Global, Race-Neutral Reference Equations and Pulmonary Function Test Interpretation

Abstract

ImportanceRace and ethnicity are routinely used to inform pulmonary function test (PFT) interpretation. However, there is no biological justification for such use, and it may reinforce health disparities.ObjectiveTo compare the PFT interpretations produced with race-neutral and race-specific equations.Design, Setting, and ParticipantsIn this cross-sectional study, race-neutral reference equations recently developed by the Global Lung Function Initiative (GLI) were used to interpret PFTs performed at an academic medical center between January 2010 and December 2020. The interpretations produced with these race-neutral reference equations were compared with those produced using the race and ethnicity–specific reference equations produced by GLI in 2012. The analysis was conducted from April to October 2022.Main Outcomes and MeasuresThe primary outcomes were differences in the percentage of obstructive, restrictive, mixed, and nonspecific lung function impairments identified using the 2 sets of reference equations. Secondary outcomes were differences in severity of these impairments.ResultsPFTs were interpreted from 2722 Black (686 men [25.4%]; mean [SD] age, 51.8 [13.9] years) and 5709 White (2654 men [46.5%]; mean [SD] age, 56.4 [14.3] years) individuals. Among Black individuals, replacing the race-specific reference equations with the race-neutral reference equations was associated with an increase in the prevalence of restriction from 26.8% (95% CI, 25.2%-28.5%) to 37.5% (95% CI, 35.7%-39.3%) and of a nonspecific pattern of impairment from 3.2% (95% CI, 2.5%- 3.8%) to 6.5% (95% CI, 5.6%-7.4%) and no significant change in the prevalence of obstruction (19.9% [95% CI, 18.4%-21.4%] vs 19.5% [95% CI, 18.0%-21.0%]). Among White individuals, replacing the race-specific reference equations with the race-neutral reference equations was associated with a decrease in the prevalence of restriction from 22.6% (95% CI, 21.5%-23.6%) to 18.0% (95% CI, 17.0%-19.0%), a decrease in the prevalence of a nonspecific pattern of impairment from 8.7% (95% CI, 7.9%-9.4%) to 4.0% (95% CI, 3.5%-4.5%), and no significant change in the percentage with obstruction from 23.9% (95% CI, 22.8%-25.1%) to 25.1% (95% CI, 23.9%- 26.2%). The race-neutral reference equations were associated with an increase in severity in 22.8% (95% CI, 21.2%-24.4%) of Black individuals and a decrease in severity in 19.3% (95% CI, 18.2%-20.3%) of White individuals vs the race-specific reference equations.Conclusions and RelevanceIn this cross-sectional study, the use of race-neutral reference equations to interpret PFTs resulted in a significant increase in the number of Black individuals with respiratory impairments along with a significant increase in the severity of the identified impairments. More work is needed to quantify the effect these reference equations would have on diagnosis, referral, and treatment patterns.

The prevalence and mortality risks of PRISm and COPD in the United States from NHANES 2007–2012

“…In recent years, a substantive body of research has demonstrated the bias associated with use of race-specific predictive equations [ 26 , 29 , 34 , 36 ]. As such, we avoided the use of race-specific equations in all our analyses and opted to use Hankinson’s non-Hispanic White predictive equation for all races and the GLI race-neutral predictive equation in a secondary analysis.…”

“…Given recent debates over the merits of race-specific predicative equations for spirometry, [ 28 , 29 , 34 – 36 ] in addition to Hankinson’s non-Hispanic White predictive equation of lung function, we also applied a race-neutral reference equation to explore differences in COPD prevalence and mortality. We used the Global Lung Function Initiative’s (GLI) race-neutral predictive equation for this secondary analysis [ 35 ].…”

TITLE: Reference lung function of Nigerian school-age children measured with electronic peak flow meter: comparison with local and Global-Lung-Initiative equations

“…Our study is one of the first to evaluate the potential impact of the new race-neutral GLI-global equations as recommended by the ATS; 15 two studies recently reported their performances in non-African populations. 32,33 Clinical utility of PEF and FEV 1 Both PEF and FEV 1 are important in the diagnosis and monitoring of CRDs like asthma. [1][2][3]6 However, FEV 1 , being the most reproducible spirometric variable, is preferred over PEF as PEF is more likely to remain normal in the presence of severe airway obstruction.…”

“…However, the determination of which of these is best for our population requires bench-marking their relative performances to relevant clinical end-points/outcomes for our population and relevant disease groups. 15,23,32,33 Correlates and determinants Anthro-demographic measurements like standing height, weight, age, chest circumference, sitting height, chest volume and lower-limb-length are known to correlate positively with LF in children. Similar to previous reports among children, [10][11][12]22,31,[50][51][52][53][54][55] standing height was the most correlated with our PEF and FEV 1 .…”

Equity360: Gender, Race, and Ethnicity—The Power of AI to Improve or Worsen Health Disparities

“…Some clinical algorithms also have been identified as racially biased. For example, pulmonary function tests traditionally included a “race correction,” which resulted in Black patients being underdiagnosed regarding the prevalence and severity of pulmonary disease [19]. These are clinically important findings.…”