Non‐invasive screening for coronary artery disease: current perspectives, patient, public health and ethical considerations in evaluating symptomatic and asymptomatic individuals

Abstract

Coronary artery disease (CAD) is a leading cause of morbidity worldwide. Although non‐invasive testing for CAD aims at reducing future disease burden, testing can often be associated with significant economic and other health‐related costs, at both an individual and societal level. Although there is an established role for screening symptomatic patients for CAD, there is still considerable debate as to the best approach for individuals who are asymptomatic. In this review, various non‐invasive tests commonly used in clinical practice will be discussed, including their potential utility, known limitations, and other considerations regarding their use. The use of such testing requires careful consideration of their diagnostic accuracy, availability, cost and patient‐specific factors that may limit their utility and safety. Future recommendations for CAD screening, especially for lower‐risk or asymptomatic individuals, should offer clinicians and patients some degree of flexibility and take into account the nuanced clinical approach that is often required to address the variability of each individual patient's biopsychosocial context and other factors relating to the suitability and accessibility of screening (e.g. financial cost and geographic location). Recommendations that are well suited to certain geographic locations or societal groups may be less appropriate for other populations, especially those that are marginalised, less well resourced or experiencing significant socioeconomic disadvantage. Screening for CAD should therefore endeavour to ensure equity and aim to improve outcomes in all patient groups, including those who are disadvantaged and most at risk.

Abbreviations

AusCVDRisk

Australian Cardiovascular Disease Risk

CAC

coronary artery calcium

CAD

coronary artery disease

CT

computed tomography

cTn

cardiac troponin

CVD

cardiovascular disease

ECG

electrocardiography

GP

general practitioner

hs‐CRP

high‐sensitivity CRP

SEIFA

socioeconomic indexes for area

Introduction

Coronary artery disease (CAD) was the leading cause of disease burden in Australia for males and the fifth leading cause for females in 2023. ¹ Similar statistics have also been seen in New Zealand, where almost one‐third of all deaths can be attributed to cardiovascular disease (CVD). ² Early detection of CAD aims to reduce disease burden by identifying at‐risk individuals. Non‐invasive tests, outlined in Table 1, can assist with risk stratification. Although there are guidelines for CAD screening in patients who are symptomatic, ³ , ⁴ there is still considerable debate and variability in clinical practice in managing individuals who are asymptomatic. Depending on the individual patient and setting, clinicians may choose to perform simple bedside tests such as ECG, laboratory testing for hypercholesterolaemia and diabetes mellitus, incorporate a cardiovascular risk calculator as part of assessment or offer specialised cardiac testing, including functional testing and radiological imaging. In this review, we discuss the various non‐invasive tests which have been used as part of screening for CAD and discuss the patient, public health and ethical issues when considering screening in asymptomatic or low‐risk individuals (Table 2).

Table 1.

