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BackgroundSocial determinants of health are relevant to cardiovascular outcomes but have had limited examination in atrial fibrillation (AF).ObjectivesThe purpose of this study was to examine the association of annual household income and cardiovascular outcomes in individuals with AF.MethodsWe analysed administrative claims for individuals with AF from 2009 to 2015 captured by a health claims database. We categorised estimates of annual household income as ResultsOur analysis included 336 736 individuals (age 72.7±11.9 years; 44.5% women; 82.6% white, 8.4% black, 7.0% Hispanic and 2.1% Asian) with AF followed for median (25th and 75th percentile) of 1.5 (95% CI 0.6 to 3.0) years. We observed an inverse association between income and heart failure and myocardial infarction (MI) with evidence of progressive risk across decreased income categories. Individuals with household income ConclusionsWe identified an association between lower household income and adverse outcomes in a large cohort of individuals with AF. Our findings support consideration of income in the evaluation of cardiovascular risk in individuals with AF.

Background Patient success with atrial fibrillation (AF) requires adequate health literacy to understand the disease and rationale for treatment. We hypothesized that individuals receiving treatment for AF would have increased knowledge about AF and that such knowledge would be modified by education and income. Methods We enrolled adults with AF receiving anticoagulation at ambulatory clinic sites. Participants responded to survey items encompassing the definitions of AF and stroke, the rationale for anticoagulation, and an estimation of their annual stroke risk. We examined responses in relation to household income and education in multivariable-adjusted models. Results We enrolled 339 individuals (age 72.0 ± 10.1; 43% women) with predominantly lower annual income ($20–49,999, n = 99, 29.2%) and a range of educational attainment (high school or vocational, n = 117, 34.5%). Participants demonstrated moderate AF knowledge (1.7 ± 0.6; range 0–2) but limited knowledge about anticoagulation (1.3 ± 0.7; range 0–3) or stroke (1.5 ± 0.8; range 0–3). Income was not associated with improvement in AF (P = 0.32 for trend), anticoagulation (P = 0.27) or stroke knowledge (P = 0.26). Individuals with bachelor or graduate degree had greater AF (1.8 ± 0.5) and stroke (1.6 ± 0.8) knowledge relative to those with high school or vocational training (1.4 ± 0.7 and 1.2 ± 0.9; P ≪ 0.01, both estimates). Education was not associated with understanding the rationale for anticoagulation. Most participants (230, 68%) estimated their annual stroke risk as ≥15%. Conclusions We identified consistent, fundamental gaps in disease-specific knowledge in a cohort of adults receiving treatment for non-valvular AF. Improved patient understanding of this complex and chronic disease may enhance shared decision making, patient engagement, anticoagulation adherence, and clinical outcomes in AF.

Introduction: Income and social resources are associated with cardiovascular health and outcomes. We examined income and medication adherence following acute coronary syndromes (ACS). We hypothesized that following percutaneous coronary intervention (PCI), individuals with lower income would have lower adherence to antiplatelet agents than higher income referents. Methods: We employed administrative claims of commercially insured and Medicare Advantage beneficiaries (Optum's de-identified Clinformatics® Data Mart Database) with incident ST- and non-ST elevation myocardial infarction from 2017-19. We collected data on age, sex, race, education, and covariates (medications, healthcare visits, insurance type, copay, antiplatelet type, and Elixhauser Comorbidity Index conditions). We compared antiplatelet adherence, measured with proportion of days covered (PDC) using up to 12 months of pharmacy claims, across income categories ( Results: Our dataset included 31,272 individuals (age 72.5 ±11.9, 34.3% women, 22.6% non-White) who presented with ACS and underwent PCI. We observed graded, decreased antiplatelet adherence across income categories (Figure): rates of PDC≥80% decreased with successively lower income, from 84.3% (≥$100K) to 73.1% ( Conclusions: Lower income is associated with lower adherence to antiplatelet agents following PCI for ACS. These results support consideration of income and long-term barriers to medication access as part of strategies to address adherence.

Introduction Despite the effectiveness of opioid agonist therapy (OAT) for treating patients with opioid use disorder (OUD), insufficient education remains a barrier to prescribing. Internal medicine (IM) residents are optimally positioned to facilitate use of OAT, especially in the inpatient setting. We implemented an educational intervention aimed at increasing IM residents' knowledge and confidence regarding prescribing OAT to inpatients with OUD. Methods We created a 35-minute, case-based presentation highlighting the management of opioid withdrawal using OAT and treating pain in inpatients on maintenance OAT. It was presented to IM residents beginning their general medicine ward rotations from November 2019 through January 2020. We developed a survey to measure participants' knowledge (mean number of questions correct out of five) and confidence (mean Likert-scale score, 1 = Not at all confident, 5 = Extremely confident, on each of five items) regarding prescribing OAT in the inpatient setting. We compared knowledge and confidence before versus 1 month after the intervention using paired Student t tests, with p < .05 indicating significance. Results Of 103 unique residents completing ward rotations, 29 (28%) completed both the pre- and 1-month postsurveys and were included in the analysis. The mean number of knowledge questions correct increased from 3.1 pre- to 4.3 postintervention, and mean confidence scores increased from below 2 pre- to over 3 postintervention in four of five items (ps < .001). Discussion A brief, generalizable, educational intervention significantly increased residents' knowledge of and confidence in prescribing OAT in inpatients with OUD.

Introduction Patient-reported outcomes are routinely assessed in atrial fibrillation (AF) to evaluate efficacy of treatment and as clinical trial outcomes. The relation of depression to such measures has had limited study in AF. Methods In a cohort receiving treatment for AF, we assessed depression with the Patient Health Questionniare-9 (PHQ; 0–4, normal range; 5–9, mild depression; ≥10 moderate depression). We related depression to disease-specific quality of life with the AF Effect on QualiTy of life (AFEQT, range 0–100) and the Global Perceived Stress Scale (GPPS, range 0–24) in multivariable-adjusted models. Results In 260 individuals (age 71.7 ± 10.1, 44.6% women) with AF, 51 (26.1%) had PHQ scores ≥5 and 17 (6.5%) ≥10. AFEQT scores decreased progressively with depression severity (normal range PHQ, 81.4 ± 14.1; mild depression, 65.8 ± 17.1; moderate depression, 50.6 ± 19.3). Individuals without depression had lower GPPS scores (3.0 ± 2.6) than those with mild (4.9 ± 2.5) or moderate (8.9 ± 4.0) depression. In multivariable-adjusted models mild depression was associated with a 12.1-point (95% confidence interval [CI], −17.2 to −6.9) decrease in AFEQT and 1.9-point (95% CI, 1.1 to 2.7) increase in GPSS, while moderate depression a 27.7-point (95% CI, −35.5 to −19.8) decrease in AFEQT and 5.5-point (95% CI, 4.2 to 6.8) increase in GPSS, relative to normal range PHQ. Regression analyses confirmed significant correlations between depression and AFEQT and GPPS scores in multivariable-adjusted models. Conclusions We determined that depression is associated with a step-wise, progressively adverse change in patient-centered outcomes in individuals with AF. Our findings suggest the importance of assessing depression in the evaluation of AF. Subject term list: health services, atrial fibrillation, risk factors