Coronary artery calcium (CAC) scoring is a validated, noninvasive tool for identifying subclinical atherosclerosis and refining risk prediction of major adverse cardiovascular events. However, referral patterns for CAC testing, including whether they reflect provider or patient demographic characteristics, remain poorly characterized. RUSH University Medical Center launched a pilot CAC screening initiative to assess real‐world referral trends within a diverse, urban academic population. We evaluated whether referrals for CAC testing differed by patient and provider sex and race and ethnicity.
The data, analytic methods, and study materials will not be made available to other researchers for purposes of reproducing the results or replicating the procedure because the data contain protected health information and institutional electronic health record data that cannot be publicly shared. We conducted a retrospective analysis of adult patients who completed CAC testing at RUSH University Medical Center from January 1 to December 31, 2022. Demographic data for patients and referring providers were extracted from the electronic health record. Race and ethnicity are self‐reported in the RUSH University Medical Center electronic health record but were not available for all patients; therefore, race and ethnicity analyses were limited to those with documented data. Descriptive statistics summarized distributions, and associations between patient and provider sex and race and ethnicity were assessed using χ2 tests (P<0.05). Differences in patient race distribution across provider race categories were evaluated using Fisher's exact test. The RUSH University Medical Center institutional review board approved this quality‐improvement study with a waiver of informed consent.
Patient and provider demographic characteristics and referral patterns are summarized in the Table1. A total of 931 patients completed CAC testing during 2022; 59.4% (n=553) were women and 40.6% (n=378) men. Patient race and ethnicity and provider sex data were available for 898 patients; 58.4% were White individuals, 21.2% Black individuals, 11.7% Hispanic or Latino individuals, 5.9% Asian individuals, and 2.9% other race and ethnicity. Female providers accounted for 53.3% of referrals, and male providers for 46.7%.
Table 1.
Patient and Provider Demographic Patterns Among Patients Referred for CAC Testing
| Group | Female provider, n (%) | Male provider, n (%) | Total, N (%) | Statistical test | |
|---|---|---|---|---|---|
| Overall | CAC referrals | 496 (53.3) | 435 (46.7) | 931 (100) | |
| Patient sex | Female patients | 382 (77.0) | 171 (39.3) | 553 (59.4) |
χ2=136.6; P<0.0001 |
| Male patients | 114 (23.0) | 264 (60.7) | 378 (40.6) | ||
| Sex‐concordant referrals | 382/496 (77.0) | 264/435 (60.7) | … | ||
| Patient race and ethnicity | Asian | 27 (5.6) | 26 (6.3) | 53 (5.9) |
χ2=29.6; P<0.0001 |
| Black | 134 (27.7) | 56 (13.5) | 190 (21.2) | ||
| Hispanic or Latino | 57 (11.8) | 48 (11.6) | 105 (11.7) | ||
| White | 255 (52.8) | 269 (64.8) | 524 (58.4) | ||
| Other | 10 (2.1) | 16 (3.9) | 26 (2.9) |
Values are n (%) unless otherwise indicated. Percentages in the female provider and male provider columns are column percentages representing referrals made by providers of each sex. Sex‐concordance values are also reported using patient sex denominators. Race and ethnicity analyses by provider sex were limited to patients with available race and ethnicity and provider sex data. χ2 tests were used for comparisons shown. CAC indicates coronary artery calcium.
Sex concordance between patients and providers was substantial. Among women, 69.1% were referred by female providers; among men, 69.8% were referred by male providers (χ2=136.6, P<0.0001). Among referrals made by female providers, 77.0% were for female patients; among referrals made by male providers, 60.7% were for male patients.
Racial and ethnic distributions also differed by provider sex. Female providers referred a higher proportion of Black patients (27.7% versus 13.5%) and a lower proportion of White patients (52.8% versus 64.8%) than male providers (χ2=29.6, P<0.0001). Separately, patient race and ethnicity distribution differed significantly across provider race and ethnicity categories (Fisher's exact test, P=0.0005), supporting the presence of racial and ethnic concordance patterns among completed CAC referrals.
These findings demonstrate significant demographic concordance between patients undergoing CAC testing and their referring clinicians within a single academic center. Even within a standardized preventive imaging pathway, significant associations were observed between patient demographics and referring clinician characteristics.
Persistent sex‐ and race‐based disparities in preventive cardiology have been attributed to factors including implicit bias, differential patient–provider communication, and structural barriers to specialty care. 1 , 2 Within this broader context, the demographic concordance observed in CAC referrals highlights the importance of evaluating how preventive cardiovascular technologies are implemented across diverse patient populations.
A key limitation of this analysis is the absence of denominator data for the full panel of patients evaluated by each clinician. Because the data set includes only patients who completed CAC testing, we cannot determine whether the observed concordance reflects referral propensity, patient preference for demographically concordant providers, underlying provider panel composition, or broader workforce patterns.
As CAC testing frequently reclassifies atherosclerotic cardiovascular disease risk and informs statin initiation, demographic patterns in access to testing may have downstream implications for preventive therapy use. Patient–provider demographic concordance has been observed in other health care settings and may reflect patient preference, geographic distribution, or workforce composition. 3 Whether the magnitude of concordance observed in CAC referrals exceeds background patterns in routine outpatient care remains unknown and warrants further investigation.
Future phases of this study will extend analyses across multiple years and incorporate denominator data from full provider panels to evaluate the proportion of eligible patients referred for CAC testing by demographic subgroup. Such analyses will enable a more robust evaluation of referral patterns over time and help clarify mechanisms underlying these associations. Future work will also examine how CAC scores themselves influence downstream preventive therapies and cardiovascular outcomes in real‐world practice.
In summary, this pilot study of CAC referrals at a large urban academic center demonstrated significant sex and race concordance between patients undergoing CAC testing and their referring clinicians. Although referral propensity cannot be determined without denominator data, the magnitude of concordance observed in referrals to a preventive imaging modality that directly informs atherosclerotic cardiovascular disease risk assessment highlights the importance of further evaluating demographic influences within cardiovascular prevention pathways. These findings provide early insight into demographic patterns in preventive cardiovascular imaging referrals within contemporary clinical practice. Multicenter studies incorporating clinical indications, full provider panels, and longitudinal outcomes are warranted to clarify underlying mechanisms and ensure equitable implementation of preventive cardiology strategies.
Sources of Funding
None.
Disclosures
Dr Volgman has received research support from Novartis, Janssen, and the National Institutes of Health. She has served as a consultant for Zoll, BMS, Omron, Sanofi, Janssen, Chiesi, and Regeneron. The remaining authors have no disclosures to report.
Supporting information
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This manuscript was sent to Olufunmilayo H. Obisesan, MD, MPH, Assistant Editor, for review by expert referees, editorial decision, and final disposition.
Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/JAHA.125.048298
For Sources of Funding and Disclosures, see page 3.
References
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