An American Thoracic Society (ATS) workshop committee, which included many UCSF researchers, recently released an official statement recommending the use of race-neutral average reference equations for pulmonary function test (PFT) interpretation. This represents a departure from the long-standing use of race- and ethnicity-specific equations, a practice that may lead to underdiagnosis and undertreatment of lung disease in people of color.
“The use of race-specific equations does not achieve desirable clinical outcomes and has the potential to exacerbate the disparities in health care that already exist,” said UCSF pulmonologist Nirav Bhakta, MD, PhD, co-chair of the committee and first author of the statement.
An illusion of precision with race-specific equations
In 2021, the ATS convened a diverse panel of clinicians and investigators for a workshop to review the use of race and ethnicity in PFT interpretation, evaluate the clinical implications, and provide guidance to enable clinicians, investigators and patients to make informed decisions.
At the workshop’s conclusion, participants hadn’t reached the necessary consensus to make a recommendation. However, for nearly two years, they continued to discuss the topic and evaluate newly published evidence. This led to the recommended use of the Global Lung Function Initiative (GLI) average equation, known as GLI-Global, in PFT laboratories and clinical practice. This equation does not require race or ethnicity as an input in spirometry interpretation.
The statement provides reasons for this new recommendation, including:
- The superficial appearance of race should not be used to infer biological characteristics. Continued use of race in PFT interpretation risks perpetuating false ideas that race distinguishes people on the basis of innate and immutable features.
- Normalization of differences with race-specific equations in PFT interpretation potentially contributes to medical harms from the lack of attention to modifiable risk factors for reduced pulmonary function resulting from racism.
- Emerging evidence from the United States shows that, compared with a race-specific interpretation, use of a single set of reference equations better matches the relationship between pulmonary function and survival and incident chronic lung disease between Black and White persons.
“The use of race-specific equations does not have a good scientific basis,” Bhakta said. “The heterogeneity within racial groups, including the social, environmental and genetic influences on lung function, is so large that to say we’re achieving precision by using one equation for one person who looks a certain way and another equation for another person is really an illusion of precision.”
Evidence supports a race-neutral approach
“Fortunately, in the last few years, investigators have found that there is no scientific evidence to show a race-specific approach to clinical care was benefiting patients,” Bhakta said. “The data show that a race-neutral approach is superior for many clinical outcomes that are meaningful for patients’ lives.”
Some of this new evidence is a result of UCSF research. A December 2021 UCSF-led study concluded that using race-based equations to evaluate lung function in patients with COPD may underestimate disease severity in Black patients.
“This is a concrete example of structural racism in health care,” said UCSF pulmonologist Aaron Baugh, MD, first author of the study and coauthor of the ATS statement. “It is built into our system and delays lung transplants for Black patients, creating a higher standard for them to get disability for lung conditions, and biases doctors toward undertreatment.”
“The desire of the American Thoracic Society to respond to the scientific evidence allowed our group to convert the workshop report into an official statement,” Bhakta said.
Expanding diversity and equity in health care
In the statement, the panel highlights the need for research that expands population diversity, pulmonary disease types and PFTs beyond spirometry. UCSF investigators are participating in studies that will help fill these gaps, including:
Additional research is being conducted at the UCSF Airway Clinical Research Center and the UCSF Collaborative Learning for Equity and Respiratory Health Lab.
“UCSF has been a leader in examining the impact of race and racism on health care, including disparities in delivery and outcomes of care for patients with asthma, COPD and other pulmonary diseases,” Bhakta said. “The journey must continue.”
To learn more
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