Significant social inequality in the treatment of atrial fibrillation

As a patient with atrial fibrillation, you are best positioned if you fall within the catchment area of St. Olav's Hospital in Trondheim. Patients residing in this area had approximately three times the likelihood of receiving ablation as a treatment method (20.1%), compared to patients living in the referral area of Finnmark Hospital (7.1%). Older women residing in Finnmark had the lowest probability of receiving this treatment.

This is shown in a study conducted on atrial fibrillation patients in Norway during the period 2008—2017. Atrial fibrillation is the most common form of arrhythmia and significantly impacts a patient's quality of life, morbidity, and mortality.

Patient-related and geographical differences

Ablation is a relatively new treatment for atrial fibrillation and is considered an effective way to stabilise a patient's heart rhythm. However, it is more common to treat atrial fibrillation patients with medication. But what determines who receives which treatment?

— In principle, all patients in Norway should have equal access to treatment, regardless of where they live in the country and their socioeconomic status (for example, income and education). This means that it is the patient's condition that should determine which treatment should be initiated. However, this study shows that both residence and socioeconomic status influence the treatment received by patients with atrial fibrillation, explains the researcher behind the study, Frank Olsen from the Centre for Clinical Documentation and Evaluation (SKDE).

He points out that patients with higher education and income were more frequently treated with ablation if they had atrial fibrillation. Moreover, the older the patients were, the more significant the effect of education became.

Photo: Randi Solhaug

More men than women received ablation

The study further shows that a higher proportion of male atrial fibrillation patients were treated with ablation compared to female patients. This was true across all age groups and throughout the study period. Particularly younger men received this treatment.

However, the gender differences diminished with increasing age, and in the age groups 60—69 and 70—75, the differences were small.

— There is a need for more research on gender differences in the treatment of patients with heart disease, emphasises Frank Olsen.

Health literacy and patient preferences play a role

Ablation treatment is offered at the four university hospitals and one private hospital in Norway. The study reveals significant geographical differences in the treatment of atrial fibrillation.

Patients in Northern Norway were the least likely to be treated with ablation, but there were also internal variations. The chance of receiving ablation was nearly twice as high for patients in the Bergen area compared to those in Stavanger. The geographical variation cannot be explained by differences in income or education levels.

— There are several reasons for the substantial differences in the treatment of atrial fibrillation. Differences in health literacy and the demands and preferences of patients are likely important factors contributing to the socioeconomic variation, but doctors' preferences and practices also play a role. Some of the geographical variation may also stem from differences in ablation capacity, says Frank Olsen.

He points out that geographical variation related to differences in clinical practice and provider preferences suggests a need for clearer guidelines, both at the specialist level and at the referring level.

— Differences in the use of health services may indicate overuse and overtreatment, but it may also mean that parts of the population do not receive the health services they are entitled to.

Part of a doctoral project

The study is part of Frank Olsen's doctoral dissertation, which maps the population's use of publicly funded health services. He investigates whether there are differences based on patients' residence, education, and income levels.

The study has been published in the medical journal BMC Public Health.

Olsen defended his thesis on 21 June this year at the Institute of Community Medicine at UiT The Arctic University of Norway.

See also: Children's hospital admissions vary with parents' education level

FACTS:

About the study

• The aim of the study was to determine whether there are patient-related or geographical differences in the use of catheter ablation among atrial fibrillation patients in Norway.

• Data were obtained from the Norwegian Patient Register (NPR) and Statistics Norway (SSB).

• The study includes individual-level data on all Norwegians aged 25 to 75 diagnosed with atrial fibrillation from 2008 to 2017.

• This comprised a total of 88,534 patients, of whom 29,233 were women and 59,301 were men.

• The data from NPR included patient demographics (residential information, year of birth, and gender), start and end dates of contact, hospital, type of contact, diagnoses, and clinical procedures.

• The data from SSB included income and education levels each year, gender, year of birth, date of death, date of emigration, and municipality of residence.

Ablation is a newer treatment method for atrial fibrillation where medical treatment is insufficient or causes adverse side effects. Ablation is performed using electrical currents, radio waves, or chemicals delivered via catheters to the heart. Ablation is a treatment method to remove the areas in the heart's atria that cause atrial fibrillation. During ablation, a small portion of the tissue is "destroyed" so that unwanted electrical disturbances are blocked. The method provides effective treatment for certain arrhythmias. Particularly, radiofrequency ablation has, due to technical innovations in recent years, gained a broader application for various rhythm disturbances, including common conditions such as atrial fibrillation. The treatment is carried out in specialised laboratories at centres for arrhythmias, in Norway at the five regional hospitals.

Sources: St. Olav's Hospital, Store norske leksikon

About atrial fibrillation (arrhythmia)

In atrial fibrillation, the heart beats irregularly and often too quickly. This is known as a heart rhythm disorder. The episode can vary from a few minutes to up to a couple of days. Many will eventually experience chronic atrial fibrillation. The heart rhythm is controlled by electrical signals from a pacemaker (sinoatrial node) in the heart. When one has atrial fibrillation, the heart muscle receives too many signals at once. The pulse can increase to more than 140 beats per minute during an episode. Normally, the heart beats between 60 and 80 beats per minute at rest. Men are more likely to develop atrial fibrillation than women. It is more common among older individuals with high blood pressure or heart problems. Other risk factors may include diabetes, high alcohol consumption, lung diseases, and hyperthyroidism.

Source: Helsenorge.no