Utility and limitations of common coronary artery disease (CAD) screening tests

Test	Main utility	Limitations
Lipids, screening diabetes mellitus and measurement of blood pressure	Part of conventional screening Evidence for screening well established Offers targets for interventions	Nil Should be performed as part of screening for the general population
Coronary calcium score	Helps to add additional information for risk stratification on top of conventional cardiovascular risk calculator May identify high‐risk patients who otherwise would not have been identified by non‐radiological testing	Radiation exposure The absence of coronary artery calcium score does not guarantee that no CAD present Some patients can have non‐calcified coronary artery plaques which are not detected by this test Less useful as a first‐line test for symptomatic individuals Not useful in patients with known CAD
Stress ECG (functional test)	Provides functional data and assesses aerobic fitness No radiation exposure Role (albeit reduced in scope compared with stress echocardiography) in screening symptomatic patients Simpler to perform than stress echocardiography (i.e. does not require a cardiac sonographer) Cheaper than stress echocardiography	Can have false positives and false negatives Reduced diagnostic accuracy in females Very limited diagnostic utility in patients who have preexisting ECG changes Does not provide direct information regarding coronary artery anatomy Largely superseded by stress echocardiography in settings where a cardiac sonographer is available
Stress echocardiography (functional test)	Proven role in screening CAD in patients with intermediate‐risk chest pain Provides functional data and assesses aerobic fitness No radiation exposure	Can have false positives and false negatives Operator dependent Reduced imaging quality in patients with body habitus that offer challenging acoustic windows, or in patients with significant lung disease or peripheral arterial disease Does not provide direct information regarding coronary artery anatomy
Myocardial perfusion scintigraphy (functional test)	Proven role in screening CAD in patients with intermediate‐risk chest pain or in assessing the functional significance of known CAD Provides functional and prognostic data Can be used in patients with renal impairment Pharmacological stress options available for patients who are unable to perform physical exercise	Radiation exposure Does not provide direct information regarding coronary artery anatomy Can have false positives and false negatives
CT coronary angiography (anatomical test)	Provides visualisation of patient's coronary arteries and information about atherosclerotic plaque and vessel morphology, beyond the degree of luminal stenosis seen in invasive coronary angiography Excellent negative predictive value Very effective at detecting minor coronary artery atherosclerosis Can be combined with coronary artery calcium scoring Role in both assessing symptomatic patients as well as a potential role in assessing select asymptomatic individuals	Higher radiation exposure than coronary artery calcium scoring, but usually less than myocardial perfusion scintigraphy Requires intravenous contrast (i.e. concerns regarding renal function and risk of contrast allergy) Reduced diagnostic accuracy, particularly in patients who have significant coronary artery calcification
hs‐CRP	Results can be obtained from simple blood test	Although elevated results are associated with CAD, hs‐CRP may be elevated for other reasons Cannot be used in isolation Remains investigational as cost‐effectiveness at a population level is unclear Currently not routinely recommended in screening
Lipoprotein(a)	Offers additional information on top of traditional lipid markers, especially in patients with family history of premature cardiovascular disease who have relatively normal LDL and triglycerides.	Additional cost

CT, computed tomography; ECG, electrocardiogram; hs‐CRP, high sensitivity C‐reactive protein; LDL, low‐density lipoprotein.

Table 2.

Key considerations when screening asymptomatic or low‐risk individuals

Challenge	Issues
Clinical utility	Risk of overdiagnosis and overtreatment: Widespread screening may lead to overdiagnosis, leading to overtreatment, exposing patients to unnecessary treatment and anxiety.
Validity	Evidence: The utility of screening tests in asymptomatic individuals in predicting patients at higher risk of adverse outcomes such as myocardial infarction or cardiovascular mortality, or mortality benefit is less clear when compared with their use in patients who are symptomatic.
Cost‐effectiveness	Financial burden of healthcare: The widespread use of imaging tests imposes significant financial burden on healthcare system.
Accessibility	Disparities in access: This is because of geographical differences in out‐of‐pocket expenses, which can lead to a situation where only those who can afford out‐of‐pocket expenses or those who are able to access bulk‐billed testing may access tests.
Variation in clinical practice	Guideline‐free area: Although there are well‐established guidelines for individuals who are symptomatic or who are at elevated risk, there is still considerable variation in clinical practice for individuals without symptoms.
Ethical and medicolegal considerations	Patient autonomy and informed consent: Patients must be adequately informed about the potential risks and benefits of screening, including the possibility of false positives, incidental findings, the cost of testing and the potential psychological impact of knowing they have subclinical disease.
Population health versus individual impact	The ‘one’ or ‘the many’? Screening programmes are administered at a population level but may have profound impact on an individual level. There will always be individuals deemed low risk who in fact harbour high‐risk CAD and who could theoretically have had an adverse outcome altered by early detection. Effective clinical practice requires balancing individual patient factors and wishes while considering the impact and costs of screening at a population level.

CAD, coronary artery disease.

Current recommendations

• All patients: Risk assessment should be offered for the general population aged 45–74 years, diabetic patients aged 35–79 and First Nations people aged 30–79. ⁵ , ⁶ This would involve a clinical examination, offering routine blood tests to screen for diabetes mellitus, renal dysfunction and conventional lipid testing.

