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Transforming Atrial Fibrillation Research to Integrate Social Determinants of HealthA National Heart, Lung, and Blood Institute Workshop Report

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Importance  Only modest attention has been paid to the contributions of social determinants of health to atrial fibrillation (AF) risk factors, diagnosis, symptoms, management, and outcomes. The diagnosis of AF provides unique challenges exacerbated by the arrhythmia’s often paroxysmal nature and individuals’ disparate access to health care and technologies that facilitate detection. Social determinants of health affect access to care and management decisions for AF, increasing the likelihood of adverse outcomes among individuals who experience systemic disadvantages. Developing effective approaches to address modifiable social determinants of health requires research to eliminate the substantive inequities in health care delivery and outcomes in AF.

Observations  The National Heart, Lung, and Blood Institute convened an expert panel to identify major knowledge gaps and research opportunities in the field of social determinants of AF. The workshop addressed the following social determinants: (1) socioeconomic status and access to care; (2) health literacy; (3) race, ethnicity, and racism; (4) sex and gender; (5) shared decision-making in systemically disadvantaged populations; and (6) place, including rurality, neighborhood, and community. Many individuals with AF have multiple adverse social determinants, which may cluster in the individual and in systemically disadvantaged places (eg, rural locations, urban neighborhoods). Cumulative disadvantages may accumulate over the life course and contribute to inequities in the diagnosis, management, and outcomes in AF.

Conclusions and Relevance  Workshop participants identified multiple critical research questions and approaches to catalyze social determinants of health research that address the distinctive aspects of AF. The long-term aspiration of this work is to eradicate the substantive inequities in AF diagnosis, management, and outcomes across populations.

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Article Information

Accepted for Publication: September 26, 2022.

Published Online: December 7, 2022. doi:10.1001/jamacardio.2022.4091

Corresponding Author: Emelia J. Benjamin, MD, ScM, Cardiovascular Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Collamore 8, 72 E Concord St, Boston, MA 02118 (emelia@bu.edu).

Author Contributions: Drs Benjamin and Thomas had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Benjamin, Thomas, Go, Desvigne-Nickens, Alonso, Chamberlain, Essien, Levy, Magnani, Matlock, O’Brien, Cooper, Al-Khatib.

Acquisition, analysis, or interpretation of data: Benjamin, Thomas, Go, Albert, Hernandez, Hills, Kershaw, Rodriguez, Russo, Soliman, Al-Khatib.

Drafting of the manuscript: Benjamin, Thomas, Albert, Alonso, Essien, Kershaw, Magnani, Matlock, Rodriguez, Russo, Soliman.

Critical revision of the manuscript for important intellectual content: Benjamin, Go, Desvigne-Nickens, Albert, Alonso, Chamberlain, Essien, Hernandez, Hills, Kershaw, Levy, Magnani, Matlock, O’Brien, Rodriguez, Russo, Soliman, Cooper, Al-Khatib.

Administrative, technical, or material support: Benjamin, Thomas, Go, Desvigne-Nickens, Magnani, Cooper.

Study supervision: Benjamin, Thomas, Cooper.

