Lower socioeconomic status is associated with lower quality of care of atrial fibrillation despite comprehensive no-cost access to medical care in Australia

BACKGROUND: Socioeconomic status (SES) is an established risk factor for poor cardiovascular outcomes, with atrial fibrillation (AF) a major contributor to cardiovascular morbidity and mortality. OBJECTIVE: To examine associations between SES, clinical outcomes and access to guideline-directed therapies in patients attended by emergency medical services (EMS) with a prehospital AF diagnosis within a universal healthcare setting METHODS: We conducted a population-based cohort study of consecutive adults attended by EMS for AF across Victoria, Australia (January-2015-June-2019). Patients were stratified into SES quintiles using census-based postcode indices. RESULTS: Primary analysis included 14,987 patients, median age 76 (Q1-Q3:67-84), 43% male. Time-to-event-analysis demonstrated a gradient of lower rates of outpatient cardioversion and ablation and increased EMS re-presentations and mortality amongst lower SES groups. On multivariable analysis compared with the highest SES quintile, the lowest SES group was associated with reduced cardioversions (aHR 0.73(0.61-0.86), p<0.001) and ablations (aHR 0.48(0.39-0.60), p<0.001) and higher risk of EMS re-presentation for AF within 30 days (aOR 1.61(1.19-2.17), p=0.002) and over median 2.1-year follow-up (aHR 1.18(1.03-1.36), p=0.019). Mortality was also higher at 30 days (aOR 1.68(1.31-2.15), p<0.001) and over median 2.1-year follow-up (aHR=1.42(1.28-1.58),p<0.001) compared to the highest SES group. In a competing-risk model treating death as a competing event, re-presentation effect estimates remained directionally similar but attenuated and no longer statistically significant. CONCLUSION: The lowest SES groups compared to the highest were associated with reduced access to cardioversion and ablation following index attendance, along with more frequent EMS re-presentations for AF and higher mortality within 30 days and long-term follow-up.