Sources of Variation in Cardiovascular Care Cascades

Clinical Snapshot

Key Findings

• P Value: Not explicitly reported but confidence intervals exclude null

• Effect Size: Medicare dual/disabled patients had 55% lower odds of completing CAD testing (aOR 0.45) and 53% lower odds of completing cardiology referrals (aOR 0.47)

• Primary Outcome: Completion of CAD testing or cardiology referrals within 6 months

• Nnt Or Sensitivity: Once scheduled, completion rates exceeded 75% across all groups

• Confidence Interval: CAD testing: 95% CI 0.36-0.56; Cardiology referrals: 95% CI 0.39-0.57

Clinical Application

Care cascade framework could be implemented in Australian EDs using existing electronic health records Limited direct applicability due to different insurance system (Medicare vs private), but principles relevant for identifying care gaps in Australian public/private healthcare divide Patients presenting to emergency departments with suspected cardiac ischemia requiring follow-up cardiovascular care

Abstract

IMPORTANCE: Variation in cardiovascular care completion is well documented. However, less is known about differences originating from earlier, intermediate stages such as ordering or scheduling of testing or referrals, despite their role as key prerequisites for care access. OBJECTIVE: To examine the care cascades for coronary artery disease (CAD) after emergency department (ED) visits and to identify the specific stages at which variation emerges for CAD testing and cardiology referrals. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study using data and metadata from electronic health records from a large multicenter health system. Participants were adult patients with established primary care and no history of ischemic heart disease or cardiology care who presented to an ED from January 1, 2020, to June 30, 2022, and underwent a troponin test, a proxy for clinically suspected myocardial ischemia. Variation in cardiovascular follow-up care (CAD testing and cardiology referrals) was identified and analyzed. Analyses were restricted to patients with above-median electrocardiogram (ECG)-derived ischemia risk scores to enrich for higher likelihood of benefit from cardiovascular follow-up. MAIN OUTCOMES AND MEASURES: Receipt of an order for CAD testing (stress tests, coronary computed tomography angiography) or cardiology referral, scheduling of the service, and completion within 6 months. Outcomes were compared by insurance type, race and ethnicity, language, and sex using multivariable logistic regression adjusted for demographic characteristics, clinical factors, and ECG-derived cardiovascular risk. RESULTS: Among 16 475 patients with an ED visit (median [IQR] age, 67.4 [54.9-77.9] years; 36% female and 64% male individuals) and elevated cardiovascular risk, marked variation in follow-up care emerged. Compared to commercially insured patients, those with Medicare dual or disabled coverage had lower adjusted odds of completing CAD testing (adjusted odds ratio [aOR], 0.45; 95% CI, 0.36-0.56) and cardiology referrals (aOR, 0.47; 95% CI, 0.39-0.57); similar patterns were seen for Medicaid coverage. Patients whose primary language was not English were less likely to complete either service (CAD testing aOR, 0.77; 95% CI, 0.61-0.98; referral aOR, 0.75, 95% CI, 0.61-0.92), and female patients had lower adjusted odds of completing CAD testing (aOR, 0.86; 95% CI, 0.77- 0.96). Adjusted differences by race and ethnicity were modest. Variation was primarily associated with ordering differences and with additional scheduling barriers for select groups. Once scheduled, completion rates exceeded 75%, without differences between groups. CONCLUSIONS AND RELEVANCE: This retrospective cohort study found that among patients who visited the ED with elevated ischemic risk, attrition in follow-up care was concentrated early in care cascades and most pronounced among those with noncommercial health insurance. This stepwise analytic framework offers a novel, reproducible approach for health systems to identify where and for whom care gaps arise, which can enable targeted interventions to improve equity and efficiency.

References

1. 1.Wang, A. Z., Shanmugam, D., Divakaran, S., Pierson, E., & Barnett, M. L. (2026). Sources of variation in cardiovascular care cascades. JAMA Health Forum, 7(4), e260491. https://doi.org/10.1001/jamahealthforum.2026.0491