New Brunswick, NJ—The initiation of DOACs for U.S. adults aged 65 years and older with atrial fibrillation showed inequities for years but began to even out more recently.

That is according to a new cohort study in the Journal of the American Medical Association Network Open. The Rutgers University–led researchers reviewed 950,698 anticoagulation initiation episodes from 2010 to 2019 and found, after adjustment, that 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,” the authors pointed out, adding that their study “highlights the evolution of atrial fibrillation management, underscoring historical imbalances that have shown signs of abatement.”

The study team advised that the influence of race and ethnicity on the initiation of DOACs tends to be understudied in Medicare data. To remedy that, the researchers sought to investigate disparities in the initiation of DOACs compared with warfarin by race, ethnicity, and social vulnerability.

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), with analysis between January 2023 and February 2024.

The research included information on older adults with atrial fibrillation who newly initiated warfarin or DOACs—dabigatran, rivaroxaban, apixaban, and edoxaban. For the study, patients were classified as non-Hispanic white, non-Hispanic black, and Hispanic.

The study team modeled the likelihood of starting the use of DOACs compared with warfarin was modeled, adjusting for race, ethnicity, age, sex, county-level social vulnerability, and other clinical factors.

The 950,698 anticoagulation initiations in the study consisted of 680,974 DOAC users and 269,724 warfarin users. The patients had a mean age of 78.5 years and were 52.6% female. Most of the anticoagulation users were white (86.7%), 5.2% were black, and 4.3% were Hispanic.

“During the 10-year study period, DOAC use increased for all demographic groups,” the authors wrote. “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 example, the study pointed out that, in 2010, the odds ratio (OR) of black patients initiating DOACs was 0.54 (95% CI, 0.50-0.57), increasing 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),” the study team noted.

The researchers added, “Identifying the factors behind these early disparities is crucial for ensuring equitable access to novel therapies as they emerge for black and Hispanic populations.”

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