In rural Rwanda, the causes of heart failure are almost exclusively nonischemic even though patients often present with advanced symptoms. Training nurses, supervised by physicians, in simplified protocols and basic echocardiography is 1 approach to integrated, decentralized care for this vulnerable population.

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Our study results suggest that significant racial and ethnic disparities exist in the ESI scores assigned to patients during nursing triage evaluation and in the intensity of services provided during physician evaluation for patients presenting with the same acute chief symptoms. When nurses assign White patients more acute ESI scores at triage, they may also order diagnostic tests prior to a physician's involvement, leading to downstream increases in wRVUs. Additional decisions made at triage associated with race, ethnicity, and socioeconomic status, such as assignment to a room or hallway bed, may also influence physicians. 6 However, our findings suggest that when controlling for triage, significant racial and ethnic disparities persist in physicians' evaluations, particularly for Black and Hispanic patients.This study has several significant limitations, including a smaller proportion of patients identifying as Asian and American Indian or Alaska Native and a heterogenous other race or ethnicity category, limiting our ability to draw conclusions about these populations. More work is needed to determine where in the triage and physician evaluation processes these disparities arise and what can be done to remedy them.