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- Title
Racial and Ethnic Disparities in Initiation of Direct Oral Anticoagulants Among Medicare Beneficiaries.
- Authors
Reynolds, Kamika R.; Khosrow-Khavar, Farzin; Dave, Chintan V.
- Abstract
Key Points: Question: How are race, ethnicity, and social vulnerability associated with the new initiation of direct oral anticoagulants (DOACs) among older US adults (aged ≥65 years) with atrial fibrillation? Findings: In this cohort study of 950 698 anticoagulation initiation episodes from 2010 to 2019, after adjustment, Black and Hispanic patients were 23% and 13% less likely to initiate DOACs, respectively. Disparities in DOAC initiation were greatest among Black patients in earlier years but attenuated during the study period and dissipated entirely by 2019. Meaning: This study highlights the evolution of atrial fibrillation management, underscoring historical imbalances that have shown signs of abatement. This cohort study investigates potential disparities by race, ethnicity, and social vulnerability in the initiation of direct oral anticoagulants among Medicare beneficiaries in the US. Importance: The influence of race and ethnicity on initiation of direct oral anticoagulants (DOACs) is relatively understudied in Medicare data. Objective: To investigate disparities in the initiation of DOACs compared with warfarin by race, ethnicity, and social vulnerability. Design, Setting, and Participants: This retrospective cohort study used a 50% sample of Medicare fee-for-service data from January 1, 2010, to December 31, 2019 (mean patient enrollment duration, 7.7 years). Analysis took place between January 2023 and February 2024. A cohort of older adults (aged ≥65 years) with atrial fibrillation who newly initiated warfarin or DOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) was identified. Exposure: Patients were classified as non-Hispanic White, non-Hispanic Black, and Hispanic. Main Outcomes and Measures: The likelihood of starting use of DOACs compared with warfarin was modeled, adjusting for race, ethnicity, age, sex, county-level social vulnerability, and other clinical factors. Results: Among 950 698 anticoagulation initiations, consisting of 680 974 DOAC users and 269 724 warfarin users (mean [SD] age, 78.5 [7.6] years; 52.6% female), 5.2% were Black, 4.3% were Hispanic, and 86.7% were White. During the 10-year study period, DOAC use increased for all demographic groups. After adjustment, compared with White patients, Black patients were 23% less likely (adjusted odds ratio [AOR, 0.77; 95% CI, 0.75-0.79) and Hispanic patients were 13% less likely (AOR, 0.87; 95% CI, 0.85-0.89) to initiate DOAC use. Disparities in DOAC initiation were greatest among Black patients in the earlier years but attenuated during the study period. For instance, in 2010, the OR of Black patients initiating DOACs was 0.54 (95% CI, 0.50-0.57), attenuating linearly over time to 0.69 by 2013 (95% CI, 0.65-0.74) and 0.83 (95% CI, 0.78-0.89) by 2017. By 2019, these differences became nonsignificant (OR, 1.08; 95% CI, 0.99-1.18). Conclusions and Relevance: In this cohort study of Medicare patients with atrial fibrillation, Black and Hispanic patients were less likely to initiate DOACs for atrial fibrillation, although these differences diminished over time. Identifying the factors behind these early disparities is crucial for ensuring equitable access to novel therapies as they emerge for Black and Hispanic populations.
- Subjects
UNITED States; WARFARIN; ANTICOAGULANTS; HEALTH services accessibility; STATISTICAL models; RISK assessment; AFRICAN Americans; SOCIAL determinants of health; RESEARCH funding; MEDICARE; HISPANIC Americans; STATISTICAL sampling; ORAL drug administration; WHITE people; RETROSPECTIVE studies; DESCRIPTIVE statistics; RACE; LONGITUDINAL method; BENZIMIDAZOLES; SOCIAL status; THEMATIC analysis; ODDS ratio; ATRIAL fibrillation; PYRIDINE; HEALTH equity; CONFIDENCE intervals; DATA analysis software; STROKE; PSYCHOLOGICAL vulnerability; RIVAROXABAN; NOSOLOGY; DISEASE risk factors
- Publication
JAMA Network Open, 2024, Vol 7, Issue 1, pe249465
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2024.9465