TY - JOUR
T1 - Association of Race/Ethnicity with Oral Anticoagulant Use in Patients with Atrial Fibrillation
T2 - Findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II
AU - Essien, Utibe R.
AU - Holmes, Dajuanicia N.
AU - Jackson, Larry R.
AU - Fonarow, Gregg C.
AU - Mahaffey, Kenneth W.
AU - Reiffel, James A.
AU - Steinberg, Benjamin A.
AU - Allen, Larry A.
AU - Chan, Paul S.
AU - Freeman, James V.
AU - Blanco, Rosalia G.
AU - Pieper, Karen S.
AU - Piccini, Jonathan P.
AU - Peterson, Eric D.
AU - Singer, Daniel E.
N1 - Funding Information:
reports serving as a consultant to Janssen. Dr Mahaffey reports receiving research grants from Afferent, Amgen, Apple Inc, AstraZeneca, Cardiva Medical Inc, Daiichi Sankyo, Ferring, Google (Verily), Johnson and Johnson, Luitpold, Medtronic, Merck, Novartis, Sanofi, St Jude, and Tenax; receiving consulting fees from Ablynx, AstraZeneca, Baim Institute, Boehringer Ingelheim, BristolMyers Squibb, Cardiometabolic Health Congress, Elsevier, GlaxoSmith Kline, Johnson and Johnson, Medergy, Medscape, Merck, Mitsubishi, Myokardia, Novartis, Oculeve, Portola, Springer Publishing, Theravance, University of California–San Francisco, and WebMD; and holding equity in Bioprint Fitness. Dr Reiffel reports receiving research funding from Janssen and Medtronic; serving as a consultant for Janssen, Acesion, InCardia Therapeutics, Portola, and Medtronic; and receiving speaker’s fee from Janssen. Dr Steinberg reports receiving research support from Janssen and Boston Scientific and consulting fees from Janssen and Bayer. Dr Allen reports receiving research funding from Patient-Centered Outcomes Research Institute, American Heart Association, and the National Institutes of Health and consulting fees from Janssen, Boston Scientific, and Cytokinetics. Dr Chan reports receiving research funding from the American Heart Association and consulting fees from Optum Rx. Dr Freeman reports receiving research funding from the Nationl Heart, Blood, and Lung Institute and consulting fees from Janssen, Boston Scientific, and Biosense Webster. Dr Piccini reports receiving grants from Abbott Laboratories, ARCA Biopharma, Boston Scientific, German AFNET, Gilead, Janssen, and Verily and consulting fees from Bayer AG, GlaxoSmith Kline, Johnson and Johnson, Medtronic, Sanofi-Aventis, Philips, and Allergan. Dr Peterson reports receiving research grants from Abiomed, AstraZeneca, Bayer AG, Janssen, Merck, Novartis, Regeneron, Sanofi-Aventis, and Society of Thoracic Surgeons and consulting fees from Bayer, Janssen, Sanofi-Aventis, and Livongo. Dr Singer reports serving as a consultant/advisory board member for Boehringer Ingelheim, Bristol-Myers Squibb, CVS Health, Merck, Johnson and Johnson, Medtronic, and Pfizer and receiving research grants from Boehringer Ingelheim and Bristol-Myers Squibb.
Funding Information:
Funding/Support: The ORBIT-AF II registry is sponsored by Janssen Scientific Affairs, LLC. This study was suppported by the Eliot B. and Edith C. Shoolman Fund of Massachusetts General Hospital (Dr Singer) and the National Research Service Award (grant T32 HP10251; Dr Essien).
Publisher Copyright:
© 2018 American Medical Association. All rights reserved.
