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Davidson SR, Idris MY, Awad CS, Henriques King M, Westney GE, Ponce M, Rodriguez AD, Lipsey KL, Flenaugh EL, Foreman MG. Race Adjustment of Pulmonary Function Tests in the Diagnosis and Management of COPD: A Scoping Review. Int J Chron Obstruct Pulmon Dis 2024; 19:969-980. [PMID: 38708410 PMCID: PMC11067926 DOI: 10.2147/copd.s430249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 02/21/2024] [Indexed: 05/07/2024] Open
Abstract
Aim Increasing evidence suggests that the inclusion of self-identified race in clinical decision algorithms may perpetuate longstanding inequities. Until recently, most pulmonary function tests utilized separate reference equations that are race/ethnicity based. Purpose We assess the magnitude and scope of the available literature on the negative impact of race-based pulmonary function prediction equations on relevant outcomes in African Americans with COPD. Methods We performed a scoping review utilizing an English language search on PubMed/Medline, Embase, Scopus, and Web of Science in September 2022 and updated it in December 2023. We searched for publications regarding the effect of race-specific vs race-neutral, race-free, or race-reversed lung function testing algorithms on the diagnosis of COPD and COPD-related physiologic and functional measures. Joanna Briggs Institute (JBI) guidelines were utilized for this scoping review. Eligibility criteria: The search was restricted to adults with COPD. We excluded publications on other lung disorders, non-English language publications, or studies that did not include African Americans. The search identified publications. Ultimately, six peer-reviewed publications and four conference abstracts were selected for this review. Results Removal of race from lung function prediction equations often had opposite effects in African Americans and Whites, specifically regarding the severity of lung function impairment. Symptoms and objective findings were better aligned when race-specific reference values were not used. Race-neutral prediction algorithms uniformly resulted in reclassifying severity in the African Americans studied. Conclusion The limited literature does not support the use of race-based lung function prediction equations. However, this assertion does not provide guidance for every specific clinical situation. For African Americans with COPD, the use of race-based prediction equations appears to fall short in enhancing diagnostic accuracy, classifying severity of impairment, or predicting subsequent clinical events. We do not have information comparing race-neutral vs race-based algorithms on prediction of progression of COPD. We conclude that the elimination of race-based reference values potentially reduces underestimation of disease severity in African Americans with COPD.
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Affiliation(s)
- Sean Richard Davidson
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Morehouse School of Medicine, Atlanta, GA, USA
| | - Muhammed Y Idris
- Clinical Research Center, Morehouse School of Medicine, Atlanta, GA, USA
- Center of Excellence for the Validation of Digital Health Technologies and Clinical Algorithms, Morehouse School of Medicine, Atlanta, GA, USA
| | - Christopher S Awad
- Clinical Research Center, Morehouse School of Medicine, Atlanta, GA, USA
| | - Marshaleen Henriques King
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Morehouse School of Medicine, Atlanta, GA, USA
| | - Gloria E Westney
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Morehouse School of Medicine, Atlanta, GA, USA
| | - Mario Ponce
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Morehouse School of Medicine, Atlanta, GA, USA
| | - Anny D Rodriguez
- Clinical Research Center, Morehouse School of Medicine, Atlanta, GA, USA
| | - Kim L Lipsey
- Bernard Becker Medical Library, Washington University in St. Louis, St. Louis, MO, USA
| | - Eric L Flenaugh
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Morehouse School of Medicine, Atlanta, GA, USA
| | - Marilyn G Foreman
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Morehouse School of Medicine, Atlanta, GA, USA
- Center of Excellence for the Validation of Digital Health Technologies and Clinical Algorithms, Morehouse School of Medicine, Atlanta, GA, USA
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Liao SY, Carbonell V. Oppressive Medical Objects and Spaces: Response to Commentaries. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:W13-W18. [PMID: 37358549 DOI: 10.1080/15265161.2023.2224289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
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Colon Hidalgo D, Ramos KJ, Harlan EA, Holguin F, Forno E, Weiner DJ, Griffith MF. Historic Use of Race-Based Spirometry Values Lowered Transplant Priority for Black Patients. Chest 2024; 165:381-388. [PMID: 37832783 PMCID: PMC11026175 DOI: 10.1016/j.chest.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 09/20/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND The lung allocation score (LAS) is a tool used to prioritize patients for lung transplantation. For patients with interstitial lung diseases (ILDs), spirometry data are used for the LAS calculation. Spirometry values such as a FVC are subjected to race-specific equations that determine expected values. The effect of race-specific equations in LAS score remains unknown. RESEARCH QUESTION Did the use of a race-based spirometry equation lead to longer waitlist times for Black patients? STUDY DESIGN AND METHODS We performed a retrospective analysis of patients listed for lung transplantation from 2005 through 2020 using publicly available data from the United Network for Organ Sharing. We recalculated LAS scores for Black patients using White-specific equations with the available variables. The primary objective was to evaluate the effect of race-specific equations on LAS scores and time on the transplant waitlist. RESULTS A total of 33,845 patients listed for lung transplantation were included in the analysis. White patients were listed at lower LAS scores, a higher proportion of White patients underwent transplantation, and White patients died on the waitlist at lower rates. When recalculating LAS scores using White-specific equations, Black patients with ILD had up to a 1.9-point higher score, which resulted in additional waitlist time. INTERPRETATION Race-specific equations led to longer wait times in Black patients listed for lung transplantation. The use of race-based equations widened already known disparities in pulmonary transplantation.
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Affiliation(s)
- Daniel Colon Hidalgo
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
| | - Emily A Harlan
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Fernando Holguin
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Erick Forno
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Daniel J Weiner
- Division of Pulmonary Medicine, Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Matthew F Griffith
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Pulmonary and Critical Care Section, VA Eastern Colorado Health Care System Aurora, Aurora, CO
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4
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Regan EA, Lowe ME, Make BJ, Curtis JL, Chen Q(G, Crooks JL, Wilson C, Oates GR, Gregg RW, Baldomero AK, Bhatt SP, Diaz AA, Benos PV, O’Brien JK, Young KA, Kinney GL, Conrad DJ, Lowe KE, DeMeo DL, Non A, Cho MH, Kallet J, Foreman MG, Westney GE, Hoth K, MacIntyre NR, Hanania NA, Wolfe A, Amaza H, Han M, Beaty TH, Hansel NN, McCormack MC, Balasubramanian A, Crapo JD, Silverman EK, Casaburi R, Wise RA. Early Evidence of Chronic Obstructive Pulmonary Disease Obscured by Race-Specific Prediction Equations. Am J Respir Crit Care Med 2024; 209:59-69. [PMID: 37611073 PMCID: PMC10870894 DOI: 10.1164/rccm.202303-0444oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/23/2023] [Indexed: 08/25/2023] Open
Abstract
Rationale: The identification of early chronic obstructive pulmonary disease (COPD) is essential to appropriately counsel patients regarding smoking cessation, provide symptomatic treatment, and eventually develop disease-modifying treatments. Disease severity in COPD is defined using race-specific spirometry equations. These may disadvantage non-White individuals in diagnosis and care. Objectives: Determine the impact of race-specific equations on African American (AA) versus non-Hispanic White individuals. Methods: Cross-sectional analyses of the COPDGene (Genetic Epidemiology of Chronic Obstructive Pulmonary Disease) cohort were conducted, comparing non-Hispanic White (n = 6,766) and AA (n = 3,366) participants for COPD manifestations. Measurements and Main Results: Spirometric classifications using race-specific, multiethnic, and "race-reversed" prediction equations (NHANES [National Health and Nutrition Examination Survey] and Global Lung Function Initiative "Other" and "Global") were compared, as were respiratory symptoms, 6-minute-walk distance, computed tomography imaging, respiratory exacerbations, and St. George's Respiratory Questionnaire. Application of different prediction equations to the cohort resulted in different classifications by stage, with NHANES and Global Lung Function Initiative race-specific equations being minimally different, but race-reversed equations moving AA participants to more severe stages and especially between the Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 0 and preserved ratio impaired spirometry groups. Classification using the established NHANES race-specific equations demonstrated that for each of GOLD stages 1-4, AA participants were younger, had fewer pack-years and more current smoking, but had more exacerbations, shorter 6-minute-walk distance, greater dyspnea, and worse BODE (body mass index, airway obstruction, dyspnea, and exercise capacity) scores and St. George's Respiratory Questionnaire scores. Differences were greatest in GOLD stages 1 and 2. Race-reversed equations reclassified 774 AA participants (43%) from GOLD stage 0 to preserved ratio impaired spirometry. Conclusions: Race-specific equations underestimated disease severity among AA participants. These effects were particularly evident in early disease and may result in late detection of COPD.
