When Black patients undergo a widely used spirometry test to measure lung function, their results differ from those of white patients. The test’s diagnostic algorithm makes adjustments based on a belief that Black children have smaller lung capacity due to innate biological differences. Spirometry is only one example of dozens of diagnostic algorithms and practice guidelines that adjust or “correct” outputs based on a patient’s race or ethnicity.
“Race-based adjustments come from the belief that race is a biological construct rather than a social construct. When we look at a lot of the clinical algorithms, they’ve adopted that assumption,” said Tyra Bryant-Stephens, MD, chief health equity officer of the Center for Health Equity at Children’s Hospital of Philadelphia (CHOP). “As we look at the science behind it, it doesn't make sense that your skin color would predict your outcomes.”
Physicians use these algorithms to make risk assessments and guide clinical decisions, which can result in less aggressive or proactive treatment protocols. For example, adjustments in a common measurement of kidney function are based on a presumption that Black patients have higher muscle mass and creatinine generation rates than patients of other races. This assumption can lead to delayed diagnoses of kidney disease and transplant referrals.
In 2022, the American Academy of Pediatrics called for eliminating race-based medicine and since then has revised many guidelines, including a guideline calculation based on the idea that Black children were at lower risk of urinary tract infections than white children.
In 2023, CHOP and several health care organizations in the Philadelphia area joined a coalition to remove race adjustments from 15 commonly used clinical decision support tools that could adversely impact patient outcomes. The Regional Coalition to Eliminate Race-Based Medicine is focusing on both adult and pediatric race-based clinical decision support tools, including:
- Pulmonary-function tests/spirometry.
- Kidney donor risk index.
- Heart failure risk score.
- Race-based anemia guidelines.
- Arteriosclerosis and cardiovascular disease risk estimator.
To select the specific tools for analysis, the Regional Coalition leaned on guidance from research published in 2020 titled, Hidden in Plain Sight—Reconsidering the Use of Race Correction in Clinical Algorithms. While many of the protocols are more commonly used in adult medicine, Bryant-Stephens hopes the coalition’s future areas of focus will have a profound impact on the region’s children.
“We will be working to identify more pediatric-specific areas in the future. Things like hyperbilirubinemia and pulse oximetry in neonates—we’ll look to see if there are some ways to improve those tests by removing race as a consideration,” Bryant-Stephens said.
Advice: Arrange logistics first
While the Regional Coalition is focused on health care entities in greater Philadelphia, the group wants to see their work spread to help address the root causes of health inequity more broadly.
Bryant-Stephens said health care organizations face two main challenges when undertaking this endeavor:
- Leveraging the available science to achieve provider approval.
- Navigating systemic and technological hurdles required to make large-scale changes to electronic medical records and other patient-related systems.
The key: don‘t act too quickly.
“Before you try to roll it out, make sure the infrastructure is there,” Bryant-Stephens said. “If you have the training but the infrastructure is not there to support it, the providers may no longer be bought in by the time you get it built. Timing is everything.”
