Racial disparities in drug prescribing for atrial fibrillation patients was the subject of the presentation by Utibe Essien, MD, MPH, at the Leonard Davis Institute of Health Economics’ 2021 Samuel P. Martin III, MD, Memorial Lecture.

Essien, an Assistant Professor at the University of Pittsburgh and a health disparities researcher at the Veterans Health Administration Pittsburgh Center for Health Equity Research and Promotion, researches racial and ethnic disparities in the use of novel therapeutics for chronic diseases.

Essien is the latest to speak at the annual Martin lecture commemorating the life and work of an academic giant who served as the second Executive Director and a guiding light in the expansion of LDI after its creation in 1967. Martin played a leading role in the then-nascent concept pioneered at Penn of training physicians in both the medical and business sides of health care. In that capacity, Martin helped create the Wharton School’s MBA Program in Health Care Management. Most of the MDs who earned MBAs in the 1970s and 1980s did so under Martin’s tutelage — his mentoring efforts were legendary and are gratefully remembered by generations of former students.

The LDI event was co-sponsored by the Penn Medicine Division of General Internal Medicine, the National Clinician Scholars Program, and the Penn Master of Science in Health Policy Research Program.

Equity, Race, Novel Drugs

Essien, whose virtual presentation was titled “In Pursuit of Equity: Race, Novel Drugs, and Health in the U.S.,” looked back at the reasons he became so interested as a medical student in health care disparities and the social determinants of health.

“I was fascinated, and sadly often troubled, by a consistent theme I’ve observed across my own experiences — patients who looked like me and my family members often seemed to be receiving their medical care in very different care settings than the majority of individuals who looked like the majority of my med school classmates.”

The son of a physician father and librarian mother who immigrated to the U.S. from Nigeria, Essien was born in New York City and went on to earn his BA in Psychology at New York University, MD at Albert Einstein College of Medicine, and MPH at the Harvard T.H. Chan School of Public health.

Social determinants

He did his residency at Massachusetts General Hospital, where he said the social determinants of health became a reality because “factors outside of my clinical spaces were impacting our patients far beyond the medications I was prescribing or the referrals I was making.”

As Essien was about to begin his research fellowship at Mass General and Harvard Medical School, he came across a 2015 paper in Circulation by Emily Bucholz et al. that redirected his thinking. Titled Race, Socioeconomic Status, and Life Expectancy After Acute Myocardial Infarction, it detailed wide gaps in life expectancy between white and Black heart attack patients regardless of their socioeconomic status.

“I wanted to understand why, regardless of one’s social status, health care outcomes could be so different just based on their race,” said Essien. “I decided that the disease condition I could use to help answer that question was atrial fibrillation.” He’s been studying it ever since.

Atrial Fibrillation

Acute Myocardial Infarctions — heart attacks — occur when arteries are narrowed by buildups of plaque choking off the flow of blood to the heart, damaging its muscles. Survivors of heart attacks are often more prone to develop atrial fibrillation — a disruption of the beating rhythm in the heart’s two upper muscular chambers. These chambers then beat out of coordination with the two lower chambers, causing the heart to pump less blood to the rest of the body.

About seven million people in the United States have atrial fibrillation, an irregular heart rhythm that can result in blood clots and strokes. Blood thinners can help prevent strokes and, until a decade ago, there was only one blood-thinning or “anticoagulant” drug available for treating this condition in the U.S.: warfarin, sold under various brand names including Coumadin. But warfarin required regular monitoring, the dosing is difficult to control, and it has a number of serious side effects.

Over the last decade, however, a number of new direct oral anticoagulant (DOAC) pharmaceuticals like Xarelto, Pradaxa, and Eliquis were developed. Essien explained that not only were these new medications easier to use with less monitoring, they had fewer side effects, and produced improved outcomes. They are in many ways superior to warfarin.

Inferior anticoagulation quality

But in their 2018 study of atrial fibrillation patients, Essien’s research team found lower use of anticoagulant therapies overall for Black patients compared to white or Hispanic patients. They also found that when anticoagulants were used, the disparities in the use of warfarin vs. the newer DOAC drugs for Black patients were “particularly pronounced,” and that “the anticoagulation quality in Black patients and Hispanic patients was inferior to that in white patients.”

The study concluded: “These results contribute toward understanding racial/ethnic differences in stroke-preventive treatment in patients with atrial fibrillation.”

Two years later, Essien’s research team completed and published another study of oral anticoagulant therapy among Medicare beneficiaries newly diagnosed with atrial fibrillation. They found “overall oral anticoagulant initiation was lower in blacks and women… Among oral anticoagulant initiators, blacks were less likely to initiate novel direct oral anticoagulants.”

Currently under peer review, his third study among a national cohort of Veterans with atrial fibrillation, Essien also examined anticoagulant use among Asian Americans, Indian Americans and Alaska Native people.

The bottom line, he said, is that all three studies found racial and ethnic minority individuals were less likely to receive these newer direct oral anticoagulants, and that disparity persisted across fully-insured individuals as well as those receiving care from a uniform integrated health system such as the VA.