Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System.
Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System.
复制标题
退伍军人健康管理系统中不同种族/族裔患者因房颤事件开始抗凝治疗的差异。
DOI：
10.1001/jamanetworkopen.2021.14234
复制
发表时间：
2021-07-01
影响因子：
13.8
通讯作者：
Fine MJ
中科院分区：
文献类型：
--
作者：
Essien UR;Kim N;Hausmann LRM;Mor MK;Good CB;Magnani JW;Litam TMA;Gellad WF;Fine MJ
在退伍军人健康管理系统治疗的房颤患者中，抗凝治疗的开始是否存在种族/民族差异？在这项对2014年至2018年接受房颤治疗的111,666例患者的全国回顾性队列研究中，黑人和亚洲患者不太可能开始任何抗凝治疗。在启动者中，黑人、西班牙裔和美洲印第安人/阿拉斯加原住民患者不太可能直接使用口服抗凝剂。在退伍军人健康管理系统中，一个通过统一的国家药物处方改善药物可及性的国家综合卫生系统，种族和民族差异似乎持续存在于房颤管理中。本队列研究使用来自退伍军人健康管理系统的数据来比较不同种族/民族抗凝治疗的起始率。心房颤动是一种常见的心律失常，引起大量的发病率和死亡率，在种族/少数民族群体中发病率和死亡率不成比例。抗凝可降低房颤卒中风险，但研究表明，在少数种族/民族患者中，抗凝治疗的处方不足。比较退伍军人健康管理局（VA）系统中房颤患者的种族/民族抗凝治疗起始情况。这项回顾性队列研究纳入了2014年1月1日至2018年12月31日期间VA系统内发生房颤的111,666例患者。数据分析时间为2019年12月1日至2020年3月31日。任何抗凝定义为接受华法林或直接作用口服抗凝剂、阿哌沙班、达比加群、依多沙班或利伐沙班。开始任何抗凝治疗（或开始任何抗凝治疗的直接作用口服抗凝治疗）在指数房颤诊断后90天内检查。我们的最终队列包括111,666例患者（男性109,386例（98.0%），白人95,493例（85.5%），平均[SD]年龄72.9[10.4]岁）。共有69 590名患者（62.3%）接受了抗凝治疗，种族/民族差异10.5个百分点（P < 0.001）；亚裔患者起始率最低（52.2% [n = 676]），黑人患者最低（60.3% [n = 6177]），白人患者最高（62.7% [n = 59 881]）。在抗凝剂启动者中，45381人（65.2%）使用直接作用口服抗凝剂，不同种族/民族差异为7.2个百分点（P < .001）；起始率在西班牙裔（58.3% [n = 1470]）、美洲印第安人/阿拉斯加原住民（59.8% [n = 201]）和黑人（60.9% [n = 3763]）患者中最低，在白人患者中最高（66.0% [n = 39502]）。与白人患者相比，亚洲患者（校正优势比[aOR]， 0.82; 95% CI, 0.72-0.94）和黑人患者（aOR, 0.90; 95% CI, 0.85-0.95）启动任何抗凝治疗的几率显著低于白人患者。在起始者中，西班牙裔（aOR, 0.79; 95% CI, 0.70-0.89）、美洲印第安人/阿拉斯加原住民（aOR, 0.75; 95% CI, 0.57-0.99）和黑人（aOR, 0.74; 95% CI 0.69-0.80）患者直接口服抗凝剂起始的调整后几率显著降低。该队列研究发现，在VA系统管理的房颤事件患者中，种族/民族与抗凝治疗和抗凝启动者使用直接作用口服抗凝剂独立相关。了解这些治疗差异的原因对于改善在VA系统中治疗的种族/少数民族患者的公平房颤管理和结果至关重要。
Among patients with atrial fibrillation treated in the Veterans Health Administration system, are there racial/ethnic differences in the initiation of anticoagulation therapy? In this cohort study of a nationally retrospective cohort of 111 666 patients with atrial fibrillation treated from 2014 to 2018, Black and Asian patients were less likely to initiate any anticoagulation therapy. Among initiators, Black, Hispanic, and American Indian/Alaska Native patients were less likely to initiate direct oral anticoagulants. In the Veterans Health Administration system, a national, integrated health system with improved access to medications through a uniform national drug formulary, racial and ethnic disparities appear to persist in atrial fibrillation management. This cohort study uses data from the Veterans Health Administration system to compare rates of initiation of anticoagulant therapy by race/ethnicity. Atrial fibrillation is a common cardiac rhythm disturbance causing substantial morbidity and mortality that disproportionately affects racial/ethnic minority groups. Anticoagulation reduces stroke risk in atrial fibrillation, yet studies show it is underprescribed in racial/ethnic minority patients. To compare initiation of anticoagulant