What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial fibrillation with elevated thromboembolic risk (n=9513). Intervention: Black race vs. White race. Primary outcome: Receipt of guideline-recommended oral anticoagulation (p=0.03).

November 21, 2023Open Access

Gaps in guideline-recommended anticoagulation in patients with atrial fibrillation and elevated thromboembolic risk within an integrated healthcare delivery system

SMSushmita MalikKaiser Permanente SGShanshan GustafsonKaiser Permanente HCHuai-En R. ChangKaiser Permanente

Key Result

Black and Asian patients with atrial fibrillation had significantly lower rates of guideline-recommended oral anticoagulation compared to White patients (70.8% and 68.3% vs. 73.1%, respectively), while rates did not differ by sex or socioeconomic status.

Study Design

Type

Cohort (n=9,513)

Multicenter

Yes

Structured PICO

Are there racial, sex, or socioeconomic disparities in the receipt of guideline-recommended oral anticoagulation among patients with atrial fibrillation and elevated stroke risk?

Population

9,513 adult patients with atrial fibrillation and elevated thromboembolic risk (CHADS2 score ≥ 2) receiving care within an integrated healthcare delivery system over a 6-month period.

Outcome

Receipt of guideline-recommended oral anticoagulation (warfarin or DOAC) based on active medication list in the electronic health record

In a diverse, integrated healthcare system, appropriate anticoagulation rates for atrial fibrillation were relatively high overall, but significant treatment gaps persisted for Black and Asian patients compared to White patients.

Main Result

Absolute Event Rate: 70.8% vs 73.1%

p-value: p=0.03

Limitations

Restricted to using CHADS2 score instead of CHA2DS2-VASc or ATRIA for stroke risk prediction
Bleeding risk among different subgroups was not assessed, representing a potential unmeasured confounder
Findings from a closed group-model integrated healthcare delivery system may not be widely generalizable to other practice settings
Retrospective cross-sectional design may have counted recently diagnosed patients as not appropriately anticoagulated before they completed evaluation
Dabigatran as the preferred DOAC may not be broadly generalizable to other U.S. practice settings where apixaban is more common

Abstract

Abstract Background Atrial Fibrillation (AF) is the leading cause of stroke, which can be reduced by 70% with appropriate oral anticoagulation (OAC) therapy. Nationally, appropriate anticoagulation rates for patients with AF with elevated thromboembolic risk are as low as 50% even across the highest stroke risk cohorts. This study aims to evaluate the variability of appropriate anticoagulation rates among patients by sex, ethnicity, and socioeconomic status within the Kaiser Permanente Mid-Atlantic States (KPMAS). Methods This retrospective study investigated 9513 patients in KPMAS’s AF registry with CHADS 2 score ≥ 2 over a 6-month period in 2021. Results Appropriately anticoagulated patients had higher rates of diabetes, prior stroke, and congestive heart failure than patients who were not appropriately anticoagulated. There were no significant differences in anticoagulation rates between males and females (71.8% vs. 71.6%%, OR 1.01; 95% CI, 0.93-1.11; P = .76) nor by SES-SVI quartiles. There was a statistically significant difference between Black and White patients (70.8% vs. 73.1%, P = .03) and Asian and White patients (68.3% vs. 71.6%, P = .005). After adjusting for CHADS 2 , this difference persisted for Black and White participants with CHADS 2 scores of ≤3 (62.6% vs. 70.6%, P 5 (68.0% vs. 79.3%, P < .001). Conclusions Black and Asian patients may have differing rates of appropriate anticoagulation when compared with White patients. Characterizing such disparities is the first step towards addressing treatment gaps in AF.

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