Regional disparities in the care and outcomes of atrial fibrillation patients in a universal health care system: a population-based cohort study

Introduction — While prior studies have shown regional disparities in patients with myocardial infarction and heart failure within a universal health care, there are limited data on the association between different regions within a universal health care system and outcomes after an atrial fibrillation (AF) diagnosis. In this context, we aimed to assess variations in processes of care and outcomes among patients with the diagnosis of AF presenting to the emergency department (ED).

Methods — We conducted a population-based retrospective cohort study of all adult patients (≥ 18 years) with their first presentation to the ED with AF between April 1, 2012, and March 31, 2022 in Ontario, Canada. We divided the analyses into five major Ontario Health Regions (North, East, Central, Toronto, and West). North was used as the reference group. The primary outcome was all-cause mortality or admission. Secondary outcomes included all-cause mortality, all-cause admission, and all-cause ED visit. We examined outcomes up to 1 year from index AF diagnosis. Cox proportional hazards regression analysis was used to study the association of different regions and outcomes.

Results — Among 104,383 patients with the diagnosis of AF in the ED (mean age 69.4 years, 47.1% female), there were significant differences between Ontario Health Regions in physician follow-up (less access to primary care in North or a cardiologist in West) and procedures performed (less cardioversions or ablations performed in North). There was a significantly lower rate of the primary outcome of all-cause mortality or admission in Ontario Health Regions compared to the North (East HR 0.87 (0.83, 0.90), Central HR 0.87 (0.83, 0.91), Toronto HR 0.88 (0.84, 0.92), and West HR 0.87 (0.84, 0.91)). Similar findings were noted with lower all-cause admission and all-cause ED visit in Ontario Health Regions compared to the North, but all-cause mortality did not differ between regions.

Conclusions — Despite universal health care and prescription medication coverage, regional variations exist in the management of AF patients. Patients in Northern Ontario were less likely to visit a primary care physician and had worse outcomes driven by higher admission rate after AF diagnosis.