• Symptomatic patients: Patients who have symptoms that may be attributable to CAD should undergo further evaluation and appropriate testing. ³ , ⁴ For high‐risk patients, an anatomical test (e.g. computed tomography (CT) coronary angiography, or even a primary invasive strategy for patients with typical symptoms and high pre‐test probability for CAD) may be preferred. For patients for whom the disadvantages associated with anatomical testing (e.g. radiation, underlying renal dysfunction or concerns regarding intravenous contrast), functional testing may be considered first, but this decision will often be undertaken in consultation with an appropriate physician. For patients with intermediate‐risk chest pain, a functional test (e.g. stress testing) is often employed to help with risk stratification and decisions relating to subsequent anatomical testing. On the other hand, patients may be referred first for CT coronary angiography, particularly if there are concerns relating to the possibility of significant obstructive CAD. Tests are sometimes organised by their general practitioner (GP) specialist (with subsequent referral to a cardiologist if there are any abnormalities), or the GP specialist may refer to a cardiologist or local acute healthcare setting, especially in patients with high‐risk features. This depends on the pre‐test likelihood of CAD as well as the specialist accessibility.

• Asymptomatic individuals: Options of screening, advantages and limitations of various modalities, as well as their cost will need to be discussed with the patient. Financial costs associated with referrals to cardiologists and subsequent downstream testing are highly variable and depend on geographic location. Patients may elect to see a cardiologist, or the GP specialist may elect to organise many of the initial investigations. It is important that appropriate information regarding the advantages and limitations of testing is provided so that an informed decision can be made.

Clinical assessment of cardiovascular risk

Information that should be obtained during the history and examination includes the presence of any cardiorespiratory symptoms, key cardiovascular risk factors including hypertension, smoking status, dyslipidaemia, diabetes mellitus, family history of early CAD and any descent from populations with higher prevalence of CAD. The purpose of this is twofold: (i) collect data that help inform cardiovascular risk factors and help formulate a baseline level of risk and (ii) identify potential areas where lifestyle and pharmacological intervention may prove useful.

Electrocardiogram

Electrocardiogram (ECG) features that may alert the clinician to the presence of underlying CAD include the presence of ST‐segment changes, T‐wave abnormalities, especially if these are dynamic or involve multiple contiguous leads, the presence of pathological Q waves, left bundle branch block or even the presence of arrhythmia. ⁷ Other signs that may indicate underlying CAD include poor R wave progression in the precordial leads, but this is non‐specific and can also be due to body habitus. Important caveats include the fact that a normal ECG does not preclude the presence of CAD. Furthermore, in stable CAD, the ECG can often remain normal or show non‐specific findings. In patients without previous assessment, further investigations are usually recommended if the ECG demonstrates left bundle branch block, significant ST, T wave changes or pathological Q waves in two or more contiguous leads.

Lipid testing

At a population level, elevated low‐density lipoprotein levels are strongly associated with the development of atherosclerosis. ⁸ The presence of significant dyslipidaemia may lead to lifestyle or pharmacological interventions, as well as help inform clinician decisions as to whether or not a patient should be referred for additional testing.

CVD risk calculation

The ECG, lipid screening and screening for diabetes mellitus, together with the clinical history and examination, constitute the initial assessment. Based on these results, a clinician can then calculate a cardiovascular risk score. Current guidelines recommend risk assessment for the general population aged 45–74 years, diabetic patients aged 35–79 and First Nations people aged 30–79 using the Australian Cardiovascular Risk (AusCVDRisk) calculator’ (https://www.cvdcheck.org.au/). ⁵ , ⁶ This calculator (Table 3) integrates variables such as age, sex, smoking status, systolic blood pressure, total cholesterol to high‐density lipoprotein ratio, diabetes mellitus status and history of atrial fibrillation to estimate the 5‐year risk of developing CVD. In patients with diabetes mellitus, other variables, including body mass index, duration of diagnosis and insulin use, as well as results of laboratory testing such as glycosylated haemoglobin, urinary albumin–creatinine ratio and renal function, are also required. Importantly, the AusCVDRisk calculator also includes postcode of residence to calculate the socioeconomic indexes for areas (SEIFA) score, because of the increasing recognition that the prevalence of CAD is higher among patients with socioeconomic disadvantage and that earlier detection and intervention in populations where there are more cardiovascular risk factors and barriers to healthcare may reduce the long‐term burden of disease. For asymptomatic individuals, stratifying CAD risk may help identify those who may benefit from closer surveillance, targeted lifestyle and/or pharmacological management, or even additional testing.

Table 3.

