Clinicians are being urged to push for equitable care as Australian research highlights financial, geographic and health system disparities between patients accessing effective atrial fibrillation (AF) procedures.
A retrospective study of 46,764 patients hospitalised for non-valvular AF found those in private care or wealthier areas were significantly more likely to receive catheter ablation than individuals in public centres or regions of lower socioeconomic status (SES), regardless of clinical factors (hazard ratio [HR]: 2.65, P < 0.001).
Private AF patients also had a better chance of getting earlier ablation than public patients (odds ratio [OR]: 2.04, P < 0.001), the study showed.
“These findings most likely reflect that private patients in Australia have increased access to elective procedures through their health insurance, including shorter waiting times and choice of treating practitioner,” the authors from University of Sydney and Concord Repatriation General Hospital, Sydney wrote in Heart, Lung and Circulation.
They “also highlight that patients living in more advantaged areas are more likely to receive ablation even after accounting for insurance status, suggesting there may also be inequities in access to the procedure — either through capacity for affording out-of-pocket costs, or in the geographic location of services”.
As a result, the authors, which featured interventional cardiologist Professor David Brieger and academic cardiologist Associate Professor Raymond Sy, are calling on clinicians and policymakers to “review existing policies to ensure effective procedures for AF are available to the whole population”.
Clinical factors and catheter ablation
Other factors associated with a higher likelihood of catheter ablation included cardioversion during index admission and year of admission (HR: 1.96, P < 0.001 and HR: 1.07, P < 0.001, respectively), with chances growing with increasing years, the study, which assessed patients hospitalised in New South Wales between 2009 and 2017, read.
Meanwhile, older patients and those with a history of congestive heart failure, hypertension, diabetes or myocardial infarction were less likely to undergo the procedure.
In saying that, cardioversion during index admission and a history of diabetes were associated with increased likelihood of early ablation (OR: 1.25, P = 0.05 and OR: 1.6, P = 0.025), the study found.
The use of cardioversions prior to ablation “likely reflects a desire for a ‘rhythm control’ strategy in these patients based on clinical factors”, the authors wrote, adding that ablation tended to be performed on patients with fewer comorbidities, who were at an earlier disease stage and “more likely to have a successful procedure”.
Patient disparities and practice
Current European Society of Cardiology guidelines recommend catheter ablation as “a preferred therapy in [AF] patients who have failed medical therapy (Class I indication) or as an alternative to medical therapy (Class IIa or IIb)”, the authors wrote.
The procedure has demonstrated superiority over medical therapy in selected populations, regarding sinus rhythm maintenance, delayed progression to persistent AF, reduced AF-related hospitalisation and improved symptoms and quality of life — and efficacy as a first-line treatment.
Despite these outcomes, health system and socioeconomic status were associated with varied access to the procedure.
Aside from their likely increased ability to bear ablation-related costs and proximity to treatment centres, patients in more advantaged areas may have been “more aware of ablation procedures and could have demanded or shown a willingness to undergo [them]”, the authors wrote.
Conversely, “the association between private patient status and early ablation highlights that public patients may first undergo alternative or lower-cost care, with ablation performed at a later stage”.
The study doesn’t explore whether earlier ablation treatment affects outcomes in AF, and risk factor outcomes “should be interpreted as associations and not as causal estimates”, the authors wrote.
They do, however, spotlight “potential disparities in the likelihood of receiving ablation and early ablation between public and private patients”.
Clinicians and policymakers should work to ensure equitable access to effective AF procedures, the authors concluded.