Addressing Race in Pulmonary Function Testing by Aligning Intent and Evidence With Practice and Perception

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.

The End of Race Correction in Spirometry for Pulmonary Function Testing and Surgical Implications

“…7,8 Additional arguments against the inclusion of race-corrected equations include the variation of how race is reported by an individual or determined by the provider, the lack of inclusion of multi-racial categories in equations, and the wide variation in spirometry values within racial groups. 7 Recent studies have demonstrated that race-correction in spirometry can lead to misdiagnosis or misclassification of medical diagnoses including asthma and chronic obstructive pulmonary dysfunction for patients. 10,11 Lastly, and importantly, the persistent use of race, a socio-political construct based on the physical appearance of an individual, as a proxy for genetic difference in lung function is wrong.…”

“…Furthermore, factors such as smoking status, childhood respiratory illness, obesity, and environmental exposures to air pollution, known contributors to lung function, are not included in interpretation of results 7,8 . Additional arguments against the inclusion of race-corrected equations include the variation of how race is reported by an individual or determined by the provider, the lack of inclusion of multi-racial categories in equations, and the wide variation in spirometry values within racial groups 7 . Recent studies have demonstrated that race-correction in spirometry can lead to misdiagnosis or misclassification of medical diagnoses including asthma and chronic obstructive pulmonary dysfunction for patients 10,11 .…”

Structural Inequities in Medicine that Contribute to Racial Inequities in Asthma Care

“…• Ignores variability in how racial/ethnic groups are defined across social settings/societies. 27 Several arguments have been put forward that oppose the removal of race in spirometry predicted equations 28 include the following:…”

Against Essentialism in Pulmonary Function Test Interpretation

“…However, these equations have been challenged on the grounds that differences in pulmonary function are the product of racism rather than race. 2 Race-specific equations present these differences as normal, the product of biology rather than of racially mediated differences in prenatal care, early childhood nutrition, health care access, and air pollution exposure. 2 In this issue of CHEST, Holland et al 3 use a systematic review to join this debate.…”

“…2 Race-specific equations present these differences as normal, the product of biology rather than of racially mediated differences in prenatal care, early childhood nutrition, health care access, and air pollution exposure. 2 In this issue of CHEST, Holland et al 3 use a systematic review to join this debate. The authors identify 10 studies that assess the effect of socioeconomic status (SES) on pulmonary function in Black and White individuals.…”