Components of Australian Cardiovascular Disease Risk calculator ^†

Component	Description
Age	Age of individual
Sex at birth
Smoking status	Current smoker, previous smoker or never smoked
Systolic BP
Ratio of total cholesterol to high‐density lipoprotein	Requires the results of a standard lipid panel
Use of cardiovascular medications in the past 6 months	For example, antihypertensive agents and lipid‐lowering therapy
History of atrial fibrillation
Diabetes mellitus
Postcode of residence	This generates a SEIFA quintile

^†Factors that automatically confer high clinical risk include moderate‐to‐severe chronic kidney disease, familial hypercholesterolaemia. Other factors that may elevate clinical risk include family history of premature cardiovascular disease, severe mental illness, history of chronic kidney disease, First Nations descent, as well as Maori, Pacific Islander, or several specific south Asian ethnicities (e.g. Fiji‐Indian).

BP, blood pressure; SEIFA, socioeconomic indexes for areas.

This is a measure of socioeconomic advantage/disadvantage and takes into account many variables according to census data.

Other available laboratory testing not routinely used in clinical practice

High‐sensitivity C‐reactive protein

Inflammation plays a central role in the pathogenesis of atherosclerosis, and elevations in high‐sensitivity C‐reactive protein have been shown to be associated with an increased risk of developing CAD. ⁹ However, it is not routinely used for CAD screening as the incremental benefit of testing on top of CVD risk calculators is unclear. ⁵

Lipoprotein(a)

Lipoprotein(a) is a lipoprotein that contains apolipoprotein(a), a hydrophilic and highly glycosylated protein bound to apolipoprotein B100. ¹⁰ Lipoprotein(a) levels are predominantly genetically determined, and it is a known risk factor for atherosclerosis, thrombosis and aortic valve calcification. Routine screening for lipoprotein(a) is not recommended. ⁵ It is, however, considered part of screening in patients with strong family history of premature CAD events, progressive disease despite optimal treatment or familial hypercholesterolaemia. ¹¹

High‐sensitivity cardiac troponin

High‐sensitivity cardiac troponin (cTn) levels are sometimes elevated in patients with underlying stable CAD, even when cTn is undetectable on conventional assays. Such elevations have been associated with an increased incidence of cardiovascular death and heart failure. ¹² There is also some evidence that elevation in high‐sensitivity cTn is associated with increased risk of death in asymptomatic populations. ¹³

Nevertheless, high‐sensitivity cTn is not used outside the research setting, as it is an insensitive and non‐specific marker. Elevations often occur in various conditions such as chronic kidney disease, as well as structural heart conditions such as left ventricular hypertrophy and cardiomyopathy, ¹² , ¹³ and often after strenuous exercise. ¹⁴ It is currently not used in routine clinical practice.

Transthoracic echocardiography

Although this is not a test used for diagnosing CAD, transthoracic echocardiography provides detailed real‐time information about cardiac structure and function without the use of ionising radiation. It can detect complications of significant CAD, such as left ventricular dysfunction, regional wall motion abnormalities and valvular regurgitation, which can sometimes occur as a result of myocardial ischaemia (e.g. mitral regurgitation secondary to papillary muscle damage). ¹⁵

Stress echocardiography

The ability of stress echocardiography to provide both a functional and electrical assessment of the left ventricle at rest and stress makes it a useful test for evaluating CAD. ¹⁶ The principle underlying this test is the concept of the ‘ischaemic cascade’, where myocardial ischaemia often causes diastolic dysfunction, then regional changes in systolic dysfunction, followed by ECG changes and chest pain. ¹⁷ Stress echocardiography is superior to exercise ECG as it provides an opportunity to identify many of the above features of ischaemia. Pharmacological stress tests are not routinely performed in asymptomatic patients. Their role is in assessing patients who are unable to exercise and who have (i) intermediate‐risk chest pain or (ii) known CAD where functional significance and/or myocardial viability needs to be determined.

Stress echocardiography requires significant expertise to perform and interpret. Factors such as obesity or significant lung disease often reduce image quality and diagnostic accuracy. Conditions that limit exercise capacity (e.g. significant lung disease or lower limb peripheral arterial disease) may also result in a non‐diagnostic test. Furthermore, stress echocardiography may often not detect non‐obstructive CAD.