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Affiliation(s)
| | - Melissa E. Lowe
- Biostatistics, Duke Cancer Center, Duke University Medical Center, Durham, North Carolina
| | - Barry J. Make
- Division of Pulmonary, Critical Care and Sleep Medicine
| | - Jeffrey L. Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
- Medical Service, Veterans Affairs Medical Center, Ann Arbor, Michigan
| | | | - James L. Crooks
- Division of Biostatistics and Bioinformatics
- Department of Immunology and Genomic Medicine, and
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado
| | - Carla Wilson
- Research Informatics Services, National Jewish Health, Denver, Colorado
| | | | - Robert W. Gregg
- Department of Epidemiology, University of Florida, Gainesville, Florida
| | - Arianne K. Baldomero
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Surya P. Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | | | - Kendra A. Young
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado
| | - Gregory L. Kinney
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado
| | | | - Katherine E. Lowe
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Dawn L. DeMeo
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amy Non
- Department of Anthropology, University of California, San Diego, La Jolla, California
| | - Michael H. Cho
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Marilyn G. Foreman
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Morehouse College, Atlanta, Georgia
| | - Gloria E. Westney
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Morehouse College, Atlanta, Georgia
| | - Karin Hoth
- Department of Psychiatry and
- Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa
| | - Neil R. MacIntyre
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University, Durham, North Carolina
| | - Nicola A. Hanania
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, College of Medicine, Baylor University, Houston, Texas
| | - Amy Wolfe
- Section of Pulmonology and Critical Care, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | | | - MeiLan Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Terri H. Beaty
- Department of Epidemiology, Bloomberg School of Public Health, and
| | - Nadia N. Hansel
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - Meredith C. McCormack
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - Aparna Balasubramanian
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | | | - Edwin K. Silverman
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard Casaburi
- Rehabilitation Clinical Trials Center, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Robert A. Wise
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland; and
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Baugh A, Buhr RG, Bush A, Foreman M, Mannino DM. Strategies to Classify Lung Function: It's Not Black and White. Am J Respir Crit Care Med 2024; 209:19-20. [PMID: 37878872 PMCID: PMC10870882 DOI: 10.1164/rccm.202305-0807vp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 10/25/2023] [Indexed: 10/27/2023] Open
Affiliation(s)
- Aaron Baugh
- College of Medicine, University of California, San Francisco, San Francisco, California
| | - Russell G. Buhr
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Andrew Bush
- Imperial Centre for Paediatrics and Child Health, Imperial College, London, United Kingdom
| | - Marilyn Foreman
- Pulmonary and Critical Care Medicine Division, Morehouse School of Medicine, Atlanta, Georgia
- Novartis Beacon of Hope Center of Excellence for Data Standards in Clinical Medicine, Atlanta, Georgia; and
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Ekström M, Mannino D. The Race to Abandon Ethnicity in Interpreting Pulmonary Function: Further Evidence. Chest 2023; 164:1348-1349. [PMID: 38070955 DOI: 10.1016/j.chest.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 12/18/2023] Open
Affiliation(s)
- Magnus Ekström
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology, and Palliative Medicine, Lund University, Lund, Sweden.
| | - David Mannino
- Department of Medicine, University of Kentucky College of Medicine, Lexington, KY; COPD Foundation, Washington, DC
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List JM, Palevsky P, Tamang S, Crowley S, Au D, Yarbrough WC, Navathe AS, Kreisler C, Parikh RB, Wang-Rodriguez J, Klutts JS, Conlin P, Pogach L, Meerwijk E, Moy E. Eliminating Algorithmic Racial Bias in Clinical Decision Support Algorithms: Use Cases from the Veterans Health Administration. Health Equity 2023; 7:809-816. [PMID: 38076213 PMCID: PMC10698768 DOI: 10.1089/heq.2023.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 01/29/2024] Open
Abstract
The Veterans Health Administration uses equity- and evidence-based principles to examine, correct, and eliminate use of potentially biased clinical equations and predictive models. We discuss the processes, successes, challenges, and next steps in four examples. We detail elimination of the race modifier for estimated kidney function and discuss steps to achieve more equitable pulmonary function testing measurement. We detail the use of equity lenses in two predictive clinical modeling tools: Stratification Tool for Opioid Risk Mitigation (STORM) and Care Assessment Need (CAN) predictive models. We conclude with consideration of ways to advance racial health equity in clinical decision support algorithms.
