Racial/Ethnic Disparities in AF Care Persist Despite Dual VA, Medicare Coverage

Even among patients with robust insurance coverage and access to care provided through both the Veterans Health Administration and Medicare, there are racial/ethnic disparities in use of oral anticoagulation for newly diagnosed atrial fibrillation (AF), a study shows.

Black patients were less likely to initiate any oral anticoagulation within 90 days of diagnosis, and both Black and Hispanic patients who started treatment had lower chances of receiving a direct oral anticoagulant (DOAC) rather than warfarin when compared with their white counterparts, Utibe Essien, MD (VA Pittsburgh Medical Center and University of Pittsburgh School of Medicine, PA), reported last weekend during the virtual American Heart Association 2021 Scientific Sessions.

Video Topical Discussion

TCTMD's Quick Takes: Dr. Essien

December 14, 2021

The findings, published simultaneously in Circulation: Cardiovascular Quality and Outcomes, follow those from another VA study Essien’s group published earlier this year showing that in the broader group of patients with AF in the REACH-AF cohort, those from racial/ethnic minority groups were less likely to initiate therapy and, if they did, to receive DOACs.

This new analysis reveals that these differences are still evident even in veterans with additional Medicare coverage, including those participating in the Medicare Part D drug benefit.

“We were really fascinated in the finding that despite dual enrollment in both the VA and Medicare, these racial and ethnic disparities persisted in this cohort of patients who presumably had robust access to insurance,” Essien told TCTMD. “And I think that’s really encouraging us to look beyond access as a big driver of racial disparities in the treatment of atrial fibrillation.”

Racial/Ethnic Inequities in AF Care

Essien said his team has been doing a deep dive on racial/ethnic inequities in AF care over the past several years. In 2018, they published an analysis of the ORBIT-AF II registry showing that the quality of anticoagulation therapy was lower in Black patients. More recently, the group has been focusing on the VA, the largest integrated health system in the United States in which there is uniform access to prescription medications with no or low co-pays.

To expand on their earlier work, the investigators focused on veterans who were also enrolled in Medicare. That’s a growing population, with about 70% of all vets over the age of 65, Essien noted.

This retrospective analysis included 43,789 veterans (mean age 73 years; 98.2% men) who received an incident AF diagnosis between 2014 and 2018 and who had continuous enrollment in both the VA and Medicare. There were three mutually exclusive racial/ethnic groups: non-Hispanic white (87.5%), non-Hispanic Black (8.9%), and Hispanic (3.6%).

The rate of initiation of any oral anticoagulant within 90 days of diagnosis was higher in patients who were white (68.0%) or Hispanic (67.6%) than in Black individuals (65.2%). A fully adjusted model accounting for demographic, clinical, provider, facility, and socioeconomic factors affirmed the lower likelihood of treatment in Black versus white patients (OR 0.89; 95% CI 0.82-0.97), with no significant difference between Hispanic and white patients.

Receipt of a DOAC instead of warfarin among patients who started treatment was greater in white patients (59.6%) than in Black or Hispanic patients (56.3% and 55.9%, respectively). Those differences remained after adjustment, with lower odds of receiving a DOAC for patients who were Black (OR 0.72; 95% CI 0.65-0.81) or Hispanic (OR 0.84; 95% CI 0.70-1.00).

If It’s Not Access, Then What?

Essien said they’ve been exploring potential reasons for these lingering racial/ethnic disparities at the patient, clinician, and system levels, and the aim is to eventually assess what’s happening in clinical spaces by talking to physicians and patients about their experiences when starting oral anticoagulation.

At the patient level, it doesn’t appear that trust of newer medications is playing a major role, because gaps between racial/ethnic groups in terms of DOAC use have actually widened over time, Essien noted.

Some possibilities at the physician level are related to referral to cardiologists who are more likely to prescribe DOACs or related to physicians’ concerns about whether their patients will take their medication. “Prior research has shown that there often can be differential assessments of patient adherence to medications based on their race and ethnicity,” Essien said.

How much racial bias among individual clinicians is influencing these issues is unclear.

“Training as a physician, we’ve always wanted to assume that we were good people, that we were giving patients the best that we could and providing every patient the same, but study after study has revealed that implicit bias does play a role in medical treatment, especially when we’re rushed, especially when there’s some urgency around decision-making,” Essien said. “And so while our data were not able to specifically look to how bias plays a role, I think that that’s certainly an important area for us to study—understanding how we assess risk, whether it’s social risk or clinical risk, differently depending on a patient’s race or ethnicity.”

And finally, at the system level, barriers to accessing these therapies—due to transportation difficulties or inability to pay, for instance—could be involved in perpetuating disparities, Essien said.

As for what can be done to address these problems, Essien noted that several VA medical centers are developing a new DOAC dashboard to help improve the quality of therapy for all patients. “We have an opportunity to implement an equity lens to dashboards like that,” he added.

In the future, Essien said that within his area of focus—which he’s termed “pharmacoequity”—he plans to move beyond doing studies that seek to describe and understand existing disparities in AF care to finding ways to address them, whether that’s through changes to electronic medical records or the larger healthcare system.

“We have to kind of reimagine what access means,” Essien urged, underscoring that the current analysis showed it’s not just about ensuring the availability of affordable medications. “How can we start to reimagine access so that we’re not holding onto the traditional factors that we think about—such as insurance or socioeconomic status—and we can really make sure that the patients who need care have access to the best care possible?”