Advancing Diagnostic Equity
By Ariqa Everett. Ariqa has degrees in biological sciences and African American studies and currently works as a program assistant for a Global Health organization.
Medical review by Diane B. Francis, PhD
Clinical equations or algorithms can play a huge role in patient care. Providers use them to calculate how much medicine to prescribe, the safe amount of anesthesia to use, and to predict the best treatment option. Algorithms are used to diagnose kidney and lung disease and to determine which method of childbirth is best for expecting mothers. These equations consider various factors, including your age, test results, and race. The role of race in medicine is still being debated. Some believe that racial and ethnic categories highlight a population's genetics and can be helpful in medical decision-making. Others point out that even if there was some small benefit, the harmful effects are much more significant as they carry on existing disparities in care.
Race has been added to clinical equations and guidelines as a “racial modifier,” adjusting an outcome. For example, racial modifiers were used by the NFL in brain testing to determine how much the organization would pay players that suffered from CTE. This brain condition leads to permanent damage. The algorithm assumed Black players started with a lower cognitive function and were less affected. False blanket assumptions led to Black players' compensation being denied, delayed, or decreased. Using racial modifiers in diagnostic tools can further inequities and increase poor health outcomes. In this article, we will explore how race can affect early diagnosis of chronic kidney disease, lung capacity, and why many Black babies are born by cesarean delivery.
Kidney and Lung Function Screening
What role do kidneys play in our health? Kidneys are our body's filtration system that removes waste from the blood. Proper kidney function helps maintain appropriate salt, water, and mineral levels. Early detection of kidney disease can be life-saving. To diagnose kidney disease, providers use an algorithm that measures the amount of creatinine in your body. If your kidneys are functioning correctly, you will have low creatinine levels. The most widely used equation considers your age, weight, and creatinine level, and includes a racial modifier, resulting in less severe cases. A Black person and a white person could share the same demographics – age, weight, creatinine level – but due to the modifier, a Black person would be viewed as having less severe kidney disease.
Chronic kidney disease (CKD) is the ninth leading cause of death in the U.S. CKD progresses more rapidly in Black people, so early and accurate diagnosis is essential to improving the mortality rate. Barriers like this impact diagnostic testing and interfere with patients' ability to participate in specific treatment measures like dialysis, radiology, and organ transplants. If the race modifier is removed from the equation, CKD could be diagnosed sooner, and the number of Black people dying from kidney disease could be significantly reduced.
A standard diagnostic tool for lung disease is the spirometry breathing test. You may have seen it before. It is the plastic canister with a spout that you use to inhale and exhale. Spirometry is one of the most commonly used methods to measure lung function. The algorithm used to read spirometry results includes racial modifiers for lung capacity. Lung capacity in Black people is assumed to be larger than that of whites by 10 to 15 percent and smaller in Asians by 4 to 6 percent. Removing racial modifiers could increase the number of people diagnosed and treated for lung issues.
Disparities in Childbirth
Black women are dying at a disproportionate rate due to pregnancy-related complications. In New York City, Black women are 9.4 times more likely to die from pregnancy complications than their white counterparts. While many factors contribute to the disparities we see in maternal health, the high rate of cesarean deliveries warrants some extra attention.
Just like in kidney disease and lung capacity tests, providers use a clinical equation to determine the risk of having a vaginal birth after a cesarean delivery (VBAC). VBAC is used as a risk calculator when combined with TOLAC. There are a few abbreviations but bear with me. TOLAC stands for Trial of Labor After a Cesarean; it describes a woman who recently had a baby through a c-section and wants to deliver the next child vaginally. TOLAC, VBAC, age, BMI, and race create an equation doctors use to determine how safe a vaginal delivery is after a previous c-section. Due to the race modifier, the equation predicts that Black and Hispanic women have a lower chance of a successful VBAC than white women of similar demographics and are administered more c-sections.
Attempting a vaginal birth after a c-section is risky, but so is having another surgery. C-sections increase the risk of pregnancy-related complications like postpartum hemorrhage, infections, organ injury, and hysterectomies. Black women are overrepresented in c-section data, and the increase hasn't improved outcomes.
Advancements Toward Diagnostic Equity
Policymakers and federal agencies have started to rethink the role of race in clinical diagnostic tools. Thanks to the advocacy of the Coalition to End Racism in Clinical Algorithms (CERCA), race-based guidelines have started to be replaced by evidence-informed policies, and racial modifiers are being removed. The VBAC calculator removed Black and Hispanic as a variable and now uses a patient's history of chronic hypertension. The National Kidney Foundation has also removed racial modifiers from the equation.
CERCA is leading the implementation of these new guidelines by creating a space for public health and healthcare to intersect while keeping anti-racism and equity at the center. Public health and clinical care leaders are committed to removing race modifiers and finding more equitable approaches. Increasing diversity in health professions, patient education on race-based algorithm limitations, and developing unbiased policies are just a few items on the agenda to advance health equity.
Next Steps in Moving Forward
Prep for your medical appointments by reading up on diagnostic tests related to your specific health concerns. Come to your appointment with questions to ask your provider. We know this can be overwhelming so use our Start Here resource.
Advocate for yourself and others. Be sure to share your concerns and opinions. You are the most important person on your healthcare team. Know your Patient Rights.
Document. Ask for a copy of your medical records for your own reference. This is a great way to hold your provider accountable and is useful if you ever need a second opinion.
Build community and a support system around you. Bring a trusted companion to your appointments for extra support or join groups focusing on your specific health concerns.
Lead. If you are a healthcare provider, examine how you currently engage with your patients. Consider joining our Pro Hub to connect with other experts committed to removing barriers to health equity.
Call to Action
DHH is expanding and amplifying research on inequities in diagnostic testing. We believe this topic impacts EVERYONE, as tests are the baseline for care and treatment of any health issue or disease. Stay tuned to learn with us, as we continue to report on what you need to know to advocate for yourself and others. Subscribe for the latest.
Sources
Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight — reconsidering the use of race correction in clinical algorithms. [Internet]. 2020;383:874–882. Available from: https://www.nejm.org/doi/full/10.1056/NEJMms2004740
Patient Rights. American Medical Association website. Accessed August 3, 2023. https://www.ama-assn.org/delivering-care/ethics/patient-rights
Coalition to End Racism in Clinical Algorithms (CERCA) Inaugural report. Accessed August 3, 2023. https://www.nyc.gov/assets/doh/downloads/pdf/cmo/cerca-report.pdf
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