Racial Disparities in Blood Thinner Use in VA Patients

PITTSBURGH – Black and Asian patients with atrial fibrillation are less likely to be treated with blood thinners than white patients, based on data from the U.S. Department of Veterans Affairs (VA). 

A paper published today in JAMA Network Open presents the findings in an extensive study looking at how VA patients are treated for newly diagnosed atrial fibrillation. These blood-thinning drugs—also called oral anticoagulants—reduce stroke risk by up to 70% and are the standard of care for atrial fibrillation. 

“Understanding the reasons for these treatment disparities is essential to improving equitable atrial fibrillation management and outcomes among racial and ethnic minority patients managed in the VA,” said Utibe R. Essien, M.D., M.P.H., health services researcher at VA Pittsburgh Healthcare System Center for Health Equity Research and Promotion and assistant professor in the University of Pittsburgh Division of General Internal Medicine. “Providers play a big role, but so does the broader health system. This includes ensuring there is equity in whether patients are referred to cardiologists or our pharmacy colleagues, who have been shown to be more likely to prescribe these medications in atrial fibrillation.”

The VA has treated nearly 1 million patients with atrial fibrillation in the past decade, a common heart rhythm disorder affecting as many as 6 million Americans. The outcomes associated with the disease disproportionately affect racial and ethnic minorities, increasing the risk of death and cardiovascular disease, including stroke. 

Essien and his fellow researchers examined data from more than 111,000 patients with atrial fibrillation at the VA from 2014 to 2018. Ninety-eight percent of the study sample were male, and 85.5% were white. Other racial and ethnic groups included Blacks (9.2%), Hispanics (3.7%), Asians (1.6%), and American Indians/Alaska Natives (0.5%).

After adjusting for clinical, sociodemographic, provider and facility factors, data revealed that Black and Asian patients were significantly less likely than white patients to be prescribed blood thinners. Black, Hispanic and American Indian/Alaska Native patients also were less likely to receive newer, more effective—and now standard-of-care—blood thinners, also known as direct oral anticoagulants.  

In 2018, Essien and other researchers published a study in JAMA Cardiology that found racial disparities in the use of blood thinners to treat atrial fibrillation for 12,000 non-VA patients. 

“We assumed that access to insurance and vastly different drug co-payment costs were a big driver of the disparities that we observed in our 2018 study,” said Essien. “But in this study, we found that those disparities persisted even in the VA’s integrated health care system that traditionally provides more equitable access to prescription medications.”

Essien believes there is an opportunity for future research to include interviews with patients and doctors to learn what happens in the exam room, what treatment doctors are offering patients and whether patients are accepting those recommended treatment options. 

“By learning what’s going on ‘under the hood,’ we’ll get a better understanding of how we fix these inequities,” said Essien. 

Additional authors on the study include Nadejda Kim, M.A., and Terrence  Litam, M.H.A., of the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System;  Leslie R.M. Hausmann, Ph.D., M.S., Walid F. Gellad, M.D., M.P.H., Michael J. Fine, M.D., M.Sc., of the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System and Division of General Internal Medicine, University of Pittsburgh School of Medicine; Maria K. Mor, Ph.D., of the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System and Department of Biostatistics, University of Pittsburgh Graduate School of Public Health; Chester B. Good, M.D., M.P.H., of the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Division of General Internal Medicine, University of Pittsburgh School of Medicine and Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan; and Jared W. Magnani, M.D., M.Sc., of the Department of Medicine, University of Pittsburgh School of Medicine.

Research reported in this publication was supported by funding from the VA VISN 4 Competitive Career Development Fund and the VA Health Services Research and Development Division (CDA-20-049).

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