Pushing Back Against Race-Based Medicine

Pharmacists should challenge the use of patients' race in clinical decision-making tools, a still-routine practice shown to delay diagnosis and treatment for Black patients, two presenters said at a Monday session of the 2024 Midyear Clinical Meeting & Exhibition.

These calculators can help determine such decisions as which children get treated for urinary tract disorders and which patients get diagnosed with kidney disease. But these algorithms include false assumptions about race, said Christine Roussel, vice president of clinical support services at Doylestown Hospital in Pennsylvania.

“Sometimes we don’t even realize that the things we’re using every day … are causing further disparities,” said Roussel.

Roussel joined John Knorr, a board-certified transplant clinical pharmacist at Jefferson Einstein Hospital Philadelphia, in leading the session Race-Based Clinical Calculations Causing Healthcare Disparities.

Knorr discussed the traditional method of estimating kidney function through glomerular filtration rate (GFR). Adjusting for race in the equation can overestimate GFR for Black patients, leading to a delayed diagnosis of chronic kidney disease. Significant to pharmacists, he added, overestimating GFR results in skewed medication dosing.

AJHP last month published a primer from a National Kidney Foundation workgroup advocating for a new race-free estimated GFR equation to measure kidney function.

The Organ Procurement and Transplantation Network also recognized that the inclusion of race in clinical equations had resulted in longer wait times for Black patients, Knorr said. In 2022, the network required all of the nation’s transplant programs to award time adjustments to Black kidney transplant candidates whose wait times had been affected by race-based calculations.

By January 2024, all 230 active kidney programs had reduced the time that more than 14,500 Black patients had to wait on the transplant lists, he said.

Because the race factor has been baked into so many calculators, clinicians may not recognize how patients’ race is shaping their decisions, said Roussel. When she was enquiring about the use of race-inclusive tools at her hospital, she was surprised how difficult it was to find answers.

She urged attendees to find out which race-inclusive tools — from vaginal birth after Cesarean calculators, to the fracture risk assessment tool, to the heart failure risk score, to the rectal cancer survival calculator — their institutions are using.

She emphasized joining with others to speak at service-line meetings or bringing in experts to discuss the pitfalls of using the tools. She said these calculators aren’t embedded only in electronic health records (EHRs); they are also available to clinicians on their smartphones.

“It’s more than getting rid of it in our EHRs,” she said. “It’s also getting it to everybody who has a computer in their pocket.”

She acknowledged that many calculators are inexpensive and considered easy-to-use and reliable. If institutions don’t want to consider dropping the tools, Roussel said clinicians could simply not input patients’ race in the equations. “Leave that part blank,” she said.