Free CAC Scans for ASCVD Risk Capture More Women, Minorities, and Low-Income Adults

A program offering free coronary artery calcium (CAC) scans for cardiovascular risk assessment led to significantly increased use of the imaging test among several subgroups not typically captured with testing, according to a study recently published in the Journal of the American College of Cardiology.

Free scans at the University Hospitals Health System, one of the largest health providers in northeast Ohio, led to an average 546% monthly increase in CAC screening when compared to typical use when they charged $99 for the imaging test. The patients receiving free CAC testing more likely to be older, female, African-American, and live in areas with lower median household incomes when compared with the era where hospitals charged for the tests. Importantly, the median 10-year risk of ASCVD for those coming in for free testing was 7.5%, significantly higher than when patients were charged for screening.

“It’s an incredibly unique program,” senior investigator Sanjay Rajagopalan, MD (University Hospitals/Case Western Reserve University School of Medicine, Cleveland, OH), told TCTMD. “It’s one of the only free programs in the world. We strongly felt that living in a community like Cleveland we have a responsibility to provide information that could be helpful to patients, just like you’d provide lung screening or mammography. . . . Calcium scoring, just to put it mildly, is the best test out there for prognostication of coronary artery disease.”

In 2014, University Hospital Health System, which includes 21 radiology locations where the test is offered, launched a low-charge program to decrease the cost of CAC screening to $99. At the time, many hospitals and centers were charging $500 or more for screening, said Rajagopalan, and their low-fee program led to a significant increase in utilization. They pushed the envelope further in 2015 when they tested a pilot program of free CAC screening and fully implemented that program in 2017.

To assess the utilization of the free program, the researchers analyzed its use among men 45 years or older/women 55 year or older with no history of ASCVD but with either one cardiovascular risk factor (for men) or the presence of a chronic inflammatory condition (for men and women ≥ 40 years). They studied all patients who underwent CAC screening from 2014, when they first implemented the low-charge CAC screening program, to April 2019. In total, 5,109 and 22,357 patients underwent CAC testing during the low-charge and no-charge phases, respectively.

With low-charge CAC testing, 46.0% of those screened were women, a percentage that increased to 51.0% when free screening was put in place. Similarly, the percentage of African Americans rose from 7.2% to 9.4% when they shifted from low-charge to no-charge CAC screening. The percentage of individuals with annual family incomes less than $60,000 USD who were screened increased from 44.0% with the low-charge program to 49.0% when it was available for free. Finally, when screening cost $99, the mean 10-year ASCVD risk of those tested was 6.4% but this increased to 7.5% when CAC screening cost nothing. These changes from the low- to no-charge programs were all statistically significant.

Among those considered low risk using the ASCVD pooled cohort equation, 8.0% had a CAC score ≥ 100. On the other hand, 36% and 15% of those at intermediate and high risk had a CAC score of zero. Overall, CAC screening reclassified ASCVD risk in 2,026 patients, or roughly one in five individuals. When compared with individuals with zero calcification, those with a CAC score > 400 were significantly more likely to be prescribed a statin, including high-intensity therapy, and aspirin.

Free Testing Once Disparaged

To TCTMD, Rajagopalan said free CAC screening programs can help provide personalized care for patients, some of whom would not undergo testing due to financial barriers. “The no-charge program was very welcome, patients liked it, and since then it’s been extraordinary,” he said. “What this has really done is that it has identified higher-risk patients so that they can be stratified for treatment at an earlier time.”

Michael Blaha, MD (Johns Hopkins Medicine, Baltimore, MD), a proponent of CAC screening for ASCVD risk assessment, said no-charge screening was initially looked down upon by the cardiology community because of its potential for abuse. For example, before CAC testing was endorsed by the American College of Cardiology (ACC) and American Heart Association (AHA) in the most recent cholesterol guidelines, some worried about the unsavory practice of using CAC to further identify people for stress testing, and with a positive stress test, to have those patients go on for coronary interventions.   

“We’ve clearly moved away from that model,” said Blaha. “We’re in an era where we look at the calcium score as a predictor of risk and where the burden of disease is the best predictor of risk. In the era of COURAGE and ISCHEMIA, we’re hopefully not doing anything to these patients except treating them medically. So I think we’re in a new world of no-cost calcium scoring where it’s no longer a business model for a healthcare system but hopefully just a common-sense way to get people treated. In this case, get the people we’re missing out on and who don’t have as much engagement with the healthcare system.”

While CAC screening has the potential to trigger unnecessary procedures, Rajagopalan said that has not been their experience.

Blaha pointed out that the no-charge program led to patients at slightly higher risk coming in for tests. “It’s a legitimate concern that all you’d really attract with free testing is healthy people, but that wasn’t the case,” he said. “What they achieved is important—they mostly got the appropriate people who were largely left out of proactive screening programs in the past.”  

Rajagopalan acknowledged that it has never been demonstrated in a randomized controlled trial that use of CAC testing translates into a significant reduction in cardiovascular events when compared with other measures of risk assessment. While that’s a drawback, he noted that traditional risk calculators, such as the ACC/AHA pooled cohort equation, don’t have this level of evidence either. “At the end of the day, a lot of things we do in medicine don’t have all the evidence,” he said.

In Europe, one prospective trial is underway. The ROBINSCA study is look at whether CAC testing in asymptomatic subjects followed by preventive medical therapy reduces the risk of coronary heart disease morbidity and mortality when compared with screening using the SCORE risk assessment model. Rajagopalan said he believes that CAC screening offers other advantages over traditional risk calculators such as SCORE and the ACC/AHA pooled cohort equations, noting there are studies showing that patients informed of a high CAC score make positive changes, including adherence to medical therapy. 

“In our experience, and we’ve now done more than 30,000 no-charge coronary calcium scoring tests over the last several years, it results in patient empowerment, which is very important,” he said. “It tells people that you have something—they see a picture, or they see a report that says they have atherosclerosis—and they’re empowered. They want to do the right thing, to take their medication, exercise.”

The approach is much clearer for patients than hearing they a 5% risk of ASCVD events in the next 10 years, he said.