Use of Race in Clinical Diagnosis and Decision Making: Overview and Implications

Table 1: Examples of Clinical Decision-Making Tools and Guidelines That Utilize Race
Calculator/Guideline Use Race Corrections Equity Implications Current Status
Atherosclerotic Cardiovascular Disease (ASCVD) Risk calculator Estimates 10-year ASCVD risk to provide guidance for statin therapy initiation Initial 10-year risk for ASCVD events is calculated to be higher for Black patients compared to all other patients with otherwise equivalent risk burden May lead to disproportionate prescription of statin therapy to Black patients Calculator that is used nationally has made race-correction factor optional
Spirometry calculator Measures lung function Uses a race corrected factor that increases estimates of lung function for Black and Asian patients (based on early epidemiological data) with origins in a spirometer created in the 1800s by Samuel Cartwright, a pro-slavery doctor May underestimate or misclassify disease in Black or Asian patients, which may limit ability to obtain disability benefits and receive lung disease treatment.

Removing race correction leads to finding more prevalent and severe lung disease among Black patients

American Thoracic Society Spirometry 2019 Update guides providers to input ethnicity into spirometry calculators, and multiple hospital institutions continue to utilize race in estimations of pulmonary function
Estimated Glomerular Filtration Rate (eGFR) Calculators (CKD-EPI equation and MDRD equation) Estimates renal function to guide transplant eligibility for donors and recipients Both clinical calculators employ renal adjustment factors based on race and report higher eGFR function (with the same Cr measurement) for Black patients Overestimates of renal function subsequently result in delayed access to specialist care or kidney transplant referral and listing Multiple institutions have eliminated use of race in renal function estimation, and nephrology specialty societies outline approaches to diagnose kidney disease without race
Obstetrics and Gynecology
Vaginal Birth After Cesarian section (VBAC) calculator Predicts success of vaginal birth after Cesarian section Uses a correction factor for both Black and Hispanic race Underestimates success of VBAC for Black and Hispanic patients, which may lead to providers counseling for patients to receive a C-section American College of Obstetrics and Gynecology submitted an updated VBAC calculator that does not use race
Hyperbilirubinemia risk factor screening criteria Used to screen for risk of jaundice and neonatal kernicterus East Asian race listed as a major risk factor under American Academy of Pediatrics (AAP) guidelines Criteria may lead to unnecessary treatment/increased hospital stays for East Asian newborns Ongoing discussion within pediatrics to move beyond “Asian” as a major risk factor for readmission due to hyperbilirubinemia and AAP has denounced race-based medicine from clinical tools and plans to release updated bilirubin management guidelines
American Diabetes Association (ADA) BMI cutoff criteria for diabetes screening Identifies asymptomatic adults recommended for diabetes/prediabetes testing Applies a lower BMI (<23) threshold for Asian Americans Increased inappropriate diabetes screening in the absence of other risk factors may increase stigmatization/ mistrust of the medical system ADA continues to recommend a lower BMI screening cutoff for diabetes screening for Asian. Ongoing dialogue among scholars includes suggestions to screen by clinical qualities (increased body fat/ fat %) distinct from race
SOURCES: Vyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight – Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020 Aug 27;383(9):874-882 and Cerdeña JP, Plaisime MV, Tsai J. From race-based to race-conscious medicine: how anti-racist uprisings call us to act. The Lancet. 2020 Oct 10; 396(10257): 125-1128.
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