At issue is whether racial considerations may lead to inequitable care for patients who are not white. A study published June 17 in the New England Journal of Medicine (NEJM) found that when doctors incorporate race into certain medical formulas and decision-making processes, Black patients may be put at a disadvantage when it comes to accessing medications, therapies, emergency room care, surgeries, and even organ transplant. Many patients may be unaware that these race-based adjustments are even happening. The study authors reviewed prior research about race-adjusted healthcare calculations and found more than a dozen instances where they skewed care. “A goal of our study was to think about revisiting instances of race adjustment that already exist in clinical algorithms, and to explore how commonplace this practice is,” says the lead study author, Darshali Vyas, MD, a resident physician in internal medicine at Massachusetts General Hospital in Boston. “Another goal was to challenge when and whether race was being used appropriately.” RELATED: Black Americans Have Been Hit Hardest by COVID-19 — Here’s Why
How a Common Measure of Kidney Function May Create Bias
One race adjustment noted by Dr. Vyas and her collaborators involves a standard test used to measure kidney function and determine stages of kidney disease. This test, called estimated glomerular filtration rate (eGFR), provides a number that indicates how much creatinine (a waste product in the blood caused by normal wear and tear on muscles) is in a person’s system and how well the kidneys are working to remove it. As the National Kidney Foundation explains, eGFR drops as serum (blood) creatinine level rises. In general, the lower the eGFR, the worse the kidneys are functioning. If the eGFR is below 60 for three months or more, that can be an indicator of chronic kidney disease. A lab will calculate eGFR based on a blood sample and information about the patient, including age, gender, and race. If the physician indicates that the patient is Black, the eGFR readout will be higher than it would be for a non-Black patient, with the initial number multiplied by either 1.16 or 1.21. This adjustment for race could hide a Black patient’s serious kidney problem. “My position now is to not accept that and so I am using the non-adjusted eGFR for everyone,” says David Power, MBBS, a doctor and professor of family medicine and community health at the University of Minnesota in Minneapolis. Dr. Power, who is an advisory board member with the National Kidney Foundation, is currently caring for a Black female patient who has a non-adjusted eGFR score between 30 and 60, which may indicate stage 3 chronic kidney disease, according to the American Kidney Fund. “It went through my mind — if I used the Black adjustment, she’d be considered just about okay,” he says. Power adds that factoring in race could deprive a Black patient of potentially life-saving surgery. “If you’re getting your eGFR adjusted upwards, you may not be considered eligible for a transplant as a Black person, whereas without the adjustment, your eGFR may be below 20, which could make you eligible.” Why use a race adjustment? A University of Pennsylvania study, published in JAMA in June 2019 and referenced in the larger NEJM investigation, says that it may be linked to “an assertion that black individuals release more creatinine into the blood, perhaps because of more muscle mass.” But the UPenn scientists write that data supporting this premise is “inconclusive.” Dr. Vyas says that several institutions have moved to drop race from the eGFR equation, including Boston Medical Center, the University of Washington in Seattle, and University of California in San Francisco. RELATED: Diabetes in African Americans: How to Lower Your Risk
Considering Race-Based Risks When It Comes to Heart Problems
“Corrections” based on race also help guide decisions in cardiology. As one example, Vyas and her colleagues spotlight the American Heart Association (AHA) Get With the Guidelines Heart Failure Risk Score. This numerical assessment, which predicts the risk of death in patients with heart failure who are admitted to the hospital, assigns three additional points to any patient identified as “nonblack.” In effect, this adjustment identifies Black patients as lower risk, which may lead to treatment directed away from them and toward white patients, according to study authors. Such an adjustment may seem counterintuitive: Overall, deaths from heart disease are higher for Black Americans than white Americans, and African Americans generally develop heart disease at a younger age than people who are white, according to the Heart Foundation. African American men and women are also at increased risk for heart failure and develop symptoms of heart failure as much as 10 years younger, on average, than men and women in other racial or ethnic groups. “When hospitalized with heart failure, however, studies have shown that African American men and women are modestly less likely to have in-hospital and 30-day mortality