An analysis of data on nearly 110,000 patients with atrial fibrillation who were treated between 2016 and 2019 revealed that Black patients were 11% less likely to receive either antiarrhythmic drugs or catheter ablation treatment compared to whites. In addition, patients from neighborhoods where incomes were typically less than $50,000 per year were 17% less likely to receive those rhythm control therapies compared to patients from wealthier neighborhoods.
Among patients who did receive rhythm control therapy, Latinx ethnicity (adjusted odds ratio 0.73) and lower household income (aOR 0.61) were independently associated with lower likelihood of receiving catheter ablation, the researchers also report in JAMA Network Open.
"The results of this study are reflective of the deep structural inequities of our American healthcare system," said lead author Dr. Lauren Eberly, a cardiovascular fellow at the Perelman School of Medicine at the University of Pennsylvania, in Philadelphia. "Our findings are consistent with numerous prior studies that have demonstrated the presence of structural racism and inequities in the receipt of important cardiovascular therapeutics," she said in an email.
"It is important to note that the differences were observed in the setting of a population with 100% commercial insurance and persisted after adjustment for numerous factors including outpatient cardiology visits," Dr. Eberly said. "Therefore, we feel this represents biases in care delivery that must be addressed."
To take a closer look at the impact of both minority and income status on the likelihood of receiving rhythm control therapies, Dr. Eberly and her colleagues turned to data from the Optum Clinformatics Data Mart, a deidentified database of administrative claims by members of commercial insurance plans and Medicare Advantage. The database includes information from inpatient, outpatient and pharmacy claims from more than 15 million patients annually.
Demographics of patients at enrollment, including age, gender and race/ethnicity, were available for each member. Socioeconomic data, including median household income came from zip-code-linked U.S. Census Bureau enrollment data.
Patients included in the analysis were aged 18 or older, and had a diagnosis of paroxysmal atrial fibrillation coded on at least two occasions between October 1, 2015 and June 30, 2019.
Patients were excluded if they did not have continuous insurance enrollment for at least one year before and six months after study entry to ensure that comorbidities, clinical data and prescription claims could be accurately identified. Patients were also excluded if they had no pharmacy claims for medication for one year before the study period.
Overall, 109,221 patients met the inclusion criteria. Of these, 86,359 (79.1%) were treated with a rate control strategy, while among those treated with rhythm control, 19,362 (17.7%) were treated with antiarrhythmic drugs and 3,500 (3.2%) received catheter ablation.
Patients' median age was 75, and half (49.5%) were female. Two thirds (67.3%) were white, 9.3% were Black, and 7.4% were Latinx. Median household income was less than $50,000 for 30.5% of patients and $100,000 or greater for 17.9%.
Overall, the cumulative rate of antiarrhythmic drug use increased from 15.8% in 2016 to 21.3% in 2019, while the cumulative rate of catheter ablation treatment increased from 1.6% in 2016 to 3.8% in 2019.
Black race (aOR 0.89) and household income below $50,000 (aOR 0.83) were independently associated with lower use of rhythm control.
Looking through a broad lens, "there are myriad examples in the literature showing racial and ethnic differences in diagnosis, management and treatment of disease, as well as different outcomes," said Dr. Jared Magnani, a cardiologist and associate professor of medicine at the University of Pittsburgh School of Medicine. "So, I don't think it should be different in a disease like atrial fibrillation."
One caveat is that race and income are "isolated factors that may not provide a substantive approach to identifying why we see these differences," said Dr. Magnani, who was not involved with the new research. "The reasons for the differences are heterogeneous and complex and reducing it to whether someone is Black or white as a simple phenotype without looking at interactions that are longstanding and multiplicative is reductionist," he said.
SOURCE: https://bit.ly/2O91VoU and https://bit.ly/3krEpiQ JAMA Network Open, online February 26, 2021.
By Linda Carroll
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