Outcome Disparities by Insurance Plan and Educational Attainment in Patients with Atrial Fibrillation

Abstract

ObjectivesDespite efforts to cut poverty, improve public health, and raise educational attainment, countries still suffer from disparities. Since 2002, Thailand has successfully implemented the Universal Health Coverage Scheme (UCS) to eradicate health care access inequity. Here, we explored the interlink between insurance plan, educational attainment, and adverse clinical outcomes in the national registry of patients with atrial fibrillation (AF) in Thailand.DesignA nationwide prospective multicenter cohort of non-valvular 3402 AF.Primary OutcomesPatients were followed for 36 months for primary outcomes of all-cause mortality, ischemic stroke, and major bleeding. Survival analysis was performed using restricted mean survival time (RMST) and adjusted with multiple covariates.ResultsData from 3026 AF patients (mean age 67, 59% male) were analyzed. The mean CHA2DS2VASc and HASBLED scores were 3.0 (SD 1.7) and 1.5 (SD 1.0) respectively. Most of the patients attained the elementary level of education (N=1739, 57.4%). The major health insurance plans were Civil Servant Medical Benefit Scheme (CSMBS; N=1397, 46.2%) and UCS (N=1333, 44.1%). After 36 months of follow-up, 248 patients died (8.2%), 95 suffered from ischemic stroke (3.1%), and 136 suffered from major bleeding (4.5%). AF patients with no formal education lost 1.78 months before they died (adjusted RMST difference -1.78; 95% CI, -3.25 to -0.30; P =.02) and 1.04 months before they developed ischemic stroke (adjusted RMST difference -1.04; 95% CI, -2.03 to -0.04; P =.04) compared to those with higher education. Educational attainment level was not associated with major bleeding. Across all types of insurance plan, RMSTs to all three clinical outcomes were essentially similar.ConclusionEducation attainment level was independently associated with all-cause mortality and ischemic stroke in AF patients.Health insurance plans were not associated with adverse clinical outcomes.Clinical Trial RegistrationThai Clinical Trial Registration; Study ID: TCTR20160113002Strengths and limitations of this studyThe study links two of the most important of sociodemographic factors, education and health insurance plan, and clinical outcomes of atrial fibrillation (AF), one of the most common cardiovascular conditions.Data is derived from a large prospective and nationwide cohort.The study evaluates healthcare quality in universal health coverage system.Causal relationship cannot be assumed from a cohort trial.Enrollment took place in the medical center, thus, excluding patients who could not access the healthcare facilities.