SCORE2 cardiovascular risk prediction models in an ethnic and socioeconomic diverse population in the Netherlands: an external validation study

Abstract

Background: Socioeconomic status and ethnicity are not explicitly incorporated as risk factors in the four SCORE2 cardiovascular disease (CVD) risk models developed for country-wide implementation across Europe (low, moderate, high and very-high model). The aim of this study was to evaluate the performance of the four SCORE2 CVD risk prediction models in an ethnic and socioeconomic diverse population in the Netherlands.

Methods: The SCORE2 CVD risk models were externally validated in socioeconomic and ethnic (by country of origin) subgroups, from a population-based cohort in the Netherlands, with GP, hospital and registry data. In total 155,000 individuals, between 40 and 70 years old in the study period from 2007 to 2020 and without previous CVD or diabetes were included. Variables (age, sex, smoking status, blood pressure, cholesterol) and outcome first CVD event (stroke, myocardial infarction, CVD death) were consistent with SCORE2.

Findings: 6966 CVD events were observed, versus 5495 events predicted by the CVD low-risk model (intended for use in the Netherlands). Relative underprediction was similar in men and women (observed/predicted (OE-ratio), 1.3 and 1.2 in men and women, respectively). Underprediction was larger in low socioeconomic subgroups of the overall study population (OE-ratio 1.5 and 1.6 in men and women, respectively), and comparable in Dutch and the combined "other ethnicities" low socioeconomic subgroups. Underprediction in the Surinamese subgroup was largest (OE-ratio 1.9, in men and women), particularly in the low socioeconomic Surinamese subgroups (OE-ratio 2.5 and 2.1 in men and women). In the subgroups with underprediction in the low-risk model, the intermediate or high-risk SCORE2 models showed improved OE-ratios. Discrimination showed moderate performance in all subgroups and the four SCORE2 models, with C-statistics between 0.65 and 0.72, similar to the SCORE2 model development study.

Interpretation: The SCORE 2 CVD risk model for low-risk countries (as the Netherlands are) was found to underpredict CVD risk, particularly in low socioeconomic and Surinamese ethnic subgroups. Including socioeconomic status and ethnicity as predictors in CVD risk models and implementing CVD risk adjustment within countries is desirable for adequate CVD risk prediction and counselling.

Funding: Leiden University Medical Centre and Leiden University.

Keywords: Cardiovascular disease; Ethnicity; Health disparities; Risk factors; Socioeconomic factors.

Fig. 1

OE-ratio external validation SCORE2 by ethnicity and socioeconomic status. OE-ratio, observed risk/mean predicted probability (<1 overprediction, >1 underprediction), the OE-ratio is an overall assessment of the correspondence of the predicted probability compared to the actual observed risks. 1st–5th SES, socioeconomic status, by disposable household income, in quintiles of the population of the Netherlands, 1st SES is lowest, 5th SES is highest. Low-, moderate-, high- and very-high-risk model, the four SCORE2 models for different regions of Europe, the low-risk model is the intended model for the Netherlands.

Fig. 2

Calibration plots, SCORE2 low-risk model by ethnicity (LOESS plotted). Calibration plots, asses model fit by graphically comparing predicted probability to the proportion of observed events in decile groups of the population. Loess, locally estimated scatterplot smoothing.