Conflict of Interest Disclosures: Dr Benjamin reported research funding from the National Heart, Lung, and Blood Institute, the National Institute of Aging, and the American Heart Association. Dr Thomas is an advisor to Johnson & Johnson and Biosense Webster; is a consultant for Pfizer and Bristol Myers Squibb; and is a steering committee member for the REACT-AF trial. Dr Go is a member of the operations committee and steering committee for the Study to Determine if Identification of Undiagnosed Atrial Fibrillation in People at Least 70 Years of Age Reduces the Risk of Stroke, sponsored by Bristol Meyers Squibb and Pfizer; has received research funding through his institution from Bristol Meyers Squibb, iRhythm Technologies, and Janssen; and reports grants from the National Heart, Lung and Blood Institute and iRhythm Technologies through his institution during the conduct of the study. Dr Albert is a member of the data safety and monitoring board for the Apple Watch Study and is on the steering committee for the CHANGE AF study. Dr Alonso reported grants from the National Institutes of Health during the conduct of the study. Dr Chamberlain reported grants from the National Institute on Aging and from Patient Centered Outcomes Research Institute paid to her institution during the conduct of the study. Dr Essien reported grants from Department of Veterans Affairs outside the submitted work. Dr Hernandez reports serving as a consultant to Pfizer and Bristol Myers Squibb. Dr Levy is immediate past chair of the accreditation oversight committee and current member of the National Cardiovascular Data Registry oversight committee at the American College of Cardiology and president of the Southeast Michigan American Heart Association. Dr Magnani reported grants from the National Heart, Lung, and Blood Institute outside the submitted work. Dr O’Brien reports research grants to her institution from Pfizer, Bristol Myers Squibb, and Novartis. Dr Rodriguez has received honoraria from Merck, grant support from the American Heart Association and the National Institutes of Health, and research support from Amgen and has served on an advisory board for Amgen. Dr Russo has served as a consultant for Abbott, Atricure, Biosense Webster, Medtronic, and PaceMate; served on research steering committees for Bayer, Boston Scientific, and Medtronic; received grants for research from Boston Scientific, Bristol Meyers Squibb–Pfizer, Kestra, Medilynx, and Medtronic; and received honoraria from Biotronik, Bristol Meyers Squibb–Pfizer, Medtronic, Sanofi, and the American Board of Internal Medicine outside the submitted work. Dr Al-Khatib has received research funding from Medtronic, Boston Scientific, and Abbott outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Benjamin receives research funding from National Heart, Lung, and Blood Institute grants R01HL128914, 2R01HL092577, and R01HL141434 01A1; National Institute of Aging grant R01AG066010; and American Heart Association grant 18SFRN34110082. Dr Thomas reports funding from Patient Centered Outcomes Research Institute grant 1503-29746 and US National Institutes of Health grants 5UL1-TR001117-03, 1R01-MD013493-01, 1R01-MD011606-03, 5U54MD012530-03, and 5R25HL135304-05. Dr Go receives research funding from National Heart, Lung, and Blood Institute grant R01HL142834 and National Institute of Diabetes and Digestive and Kidney Diseases grant R01DK103612. Dr Albert receives research funding from National Heart, Lung, and Blood Institute grant R01HL116690. Dr Essien receives research funding from Veterans Health Administration grant IK2HX003176. Dr Hernandez receives research funding from National Heart, Lung, and Blood Institute grants R01HL157051 and K01HL142847. Dr Kershaw receives research funding from National Institute of Aging grants 5R01AG67557, 5R01AG062180, and 1R21AG069435 and American Heart Association grant 22HERNPMI985236. Dr Levy receives research funding from National Heart, Lung, and Blood Institute grants R01 HL153607, R01 HL163377, R01 HL146059, R01 HL127215, and T32 HL120822; National Institute of Minority Health and Health Disparities grant P50 MD017351; and the American Heart Association Health Equity Research Network. Dr Magnani receives research funding from National Heart, Lung, and Blood Institute grants R01HL143010, R33HL144669, and K24HL160527. Dr Rodriguez receives funding from the National Heart, Lung, and Blood Institute and the American Heart Association. Dr Alonso receives funding from National Heart, Lung, and Blood Institute grants K24HL148521 and R01HL137338 and American Heart Association grant 16EIA26410001. Dr Kershaw receives research funding from National Institute on Aging grants R01AG067557, R01AG062180, and R21AG069435. Dr Chamberlain receives funding from National Institute on Aging grants R21AG62580 and R21AG64804 and Patient Centered Outcomes Research Institute grant RI-CRN-2020-009.

Role of the Funder/Sponsor: The funders reviewed the manuscript to confirm policy compliance but had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institutes of Health; or the US Department of Health and Human Services.

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Wändell  P , Carlsson  AC , Gasevic  D , Sundquist  J , Sundquist  K .  Neighbourhood socio-economic status and all-cause mortality in adults with atrial fibrillation: a cohort study of patients treated in primary care in Sweden.   Int J Cardiol. 2016;202:776-781. doi:10.1016/j.ijcard.2015.09.027PubMedGoogle ScholarCrossref
Rhinehart  ZJ , Kinnee  E , Essien  UR ,  et al.  Association of fine particulate matter and risk of stroke in patients with atrial fibrillation.   JAMA Netw Open. 2020;3(9):e2011760. doi:10.1001/jamanetworkopen.2020.11760PubMedGoogle ScholarCrossref
O’Neal  WT , Sandesara  PB , Kelli  HM , Venkatesh  S , Soliman  EZ .  Urban-rural differences in mortality for atrial fibrillation hospitalizations in the United States.   Heart Rhythm. 2018;15(2):175-179. doi:10.1016/j.hrthm.2017.10.019PubMedGoogle ScholarCrossref
Carlsson  AC , Wändell  P , Gasevic  D , Sundquist  J , Sundquist  K .  Neighborhood deprivation and warfarin, aspirin and statin prescription: a cohort study of men and women treated for atrial fibrillation in Swedish primary care.   Int J Cardiol. 2015;187:547-552. doi:10.1016/j.ijcard.2015.04.005PubMedGoogle ScholarCrossref
Norby  FL , Lutsey  PL , Shippee  ND ,  et al.  Direct oral anticoagulants and warfarin for atrial fibrillation treatment: rural and urban trends in Medicare beneficiaries.   Am J Cardiovasc Drugs. 2022;22(2):207-217. doi:10.1007/s40256-021-00502-9PubMedGoogle ScholarCrossref
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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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