Association of income and educational levels with adherence to direct oral anticoagulant therapy in patients with incident atrial fibrillation: A Finnish nationwide cohort study

Abstract

Low socioeconomic status has been associated with poor outcomes in patients with atrial fibrillation (AF). However, little is known about socioeconomic disparities in adherence to stroke prevention with direct oral anticoagulants (DOACs). We assessed the hypothesis that AF patients with higher income or educational levels have better adherence to DOACs in terms of treatment implementation and persistence. The used nationwide registry‐based FinACAF cohort covers all patients with incident AF starting DOACs in Finland during 2011–2018. The implementation analyses included 74 222 (mean age 72.7 ± 10.5 years, 50.8% female) patients, and persistence analyses included 67 503 (mean age 75.3 ± 8.9 years, 53.6% female) patients with indication for permanent anticoagulation (CHA 2 DS 2 ‐VASc score >1 in men and >2 in women). Patients were divided into income quartiles and into three categories based on their educational attainment. Therapy implementation was measured using the medication possession ratio (MPR), and patients with MPR ≥0.90 were defined adherent. Persistence was measured as the incidence of therapy discontinuation, defined as the first 135‐day period without DOAC purchases after drug initiation. Patients with higher income or education were consistently more likely adherent to DOACs in the implementation phase (comparing the highest income or educational category to the lowest: adjusted odds ratios 1.18 (1.12–1.25) and 1.21 (1.15–1.27), respectively). No association with income or educational levels was observed on the incidence of therapy discontinuation. In conclusion, we observed that income and educational levels both have independent positive association on the implementation of DOAC therapy but no association on therapy persistence in patients with AF.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

“…20 Therefore, ensuring timely and equitable referral of women, individuals from UREG, and those with adverse SDOH for rhythm control therapy is important. In patients with AF, indicators of lower socioeconomic status were associated with lower oral anticoagulation rates, 21 lower rate of adherence during direct oral anticoagulant (DOAC) initiation, 22 specialty care, 21,23 and less use of cardioversion 4,21 and catheter ablation. 4,21,24 Indicators of socioeconomic disadvantages, such as increased risk of hospitalization, 25 stroke, 4,21 HF, 4,21,26 and death, were also associated with complications in patients with AF.…”

Sociodemographic determinants of oral anticoagulant prescription in patients with atrial fibrillations: findings from the PINNACLE registry using machine learning

“…Cost of medication and follow-up of OAC can influence the prescription rates. 25 , 26 Unequal access to OAC in socioeconomically disadvantaged patients and different geographical areas have been shown in previous studies. 26 In a study by Llorca and colleagues, 25 those living in more socioeconomically deprived and rural areas had lower OAC prescription rates.…”

“… 25 , 26 Unequal access to OAC in socioeconomically disadvantaged patients and different geographical areas have been shown in previous studies. 26 In a study by Llorca and colleagues, 25 those living in more socioeconomically deprived and rural areas had lower OAC prescription rates. Moreover, previous studies by Essien and colleagues 27 , 28 showed lower initiation of OAC for Black patients and lower DOAC use for Black and Hispanic patients.…”

Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios

“…Several methods for estimating adherence are available. Medication refill adherence may be obtained through health administrative claim databases using the proportion of days covered (PDC) or medication possession ratio (MPR), and patients with PDC or MPR ≥ 0.80–0.90 are defined as adherent [ 165 ]. Self-reported adherence may be obtained through interviews with questionnaires.…”

“…Socioeconomic status, income, and educational levels do not seem to be associated with medication adherence [ 191 , 203 ]. However, in the nationwide registry-based FinACAF cohort, covering 74,222 adults with AF on DOACs, higher income or education has been associated with adherence to DOACs (OR 1.18 (1.12–1.25) and 1.21 (1.15–1.27), respectively) [ 165 ].…”