The End of Race Correction in Spirometry for Pulmonary Function Testing and Surgical Implications

Bonner, Sidra N.; Wakeam, Elliot

doi:10.1097/sla.0000000000005431

Cited by 10 publications

(12 citation statements)

References 12 publications

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“…Surgeons were more than 25 percentage points less likely to recommend lobectomy when race-neutral values were used compared with African American race–corrected values. Taken together, these results demonstrate that transitioning from race-corrected to race-neutral equations could have broad impact, could result in unintended harm to African American patients with lung cancer, and may widen existing disparities in lung cancer treatment …”

Section: Discussionmentioning

confidence: 77%

“…The presence of race correction in clinical algorithms, including PFTs, is rooted in racist beliefs regarding the bio- logical inferiority of African Americans. [4][5][6]17 However, our findings highlight that removing race correction cannot happen in isolation and must occur alongside large-scale efforts to develop interventions to educate clinicians, improve shared decision-making with patients, and create new guidelines and preoperative diagnostic studies of lung function for lung cancer surgery.…”

Section: Discussionmentioning

confidence: 96%

“…Taken together, these results demonstrate that transitioning from race-corrected to race-neutral equations could have broad impact, could result in unintended harm to African American patients with lung cancer, and may widen existing disparities in lung cancer treatment. 17,18 Prior research 4,7-10 focused on race correction in PFTs has focused on medical conditions without considering the effect on surgical decision-making. For instance, a prior assessment 10 of the use of race correction in PFTs among biracial pediatric patients demonstrated a 15% difference in predicted FEV 1 values based on whether the patient's racial category was selected as African American or White.…”

Section: Discussionmentioning

confidence: 99%

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Clinical Implications of Removing Race-Corrected Pulmonary Function Tests for African American Patients Requiring Surgery for Lung Cancer

et al. 2023

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ImportanceRemoval of race correction in pulmonary function tests (PFTs) is a priority, given that race correction inappropriately conflates race, a social construct, with biological differences and falsely assumes worse lung function in African American than White individuals. However, the impact of decorrecting PFTs for African American patients with lung cancer is unknown.ObjectivesTo identify how many hospitals providing lung cancer surgery use race correction, examine the association of race correction with predicted lung function, and test the effect of decorrection on surgeons’ treatment recommendations.Design, Setting, and ParticipantsIn this quality improvement study, hospitals participating in a statewide quality collaborative were contacted to determine use of race correction in PFTs. For hospitals performing race correction, percent predicted preoperative and postoperative forced expiratory volume in 1 second (FEV1) was calculated for African American patients who underwent lung cancer resection between January 1, 2015, and September 31, 2022, using race-corrected and race-neutral equations. US cardiothoracic surgeons were then randomized to receive 1 clinical vignette that differed by the use of Global Lung Function Initiative equations for (1) African American patients (percent predicted postoperative FEV1, 49%), (2) other race or multiracial patients (percent predicted postoperative FEV1, 45%), and (3) race-neutral patients (percent predicted postoperative FEV1, 42%).Main Outcomes and MeasuresNumber of hospitals using race correction in PFTs, change in preoperative and postoperative FEV1 estimates based on race-neutral or race-corrected equations, and surgeon treatment recommendations for clinical vignettes.ResultsA total of 515 African American patients (308 [59.8%] female; mean [SD] age, 66.2 [9.4] years) were included in the study. Fifteen of the 16 hospitals (93.8%) performing lung cancer resection for African American patients during the study period reported using race correction, which corresponds to 473 African American patients (91.8%) having race-corrected PFTs. Among these patients, the percent predicted preoperative FEV1 and postoperative FEV1 would have decreased by 9.2% (95% CI, −9.0% to −9.5%; P &lt; .001) and 7.6% (95% CI, −7.3% to −7.9%; P &lt; .001), respectively, if race-neutral equations had been used. A total of 225 surgeons (194 male [87.8%]; mean [SD] time in practice, 19.4 [11.3] years) were successfully randomized and completed the vignette items regarding risk perception and treatment outcomes (76% completion rate). Surgeons randomized to the vignette with African American race–corrected PFTs were more likely to recommend lobectomy (79.2%; 95% CI, 69.8%-88.5%) compared with surgeons randomized to the other race or multiracial–corrected (61.7%; 95% CI, 51.1%-72.3%; P = .02) or race-neutral PFTs (52.8%; 95% CI, 41.2%-64.3%; P = .001).Conclusions and RelevanceGiven the findings of this quality improvement study, surgeons should be aware of changes in PFT testing because removal of race correction PFTs may change surgeons’ treatment decisions and potentially worsen existing disparities in receipt of lung cancer surgery among African American patients.

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Section: Discussionmentioning

confidence: 77%

Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 99%

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Clinical Implications of Removing Race-Corrected Pulmonary Function Tests for African American Patients Requiring Surgery for Lung Cancer

et al. 2023

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“…In an analysis of the clinical implications of race-based pulmonary function tests (PFTs), Bonner et al explored the implications of removing race correction in PFTs. The authors demonstrated significant differences in thoracic surgeons’ perceptions of clinical management for a hypothetical African American patient with lung cancer.…”

mentioning

confidence: 99%

“…The authors demonstrated significant differences in thoracic surgeons’ perceptions of clinical management for a hypothetical African American patient with lung cancer. By using a randomized clinical vignette of an African American woman with lung cancer, the authors demonstrated how treatment recommendations and risk perception would change among thoracic surgeons when interpreting risk for the same patient with a percent predicted postoperative forced expiratory volume in 1 second (FEV 1 ) that was calculated using a standard of care Global Lung Initiative (GLI) race-corrected, GLI other race or multiracial–corrected, or GLI race-neutral equation …”

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confidence: 99%

Removing Structural Racism in Pulmonary Function Testing—Why Nothing Is Ever Easy

Medlock

Cooke

2023

JAMA Surg

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In an analysis of the clinical implications of race-based pulmonary function tests (PFTs), Bonner et al 1 explored the implications of removing race correction in PFTs. The authors demonstrated significant differences in thoracic surgeons' perceptions of clinical management for a hypothetical African American patient with lung cancer. By using a randomized clinical vignette of an African American woman with lung cancer, the authors demonstrated how treatment recommendations and risk perception would change among thoracic surgeons when interpreting risk for the same patient with a percent predicted postoperative forced expiratory volume in 1 second (FEV 1 ) that was calculated using a standard of care Global Lung Initiative (GLI) race-corrected, GLI other race or multiracial-corrected, or GLI race-neutral equation. 1 With 15 of 16 hospitals in a statewide collaborative reporting using race correction in PFTs for African American patients, the unnecessary use of race in medicine affected 91.8% of African American patients in the statewide collaborative. However, as the authors demonstrate, decorrecting PFT values may result in fewer of these patients qualifying for potentially curative lung resection. Surgeons randomized to assess the percent predicted postoperative FEV 1 race-corrected values were significantly more likely to recommend lobectomy compared with surgeons randomized to the race-neutral equation values.

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

et al. 2023

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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.

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The End of Race Correction in Spirometry for Pulmonary Function Testing and Surgical Implications

Cited by 10 publications

References 12 publications

Clinical Implications of Removing Race-Corrected Pulmonary Function Tests for African American Patients Requiring Surgery for Lung Cancer

Clinical Implications of Removing Race-Corrected Pulmonary Function Tests for African American Patients Requiring Surgery for Lung Cancer

Removing Structural Racism in Pulmonary Function Testing—Why Nothing Is Ever Easy

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

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