Racial and Ethnic Disparities in Catheter Ablation Utilization for Atrial Fibrillation

Figures

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  Figure 1. Different Definitions of Disparity Influence Scale of Disparity Estimates Institute of Medicine (IOM) definition of disparity equates disparity with any unjust difference between 2 groups that is not explained by group differences in health needs, clinical appropriateness, and patient preference. Mechanisms of disparity may include implicit or structural bias and inequities stemming from the health access and care. The “residual direct effect” equates disparity with a race/ethnicity coefficient after adjusting for all available covariates but may underestimate disparity by adjusting for mediators that are linked to race/ethnicity like social determinants of health (SDOH). The definition by the Agency for Healthcare Quality and Research (AHRQ) counts the total difference in outcome as disparity but does not differentiate between acceptable or clinically appropriate reasons and unjust causes of disparity. Adapted with permission from Lê Cook et al9. RDE = residual direct effect.

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  Figure 2. Differences in Study Covariate Adjustment for Disparities in Catheter Ablation Heat map displaying which covariates were adjusted for by individual studies of catheter ablation (CA) utilization for atrial fibrillation (AF). Most studies adjusted for demographics and health status. Studies variably adjusted for socioeconomic status (SES), and health access (insurance type), and geographic location. One study adjusted for clinical variables important for catheter ablation selection including atrial fibrillation (AF) type, symptom burden, and echocardiographic data. None adjusted for AF burden or patient preference, 2 key determinants in the decision to pursue CA.

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  Figure 3. Differences in Catheter Ablation Utilization by Race and Ethnicity Forest plots of studies comparing catheter ablation utilization for atrial fibrillation between (A) non-Hispanic Black (NHB), (B) Hispanic/LatinX (HLx), and (C) Asian patients compared to non-Hispanic White (NHW) patients as reference group. For each race or ethnic group, cross-sectional studies reporting ORs were pooled separately from studies reporting time-to-event data as HRs. For each plot, the squares represent the ORs for individual studies, with the size of the square proportional to the study's weight. The horizontal lines represent the 95% CIs. The diamond represents the pooled OR, and its width represents the 95% CI. The vertical dashed line represents an OR or HR of 1 (no difference). Prediction intervals (PIs), which represent the range in which a future study will fall taking into account intra- and between-study heterogeneity is also reported with the pooled effect size. Between-study heterogeneity is reported as the I2 value.

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  Central Illustration. Heterogeneity Prevents Reduction of Disparities in Catheter Ablation Utilization The current evidence demonstrates racial and ethnic disparities in catheter ablation utilization for atrial fibrillation, however high between-study heterogeneity exists due to differences in data sources and a lack of a standardized definition of disparity and covariate adjustment methods. This heterogeneity limits understanding of underlying mechanisms and ultimately ability to reduce disparities in care for atrial fibrillation. Several recommendations and tools are already available to improve consistency of future research to address this important problem. AF = atrial fibrillation; SDOH = social determinants of health.