Sources of Variation in Cardiovascular Care Cascades

Area of Science:

• Cardiovascular Medicine
• Health Services Research
• Health Equity

Background:

• Variation in cardiovascular care completion is documented, but early-stage differences in ordering and scheduling remain less understood.
• These intermediate stages are critical prerequisites for accessing timely cardiovascular care.
• Understanding these early gaps is essential for improving patient outcomes and reducing health disparities.

Purpose of the Study:

• To analyze care cascades for coronary artery disease (CAD) following emergency department (ED) visits.
• To pinpoint specific stages where variations in CAD testing and cardiology referrals emerge.
• To identify patient groups disproportionately affected by these early care gaps.

Main Methods:

• Retrospective cohort study utilizing electronic health records from a large, multicenter health system.
• Included adult patients with elevated ECG-derived ischemia risk scores presenting to the ED for troponin testing.
• Compared outcomes (testing orders, scheduling, completion) by insurance type, race/ethnicity, language, and sex using multivariable logistic regression.

Main Results:

• Significant variation in follow-up cardiovascular care was observed among 16,475 high-risk ED patients.
• Patients with Medicare dual/disabled or Medicaid coverage, non-English primary language, and female sex had lower odds of CAD testing and cardiology referrals.
• Variation was primarily driven by differences in test ordering and scheduling, not by completion rates once scheduled.

Conclusions:

• Attrition in cardiovascular follow-up care is concentrated in the early stages of the care cascade, particularly for patients with non-commercial insurance.
• A stepwise analytic approach can identify specific care gaps and patient subgroups needing targeted interventions.
• This framework aids health systems in improving care equity and efficiency for cardiovascular conditions.