Socioeconomic disparities in access for Watchman device insertion in patients with atrial fibrillation and at elevated risk of bleeding
Kupsky D, Dee Wang D, Eng M, Gheewala N, Nakhle A, Georgie F, Shah R, Mahan M, Greenbaum A, O'Neill W. Socioeconomic disparities in access for Watchman device insertion in patients with atrial fibrillation and at elevated risk of bleeding. J Am Coll Cardiol. 2017;70(18):B177.
Journal of the American College of Cardiology
BACKGROUND Socioeconomic disparities exist in patient access to advanced cardiac therapies. We sought to investigate if there were any socioeconomic or racial disparities among patients with atrial fibrillation (AF), at elevated thromboembolic risk, and with contraindication to anticoagulation who were undergoing consideration for Watchman implantation at our institution.
METHODS June 2015 to December 2016, all patients with non-valvular AF requiring long term anticoagulation who underwent LAA exclusion with Watchman device were evaluated. Simultaneous control group was generated through electronic medical record query of patients with non-valvular atrial fibrillation, and criteria for LAA occlusion candidacy as deemed by WATCHMAN instructions for use, who were not referred for LAA closure within the predefined study time frame. The primary end point was disparities in socioeconomic status as defined by differences in median income between the control and study group. Mean household income was estimated utilizing Geocoding and 2016 US Census Data. Secondary endpoints included analysis for differences in patients receiving coverage for Medicaid, race, sex, and age.
RESULTS 201 patients with non-valvular AF were included (98 patients received Watchman device and 103 in the control arm). The mean estimated income was significantly higher in the Watchman insertion group compared to those who did not receive the device ($70,908.50 ± $25,847.20 vs. $56,569.90 ± $17,730.90; p <0.001). African- American patients were found to be less likely to receive Watchman insertion (5% vs. 27%; p<0.001). There was a higher percentage of patients in the control arm covered under Medicaid by both primary coverage (6% vs. 0; p=0.029) and with dual coverage of Medicare and Medicaid (13% vs. 4%; p=0.041). There was no significant difference between women referred for Watchman or women in the control arm (50% vs. 45%; p=0.428).
CONCLUSION Socioeconomic and racial disparities exist in patients with non-valvular AF at elevated risk of bleeding. African-American patients and those of lower incomes appear less likely to receive LAA exclusion. It remains essential to continually strive to improve access of cardiac procedures to patients of all races and socioeconomic classes.