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Affiliation(s)
- Justin M. List
- VA Office of Health Equity, Washington, District of Columbia, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Paul Palevsky
- Kidney Medicine Section, Medical Service, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Suzanne Tamang
- Department of Veterans Affairs, Palo Alto, California, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Susan Crowley
- Nephrology Section, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - David Au
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - William C. Yarbrough
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
- VA North Texas Health Care System, Dallas, Texas, USA
| | - Amol S. Navathe
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Craig Kreisler
- Analytics and Performance Integration (API), Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia, USA
| | - Ravi B. Parikh
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jessica Wang-Rodriguez
- VA National Pathology and Laboratory Medicine Service, Washington, District of Columbia, USA
- Department of Pathology, University of California San Diego School of Medicine, La Jolla, California, USA
| | - J. Stacey Klutts
- National VHA Diagnostics Office, Washington, District of Columbia, USA
- Iowa City VA Healthcare System, Iowa City, Iowa, USA
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Paul Conlin
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Leonard Pogach
- Department of Veterans Affairs, New Jersey Health Care System, East Orange, New Jersey, USA
| | | | - Ernest Moy
- VA Office of Health Equity, Washington, District of Columbia, USA
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8
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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 2023; 158:1061-1068. [PMID: 37585181 PMCID: PMC10433136 DOI: 10.1001/jamasurg.2023.3239] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/20/2023] [Indexed: 08/17/2023]
Abstract
Importance Removal of race correction in pulmonary function tests (PFTs) is a priority, given that race correction inappropriately conflates race, a social construct, with biological differences and falsely assumes worse lung function in African American than White individuals. However, the impact of decorrecting PFTs for African American patients with lung cancer is unknown. Objectives To identify how many hospitals providing lung cancer surgery use race correction, examine the association of race correction with predicted lung function, and test the effect of decorrection on surgeons' treatment recommendations. Design, Setting, and Participants In this quality improvement study, hospitals participating in a statewide quality collaborative were contacted to determine use of race correction in PFTs. For hospitals performing race correction, percent predicted preoperative and postoperative forced expiratory volume in 1 second (FEV1) was calculated for African American patients who underwent lung cancer resection between January 1, 2015, and September 31, 2022, using race-corrected and race-neutral equations. US cardiothoracic surgeons were then randomized to receive 1 clinical vignette that differed by the use of Global Lung Function Initiative equations for (1) African American patients (percent predicted postoperative FEV1, 49%), (2) other race or multiracial patients (percent predicted postoperative FEV1, 45%), and (3) race-neutral patients (percent predicted postoperative FEV1, 42%). Main Outcomes and Measures Number of hospitals using race correction in PFTs, change in preoperative and postoperative FEV1 estimates based on race-neutral or race-corrected equations, and surgeon treatment recommendations for clinical vignettes. Results A total of 515 African American patients (308 [59.8%] female; mean [SD] age, 66.2 [9.4] years) were included in the study. Fifteen of the 16 hospitals (93.8%) performing lung cancer resection for African American patients during the study period reported using race correction, which corresponds to 473 African American patients (91.8%) having race-corrected PFTs. Among these patients, the percent predicted preoperative FEV1 and postoperative FEV1 would have decreased by 9.2% (95% CI, -9.0% to -9.5%; P < .001) and 7.6% (95% CI, -7.3% to -7.9%; P < .001), respectively, if race-neutral equations had been used. A total of 225 surgeons (194 male [87.8%]; mean [SD] time in practice, 19.4 [11.3] years) were successfully randomized and completed the vignette items regarding risk perception and treatment outcomes (76% completion rate). Surgeons randomized to the vignette with African American race-corrected PFTs were more likely to recommend lobectomy (79.2%; 95% CI, 69.8%-88.5%) compared with surgeons randomized to the other race or multiracial-corrected (61.7%; 95% CI, 51.1%-72.3%; P = .02) or race-neutral PFTs (52.8%; 95% CI, 41.2%-64.3%; P = .001). Conclusions and Relevance Given the findings of this quality improvement study, surgeons should be aware of changes in PFT testing because removal of race correction PFTs may change surgeons' treatment decisions and potentially worsen existing disparities in receipt of lung cancer surgery among African American patients.
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Affiliation(s)
- Sidra N. Bonner
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor
- National Clinician Scholars Program, University of Michigan, Ann Arbor
| | - Kiran Lagisetty
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor
- Veterans Affairs Ann Arbor Healthcare System, Department of Veterans Affairs, Ann Arbor, Michigan
| | - Rishindra M. Reddy
- Veterans Affairs Ann Arbor Healthcare System, Department of Veterans Affairs, Ann Arbor, Michigan
- Michigan Society of Thoracic and Cardiovascular Surgeons General Thoracic Quality Collaborative, Ann Arbor
| | | | - Jennifer J. Griggs
- Department of Internal Medicine, Division of Hematology and Oncology, Department of Health Management and Policy, School of Public Health University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Thomas S. Valley
- Veterans Affairs Ann Arbor Healthcare System, Department of Veterans Affairs, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor
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9
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Regan EA, Lowe ME, Make BJ, Curtis JL, Chen QG, Cho MH, Crooks JL, Lowe KE, Wilson C, O'Brien JK, Oates GR, Baldomero AK, Kinney GL, Young KA, Diaz AA, Bhatt SP, McCormack MC, Hansel NN, Kim V, Richmond NE, Westney GE, Foreman MG, Conrad DJ, DeMeo DL, Hoth KF, Amaza H, Balasubramanian A, Kallet J, Watts S, Hanania NA, Hokanson J, Beaty TH, Crapo JD, Silverman EK, Casaburi R, Wise R. Use of the Spirometric "Fixed-Ratio" Underdiagnoses COPD in African-Americans in a Longitudinal Cohort Study. J Gen Intern Med 2023; 38:2988-2997. [PMID: 37072532 PMCID: PMC10593702 DOI: 10.1007/s11606-023-08185-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/21/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND COPD diagnosis is tightly linked to the fixed-ratio spirometry criteria of FEV1/FVC < 0.7. African-Americans are less often diagnosed with COPD. OBJECTIVE Compare COPD diagnosis by fixed-ratio with findings and outcomes by race. DESIGN Genetic Epidemiology of COPD (COPDGene) (2007-present), cross-sectional comparing non-Hispanic white (NHW) and African-American (AA) participants for COPD diagnosis, manifestations, and outcomes. SETTING Multicenter, longitudinal US cohort study. PARTICIPANTS Current or former smokers with ≥ 10-pack-year smoking history enrolled at 21 clinical centers including over-sampling of participants with known COPD and AA. Exclusions were pre-existing non-COPD lung disease, except for a history of asthma. MEASUREMENTS Subject diagnosis by conventional criteria. Mortality, imaging, respiratory symptoms, function, and socioeconomic characteristics, including area deprivation index (ADI). Matched analysis (age, sex, and smoking status) of AA vs. NHW within participants without diagnosed COPD (GOLD 0; FEV1 ≥ 80% predicted and FEV1/FVC ≥ 0.7). RESULTS Using the fixed ratio, 70% of AA (n = 3366) were classified as non-COPD, versus 49% of NHW (n = 6766). AA smokers were younger (55 vs. 62 years), more often current smoking (80% vs. 39%), with fewer pack-years but similar 12-year mortality. Density distribution plots for FEV1 and FVC raw spirometry values showed disproportionate reductions in FVC relative to FEV1 in AA that systematically led to higher ratios. The matched analysis demonstrated GOLD 0 AA had greater symptoms, worse DLCO, spirometry, BODE scores (1.03 vs 0.54, p < 0.0001), and greater deprivation than NHW. LIMITATIONS Lack of an alternative diagnostic metric for comparison. CONCLUSIONS The fixed-ratio spirometric criteria for COPD underdiagnosed potential COPD in AA participants when compared to broader diagnostic criteria. Disproportionate reductions in FVC relative to FEV1 leading to higher FEV1/FVC were identified in these participants and associated with deprivation. Broader diagnostic criteria for COPD are needed to identify the disease across all populations.
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Affiliation(s)
| | - Melissa E Lowe
- Duke Cancer Center, Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Barry J Make
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Jeffrey L Curtis
- Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
- Pulmonary & Critical Care Medicine Section, Veterans Affairs Medical Center, Ann Arbor, MI, USA
| | | | - Michael H Cho
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - James L Crooks
- Division of Biostatistics and Bioinformatics and Department of Immunology and Genomic Medicine, National Jewish Health, Denver, CO, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Katherine E Lowe
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Carla Wilson
- Research Informatics Services, National Jewish Health, Denver, CO, USA
| | - James K O'Brien
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO, USA
| | | | - Arianne K Baldomero
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Gregory L Kinney
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Kendra A Young
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Alejandro A Diaz
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Meredith C McCormack
- Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nadia N Hansel
- Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Victor Kim
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Nicole E Richmond
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Gloria E Westney
- Pulmonary and Critical Care Medicine, Morehouse School of Medicine, Atlanta, GA, USA
| | - Marilyn G Foreman
- Pulmonary and Critical Care Medicine, Morehouse School of Medicine, Atlanta, GA, USA
| | - Douglas J Conrad
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Dawn L DeMeo
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Karin F Hoth
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
- Iowa Neuroscience Institute, University of Iowa, Iowa City, IA, USA
| | - Hannatu Amaza
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
| | - Aparna Balasubramanian
- Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julia Kallet
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Shandi Watts
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Nicola A Hanania
- Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - John Hokanson
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Terri H Beaty
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - James D Crapo
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Edwin K Silverman
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Richard Casaburi
- Rehabilitation Clinical Trials Center, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Robert Wise
- Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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10
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Raoof S, Shah M, Braman S, Agrawal A, Allaqaband H, Bowler R, Castaldi P, DeMeo D, Fernando S, Hall CS, Han MK, Hogg J, Humphries S, Lee HY, Lee KS, Lynch D, Machnicki S, Mehta A, Mehta S, Mina B, Naidich D, Naidich J, Ohno Y, Regan E, van Beek EJR, Washko G, Make B. Lung Imaging in COPD Part 2: Emerging Concepts. Chest 2023; 164:339-354. [PMID: 36907375 PMCID: PMC10475822 DOI: 10.1016/j.chest.2023.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/23/2023] [Accepted: 02/25/2023] [Indexed: 03/13/2023] Open
Abstract
The diagnosis, prognostication, and differentiation of phenotypes of COPD can be facilitated by CT scan imaging of the chest. CT scan imaging of the chest is a prerequisite for lung volume reduction surgery and lung transplantation. Quantitative analysis can be used to evaluate extent of disease progression. Evolving imaging techniques include micro-CT scan, ultra-high-resolution and photon-counting CT scan imaging, and MRI. Potential advantages of these newer techniques include improved resolution, prediction of reversibility, and obviation of radiation exposure. This article discusses important emerging techniques in imaging patients with COPD. The clinical usefulness of these emerging techniques as they stand today are tabulated for the benefit of the practicing pulmonologist.
