Assessing Racial Bias in Pulmonary Medicine from the Interpretation of Pulmonary Function Tests

Johns Hopkins University, Baltimore MD

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Abstract

Project Summary Racism in medicine causes significant harm to non-White patients in the U.S., and one way this may occur is via the use of racially biased clinical algorithms such as pulmonary function tests (PFTs). PFTs are widely used for the diagnosis, treatment, and related care of respiratory diseases. Currently, interpretation of PFTs relies on race-specific reference equations, which are based on the observation that average lung function varies between different racial groups on a population level. However, with the recognition of race as a social rather than biological construct, race-specific equations may inappropriately ‘normalize’ the lower observed lung function in non-White populations. As such, there exists significant concern that a race-specific interpretation of PFTs promotes racial bias in the care of pulmonary disease. Following a broader trend in medicine as seen with the recent elimination of race from the Glomerular Filtration Rate calculator, many are now calling for a shift to race-neutral equations. Importantly, the clinical implications of the current race-specific or proposed race-neutral interpretations of PFTs remain largely unknown. It has been suggested that race-specific equations may racially bias care via delayed diagnosis and treatment, misclassification of disease severity, and decreased rates of lung transplantation for Black patients. However, there are little data on how these outcomes would change under a race-neutral approach. Further, it is unknown how physicians understand race-specific equations or translate the results into clinical practice. Understanding the clinical implications of a race-specific versus race-neutral interpretation of PFTs among patients with respiratory disease is critical to both informing the current debate and guiding a safe and ethically just transition to race-neutral equations. The main goals of this NRSA application are i) to develop research skills that will allow the applicant to become a successful, independent physician scientist and ii) to better understand how a race-specific interpretation of PFTs may bias treatment of pulmonary disease. Two novel aims are proposed to achieve this objective. First, using COPD as a model respiratory disease, we will estimate the impact that a race-specific approach has on the treatment of patients with COPD by investigating its effect on both inhaler prescriptions and priority for lung transplantation. Second, we will assess physicians’ perspectives on the use of race in PFTs at both a local and national level in order to understand their awareness of how race is used and to identify potential barriers to the elimination of race from reference equations. This application has been structured to provide the applicant with the necessary training to pursue a career as an independently funded researcher working at the intersection of bioethics, race, and pulmonary disease. By incorporating an inter-disciplinary mentorship team, formal education via a Masters in Health Science, and a research plan utilizing both quantitative and qualitative methodologies, the training plan will provide the applicant skills necessary to succeed as an independent investigator.