Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms

In the paper

“Explanations that have been given for this finding include the notion that black people release more creatinine into their blood at baseline, in part because they are reportedly more muscular.11,25”

What the sources say

• Not checked yetcites [11] source
• Not checked yetcites [25] source

In the paper

“It assigns three additional points to any patient identified as “nonblack,” thereby categorizing all black patients as being at lower risk.”

What the sources say

• Not checked yetcites [9] source

In the paper

“Epidemiologists continue to debate how to responsibly make causal inferences based on race.33”

What the sources say

• Not checked yetcites [33] source

In the paper

“For example, despite mounting evidence that race is not a reliable proxy for genetic difference, the belief that it is has become embedded, sometimes insidiously, within medical practice.”

In the paper

“Clinicians are advised to use this risk score to guide decisions about referral to cardiology and allocation of health care resources.”

What the sources say

• Not checked yetcites [9] source

In the paper

“The Vaginal Birth after Cesarean (VBAC) algorithm predicts the risk posed by a trial of labor for someone who has previously undergone cesarean section.”

In the paper

“Such situations, however, are exceedingly unlikely.”

In the paper

“while black people already have higher rates of end-stage kidney disease and death due to kidney failure than the overall population.25”

What the sources say

• Not checked yetcites [25] source

In the paper

“Our understanding of race and human genetics has advanced considerably since 2003, yet these insights have not led to clear guidelines on the use of race in medicine.”

In the paper

“Physicians use these algorithms to individualize risk assessment and guide clinical decisions.”

In the paper

“Analyses have cast doubt on this claim, 26 but the “race-corrected” eGFR remains the standard.”

What the sources say

• Not checked yetcites [26] source

In the paper

“Some algorithm developers offer no explanation of why racial or ethnic differences might exist.Others offer rationales, but when these are traced to their origins, they lead to outdated, suspect racial science or to biased data.22,30,31”

What the sources say

• Not checked yetcites [22] source
• Not checked yetcites [30] source
• Not checked yetcites [31] source

In the paper

“troubling because black people already have higher rates of maternal mortality.30”

What the sources say

• Not checked yetcites [30] source

In the paper

“Given this complexity, it is insufficient to translate a data signal into a race adjustment without determining what race might represent in the particular context.”

In the paper

“They examined data sets of clinical outcomes and patient characteristics and then performed regression analyses to identify which patient factors correlated significantly with the relevant outcomes.”

In the paper

“Researchers then decided that it was appropriate -even essential -to adjust for race in their model.”

In the paper

“The Society of Thoracic Surgeons produces elaborate calculators to estimate the risk of death and other complications during surgery.10”

What the sources say

• Not checked yetcites [10] source

In the paper

“Use of the KDRI may do just that.”

In the paper

“Changing to any other race or ethnicity does not increase the estimated risk of death as compared with a white patient, but it does change the risk of renal failure, stroke, or prolonged ventilation.”

What the sources say

• Not checked yetcites [10] source

In the paper

“If the empirical differences seen between racial groups were actually due to genetic differences, then race adjustment might be justified: different coefficients for different bodies.”

In the paper

“Since it is cumbersome to measure kidney function directly, researchers have developed equations that determine the estimated glomerular filtration rate (eGFR) from an accessible measure, the serum creatinine level.”

In the paper

“The calculators include race and ethnicity because of observed differences in surgical outcomes among racial and ethnic groups; the authors acknowledge that the mechanism underlying these differences is not known.”

What the sources say

• Not checked yetcites [10] source

In the paper

“Conversely, race adjustments that yield higher estimates of kidney function in black patients might delay their referral for specialist care or transplantation and lead to worse outcomes”

In the paper

“Since the health care system has spent more money, on average, on white patients than on black patients, the tool returned higher risk scores for white patients than for black patients.”

What the sources say

• Not checked yetcites [36] source

In the paper

“This decision reflects a default assumption in medicine: it is acceptable to use race adjustment even without understanding what race represents in a given context.”

In the paper

“Some tools, including eGFR and the VBAC calculator, have already been challenged; clinicians have advocated successfully for their institutions to remove the adjustment for race.43,44”

What the sources say

• Not checked yetcites [43]
• Not checked yetcites [44]

In the paper

“However, when clinicians insert race into their tools, they risk interpreting racial disparities as immutable facts rather than as injustices that require intervention.”

In the paper

“The criminal justice system, for instance, uses recidivism-prediction tools to guide decisions about bond amounts and prison sentences.”

In the paper

“Clinicians and medical researchers typically use the categories recommended by the Office of Management and Budget: five races and two ethnicities.”

In the paper

“Guidelines are silent on such issues -an indication of their inadequacy.”

In the paper

“But if the underlying data reflect racist social structures, then their use in predictive tools cements racism into practice and policy.”

In the paper

“When these tools influence high-stakes decisions, whether in the clinic or the courtroom, they propagate inequity into our future.”

In the paper

“The Society of Thoracic Surgeons acknowledged concerns raised by clinicians and policymakers “that inclusion of SES factors in risk models may 'adjust away' disparities in quality of care.”Nonetheless, it proceeded to consider “all preoperative factors that are independently and significantly associated with outcomes””

What the sources say

• Not checked yetcites [10] source

In the paper

“Our understanding of race has advanced considerably in the past two decades.”

In the paper

“One tool, COMPAS (Correctional Offender Management Profiling for Alternative Sanctions), while not using race per se, uses many factors that correlate with race and returns higher risk scores for black defendants.40”

What the sources say

• Not checked yetcites [40]

In the paper

“A second problem arises from the ways in which racial and ethnic categories are operationalized.”

In the paper

“These scores may well have led to more referrals for white patients to specialty services, perpetuating both spending discrepancies and race bias in health care.”