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Affiliation(s)
- Suhail Raoof
- Northwell Health, Lenox Hill Hospital, New York, NY.
| | - Manav Shah
- Northwell Health, Lenox Hill Hospital, New York, NY
| | - Sidney Braman
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | | | - Dawn DeMeo
- Brigham and Women's Hospital, Boston, MA
| | | | | | | | - James Hogg
- University of British Columbia, Vancouver, BC, Canada
| | | | - Ho Yun Lee
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Department of Health Sciences and Technology, Sungkyunkwan University, ChangWon, South Korea
| | - Kyung Soo Lee
- Sungkyunkwan University School of Medicine, Samsung ChangWon Hospital, ChangWon, South Korea
| | | | | | | | | | - Bushra Mina
- Northwell Health, Lenox Hill Hospital, New York, NY
| | | | | | | | | | | | | | | |
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11
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Liao SY, Carbonell V. Materialized Oppression in Medical Tools and Technologies. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:9-23. [PMID: 35262465 DOI: 10.1080/15265161.2022.2044543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
It is well-known that racism is encoded into the social practices and institutions of medicine. Less well-known is that racism is encoded into the material artifacts of medicine. We argue that many medical devices are not merely biased, but materialize oppression. An oppressive device exhibits a harmful bias that reflects and perpetuates unjust power relations. Using pulse oximeters and spirometers as case studies, we show how medical devices can materialize oppression along various axes of social difference, including race, gender, class, and ability. Our account uses political philosophy and cognitive science to give a theoretical basis for understanding materialized oppression, explaining how artifacts encode and carry oppressive ideas from the past to the present and future. Oppressive medical devices present a moral aggregation problem. To remedy this problem, we suggest redundantly layered solutions that are coordinated to disrupt reciprocal causal connections between the attitudes, practices, and artifacts of oppressive systems.
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12
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Mannino DM, Townsend MC. Spirometry in 2022: Is a Single Set of Prediction Equations for All the Best Path Forward? Am J Respir Crit Care Med 2023; 207:659-661. [PMID: 36630683 PMCID: PMC10037465 DOI: 10.1164/rccm.202211-2181ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- David M Mannino
- Department of Medicine University of Kentucky College of Medicine Lexington, Kentucky and COPD Foundation Miami, Florida
| | - Mary C Townsend
- M.C. Townsend Associates, LLC Pittsburgh, Pennsylvania and University of Pittsburgh School of Public Health Pittsburgh, Pennsylvania
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13
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Bowerman C, Bhakta NR, Brazzale D, Cooper BR, Cooper J, Gochicoa-Rangel L, Haynes J, Kaminsky DA, Lan LTT, Masekela R, McCormack MC, Steenbruggen I, Stanojevic S. A Race-neutral Approach to the Interpretation of Lung Function Measurements. Am J Respir Crit Care Med 2023; 207:768-774. [PMID: 36383197 DOI: 10.1164/rccm.202205-0963oc] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Rationale: The use of self-reported race and ethnicity to interpret lung function measurements has historically assumed that the observed differences in lung function between racial and ethnic groups were because of thoracic cavity size differences relative to standing height. Very few studies have considered the influence of environmental and social determinants on pulmonary function. Consequently, the use of race and ethnicity-specific reference equations may further marginalize disadvantaged populations. Objectives: To develop a race-neutral reference equation for spirometry interpretation. Methods: National Health and Nutrition Examination Survey (NHANES) III data (n = 6,984) were reanalyzed with sitting height and the Cormic index to investigate whether body proportions were better predictors of lung function than race and ethnicity. Furthermore, the original GLI (Global Lung Function Initiative) data (n = 74,185) were reanalyzed with inverse-probability weights to create race-neutral GLI global (2022) equations. Measurements and Main Results: The inclusion of sitting height slightly improved the statistical precision of reference equations compared with using standing height alone but did not explain observed differences in spirometry between the NHANES III race and ethnic groups. GLI global (2022) equations, which do not require the selection of race and ethnicity, had a similar fit to the GLI 2012 "other" equations and wider limits of normal. Conclusions: The use of a single global spirometry equation reflects the wide range of lung function observed within and between populations. Given the inherent limitations of any reference equation, the use of GLI global equations to interpret spirometry requires careful consideration of an individual's symptoms and medical history when used to make clinical, employment, and insurance decisions.
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Affiliation(s)
- Cole Bowerman
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Nirav R Bhakta
- Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco, California
| | - Danny Brazzale
- Department of Respiratory and Sleep Medicine, Austin Hospital, Heidelberg, Germany
| | - Brendan R Cooper
- Lung Function & Sleep, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Julie Cooper
- Lung Function & Sleep, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Laura Gochicoa-Rangel
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Jeffrey Haynes
- Pulmonary Function Laboratory, Elliot Health System, Manchester, New Hampshire
| | - David A Kaminsky
- Pulmonary Disease and Critical Care Medicine, University of Vermont College of Medicine, Burlington, Vermont
| | | | - Refiloe Masekela
- Department of Paediatrics and Child Health, Faculty of Health Sciences, School of Clinical Medicine, University of Kwazulu-Natal, Durban, South Africa
| | - Meredith C McCormack
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | | | - Sanja Stanojevic
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
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14
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Sjoding MW, Ansari S, Valley TS. Origins of Racial and Ethnic Bias in Pulmonary Technologies. Annu Rev Med 2023; 74:401-412. [PMID: 35901314 PMCID: PMC9883596 DOI: 10.1146/annurev-med-043021-024004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Understanding how biases originate in medical technologies and developing safeguards to identify, mitigate, and remove their harms are essential to ensuring equal performance in all individuals. Drawing upon examples from pulmonary medicine, this article describes how bias can be introduced in the physical aspects of the technology design, via unrepresentative data, or by conflation of biological with social determinants of health. It then can be perpetuated by inadequate evaluation and regulatory standards. Research demonstrates that pulse oximeters perform differently depending on patient race and ethnicity. Pulmonary function testing and algorithms used to predict healthcare needs are two additional examples of medical technologies with racial and ethnic biases that may perpetuate health disparities.
