Removal of Race Correction for Pulmonary Function Testing Could Worsen Disparities in Lung Cancer Surgeries

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This new analysis demonstrated the importance of carefully considering the unintended results of removing race correction from PFTs to prevent exacerbating disparities among Black patients.

Eliminating the use of race correction in pulmonary function test (PFTs) could affect surgeons' choices, according to new findings, though the removal of the correction should be followed by initiatives to enhance surgeons’ knowledge of PFT modifications and explore different diagnostic methods.1

These findings came from a recent study examining the clinical implications of attempting to remove race correction for patients who are African American and having surgery to treat lung cancer.

Surgeons often use preoperative PFTs—more specifically the forced expiratory volume in 1 second (FEV1)—to determine surgical risk and to provide treatment advice; for African American individuals, the predicted FEV1 is notably often adjusted for race, which can then lead to an artificially elevated race-corrected percent predicted FEV1 versus using a race-neutral prediction technique.2

This new research was authored by Sidra N. Bonner, MD, MPH, MSc, from the Section of General Surgery at the University of Michigan, Ann Arbor.

“In this context, we used a multimethods approach to examine the implications of removing race correction in PFTs for health care systems, patients, and surgeons,” Bonner and colleagues wrote.

Background and Findings

As far as methodology is concerned, the investigators conducted a quality improvement investigation with communication being established with hospitals taking part in a statewide quality collaborative to determine the use of race correction in PFTs.

Those hospitals applying race correction were given an assessment of their percent predicted preoperative as well as their postoperative forced expiratory volume in 1 second (FEV1) for African American study participants who reported lung cancer resection between January of 2015 and September of 2022. The team did this using both race-corrected as well as race-neutral equations.

Later on, cardiothoracic surgeons who were known to be based in the US were randomly assigned to then be given distinct clinical vignettes which would involve the Global Lung Function Initiative equations. Each one was tailored for, first, African American patients who had a percent predicted postoperative FEV1 of 49%, second, individuals of other races or with multiracial backgrounds who showed a percent predicted postoperative FEV1 of 45%, and third, individuals who did not have race considered and also had a percent predicted postoperative FEV1 of 42%.

The major points of the research team’s work involved pointing out the amount of hospitals which were found to have used race correction in their PFTs, assessing alterations in both the preoperative as well as postoperative FEV1 estimations that were attributable to race-neutral or race-corrected equations. They also sought to appraise the treatment recommendations which had been provided by surgeons in the research and which were based upon the clinical vignettes.

The research team ended up with 515 African American study participants involved, with 59.8% being female and the mean age being about 66.2 years. The team reported that 93.8% of the hospitals did lung cancer resections for participants who were African American, using the race correction in the hospitals’ preoperative PFTs and leading to 91.8% of their patients reporting race-corrected PFTs.

Among this group of participants, the use of race-neutral equations was found by the investigators to potentially lead to a 9.2% decrease in predicted preoperative FEV1 as well as a 7.6% decrease in predicted postoperative FEV1.

Additionally, the research team randomized 225 surgeons, and these doctors did risk perception and treatment outcome assessments; the team found that those who had been exposed to African American race-corrected PFT vignettes were shown to be more commonly recommending lobectomy at 79.2%, versus those exposed to other race or multiracial-corrected PFT vignettes at 61.7%, or race-neutral at 52.8%.

“Surgeons exposed to race-neutral PFT values were less likely to offer surgery than surgeons exposed to race-corrected PFTs,” they wrote. “These results highlight the need to carefully consider the potential unintended consequences of removing race correction from PFTs to avoid exacerbating existing racial disparities in lung cancer surgery.”

References

  1. Bonner SN, Lagisetty K, Reddy RM, Engeda Y, Griggs JJ, Valley TS. Clinical Implications of Removing Race-Corrected Pulmonary Function Tests for African American Patients Requiring Surgery for Lung Cancer. JAMA Surg. Published online August 16, 2023. doi:10.1001/jamasurg.2023.3239.
  2. Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight - reconsidering the use of race correction in clinical algorithms. N Engl J Med. 2020;383(9):874-882. doi:10.1056/NEJMms2004740.
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