Oral Anticoagulant Use in a Racial and Ethnically Diverse Population with Atrial Fibrillation
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J Gen Intern Med DOI: 10.1007/s11606-020-06184-4 © Society of General Internal Medicine 2020
INTRODUCTION
Warfarin is an established therapy to prevent ischemic stroke in patients with atrial fibrillation.1 Direct oral anticoagulants (DOACs) have emerged as alternative therapies due to favorable risk-benefit profiles compared with warfarin.1 Many patients with atrial fibrillation that meet guideline recommended criteria, especially Black and Hispanic patients, are not treated with anticoagulants.2 Several investigators have noted differences in oral anticoagulant treatment for atrial fibrillation in Black and Hispanic patients compared with their white counterparts.2, 3 However, a major shortcoming of these studies is the limited representation of patients of color. We aimed to investigate oral anticoagulant use in a diverse population with atrial fibrillation.
METHODS
This is a retrospective epidemiological study of patients with non-valvular atrial fibrillation diagnosed at the Montefiore Medical Center (Bronx, New York) between January 1, 2015, and January 1, 2019 (n = 1674) in an outpatient setting. Patients older than 18 were included if they were prescribed anticoagulation, as per the 2019 ACC-AHA-HRS guidelines, with warfarin, apixaban, rivaroxaban, edoxaban, or dabigatran.1 Patients with valvular atrial fibrillation and stroke within 1 month of diagnosis were excluded. This study protocol was approved by the Montefiore Medical Center IRB. Statistical analysis was performed with SPSS Version 25 (IBM SPSS Statistics for Windows). Differences in continuous and discrete variables were assessed using ANOVA test with Tukey’s post hoc analysis and chi-squared test, respectively. The relationship between race and anticoagulation use was analyzed using a logistic regression model, which controlled for prescriber, insurance status, baseline creatinine, and CHADSVASC score. A p value of < 0.05 was considered statistically significant. Ankur Srivastava and Eric Sun contributed equally to this work. Received May 27, 2020 Accepted August 24, 2020
RESULTS
A total of 1674 patients were included in the study. White, Black, Hispanic, and other racial/ethnic identifying subjects comprised 47.1%, 18%, 28.5%, and 6.5% of the patient population, respectively (Table 1). Overall, 62.4% of patients were Medicare recipients. Baseline creatinine was significantly higher among Black patients (1.4 ± 1.4) as compared with white patients (1.1 ± 1.1) (p = 0.001). Overall, 73.3% of the patient cohort was prescribed DOAC for atrial fibrillation, whereas only 26.7% of patients were prescribed warfarin (Table 1). White patients were prescribed DOACs less often than Hispanic patients (70.2% vs. 78.8% p = 0.001, unadjusted OR 0.6, 95% CI 0.5–0.8; adjusted OR 0.6, 95% CI 0.4–0.8, p = 0.002) (Table 2). There was no significant difference in the unadjusted and adjusted odds ratio comparing treatment differences between Hispanic and Black patients (unadjusted OR 0.7, 95% CI 0.5– 1.0, p = 0.052; adjusted OR 0.8, 95% CI 0.6–1.2, p = 0.251) (Tab
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