Key result
ACES pathway eliminates racial disparities in index cardiac testing, achieving ~98% uptake across groups.
Why the study?
Patients from racial and ethnic minority groups presenting to the ED with chest pain experience lower odds of receiving stress testing compared with nonminorities, and it was unknown if a care pathway could reduce this disparity.
RCT (n=329)
Randomized
No
Odds Ratio: 1.77 (95% CI 0.24–12.8)
Absolute Event Rate: 99% vs 98%
p-value: p=0.623
May support standardized pathways to reduce racial testing disparities; leaves open prospective outcome validation.
BACKGROUND: Patients from racial and ethnic minority groups presenting to the Emergency Department (ED) with chest pain experience lower odds of receiving stress testing compared with nonminorities. Studies have demonstrated that care pathways administered within the ED can reduce health disparities, but this has yet to be studied as a strategy to increase stress testing equity. METHODS: A secondary analysis from 3 randomized clinical trials involving ED patients with acute chest pain was performed to determine whether a care pathway, ACES (Accelerated Chest pain Evaluation with Stress imaging), reduces the racial disparity in index visit cardiac testing between African American (AA) and White patients. Three hundred thirty-four participants with symptoms and findings indicating intermediate to high risk for acute coronary syndrome were enrolled in 3 clinical trials. Major exclusions were ST-segment elevation, initial troponin elevation, and hemodynamic instability. Participants were randomly assigned to receive usual inpatient care, or ACES. The ACES care pathway includes placement in observation for serial cardiac markers, with an expectation for stress imaging. The primary outcome was index visit objective cardiac testing, compared among AA and White participants. RESULTS: AA participants represented 111/329 (34%) of the study population, 80/220 (36%) of the ACES group and 31/109 (28%) of the usual care group. In usual care, objective testing occurred less frequently among AA (22/31, 71%) than among White (69/78, 88%, P = 0.027) participants, primarily driven by cardiac catheterization (3% vs. 24%; P = 0.012). In ACES, testing rates did not differ by race [AA 78/80 (98%) vs. White 138/140 (99%); P = 0.623]. At 90 days, death, MI, and revascularization did not differ in either group between AA and White participants. CONCLUSIONS: A care pathway with the expectation for stress imaging eliminates the racial disparity among AA and White participants with chest pain in the acquisition of index-visit cardiovascular testing.
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Miller et al. (2019) conducted an RCT in Acute chest pain at intermediate to high risk for acute coronary syndrome (n=329). ACES (Accelerated Chest pain Evaluation with Stress imaging) care pathway vs. Usual inpatient care was evaluated on Objective cardiac testing during the index visit in the ACES group (White vs African American participants) (OR 1.77, 95% CI 0.24-12.8, p=0.623). The ACES care pathway eliminated racial disparities in index-visit objective cardiac testing, with 99% of White and 98% of African American patients receiving testing (OR 1.77).
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