therapy by race/ethnicity for patients in the Veterans Health Administration (VA) system with atrial fibrillation. This retrospective cohort study included 111 666 patients within the VA system with incident atrial fibrillation between January 1, 2014, and December 31, 2018. Data were analyzed between December 1, 2019, and March 31, 2020. Any anticoagulation was defined as receipt of warfarin or direct-acting oral anticoagulants, apixaban, dabigatran, edoxaban, or rivaroxaban. Initiation of any anticoagulation (or direct-acting oral anticoagulant therapy in those who initiated any anticoagulation) was examined within 90 days of an index atrial fibrillation diagnosis. Our final cohort comprised 111 666 patients (109 386 men [98.0%] and 95 493 White patients [85.5%]; mean [SD] age, 72.9 [10.4] years). A total of 69 590 patients (62.3%) initiated any anticoagulant therapy, varying 10.5 percentage points by race/ethnicity (P < .001); initiation was lowest in Asian (52.2% [n = 676]) and Black (60.3% [n = 6177]) patients and highest in White patients (62.7% [n = 59 881]). Among anticoagulant initiators, 45 381 (65.2%) used direct-acting oral anticoagulants, varying 7.2 percentage points by race/ethnicity (P < .001); initiation was lowest in Hispanic (58.3% [n = 1470]), American Indian/Alaska Native (59.8% [n = 201]), and Black (60.9% [n = 3763]) patients and highest in White patients (66.0% [n = 39 502). Compared with White patients, the odds of initiating any anticoagulant therapy were significantly lower for Asian (adjusted odds ratio [aOR], 0.82; 95% CI, 0.72-0.94) and Black (aOR, 0.90; 95% CI 0.85-0.95) patients. Among initiators, the adjusted odds of direct-acting oral anticoagulant initiation were significantly lower for Hispanic (aOR, 0.79; 95% CI, 0.70-0.89), American Indian/Alaska Native (aOR, 0.75; 95% CI, 0.57-0.99), and Black (aOR, 0.74; 95% CI 0.69-0.80) patients. This cohort study found that in patients with incident atrial fibrillation managed in the VA system, race/ethnicity was independently associated with initiating any anticoagulant therapy and direct-acting oral anticoagulant use among anticoagulant initiators. Understanding the reasons for these treatment disparities is essential to improving equitable atrial fibrillation management and outcomes among racial/ethnic minority patients treated in the VA system.
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DOI：
10.1016/j.jacc.2016.03.521
发表时间：
2016-07-01
影响因子：
6.9
作者：
Heidenreich, Paul A.;Solis, Penelope;Varosy, Paul D.
通讯作者：
Varosy, Paul D.
影响因子：
5.4
作者：
Hernandez, Inmaculada;He, Meiqi;Gellad, Walid F.
通讯作者：
Gellad, Walid F.
影响因子：
3
作者：
Hausmann, Leslie R. M.;Gao, Shasha;Fine, Michael J.
通讯作者：
Fine, Michael J.
影响因子：
5.7
作者：
Groeneveld, Peter W.;Sonnad, Seema S.;Shea, Judy E.
通讯作者：
Shea, Judy E.
影响因子：
3
作者：
Jia, Huanguang;Pei, Qinglin;Hoffman, Nannette
通讯作者：
Hoffman, Nannette