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Affiliation(s)
- Michael W. Sjoding
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA,Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan, USA,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Sardar Ansari
- Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan, USA; .,Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Thomas S. Valley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA,Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, USA
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15
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Sinkala M, Elsheikh SSM, Mbiyavanga M, Cullinan J, Mulder NJ. A genome-wide association study identifies distinct variants associated with pulmonary function among European and African ancestries from the UK Biobank. Commun Biol 2023; 6:49. [PMID: 36641522 PMCID: PMC9840173 DOI: 10.1038/s42003-023-04443-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 01/09/2023] [Indexed: 01/16/2023] Open
Abstract
Pulmonary function is an indicator of well-being, and pulmonary pathologies are the third major cause of death worldwide. We analysed the UK Biobank genome-wide association summary statistics of pulmonary function for Europeans and individuals of recent African descent to identify variants associated with the trait in the two ancestries. Here, we show 627 variants in Europeans and 3 in Africans associated with three pulmonary function parameters. In addition to the 110 variants in Europeans previously reported to be associated with phenotypes related to pulmonary function, we identify 279 novel loci, including an ISX intergenic variant rs369476290 on chromosome 22 in Africans. Remarkably, we find no shared variants among Africans and Europeans. Furthermore, enrichment analyses of variants separately for each ancestry background reveal significant enrichment for terms related to pulmonary phenotypes in Europeans but not Africans. Further analysis of studies of pulmonary phenotypes reveals that individuals of European background are disproportionally overrepresented in datasets compared to Africans, with the gap widening over the past five years. Our findings extend our understanding of the different variants that modify the pulmonary function in Africans and Europeans, a promising finding for future GWASs and medical studies.
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Affiliation(s)
- Musalula Sinkala
- Computational Biology Division, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Cape Town, South Africa.
| | - Samar S M Elsheikh
- Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Mamana Mbiyavanga
- Computational Biology Division, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Cape Town, South Africa
| | - Joshua Cullinan
- Computational Biology Division, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Cape Town, South Africa
| | - Nicola J Mulder
- Computational Biology Division, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Cape Town, South Africa
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16
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Vo H, Campelia GD, Olszewski AE. Addressing Racism in Ethics Consultation: An Expansion of the Four-Box Method. THE JOURNAL OF CLINICAL ETHICS 2023; 34:11-26. [PMID: 36940357 DOI: 10.1086/723322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
AbstractRacism is a pervasive issue in patient care and a key social determinant of health. Clinical ethicists, like others involved in patient care, have a duty to recognize and respond to racism on both individual and systems-wide levels to improve patient care. Doing so can be challenging and, like other skills in ethics consultation, may benefit from specialized training, standardized tools and approaches, and practice. Learning from existing frameworks and tools, as well as building new ones, can help guide clinical ethicists to systematically approach racism as it affects clinical cases. Here, we propose an expansion of the commonly used four-box method to clinical ethics consultation, where racism is considered as a potential factor in each of the four boxes. We apply this method to two clinical cases to highlight ethically salient information that might be missed using the standard formulation of the four boxes but captured with the expanded version. We argue that this expansion of an existing clinical ethics consultation tool is ethically justified insofar as it (a) creates a more just approach, (b) supports individual consultants and services, and (c) facilitates communication in contexts where racism impinges on effecting good patient care.
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17
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Farrell TW, Hung WW, Unroe KT, Brown TR, Furman CD, Jih J, Karani R, Mulhausen P, Nápoles AM, Nnodim JO, Upchurch G, Whittaker CF, Kim A, Lundebjerg NE, Rhodes RL. Exploring the intersection of structural racism and ageism in healthcare. J Am Geriatr Soc 2022; 70:3366-3377. [PMID: 36260413 PMCID: PMC9886231 DOI: 10.1111/jgs.18105] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 02/01/2023]
Abstract
The American Geriatrics Society (AGS) has consistently advocated for a healthcare system that meets the needs of older adults, including addressing impacts of ageism in healthcare. The intersection of structural racism and ageism compounds the disadvantage experienced by historically marginalized communities. Structural racism and ageism have long been ingrained in all aspects of US society, including healthcare. This intersection exacerbates disparities in social determinants of health, including poor access to healthcare and poor outcomes. These deeply rooted societal injustices have been brought to the forefront of the collective public consciousness at different points throughout history. The COVID-19 pandemic laid bare and exacerbated existing inequities inflicted on historically marginalized communities. Ageist rhetoric and policies during the COVID-19 pandemic further marginalized older adults. Although the detrimental impact of structural racism on health has been well-documented in the literature, generative research on the intersection of structural racism and ageism is limited. The AGS is working to identify and dismantle the healthcare structures that create and perpetuate these combined injustices and, in so doing, create a more just US healthcare system. This paper is intended to provide an overview of important frameworks and guide future efforts to both identify and eliminate bias within healthcare delivery systems and health professions training with a particular focus on the intersection of structural racism and ageism.
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Affiliation(s)
- Timothy W. Farrell
- Division of Geriatrics, Spencer Fox Eccles School of
Medicine, University of Utah, Salt Lake City, Utah, USA
- VA Salt Lake City Geriatric Research, Education, and
Clinical Center, Salt Lake City, Utah, USA
| | - William W. Hung
- Department of Geriatrics and Palliative Medicine, Icahn
School of Medicine at Mount Sinai, New York New York, USA
- Geriatric Research, Education and Clinical Center, James J
Peters VA Medical Center, New York New York, USA
| | - Kathleen T. Unroe
- Department of Medicine, Indiana University, Indianapolis,
Indiana, USA
- Regenstrief Institute, Indiana University Center for Aging
Research Indianapolis, Indianapolis, Indiana, USA
| | - Teneille R. Brown
- Center for Law and Biomedical Sciences, University of Utah
S.J. Quinney College of Law, Salt Lake City, Utah, USA
| | - Christian D. Furman
- Department of Geriatric Medicine, Department of Geriatric
and Palliative Medicine, Trager Institute/Optimal Aging Clinic, University of
Louisville, Louisville, Kentucky, USA
| | - Jane Jih
- Division of General Internal Medicine, Multiethnic Health
Equity Research Center, Asian American Research Center on Health, University of
California, San Francisco, San Francisco, California, USA
| | - Reena Karani
- Department of Medical Education, Department of Medicine,
Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine
at Mount Sinai, New York New York, USA
| | | | - Anna María Nápoles
- Division of Intramural Research, National Institute on
Minority Health and Health Disparities, National Institutes of Health, Bethesda,
Maryland, USA
| | - Joseph O. Nnodim
- Division of Geriatric and Palliative Medicine, Department
of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Gina Upchurch
- Senior PharmAssist, Durham, North Carolina, USA
- Eshelman School of Pharmacy, Department of Public Health
Leadership, Gillings School of Global Public Health, University of North Carolina at
Chapel Hill, Chapel Hill, North Carolina, USA
| | - Chanel F. Whittaker
- Department of Practice, Sciences, and Health Outcomes
Research (P-SHOR), The Peter Lamy Center on Drug Therapy and Aging, University of
Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Anna Kim
- American Geriatrics Society, New York New York, USA
| | | | - Ramona L. Rhodes
- Central Arkansas Veterans Healthcare System, Geriatric
Research Education and Clinical Center, North Little Rock, Arkansas, USA
- Department of Geriatrics, University of Arkansas for
Medical Sciences, Little Rock, Arkansas, USA
- Division of Geriatric Medicine, University of Texas
Southwestern Medical Center, Dallas, Texas, USA
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18
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Okelo SO. Structural Inequities in Medicine that Contribute to Racial Inequities in Asthma Care. Semin Respir Crit Care Med 2022; 43:752-762. [DOI: 10.1055/s-0042-1756491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractStructural inequities in medicine have been present for centuries in the United States, but only recently are these being recognized as contributors to racial inequities in asthma care and asthma outcomes. This chapter provides a systematic review of structural factors such as racial bias in spirometry algorithms, the history of systemic racism in medicine, workforce/pipeline limitations to the presence of underrepresented minority health care providers, bias in research funding awards, and strategies to solve these problems.