compared with other race or ethnic groups,” says Gregg C. Fonarow, MD, the interim chief of UCLA’s division of cardiology and a longtime volunteer expert for the AHA. Dr. Fonarow points out that the AHA heart failure guidelines were formulated with good intentions: “The intended use was as one of many tools to potentially help inform clinicians regarding short-term risk during hospitalization for heart failure,” he says. “To date, analyses of these data suggest patients at participating hospitals [following the AHA guidelines] have had better clinical outcomes compared to hospitals not participating.” The NEJM study, however, suggests that the calculation creates a bias that may explain why Black patients coming to a Boston emergency department with heart failure were less likely than white patients to be admitted to the cardiology service. “We must exercise considerable thought in how we assess the association of race with clinical events, prediction models, and disease severity rankings,” says Clyde W. Yancy, MD, the vice dean of diversity and inclusion and the chief of the cardiology division at Northwestern University Feinberg School of Medicine in Chicago. Dr. Yancy, who is also a spokesperson for the AHA, adds that if race hadn’t been incorporated into the original data set, doctors would have missed factors such as the earlier onset of symptomatic heart failure in Blacks and the higher rate of hospitalization for acute episodes of heart failure. “The correction of bias [in healthcare] is not rooted in recalibration of risk scores but in a refocused awareness of provider and healthcare system bias,” says Yancy. RELATED: African Americans Who Smoke Are at Least Twice as Likely to Have Stroke, Study Finds
How Race May Factor Into Heart Surgery
Algorithms may indicate that Black patients are at higher risk when it comes to artery bypass and other heart surgeries. The authors of the NEJM study suggest that these calculations could steer minority patients away from such treatments. Sarah Samaan, MD, a cardiologist with Baylor Scott & White Legacy Heart Center in Plano, Texas, notes that if the risk seems too high, a patient may decide against an operation that could potentially save, extend, or improve his or her life. “As a general cardiologist, I am aware of such algorithms being used by surgeons and hospitals to determine surgical risk. When using such a calculator, surgeons or hospital administrators may not stop to question how or why the risk associated with race may have been determined,” says Dr. Samaan. “While it is true that Black Americans may be at higher risk for certain medical conditions, generalizations are fraught when we consider the uncertain impact of socioeconomic and geographical differences. In the case of healthcare, race is often a too simplistic way of quantifying differences among people.” RELATED: Discrimination’s Role in Hypertension in Black Americans
How Formulas Came to Incorporate Race Factors
In their NEJM study, Vyas and her collaborators explained that the rationale behind race-based adjustments often relies on verifiable, data-supported logic. Scientists examined data sets of clinical outcomes and patient characteristics and then performed analyses to identify which patient factors aligned significantly with the relevant outcomes. “Researchers then decided that it was appropriate — even essential — to adjust for race in their model,” wrote the study authors. Vyas says, “This in no way suggests that any of the developers of the algorithms themselves had malicious intent.” The question for her and her collaborators became: “If race does appear to correlate with clinical outcomes, does that justify its inclusion in diagnostic or predictive tools?” According to this investigation, the answer may be no: “If adjustments deter clinicians from offering clinical services to certain patients, they risk baking inequity into the system.” RELATED: Facing Common Health Threats Among African Americans
Why Now May Be the Time for Reevaluation and Change
Power suggests that awareness of systemic racism in medicine is greater than ever following the recent wave of Black Lives Matter protests. “We are much more aware that there are social barriers and social determinants that account for people’s health,” he says. “There remains a lot of social unrest, but the next generation and the medical community overall are very aware and involved in bringing about solutions.” For Vyas and colleagues, now is a crucial time to step back and reevaluate how race is incorporated into the medical field. “Researchers and clinicians must distinguish between the use of race in descriptive statistics, where it plays a vital role in epidemiological analyses, and in prescriptive clinical guidelines, where it can exacerbate inequities,” they concluded in the NEJM study. “Many groups have worked on racial justice within medicine and challenging race-based medicine,” says Vyas. “It will be interesting to see how we can continue to drive the conversation forward and reconsider how we’re using race in healthcare.”
