Background:Racial and ethnic disparities in anticoagulation exist in atrial fibrillation management in Medicare and the Veterans Health Administration, but the influence of dual Veterans Health Administration and Medicare enrollment is unclear. We compared anticoagulant initiation by race and ethnicity in dually enrolled patients and assessed the role of Medicare part D enrollment on anticoagulation disparities.Methods:We identified patients with incident atrial fibrillation (2014–2018) dually enrolled in Veterans Health Administration and Medicare. We assessed any anticoagulant initiation (warfarin or direct-acting oral anticoagulants [DOACs]) within 90 days of atrial fibrillation diagnosis and DOAC use among anticoagulant initiators. We modeled anticoagulant initiation, adjusting for patient, provider, and facility factors, including main effects for race and ethnicity and Medicare part D enrollment and an interaction term for these variables.Results:In 43 789 patients, 8.9% were Black, 3.6% Hispanic, and 87.5% White; 10.9% participated in Medicare part D. Overall, 29 680 (67.8%) patients initiated any anticoagulant, of whom 17 568 (59.2%) initiated DOACs. Lower proportions of Black (65.2%) than Hispanic (67.6%) or White (68.0%) patients initiated any anticoagulant (P=0.001) and, lower proportions of Black (56.3%) and Hispanic (55.9%) than White (59.6%) patients (P=0.001) initiated DOACs. Compared with White patients, Black patients had significantly lower initiation of any anticoagulant (adjusted odds ratio, 0.89 [95% CI, 0.82–0.97]). The adjusted odds ratios for DOAC initiation were significantly lower for Black (0.72 [95% CI, 0.65–0.81]) and Hispanic (0.84 [95% CI, 0.70–1.00]) than White patients. The interaction between race and ethnicity and Medicare part D enrollment was nonsignificant for any anticoagulant (P=0.99) and DOAC (P=0.27) therapies.Conclusions:In dually enrolled Veterans Health Administration and Medicare patients with atrial fibrillation, Black patients were less likely to initiate any anticoagulant, and Black and Hispanic patients were less likely to initiate DOACs. Medicare part D enrollment did not moderate the associations between race and ethnicity and anticoagulant therapies.

中文翻译：

---

退伍军人健康管理局和医疗保险双重登记的房颤患者的种族和民族与抗凝的关联：医疗保险 D 部分对处方差异的影响

背景：Medicare 和 Veterans Health Administration 的房颤管理中存在抗凝方面的种族和民族差异，但 Veterans Health Administration 和 Medicare 双重注册的影响尚不清楚。我们比较了双入组患者中不同种族和民族的抗凝剂启动情况，并评估了 Medicare D 部分入组对抗凝差异的作用。方法：我们确定了同时入组退伍军人健康管理局和 Medicare 的房颤患者（2014-2018 年）。我们评估了房颤诊断后 90 天内的任何抗凝剂启动（华法林或直接作用口服抗凝剂 [DOACs]）和抗凝剂启动者中 DOAC 的使用情况。我们模拟了抗凝剂的启动，调整了患者、提供者和设施因素，包括种族和民族的主要影响以及医疗保险 D 部分的登记以及这些变量的交互项。结果：在 43 789 名患者中，8.9% 是黑人，3.6% 西班牙裔和 87.5% 白人；10.9% 参加了 Medicare D 部分。总体而言，29680 名（67.8%）患者开始使用任何抗凝剂，其中 17568 名（59.2%）开始使用 DOAC。黑人 (65.2%) 的比例低于西班牙裔 (67.6%) 或白人 (68.0%) 患者开始使用任何抗凝剂 (P = 0.001)，并且黑人 (56.3%) 和西班牙裔 (55.9%) 的比例低于白人 (59.6%) 患者 ( P = 0.001) 发起 DOAC。与白人患者相比，黑人患者开始使用任何抗凝剂的几率显着降低（调整优势比，0.89 [95% CI，0.82–0.97]）。黑人 (0.72 [95% CI, 0.65–0.81]) 和西班牙裔 (0.84 [95% CI, 0.70–1.00]) 的 DOAC 启动调整优势比显着低于白人患者。对于任何抗凝剂（P = 0.99）和 DOAC（P=0.27) 治疗。结论：在退伍军人健康管理局和医疗保险双重登记的房颤患者中，黑人患者不太可能开始使用任何抗凝剂，黑人和西班牙裔患者不太可能开始 DOAC。医疗保险 D 部分的注册并未缓和种族和民族与抗凝治疗之间的关联。