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Affiliation(s)
- Sande O. Okelo
- Division of Pediatric Pulmonology and Sleep Medicine, The David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
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19
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Feasibility of an Antiracism Curriculum in an Academic Pulmonary, Critical Care, and Sleep Medicine Division. ATS Sch 2022; 3:433-448. [PMID: 36312797 PMCID: PMC9590586 DOI: 10.34197/ats-scholar.2022-0015oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 07/27/2022] [Indexed: 11/18/2022] Open
Abstract
Background Objective Methods Results Conclusion
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20
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Sanky C, Bai H, He C, Appel JM. Medical students' knowledge of race-related history reveals areas for improvement in achieving health equity. BMC MEDICAL EDUCATION 2022; 22:612. [PMID: 35948907 PMCID: PMC9365447 DOI: 10.1186/s12909-022-03650-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 07/22/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Medical schools have increasingly integrated social justice, anti-racism, and health equity training into their curricula. Yet, no research examines whether medical students understand the complex history of racial injustice. We sought to investigate the relationship between medical students' historical knowledge and their perceptions regarding health equity. METHODS Medical students at one large urban medical school self-rated their familiarity and importance of various racially-significant historical events and persons, as well as their agreement with statements regarding health equity, education, and preparedness to act. Descriptive and multivariate analyses were conducted in R. RESULTS Of 166 (RR=31.3%) participants, 96% agreed that understanding historical context is necessary in medicine; yet 65% of students could not describe the historical significance of racial events or persons. Only 57% felt that they understood this context, and the same percentage felt other medical students did not. A minority of students felt empowered (40%) or prepared (31%) to take action when they witness racial injustice in healthcare. Multiracial identity was significantly associated with increased knowledge of African American history (p<0.01), and a humanities background was significantly associated with increased knowledge of Latin American history (p=0.017). There was a positive, significant relationship between advocacy statements, such as "I have taken action" (p<0.001) and "I know the roots of racism" (p<0.001) with mean familiarity of historical events. CONCLUSIONS This study demonstrates that while students agree that racism has no place in healthcare, there remains a paucity of knowledge regarding many events and figures in the history of American race relations and civil rights, with implications for future physicians' patient care and health equity efforts.
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Affiliation(s)
- Charles Sanky
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Halbert Bai
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Celestine He
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jacob M Appel
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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21
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Adegunsoye A, Vela M, Saunders M. Racial Disparities in Pulmonary Fibrosis and the Impact on the Black Population. Arch Bronconeumol 2022; 58:590-592. [PMID: 35312569 DOI: 10.1016/j.arbres.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Ayodeji Adegunsoye
- Pulmonary/Critical Care, University of Chicago, Chicago, IL, United States.
| | - Monica Vela
- General Internal Medicine, University of Chicago, Chicago, IL, United States
| | - Milda Saunders
- General Internal Medicine, University of Chicago, Chicago, IL, United States
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22
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Wright JL, Davis WS, Joseph MM, Ellison AM, Heard-Garris NJ, Johnson TL. Eliminating Race-Based Medicine. Pediatrics 2022; 150:186963. [PMID: 35491483 DOI: 10.1542/peds.2022-057998] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 02/03/2023] Open
Affiliation(s)
- Joseph L Wright
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland.,Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Maryland
| | - Wendy S Davis
- Department of Pediatrics, Robert Larner, MD, College of Medicine, University of Vermont, Burlington, Vermont
| | - Madeline M Joseph
- Departments of Emergency Medicine and Pediatrics, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
| | - Angela M Ellison
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nia J Heard-Garris
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tiffani L Johnson
- Department of Emergency Medicine, University of California, Davis, Sacramento, California
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23
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Fawzy A, Wu TD, Wang K, Robinson ML, Farha J, Bradke A, Golden SH, Xu Y, Garibaldi BT. Racial and Ethnic Discrepancy in Pulse Oximetry and Delayed Identification of Treatment Eligibility Among Patients With COVID-19. JAMA Intern Med 2022; 182:730-738. [PMID: 35639368 PMCID: PMC9257583 DOI: 10.1001/jamainternmed.2022.1906] [Citation(s) in RCA: 112] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Pulse oximetry guides triage and therapy decisions for COVID-19. Whether reported racial inaccuracies in oxygen saturation measured by pulse oximetry are present in patients with COVID-19 and associated with treatment decisions is unknown. OBJECTIVE To determine whether there is differential inaccuracy of pulse oximetry by race or ethnicity among patients with COVID-19 and estimate the association of such inaccuracies with time to recognition of eligibility for oxygen threshold-specific COVID-19 therapies. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of clinical data from 5 referral centers and community hospitals in the Johns Hopkins Health System included patients with COVID-19 who self-identified as Asian, Black, Hispanic, or White. EXPOSURES Concurrent measurements (within 10 minutes) of oxygen saturation levels in arterial blood (SaO2) and by pulse oximetry (SpO2). MAIN OUTCOMES AND MEASURES For patients with concurrent SpO2 and SaO2 measurements, the proportion with occult hypoxemia (SaO2<88% with concurrent SpO2 of 92%-96%) was compared by race and ethnicity, and a covariate-adjusted linear mixed-effects model was produced to estimate the association of race and ethnicity with SpO2 and SaO2 difference. This model was applied to identify a separate sample of patients with predicted SaO2 levels of 94% or less before an SpO2 level of 94% or less or oxygen treatment initiation. Cox proportional hazards models were used to estimate differences by race and ethnicity in time to recognition of eligibility for guideline-recommended COVID-19 therapies, defined as an SpO2 level of 94% or less or oxygen treatment initiation. The median delay among individuals who ultimately had recognition of eligibility was then compared. RESULTS Of 7126 patients with COVID-19, 1216 patients (63 Asian [5.2%], 478 Black [39.3%], 215 Hispanic [17.7%], and 460 White [37.8%] individuals; 507 women [41.7%]) had 32 282 concurrently measured SpO2 and SaO2. Occult hypoxemia occurred in 19 Asian (30.2%), 136 Black (28.5%), and 64 non-Black Hispanic (29.8%) patients compared with 79 White patients (17.2%). Compared with White patients, SpO2 overestimated SaO2 by an average of 1.7% among Asian (95% CI, 0.5%-3.0%), 1.2% among Black (95% CI, 0.6%-1.9%), and 1.1% among non-Black Hispanic patients (95% CI, 0.3%-1.9%). Separately, among 1903 patients with predicted SaO2 levels of 94% or less before an SpO2 level of 94% or less or oxygen treatment initiation, compared with White patients, Black patients had a 29% lower hazard (hazard ratio, 0.71; 95% CI, 0.63-0.80), and non-Black Hispanic patients had a 23% lower hazard (hazard ratio, 0.77; 95% CI, 0.66-0.89) of treatment eligibility recognition. A total of 451 patients (23.7%) never had their treatment eligibility recognized, most of whom (247 [54.8%]) were Black. Among the remaining 1452 (76.3%) who had eventual recognition of treatment eligibility, Black patients had a median delay of 1.0 hour (95% CI, 0.23-1.9 hours; P = .01) longer than White patients. There was no significant median difference in delay between individuals of other racial and ethnic minority groups and White patients. CONCLUSIONS AND RELEVANCE The results of this cohort study suggest that racial and ethnic biases in pulse oximetry accuracy were associated with greater occult hypoxemia in Asian, Black, and non-Black Hispanic patients with COVID-19, which was associated with significantly delayed or unrecognized eligibility for COVID-19 therapies among Black and Hispanic patients. This disparity may contribute to worse outcomes among Black and Hispanic patients with COVID-19.
