Race and Ethnic Disparities in Catheter Ablation Utilization for Atrial Fibrillation: A Meta-analysis and Framework for Implementation Research

BackgroundRace/ethnic disparities in catheter ablation utilization for atrial fibrillation (AF) have been reported in the literature, however the data have not been systematically reviewed. ObjectivesTo perform a systematic review and meta-analysis of studies reporting on disparities in the utilization of catheter ablation (CA) and to explore possible root causes of disparities using a behavioral model of health service utilization. MethodsWe searched PubMed/MEDLINE, Web of Science and Embase for studies reporting on race/ethnic disparities in the utilization of CA for AF in the United States. A meta-analysis was performed on a subset of included articles using a random-effects model. Publication bias was assessed for race/ethnic groups pooled from 10 or more studies. We adapted a behavioral model of health service utilization to identify root causes of disparities. ResultsOur search identified 20 studies published between 2011 and 2023, representing 47,700,642 patients with AF of whom over 561,490 underwent CA. Compared to non-Hispanic White patients, racial minorities had a lower odds of utilization of catheter ablation: 0.68 (95%CI 0.58 - 0.77) for non-Hispanic black (NHB) patients, 0.72 (95%CI 0.65 - 0.79) for Hispanic/LatinX (HLx) patients, and 0.62 (95%CI 0.45 - 0.78) for Asian patients. Other race groups were excluded due to insufficient data. There was a moderate to high degree of between-study heterogeneity for each race/ethnicity group: HLx (I2 = 58.2%), Asian (I2 = 80.9%), and NHB (I2 = 90.4%). Only NHB patients had sufficient data to generate a funnel plot which showed evidence of publication bias. ConclusionsThe high between-study heterogeneity reveals varying degrees of disparities across studies and settings. Further research adjusting for patient-provider preferences and factors, echocardiographic data and social determinants of health is needed to clarify root causes of disparities and to promote equitable adoption of this important therapy in AF care.