Greater Philly health systems remove race from clinical algorithms that guide decisions in kidney, lung and pregnancy care
The regional coalition of health systems is reevaluating the role of race in tools used to assess kidney and lung function and other health conditions.
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Thirteen health systems in Greater Philadelphia are working as a coalition to reevaluate what role race has played in tools and guidelines that doctors and nurses use to diagnose and treat patients.
Some tools involve clinical algorithms or calculators designed to help guide providers as they decide who should get certain treatments, medications or procedures, and when.
And for many decades, these algorithms factored in race, because previous research and data that has since been disproven had indicated that different races of people had biological differences that were important to treatment decisions.
For example, a tool called the eGFR score is used to determine a person’s kidney functioning, which is important in treating early kidney disease. It estimates the kidney filtration rate based on creatinine levels in the blood. The tool had used different numbers for Black patients since earlier research had found that they had higher creatinine levels in their blood. But experts now say that this meant that the tool often suggested that Black patients’ kidneys were functioning better than they really were.
“They look up and they see a face that they think is Black and they say, ‘Well, no, maybe it isn’t as bad anymore,’” said Dr. Abiona Berkeley, an anesthesiologist at Temple University Health System. “So, you’re late to diagnosis and you’re late to treatment.”
Spirometry is a lung function test that can help diagnose and monitor asthma, cystic fibrosis and other lung disorders. But calculations assumed that Black and Asian patients inherently have a smaller lung capacity compared to their white counterparts, so the test has failed to detect lung disease in many of these patients.
Providers now hope that by removing race as a factor, people will be more accurately evaluated for health conditions and get earlier access to care.
“At the end of the day, race is a social construct, it’s not a scientific one,” said Berkeley, who is also the interim senior associate dean of Diversity, Equity and Inclusion at Temple’s Lewis Katz School of Medicine. “It’s great to be in the space where we can start to deconstruct that. And that’s what we’re doing right now. We’re really sitting down and dismantling it.”
The regional coalition, which convenes under Independence Blue Cross, has so far removed race from clinical algorithms used in kidney function assessment, lung function testing, a calculator that estimates likelihood of a successful vaginal birth after cesarean (VBAC), and race-based gestational anemia guidelines.
“Now we are more proactive about Black people’s kidney health, and hopefully we see less people who end up with chronic kidney disease or on dialysis or needing a kidney transplant,” said Sean Ross, a family nurse practitioner and executive director of health equity at Independence Blue Cross.
Pharmacist Christine Roussel, senior executive director of pharmacy, laboratory and medical research at Doylestown Health, said providers are already seeing patients, especially Black patients, move up on the kidney transplant waiting list by several years after their eGFR scores were adjusted, “which is profound.”
The coalition supported the removal of race from the Kidney Donor Risk Index, which national organ and transplant networks use to calculate organ function of deceased donations. Advocates say the change should make more kidneys available, particularly from Black donors.
Leaders also hope that more Black and Hispanic mothers will be better informed about their labor and delivery options and get earlier proactive treatment for anemia, and that Black and Asian patients get earlier diagnoses and treatment for lung disease, more on par with their white counterparts.
“The coalition really opened my eyes to how extensive the problem was,” Roussel said. “I was really grateful when I got involved to be like, ‘Oh my gosh, there’s so much more work that we need to do.’”
Moving forward, the coalition plans to reevaluate how race is used in other clinical tools and algorithms that calculate risks for arteriosclerosis and cardiovascular disease, fractures, osteoporosis, pediatric urinary tract infections, breast cancer, heart failure and more.
Their focus areas are based on findings outlined in an article titled “Hidden in Plain Sight,” published in the New England Journal of Medicine in 2020. Researchers analyzed the level of understanding of race and human genetics among physicians and health care providers, and identified gaps in guidelines on clinical decision making.
“Our knowledge evolves,” Roussel said. “Our ability to look at the same data and form different theories related to them and to test them continues to evolve, and we’re always trying to do the best we can for our patients. That’s the best part of medicine, it’s forever changing, forever evaluating.”
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