Stress ECG

Stress ECG became obsolescent with the widespread availability of stress echocardiography. It, however, can still be useful in select clinical settings, especially in resource settings where a cardiac sonographer is not available. Stress ECG, however, has important limitations. It has very limited utility in patients with baseline ECG abnormalities, such as left bundle branch block or ST/T‐wave segment changes, and should be avoided in patients with preexisting baseline ECG changes. Additionally, the accuracy of stress ECG is less in women than in men, a finding thought to be because of the increased chances of false positive ECG changes mediated by the effects of oestrogen, as well as sex differences in exercise capacity. ¹⁸

Stress myocardial perfusion scintigraphy

Myocardial perfusion scintigraphy is an option for assessing some patients with intermediate‐risk chest pain. This test is generally not routinely recommended for asymptomatic patients. It is associated with a significant radiation dose (Table 4). It is, however, a potential option in patients who have symptoms or among patients in whom there is high suspicion of significant CAD, who are unable to exercise or undergo stress echocardiography (thereby justifying a test involving ionising radiation) and who also have significant renal dysfunction or intravenous contrast allergy. It is not routinely employed, however, and will be used only after consideration on a case‐by‐case basis. ¹⁹

Table 4.

Comparison of radiation doses for cardiac imaging tests that use ionising radiation (dose data from Hirshfeld et al.) ²⁹

Test	Radiation dose (milli‐Sieverts, mSv)
Coronary artery calcium score
EBCT	1.0
CT coronary angiography
MDCT, prospectively triggered axial	0.5–7
MDCT, high‐pitch helical	<0.5–3.0
Myocardial perfusion scintigraphy
99mTc sestamibi rest/stress	11–18
99mTc sestamibi stress only	2.7–8.0
Diagnostic invasive coronary angiography	2.0–20
Reference values
Chest X‐ray
Posteroanterior	0.02
Combined posteroanterior and lateral	0.06
Annual average background radiation in Australia 30	1.8

CT, computed tomography; EBCT, electron‐beam computed tomography; MDCT, multidetector‐row computed tomography.

A Sievert (Sv) is a unit of measure for the biological effect of ionising radiation, accounting for the type of radiation and the sensitivity of different tissues. 1 Sv = 1 Gy × radiation weighting factor, which accounts for the biological impact of the type of radiation.

Coronary artery calcium score

The coronary artery calcium (CAC) score is a non‐invasive radiological test (Table 4) that measures the burden of calcified plaque in the coronary arteries using CT without the use of intravenous contrast. Atherosclerotic calcific plaque burden is quantified using a numerical Agatston score. A CAC score of 0 indicates a low risk of future CAD events, whereas higher scores are associated with incremental risk. ²⁰

Although CAC scoring offers important prognostic data in asymptomatic individuals, ²¹ population‐level screening using the CAC score is not recommended. ⁵ It is also not recommended in patients with a history of myocardial infarction or known CAD (as the CAC score will likely be significantly elevated and will therefore provide limited, useful additional information) or in patients for whom pharmacotherapy is already recommended. Its main utility is in reclassifying initial CAD risk when treatment decisions are uncertain (i.e. an elevated CAC score may convince the clinician and patient to proceed with pharmacological intervention for cardiac risk factors). As an example, an Australian study published in 2020 found that of 151 participants with calcium scores of 100 or more, 77% originally had been classified by risk calculators as having low cardiovascular risk, whereas 19% of patients deemed to be intermediate risk had zero calcium scores. ²² High CAC scores in an asymptomatic patient may prompt more aggressive risk factor modification or consideration of pharmacological intervention. ²¹ , ²³

CAC scoring has important limitations. As CAC scoring focusses on detecting calcified plaque, it may miss early or non‐calcified lesions. This can result in a false sense of security, as the lack of calcification does not exclude the presence of soft, non‐calcified plaques. ²⁴ Guidelines have suggested that it is reasonable to repeat a CAC score within 2–5 years in patients with a normal CAC score who are not receiving any pharmacological intervention and in whom there are concerns of interval development of CAD to assess whether there has been an increase in score and therefore change in CAD risk. ⁵

CT coronary angiography

CT coronary angiography provides direct visualisation of the coronary arteries, allowing for the assessment of both the degree of coronary stenosis and the composition of atherosclerotic plaques. It is a useful investigation, especially in symptomatic patients. It can also be useful in asymptomatic populations, as it provides additional anatomical and prognostic information not provided by the CAC score. ²⁵ , ²⁶ Importantly, of the tests discussed in this review, it is the only non‐invasive test that, except in cases of poor image quality, it has a sufficiently high negative predictive value to provide reassurance that significant or obstructive CAD is not present. It can also detect early CAD, which may help inform decisions regarding risk factor modification and pharmacological intervention.

