Social Determinants of Guideline-Directed Oral Anticoagulation Prescription in Patients With Atrial Fibrillation Without Contraindications: Findings From the American Heart Association Get With the Guidelines-Atrial Fibrillation Registry.

BACKGROUND: Oral anticoagulant (OAC) prescriptions recommended by atrial fibrillation guidelines to prevent stroke may be influenced by social determinants of health (SDOH). We aimed to uncover patient and institutional SDOH associated with failure to prescribe guideline-directed OAC and to develop an SDOH-based scoring system to predict failure to prescribe OAC. METHODS: We analyzed the nationwide, 249-hospital American Heart Association GWTG-AFib (Get With The Guidelines-Atrial Fibrillation) registry. We included adult patients hospitalized for atrial fibrillation with class I indication for OAC and no contraindications. Using a logistic regression model, we identified patient and institutional SDOH of failure to prescribe OAC, adjusting for the other SDOH. Next, we developed a machine learning-based prediction model in a training data set and examined the relative contribution of each SDOH. We then compared the risk of failure to prescribe OAC in an independent test data set for validation. RESULTS: Among 68 628 eligible patients, 1345 (2.0%) patients did not receive guideline-directed OAC prescription. The guideline-directed OAC prescription was influenced by both institutional SDOH (eg, hospital region, hospital size, the absence of a cardiology team) and patient SDOH (eg, sex, insurance). The absence of a cardiology team was the most important predictor (adjusted odds ratio [OR], 3.72 [95% CI, 3.20-4.32]). Patients with the higher-than-Youden-index-cutoff prediction score had higher risk of failure to prescribe OAC than those with the lower-than-cutoff prediction score (OR, 3.11 [95% CI, 2.67-3.63]). CONCLUSIONS: We identified both institutional and patient SDOH of guideline-directed OAC prescription failure. We further developed and validated a SDOH-based scoring system to predict failure to prescribe OAC.