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"Race Correction" Impacts Pulmonary Function Testing Interpretation Among Black Patients

Presenter: Alexander Moffett, MD

Removing “race correction” from the interpretation of pulmonary function test (PFT) results shows black patients have a significantly higher prevalence and severity of lung disease.

Race correction, a standard practice in PFT interpretation, has no biological basis and results in a decrease in the predicted lower limit of “normal” for forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) for black patients.

“The use of race correction in clinical algorithms may mask and, thus, reinforce the effects of structural racism, including known disparities in care processes and outcomes for black patients with lung diseases,” said Alexander Moffett, MD, clinical fellow, Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania Perelman School of Medicine. “Black patients are both undiagnosed and underdiagnosed.”

Moffett and colleagues used American Thoracic Society guidelines to interpret PFTs performed at the University of Pennsylvania Health System between 2010 and 2020 involving patients who self-identified as black or African-American. The researchers applied guidelines using the reference values for spirometry developed by the Global Lung Function Initiative, both with and without race correction. They compared the two sets of interpretations with respect to the diagnosis of obstructive, restrictive, and mixed pulmonary defects, along with the gradation of severity of these defects, and also identified a composite diagnosis of any pulmonary defect, defined as an FEV1, FVC, FEV1/FVC, or total lung capacity below the lower limit of normal.

After interpreting 14,080 pulmonary function tests, both with and without race correction, they found that removal of race correction led to results indicating the presence of more serious pulmonary disease. The removal of race correction led to an increase in the percentage of patients with any pulmonary defect from 59.5% to 81.7%, a significant difference of 20.8%. “This means that we may be missing a large number of patients who may be undertreated or not treated at all,” said Moffett.

Looking at specific pulmonary disease categories, the removal of black race correction led to a diagnosis of obstruction for an additional 414 patients and an increase in the prevalence of obstructive lung disease in this cohort from 22.1% to 23.9%, a difference of 1.75%. Removal of race correction also led to the diagnosis of restricted breathing for an additional 665 patients, an increase in the prevalence of restrictive lung disease from 8.8% to 13.5%, a difference of 4.7%. Among patients with an obstructive, restrictive, or mixed defect, the percentage for whom correction removal led to an increase in the severity of disease was 48.6%.

“There are many ways one might remove race correction from pulmonary function test interpretation, and further work is needed, involving the collaboration of patients and clinicians, to develop a broad consensus on this point,” said Moffett. “The preliminary research reported here is intended to start a larger conversation concerning the current assumptions that inform pulmonary function test interpretation and the ways in which these assumptions may promote the unequal distribution of medical resources. Our hope is that in identifying the clinical implications of race correction, we can begin to convince other health professionals of the importance of this topic of conversation, developing the science of pulmonary function test interpretation on a stronger scientific foundation to promote more just medical care.”

Link to abstract: The Impact of Race Correction on the Interpretation of Pulmonary Function Testing Among Black Patients

Alexander Moffett, MD has nothing to disclose

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