. Socioeconomic disparities in access for Watchman device insertion in patients with atrial fibrillation and at elevated risk of bleeding

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BACKGROUND Socioeconomic disparities exist inpatient access to advanced cardiac therapies. We sought to investigate if there were any socioeconomic or racial disparities among patientswith atrial fibrillation (AF), at elevatedthromboembolic risk, and with contraindication to anticoagulation who were undergoing consideration for Watchman implantation at our institution.METHODS June 2015 to December 2016, all patientswith non-valvular AF requiring long term anticoagulation who underwent LAA exclusion withWatchman 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 ofpatients 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 disparitiesexist in patients with non-valvular AF at elevated riskof bleeding. African-American patients and those oflower incomes appear less likely to receive LAA exclusion. It remains essential to continually strive to improve access of cardiac procedures to patients ofall races and socioeconomic classes.





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