Maximizing Equity in Acute Coronary Syndrome Screening across Sociodemographic Characteristics of Patients

Figures

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  Figure 1. Prevalence of key screening criteria/predictors by demographic group. NAAH/PI = Native American, Alaskan, or Hawaiian/Pacific Islander. This figure presents the prevalence of the screening criteria used as guidance for human practice and as predictors in the model.

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  Figure 2. Acute coronary syndrome (ACS) and STEMI patient age by race. Using ‘age >65 years’ as a screening criterion to identify those at risk of ACS introduces substantial inequity. Panel A shows that Black and NAAH/PI ACS patients are generally younger than White, Asian, or other race patients, and many are under age 65. The concentration of cases in the younger age group is even more pronounced among STEMI patients (Panel B), including those of Asian or other race. The sharp cut-off at age 65 for screening inadvertently disadvantages sub-groups with younger age structures, which can fall along racial lines in the US. NAAH/PI = Native American, Alaskan, or Hawaiian/Pacific Islander.

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  Figure 3. Sensitivity and specificity of screening approaches for acute coronary syndrome by demographic subgroup. NAAH/PI = Native American, Alaskan, or Hawaiian/Pacific Islander. screening per clinical protocol had the widest variation in sensitivity across the demographic groups, and observed human practice had lower variation. When observed practice was augmented by the predictive model, sensitivity increased for all sub-groups except those >80 years of age, which already had a sensitivity of nearly 100%. Increased ACS case detection with the model-augmented human practice screen results in a lower specificity by about 10 percentage points compared to observed human practice alone. Sensitivity and specificity are not equally important, however, given the high intolerance for missed ACS and the low burden of performing additional early ECGs.

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  Figure 4. ACS and STEMI incidence, positive ACS screens, and true positive case capture. NAAH/PI = Native American, Alaskan, or Hawaiian/Pacific Islander. Panel A presents the incidence of ACS across the demographic subgroups, illustrating differential risk. Panel B presents the percent of the total ED population who screened positive under observed human practice (yellow) and the positive screens that would be added under the model-augmented human practice approach (orange). Panels C and D present the proportion of ACS patients in each subgroup identified via observed human practice (green) and those that would be added with model-augmented human practice screening (dark green).