% CI, 0. 54-0. 69; P <. 001; aOR for 50 000-99 999: 0. 81 95% CI, 0. 72-0. 90; P <. 001 compared with ≥100 000) were independently associated with lower catheter ablation use among those receiving rhythm control. Conclusions and Relevance: This study found that despite increased use of rhythm control strategies for treatment of paroxysmal AF, catheter ablation use remained low and patients from racial/ethnic minority groups and those with lower income were less likely to receive rhythm control treatment, especially catheter ablation. These findings highlight inequities in paroxysmal AF management based on race/ethnicity and socioeconomic status.