PY - 2018/12
Y1 - 2018/12
N2 - Importance: Black and Hispanic patients are less likely than white patients to use oral anticoagulants for atrial fibrillation. Little is known about racial/ethnic differences in use of direct-acting oral anticoagulants (DOACs) for atrial fibrillation. Objective: To assess racial/ethnic differences in the use of oral anticoagulants, particularly DOACs, in patients with atrial fibrillation. Design, Setting, and Participants: This cohort study used data from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II, a prospective, US-based registry of outpatients with nontransient atrial fibrillation 21 years and older who were followed up from February 2013 to July 2016. Data were analyzed from February 2017 to February 2018. Exposures: Self-reported race/ethnicity as white, black, or Hispanic. Main Outcomes and Measures: The primary outcome was use of any oral anticoagulant, particularly DOACs. Secondary outcomes included the quality of anticoagulation received and oral anticoagulant discontinuation at 1 year. Results: Of 12417 patients, 11100 were white individuals (88.6%), 646 were black individuals (5.2%), and 671 were Hispanic individuals (5.4%) with atrial fibrillation. After adjusting for clinical features, black individuals were less likely to receive any oral anticoagulant than white individuals (adjusted odds ratio [aOR], 0.75 [95% CI, 0.56, 0.99]) and less likely to receive DOACs if an anticoagulant was prescribed (aOR, 0.63 [95% CI, 0.49-0.83]). After further controlling for socioeconomic factors, oral anticoagulant use was no longer significantly different in black individuals (aOR, 0.78 [95% CI, 0.59-1.04]); among patients using oral anticoagulants, DOAC use remained significantly lower in black individuals (aOR, 0.73 [95% CI, 0.55-0.95]). There was no significant difference between white and Hispanic groups in use of oral anticoagulants. Among patients receiving warfarin, the median time in therapeutic range was lower in black individuals (57.1% [IQR, 39.9%-72.5%]) and Hispanic individuals (51.7% [interquartile range {IQR}, 39.1%-66.7%]) than white individuals (67.1% [IQR, 51.8%-80.6%]; P <.001). Black and Hispanic individuals treated with DOACs were more likely to receive inappropriate dosing than white individuals (black patients, 61 of 394 [15.5%]; Hispanic patients, 74 of 409 [18.1%]; white patients, 1003 of 7988 [12.6%]; P =.01). One-year persistence on oral anticoagulants was the same across groups. Conclusions and Relevance: After controlling for clinical and socioeconomic factors, black individuals were less likely than white individuals to receive DOACs for atrial fibrillation, with no difference between white and Hispanic groups. When atrial fibrillation was treated, the quality of anticoagulant use was lower in black and Hispanic individuals. Identifying modifiable causes of these disparities could improve the quality of care in atrial fibrillation.
AB - Importance: Black and Hispanic patients are less likely than white patients to use oral anticoagulants for atrial fibrillation. Little is known about racial/ethnic differences in use of direct-acting oral anticoagulants (DOACs) for atrial fibrillation. Objective: To assess racial/ethnic differences in the use of oral anticoagulants, particularly DOACs, in patients with atrial fibrillation. Design, Setting, and Participants: This cohort study used data from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II, a prospective, US-based registry of outpatients with nontransient atrial fibrillation 21 years and older who were followed up from February 2013 to July 2016. Data were analyzed from February 2017 to February 2018. Exposures: Self-reported race/ethnicity as white, black, or Hispanic. Main Outcomes and Measures: The primary outcome was use of any oral anticoagulant, particularly DOACs. Secondary outcomes included the quality of anticoagulation received and oral anticoagulant discontinuation at 1 year. Results: Of 12417 patients, 11100 were white individuals (88.6%), 646 were black individuals (5.2%), and 671 were Hispanic individuals (5.4%) with atrial fibrillation. After adjusting for clinical features, black individuals were less likely to receive any oral anticoagulant than white individuals (adjusted odds ratio [aOR], 0.75 [95% CI, 0.56, 0.99]) and less likely to receive DOACs if an anticoagulant was prescribed (aOR, 0.63 [95% CI, 0.49-0.83]). After further controlling for socioeconomic factors, oral anticoagulant use was no longer significantly different in black individuals (aOR, 0.78 [95% CI, 0.59-1.04]); among patients using oral anticoagulants, DOAC use remained significantly lower in black individuals (aOR, 0.73 [95% CI, 0.55-0.95]). There was no significant difference between white and Hispanic groups in use of oral anticoagulants. Among patients receiving warfarin, the median time in therapeutic range was lower in black individuals (57.1% [IQR, 39.9%-72.5%]) and Hispanic individuals (51.7% [interquartile range {IQR}, 39.1%-66.7%]) than white individuals (67.1% [IQR, 51.8%-80.6%]; P <.001). Black and Hispanic individuals treated with DOACs were more likely to receive inappropriate dosing than white individuals (black patients, 61 of 394 [15.5%]; Hispanic patients, 74 of 409 [18.1%]; white patients, 1003 of 7988 [12.6%]; P =.01). One-year persistence on oral anticoagulants was the same across groups. Conclusions and Relevance: After controlling for clinical and socioeconomic factors, black individuals were less likely than white individuals to receive DOACs for atrial fibrillation, with no difference between white and Hispanic groups. When atrial fibrillation was treated, the quality of anticoagulant use was lower in black and Hispanic individuals. Identifying modifiable causes of these disparities could improve the quality of care in atrial fibrillation.
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U2 - 10.1001/jamacardio.2018.3945
DO - 10.1001/jamacardio.2018.3945
M3 - Article
C2 - 30484833
AN - SCOPUS:85057865528
VL - 3
SP - 1174
EP - 1182
JO - JAMA Cardiology
JF - JAMA Cardiology
SN - 2380-6583
IS - 12
ER -