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Affiliation(s)
- Ashraf Fawzy
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tianshi David Wu
- Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, Texas.,Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Kunbo Wang
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, Maryland
| | - Matthew L Robinson
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jad Farha
- Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amanda Bradke
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Sherita H Golden
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yanxun Xu
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, Maryland
| | - Brian T Garibaldi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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24
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Ramsey NB, Apter AJ, Israel E, Louisias M, Noroski LM, Nyenhuis SM, Ogbogu PU, Perry TT, Wang J, Davis CM. Deconstructing the Way We Use Pulmonary Function Test Race-Based Adjustments. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:972-978. [PMID: 35184982 DOI: 10.1016/j.jaip.2022.01.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 01/08/2022] [Accepted: 01/21/2022] [Indexed: 06/14/2023]
Abstract
Race is a social construct. It is used in medical diagnostic algorithms to adjust the readout for spirometry and other diagnostic tests. The authors review historic evidence about the origins of race adjustment in spirometry, and recent attention to the lack of scientific evidence for their continued use. Existing reference values imply that White patients have better lung function than non-White patients. They perpetuate the historical assumptions that human biological functions of the lung should be calculated differently on the basis of racial-skin color without considering the difficulty of using self-identified race. More importantly, they fail to consider the important effects of environmental exposures, socioeconomic differences, health care access, and prenatal factors on lung function. In addition, the use of "race adjustment" implies a White standard to which other non-White values need "adjustment." Because of the spirometric guidelines in place, the current diagnostic prediction adjustment practice may have untoward effects on patients not categorized as "White," including underdiagnosis in asthma and restrictive lung disease, undertreatment with lung transplant, undercompensation in workers compensation cases, and other unintended consequences. Individuals, institutions, national organizations, and policymakers should carefully consider the historic basis, and reconsider the current role of an automated, race-based adjustment in spirometry.
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Affiliation(s)
- Nicole B Ramsey
- Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, Department of Pediatrics, Division of Allergy and Immunology, The Elliot and Roslyn Jaffe Food Allergy Institute, New York, NY.
| | - Andrea J Apter
- University of Pennsylvania, Department of Medicine, Division of Allergy & Immunology, Philadelphia, Pa
| | - Elliot Israel
- Harvard Medical School, Brigham Women's Hospital, Divisions of Pulmonary & Critical Care and Allergy & Immunology, Boston, Mass
| | - Margee Louisias
- Brigham and Women's Hospital, Division of Allergy and Clinical Immunology, Harvard Medical School, Boston, Mass; Boston Children's Hospital, Division of Immunology, Boston, Mass
| | - Lenora M Noroski
- Division of Immunology, Allergy, and Retrovirology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Sharmilee M Nyenhuis
- University of Illinois at Chicago, Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy, Chicago, Ill
| | - Princess U Ogbogu
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Tamara T Perry
- University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, Ark
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, Department of Pediatrics, Division of Allergy and Immunology, The Elliot and Roslyn Jaffe Food Allergy Institute, New York, NY
| | - Carla M Davis
- Division of Immunology, Allergy, and Retrovirology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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Perry TT, Patel MR, Li JT. Elevating Health Disparities Education Among Trainees and Physicians. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:918-922. [PMID: 35033699 DOI: 10.1016/j.jaip.2022.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/08/2021] [Accepted: 01/10/2022] [Indexed: 06/14/2023]
Abstract
Health disparities disproportionately affect patients in racial and ethnic minority groups, and these disparities are linked to economic, environmental, and social disadvantage. It is widely known that health disparities impact patients with allergic and immunologic conditions, yet universal and comprehensive training in health disparities is lacking. More robust educational opportunities are needed to fully equip trainees with tools to recognize and develop effective strategies to reduce the burden of health disparities. Also, there are no universal standards or requirements for professional medical boards in their respective maintenance of certification programs that will ensure ongoing training for practicing providers that will help them identify and manage individual or societal issues such as social determinants that contribute to health disparities. Further, the long-term impact of systematic discrimination, implicit and overt bias, and medical mistrust among populations most often affected by disparities compounds the complexity of the methods and types of training that is desperately needed to overcome health disparities. We provide a commentary on important topics that should be addressed during allergy and immunology training and beyond. We further highlight strategies and tools that should be used to tackle this important issue affecting millions of patients under our specialty care. It is past time for us to go beyond the bedside and comprehensively integrate health disparities training in our fellowship programs and in our practices.
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Affiliation(s)
- Tamara T Perry
- University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, Ark.
| | - Minal R Patel
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Mich
| | - James T Li
- Division of Allergy and Immunology, Mayo Clinic, Rochester, Minn
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26
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The End of Race Correction in Spirometry for Pulmonary Function Testing and Surgical Implications. Ann Surg 2022; 276:e3-e5. [DOI: 10.1097/sla.0000000000005431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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27
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Hall NB, Nye MJ, Blackley DJ, Laney AS, Mazurek JM, Halldin CN. Respiratory health of American Indian and Alaska Native coal miners participating in the Coal Workers' Health Surveillance Program, 2014-2019. Am J Ind Med 2022; 65:162-165. [PMID: 35032040 PMCID: PMC10870733 DOI: 10.1002/ajim.23324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/15/2021] [Accepted: 01/03/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND In 2014, a federal rule reduced occupational exposure limits to coal mine dust and expanded medical surveillance eligibility beyond underground miners to surface and contract coal miners. This expansion may have provided an opportunity for more American Indian and Alaska Native (AI/AN) coal miners to participate in screening, since many surface coal mines are located near AI/AN communities and may employ AI/AN miners. Therefore we sought to better understand the respiratory health of AI/AN coal miners by characterizing prevalence of coal workers' pneumoconiosis (CWP), progressive massive fibrosis (PMF), and abnormal lung function in this population. METHODS Descriptive analysis of 1405 chest radiographs and 627 spirometry test results for AI/AN miners who participated in the Coal Workers' Health Surveillance Program (CWHSP) during 2014-2019 was conducted. RESULTS Most AI/AN miners (0-25+ years of tenure) were western United States residents (82.3%) and active surface miners (76.9%) with no underground tenure. Among miners with at least 10 years of tenure, prevalence of CWP was 3.0%, and of PMF was 0.3%. Lung function abnormalities were seen in 9.0% with primarily restrictive patterns. CONCLUSIONS The prevalence of CWP, PMF, and lung function abnormality among active and former AI/AN coal miners was higher than seen in a larger CWHSP study of active western miners working primarily underground with 10+ years of tenure. Interventions that eliminate or control coal mine dust exposure, identify miners with CWP early, and limit respiratory disease progression and complications remain vital for eliminating the preventable adverse health effects of coal mining. Comprehensive demographic data on the coal mining workforce are needed to improve CWHSP participation assessment.
