Outcome disparities in patients with atrial fibrillation based on insurance plan and educational attainment: a nationwide, multicenter and prospective cohort trial

Abstract

Background: Atrial fibrillation (AF) is a complex disease. The management of AF requires continuous patient engagement and integrative healthcare.

Objectives: To explore the association between adverse AF-related clinical outcomes and the following two sociodemographic factors: educational attainment and insurance plan.

Design: A nationwide, prospective, multicenter, cohort trial.

Setting: National registry of 3402 patients with non-valvular AF in Thailand.

Participants: All patients enrolled in the registry, except those with missing information on educational attainment or insurance plan. Finally, data from 3026 patients (mean age 67 years, SD 11.3; 59% male sex) were analysed.

Primary outcomes: Incidences of all-cause mortality, ischaemic stroke and major bleeding during the 36-month follow-up period. Survival analysis was performed using restricted mean survival time (RMST) and adjusted for multiple covariates. The levels of the educational attainment were as follows: no formal education, elementary (grade 1-6), secondary (grade 7-12) and higher education (tertiary education).

Results: The educational attainment of the majority of patients was elementary (N=1739, 57.4%). The predominant health insurance plans were the Civil Servant Medical Benefit Scheme (N=1397, 46.2%) and the Universal Coverage Scheme (N=1333, 44.1%). After 36 months of follow-up, 248 patients died (8.2%), 95 had ischaemic stroke (3.1%) and 136 had major bleeding (4.5%). Patients without formal education died 1.78 months earlier (adjusted RMST difference -1.78; 95% CI, -3.25 to -0.30; p=0.02) and developed ischaemic stroke 1.04 months sooner (adjusted RMST difference -1.04; 95% CI, -2.03 to -0.04; p=0.04) than those attained a level of higher education. There were no significant differences in RMSTs for all three clinical outcomes when considering the type of health insurance plan.

Conclusion: Educational attainment was independently associated with all-cause mortality and ischaemic stroke in patients with AF, but adverse clinical outcomes were not related to the types of health insurance in Thailand.

Trial registration number: Thai Clinical Trial Registration; Study ID: TCTR20160113002.

Keywords: Adult cardiology; Health policy; PUBLIC HEALTH; Thromboembolism.

Figure 1

Kaplan-Meier curve for all-cause mortality with 95% confidence limits. (A) Kaplan-Meier curve for all-cause mortality by insurance plans. (B) Kaplan-Meier curve for all-cause mortality by educational attainment. CSMBS, civil servant medical benefit scheme; NGS, non-government-based scheme; SSS, social-security scheme; UCS, universal coverage scheme.

Figure 2

Differences in adjusted restricted median survival time to all-cause mortality over a period of 36 months. The model was adjusted for of age, sex, educational attainment, insurance plan, types of anticoagulant, CHA₂DS₂VAS_c, and HASBLED scores. CAD, coronary artery disease; CHA₂DS₂-VAS_c, congestive heart failure, hypertension, age≥75 years, diabetes mellitus, stroke or transient ischaemic attack (TIA), vascular disease, age 65–74 years, sex category; CHF, congestive heart failure; CSMBS, civil servant medical benefit scheme; DOAC, direct oral anticoagulant; HASBLED, hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly (>65 years), drugs/alcohol concomitantly; NGS, non-government-based scheme; SSS, social-security scheme; UCS, universal coverage scheme; VKA, vitamin K antagonist.

Figure 3

Differences in adjusted restricted median survival time to ischaemic stroke over a period of 36 months. The model was adjusted for of age, sex, educational attainment, insurance plan, types of anticoagulant, CHA₂DS₂VAS_c and HASBLED scores. CAD, coronary artery disease; CHA₂DS₂VAS_c, congestive heart failure, hypertension, age≥75 years, diabetes mellitus, stroke or transient ischaemic attack (TIA), vascular disease, age 65–74 years, sex category; CHF, congestive heart failure; CSMBS, civil servant medical benefit scheme; DOAC, direct oral anticoagulant; HASBLED, hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly (>65 years), drugs/alcohol concomitantly; NGS, non-government-based scheme; SSS, social-security scheme; UCS, universal coverage scheme; VKA, vitamin K antagonist.

Figure 4

Differences in adjusted restricted median survival time to major bleeding over a period of 36 months. The model was adjusted for of age, sex, educational attainment, insurance plan, types of anticoagulant, CHA₂DS₂VAS_c and HASBLED scores. CAD, coronary artery disease; CHA₂DS₂VAS_c, congestive heart failure, hypertension, age≥75 years, diabetes mellitus, stroke or transient ischaemic attack (TIA), vascular disease, age 65–74 years, sex category; CHF, congestive heart failure; CSMBS, civil servant medical benefit scheme; DOAC, direct oral anticoagulant; HASBLED, hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly (>65 years), drugs/alcohol concomitantly; NGS, non-government-based scheme; SSS, social-security scheme; UCS, universal coverage scheme; VKA, vitamin K antagonist.