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

Abstract

BackgroundAtrial fibrillation (AF) is a complex disease. The management of AF requires continuous patient engagement and integrative healthcare.ObjectivesTo explore the association between adverse AF-related clinical outcomes and the following two sociodemographic factors: educational attainment and insurance plan.DesignA nationwide, prospective, multicenter, cohort trial.SettingNational registry of 3402 patients with non-valvular AF in Thailand.ParticipantsAll 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 outcomesIncidences 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).ResultsThe 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.ConclusionEducational 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 numberThai Clinical Trial Registration; Study ID: TCTR20160113002.