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Affiliation(s)
- Noemi B. Hall
- Surveillance Branch, Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Maya J. Nye
- Surveillance Branch, Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
- Association of Schools and Programs of Public Health (ASPPH)/Centers for Disease Control and Prevention (CDC) Public Health Fellow, Morgantown, West Virginia, USA
| | - David J. Blackley
- Surveillance Branch, Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - A. Scott Laney
- Surveillance Branch, Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Jacek M. Mazurek
- Surveillance Branch, Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Cara N. Halldin
- Surveillance Branch, Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
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28
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Schluger NW. The Vanishing Rationale for the Race Adjustment in Pulmonary Function Test Interpretation. Am J Respir Crit Care Med 2022; 205:612-614. [PMID: 35085469 DOI: 10.1164/rccm.202112-2772ed] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Neil W Schluger
- New York Medical College, 8137, Medicine, Valhalla, New York, United States;
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29
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Ekström M, Mannino D. Research race-specific reference values and lung function impairment, breathlessness and prognosis: Analysis of NHANES 2007-2012. Respir Res 2022; 23:271. [PMID: 36182912 PMCID: PMC9526909 DOI: 10.1186/s12931-022-02194-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 09/22/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Spirometry reference values differ by race/ethnicity, which is controversial. We evaluated the effect of race-specific references on prevalence of lung function impairment and its relation to breathlessness and mortality in the US population. METHODS Population-based analysis of the National Health and Nutrition Examination Survey (NHANES) 2007-2012. Race/ethnicity was analyzed as black, white, or other. Reference values for forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were calculated for each person using the Global Lung Initiative (GLI)-2012 equations for (1) white; (2) black; and (3) other/mixed people. Outcomes were prevalence of lung function impairment (< lower limit of normal [LLN]), moderate/severe impairment (< 50%pred); exertional breathlessness; and mortality until 31 December, 2015. RESULTS We studied 14,123 people (50% female). Compared to those for white, black reference values identified markedly fewer cases of lung function impairment (FEV1) both in black people (9.3% vs. 36.9%) and other non-white (1.5% vs. 9.5%); and prevalence of moderate/severe impairment was approximately halved. Outcomes by impairment differed by reference used: white (best), other/mixed (intermediate), and black (worst outcomes). Black people with FEV1 ≥ LLNblack but < LLNwhite had 48% increased rate of breathlessness and almost doubled mortality, compared to blacks ≥ LLNwhite. White references identified people with good outcomes similarly in black and white people. Findings were similar for FEV1 and FVC. CONCLUSION Compared to using a common reference (for white) across the population, race-specific spirometry references did not improve prediction of breathlessness and prognosis, and may misclassify lung function as normal despite worse outcomes in black people.
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Affiliation(s)
- Magnus Ekström
- grid.4514.40000 0001 0930 2361Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund University, Lund, Sweden ,grid.414525.30000 0004 0624 0881Department of Medicine, Blekinge Hospital, SE-37185 Karlskrona, Sweden
| | - David Mannino
- grid.266539.d0000 0004 1936 8438Department of Medicine, University of Kentucky College of Medicine, Lexington, KY USA ,grid.477168.b0000 0004 5897 5206COPD Foundation, Washington, D.C USA
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30
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Kouri A, Dandurand RJ, Usmani OS, Chow CW. Exploring the 175-year history of spirometry and the vital lessons it can teach us today. Eur Respir Rev 2021; 30:30/162/210081. [PMID: 34615699 DOI: 10.1183/16000617.0081-2021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 07/02/2021] [Indexed: 12/25/2022] Open
Abstract
175 years have elapsed since John Hutchinson introduced the world to his version of an apparatus that had been in development for nearly two centuries, the spirometer. Though he was not the first to build a device that sought to measure breathing and quantify the impact of disease and occupation on lung function, Hutchison coined the terms spirometer and vital capacity that are still in use today, securing his place in medical history. As Hutchinson envisioned, spirometry would become crucial to our growing knowledge of respiratory pathophysiology, from Tiffeneau and Pinelli's work on forced expiratory volumes, to Fry and Hyatt's description of the flow-volume curve. In the 20th century, standardization of spirometry further broadened its reach and prognostic potential. Today, spirometry is recognized as essential to respiratory disease diagnosis, management and research. However, controversy exists in some of its applications, uptake in primary care remains sub-optimal and there are concerns related to the way in which race is factored into interpretation. Moving forward, these failings must be addressed, and innovations like Internet-enabled portable spirometers may present novel opportunities. We must also consider the physiologic and practical limitations inherent to spirometry and further investigate complementary technologies such as respiratory oscillometry and other emerging technologies that assess lung function. Through an exploration of the storied history of spirometry, we can better contextualize its current landscape and appreciate the trends that have repeatedly arisen over time. This may help to improve our current use of spirometry and may allow us to anticipate the obstacles confronting emerging pulmonary function technologies.
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Affiliation(s)
- Andrew Kouri
- Division of Respirology, Dept of Medicine, St. Michael's Hospital, Unity Health Toronto, Ontario, Canada
| | - Ronald J Dandurand
- Lakeshore General Hospital, Quebec, Canada.,Dept of Medicine, Respiratory Division, McGill University, Montreal, Quebec, Canada.,Montreal Chest Institute, Meakins-Christie Labs and Oscillometry Unit of the Centre for Innovative Medicine, McGill University Health Centre and Research Institute, Montreal, Canada
| | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
| | - Chung-Wai Chow
- Dept of Medicine, University of Toronto, Toronto, Canada.,Division of Respirology and Multi-Organ Transplant Programme, Dept of Medicine, Toronto General Hospital, University Health Network, Toronto, Canada
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31
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Bhakta NR, Kaminsky DA, Bime C, Thakur N, Hall GL, McCormack MC, Stanojevic S. Addressing Race in Pulmonary Function Testing by Aligning Intent and Evidence With Practice and Perception. Chest 2021; 161:288-297. [PMID: 34437887 PMCID: PMC8783030 DOI: 10.1016/j.chest.2021.08.053] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/29/2021] [Accepted: 08/17/2021] [Indexed: 10/27/2022] Open
Abstract
The practice of using race or ethnicity in medicine to explain differences between individuals is being called into question because it may contribute to biased medical care and research that perpetuates health disparities and structural racism. A commonly cited example is the use of race or ethnicity in the interpretation of pulmonary function test (PFT) results, yet the perspectives of practicing pulmonologists and physiologists are missing from this discussion. This discussion has global relevance for increasingly multicultural communities in which the range of values that represent normal lung function is uncertain. We review the underlying sources of differences in lung function, including those that may be captured by race or ethnicity, and demonstrate how the current practice of PFT measurement and interpretation is imperfect in its ability to describe accurately the relationship between function and health outcomes. We summarize the arguments against using race-specific equations as well as address concerns about removing race from the interpretation of PFT results. Further, we outline knowledge gaps and critical questions that need to be answered to change the current approach of including race or ethnicity in PFT results interpretation thoughtfully. Finally, we propose changes in interpretation strategies and future research to reduce health disparities.
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Affiliation(s)
- Nirav R Bhakta
- University of California, San Francisco, San Francisco, CA.
| | | | - Christian Bime
- College of Medicine, The University of Arizona Health Science, Tucson, AZ
| | - Neeta Thakur
- University of California, San Francisco, San Francisco, CA; Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Graham L Hall
- Children's Lung Health, Wal-yan Respiratory Research Centre, Telethon Kids Institute and School of Allied Health, Curtin University, Perth, WA, Australia
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32
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Neuss MJ. The Historian as Consultant: History of Medicine in the New Humanities in Chest Medicine Section. Chest 2021; 159:1332-1333. [PMID: 34021994 DOI: 10.1016/j.chest.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/03/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Michael J Neuss
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.
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