Health Equity

Johanna Taylor Katroscik, PharmD

Height, age, weight, race. Three of these things are objectively measurable items. One is not. Yet somehow health care professionals are still using race in practice as though it is an objective measure. This practice is largely based on the fact that practitioners trust guidelines and algorithms to be evidence-based. Unfortunately, some of these guidelines and algorithms are based on antiquated beliefs. Practitioners are still using diagnostic algorithms that include race, which ultimately perpetuates both implicit and explicit bias and ends up potentiating race-based medicine. As health care providers, we bear a responsibility to question and dig deep into clinical trials and guidelines to best serve our patients.

eGFR: An example of how race has been used as a biological proxy in medicine

Race has been used in clinical algorithms for decades, and it is largely based on inaccurate or nonexistent data. For example, the Chronic Kidney Disease Modification of Diet in Renal Disease (CKD MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations have historically used race to calculate a patient’s estimated glomerular filtration rate (eGFR). The choices for race in these equations are Black or non-Black. As a trained clinician this might seem normal, but when stopping and thinking about the actual terminology of “Black or non-Black,” there is a lot of room for subjective interpretation and bias.

Race was originally used in the calculation because it was thought that Black people had higher muscle mass and produced more creatinine than non-Black people. However, there is no scientific data to support this, and no definition exists for what constitutes a Black versus a non-Black person so practitioners must subjectively look at someone’s skin color to make this assessment. How, for example, does a clinician decide which race to put into the equation if a patient has one parent who is white and one parent who is Black? For years, clinicians have made these assessments that likely had tremendous health-related impacts on their patients without questioning why they were being asked to consider race.

Even today, most clinicians still use race as an objective measure, but progress is slowly being made in the right direction. In 2020, the National Kidney Foundation and the American Society for Nephrology established a task force to address if race should continue to be used in eGFR algorithms. In September 2021, they published their results and recommendations. Three key recommendations were made:

• Implementation and use of a refit CKD-EPI equation that does not include race as a variable

• Use of cystatin C to confirm eGFR in adults who have or are at risk for CKD

• Increased funding and continued research on eGFR with endogenous filtration markers, with the intention of removing race from equations to promote health equity

How to move forward to provide equitable care

The New England Journal of Medicine has an entire collection of articles on their website titled “Race and Medicine” that offers both scientific and personal perspectives of race in medicine.

The authors of one of the articles in this collection, “Hidden in plain sight—reconsidering the use of race correction in clinical algorithms,” offer 3 questions that practitioners should ask when factoring race into a clinical algorithm:

• Is there the need for race correction based on robust evidence and statistical analyses?

• Is there a plausible causal mechanism for the racial difference that justifies racial correction?

• Would implementing this race correction relieve or exacerbate health inequities?

As mentioned previously, health care providers must use their voices to question clinical trials and guidelines to ensure that treatment decisions are evidence-based. It’s also important to be willing to have potentially difficult conversations with other providers who may not know or understand why race should not be used as an objective measurement—and, on the flip side, be open to learning and being corrected by others who may know more than you. The most important thing is to keep reading, learning, and growing as a practitioner. ■

Editor’s note: This article is part of Pharmacy Today’s ongoing coverage of structural racism.

Some good news

While there are clinical tools and algorithms that continue to use race as a variable, over the past several years, a number of journal articles have been published that have questioned this practice.

Several of the tools and algorithms that had previously used race as a measure and were included in the NEJM article used to adapt the chart in this article have since removed race as an input including the CKD-EPI and the vaginal birth after cesarean calculations.