Racial, Ethnic, and Socioeconomic Inequities in the Prescription of Direct Oral Anticoagulants in Patients With Venous Thromboembolism in the United States

• Published in: Circulation Cardiovascular quality and outcomes Vol. 12; no. 4; p. e005600
• Main Authors: Nathan, Ashwin S, Geng, Zhi, Dayoub, Elias J, Khatana, Sameed Ahmed M, Eberly, Lauren A, Kobayashi, Taisei, Pugliese, Steven C, Adusumalli, Srinath, Giri, Jay, Groeneveld, Peter W
• Format: Journal Article
• Language: English
• Published: United States 01.04.2019
• Subjects: Administration, Oral; Adult; Aged; Asian; Black or African American; Databases, Factual; Factor Xa Inhibitors - administration & dosage; Female; Health Services Accessibility - economics; Healthcare Disparities - ethnology; Hispanic or Latino; Humans; Incidence; Income; Male; Middle Aged; Retrospective Studies; Risk Assessment; Risk Factors; Social Determinants of Health; Socioeconomic Factors; Time Factors; Treatment Outcome; United States - epidemiology; Venous Thromboembolism - drug therapy; Venous Thromboembolism - economics; Venous Thromboembolism - ethnology; White People; United States; anticoagulants; socioeconomic factors; vitamin K; venous thromboembolism
• ISSN: 1941-7713; 1941-7705
• DOI: 10.1161/CIRCOUTCOMES.119.005600

Beginning in 2012, direct oral anticoagulants (DOACs) were approved for treatment and prevention of venous thromboembolism. Prior investigations have demonstrated slow rates of adoption of novel therapeutics for black patients. We assessed the association of racial/ethnic and socioeconomic factors with DOAC use among commercially insured venous thromboembolism patients. We performed a retrospective cohort analysis of adult patients with an incident diagnosis of venous thromboembolism between January 2010 and December 2016 using OptumInsight's Clinformatics Data Mart. We identified the first filled oral anticoagulant prescription within 30 days of discharge of an inpatient admission. We performed a multivariable logistic regression, adjusting for age, sex, race/ethnicity, region, zip code-linked household income, and clinical covariates to identify factors associated with the use of DOACs. Race and ethnicity were determined in this database through a combination of public records, self-report, and proprietary ethnicity code tables. There were 14 140 patients included in the analysis. Treatment with DOACs increased from <0.1% in 2010 to 65.6% in 2016. In multivariable analyses, black patients were less likely to receive a DOAC compared with white patients (odds ratio, 0.86; 95% CI, 0.77-0.97; P=0.02). There were no differences in DOAC utilization among Asian (odds ratio, 1.06; 95% CI, 0.75-1.49; P=0.74) or Hispanic patients (odds ratio, 1.04; 95% CI, 0.88-1.22; P=0.66) compared with whites. Patients with a household income over $100 000 per year were more likely to receive DOAC therapy compared with patients with a household income of <$40 000 per year (odds ratio, 1.50; 95% CI, 1.33-1.69; P<0.0001). Although DOAC adoption has increased steadily since 2012, among a commercially insured population, black race and low household income were associated with lower use of DOACs for incident venous thromboembolism despite controlling for other clinical and socioeconomic factors. These findings suggest the possibility of both racial and socioeconomic inequity in access to this novel pharmacotherapy.