CT coronary angiography, however, has important limitations. It uses iodine contrast, which is an important consideration in patients with significant renal impairment or contrast allergies. The test also uses ionising radiation (Table 4). Another limitation is that in patients with significant coronary artery calcification, there is the potential for beam hardening artefact to overestimate CAD stenosis severity. The uncertainty in the degree of CAD stenosis in these patients can lead to referrals for invasive coronary angiography or additional functional testing. CT coronary angiography can be associated with additional downstream tests, especially in patients found to have CAD, as well as investigations to clarify the results of incidental findings (e.g. pulmonary nodules). CT coronary angiography should therefore be considered in symptomatic patients, where the benefits of imaging are more likely to outweigh the risks. It may also have a role in select asymptomatic high‐risk patients who wish to have more definitive reassurance that they do not have CAD.

From a diagnostic flow perspective, strategies that utilise early CT coronary angiography testing in patients with stable chest pain have been found to be cost‐effective compared with functional testing. ²⁷ The routine widespread use of CT coronary angiography as a screening test in asymptomatic individuals, however, is not recommended.

Cost‐effectiveness concerns

CAD screening is associated with significant healthcare‐related costs, both at an individual and societal level. From an epidemiological perspective, the potential for harm arising from false‐positive imaging test results is an important consideration. In low‐risk populations, the lower prevalence of disease increases the likelihood of false positives, which can lead to anxiety, unnecessary further testing and increased healthcare costs. Patient education as well as changes in reimbursement, both in terms of the amount of reimbursement and the implementation of minimal time intervals for rebates in serial testing, have helped limit the overuse of cardiac testing. ²⁸

Ethical and medicolegal considerations

Despite the concerns relating to the reduced cost‐effectiveness of CAD screening in lower‐risk populations, it is important to recognise that patients and their referring clinicians may not be aware of the many issues detailed in this review, nor consider these factors relevant for their individual situation.

Common scenarios where an asymptomatic or low‐risk individual will present for assessment include: (i) preoperative risk evaluation for a patient undergoing a major operation, for which pre‐knowledge of CAD may impact decisions regarding whether or not surgery will proceed, how it will perform or its setting; (ii) a sudden CVD‐related death or significant CVD illness in a family member or acquaintance; (iii) another clinician requesting evaluation in a patient with significant CAD risk factors. In such cases, patients will attend for CAD screening, either because they themselves are concerned about CAD or because another clinician is concerned about their risk of CAD. If a patient who has declined screening subsequently develops a CAD‐related adverse event, the physician's decision not to proceed with screening may be questioned or even criticised.

Informed consent through patient education is therefore very important. Failure to offer screening without discussion may be perceived as paternalistic or even dismissive, particularly if the patient was not adequately informed about the risks, benefits and imperfect diagnostic accuracy associated with many non‐invasive screening tests. In such cases, communication with the patient and referring practitioners is also essential. Other factors that may influence the decision to proceed to screening include a patient's concerns and wishes, accessibility (which, in turn, may be related to the ability to afford or attend evaluation and testing) and the possibility of a missed opportunity for intervention in a patient at risk of being lost to follow up. The latter is a particularly important consideration in high‐risk patients from socioeconomically disadvantaged communities.

Clinicians should involve patients in the decision process. A discussion balancing the benefits against potential harms or inconveniences associated with screening is crucial to effective communication. This ensures that patients are adequately informed and that patient autonomy is considered along with evidence‐based best practice – the hallmarks of providing high‐quality care in an era of personalised medicine.

Conclusion

The use of non‐invasive cardiac screening requires careful consideration of each test's utility, availability, cost and patient factors. Considered use of these tests has the potential to allow effective risk stratification, early disease detection and management of at‐risk patients. Many clinicians have encountered patients who were originally deemed low risk, but who were subsequently found to have high‐risk CAD, fortunately identified during cardiac screening. Future recommendations for CAD screening, especially for asymptomatic and low‐risk individuals, should offer clinicians and patients some flexibility, especially as patient factors relating to the suitability and accessibility of screening may vary. This should endeavour to ensure equity and improve outcomes for all patient groups, including those who are disadvantaged and most at‐risk.