Physicians often use algorithms incorporating race for risk assessment, diagnosis, and treatment guidance, but David S. Jones, MD, PhD, of Harvard Medical School in Boston, and colleagues contend in a paper published in the New England Journal of Medicine that a race-based approach to medicine may perpetuate and amplify healthcare disparities.
The decision to adjust for race is often flawed because race is not a reliable proxy for genetic differences but may reflect other factors, according to the editorialists.
“Researchers and clinicians must distinguish between the use of race in descriptive statistics, where it plays a vital role in epidemiologic analyses, and in prescriptive clinical guidelines, where is can exacerbate inequities,” they wrote.
The authors gave examples of where using race-based determinations of risk may result in less than optimal treatment for black patients. The Modification of Diet in Renal Disease (MDRD) Study equation and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation for determining estimated glomerular filtration rate (eGFR) incorporate black race and yield higher eGFRs — and lower risks — for black than nonblack individuals. In this scenario, black patients with higher eGFRs may be referred less for specialty care and waitlisting for transplantation. Yet black patients are more prone to kidney failure than the US general population.
Similarly, the Kidney Donor Risk Index (KDRI) uses donor race to predict the risk that a kidney graft will fail. It confers a higher risk of graft failure (and less desirability) to black donors. Use of this tool may reduce the pool of black kidney donors in the United States. The American Heart Association Guidelines—Heart Failure Risk Score for predicting death in hospitalized patients categorizes black adults as lower-risk patients, raising the threshold for clinical resources for black patients.
The STONE score, which is used to predict the likelihood of kidney stones in emergency department patients with flank pain, confers a lower risk to black individuals, possibly precluding aggressive evaluations. A new model for predicting urinary tract infection in children also assigns lower risk to black patients and may deter testing.
The Rectal Cancer Survival Calculator, which incorporates, race predicts shorter survival for black versus white patients, perhaps discouraging clinicians from offering interventions.
“If doctors and clinical educators rigorously analyze algorithms that include race correction, they can judge, with fresh eyes, whether the use of race or ethnicity is appropriate,” the authors wrote. “In many cases, this appraisal will require further research into the complex interactions among ancestry, race, racism, socioeconomic status, and environment.”
They also observed, “Our understanding of race has advanced considerably in the past two decades. The clinical tools we use daily should reflect these new insights to remain scientifically rigorous.”
Vyas DA, Eisenstein LG, Jones DS. Medicine and society: Hidden in plain sight — Reconsidering the use of race correction in clinical algorithms [published online June 17, 2020]. N Engl J Med. doi: 10.1056/NEJMms2004740