To assess whether neighborhood disadvantage is associated with differences in atrial fibrillation (AF) diagnosis and treatment.
Approach:
Population and exposure: Amagai and colleagues studied more than 500,000 commercially insured and Medicare Advantage adults in the Philadelphia metropolitan area, using census tract-level Social Barrier Index scores to measure neighborhood disadvantage.
Analyses: They examined AF diagnosis and, among participants diagnosed with AF, oral anticoagulant prescription fills. Sensitivity analyses used alternative deprivation indices and other analytic restrictions.
Key Findings:
Greater neighborhood disadvantage was associated with higher odds of AF diagnosis among non-Hispanic White participants and lower odds among non-Hispanic Black participants.
Non-Hispanic Black participants were disproportionately represented in the most disadvantaged neighborhoods.
Differences in oral anticoagulant prescription fills were smaller and less consistent than differences in diagnosis.
Findings were consistent across alternative neighborhood indices and several sensitivity analyses.
Interpretation:
Claims-based diagnoses reflect clinically recognized AF, not underlying AF burden, so the study cannot determine whether differences reflect AF incidence or detection. The authors emphasize that treatment comparisons among diagnosed participants do not capture people whose AF was not recognized.
Limitations:
Race and ethnicity were imputed from census tract composition for 27% of participants, potentially creating correlated misclassification with neighborhood disadvantage.
The study included one insurer and one metropolitan area and excluded traditional Medicare and uninsured populations.
Pharmacy claims do not establish medication adherence, and prescription fills alone cannot determine whether treatment was appropriate.
Conclusion:
The authors argue that AF equity assessments should address opportunities for diagnosis as well as treatment. They call for research that directly evaluates diagnostic processes and includes broader populations; the findings do not warrant indiscriminate screening.
Pulmonary vascular disease is a rapidly evolving field, with emerging therapies, new diagnostic approaches and ongoing research reshaping how patients with pulmonary hypertension are evaluated and treated.
