Hospitals, Diagnostics, Social Determinants

NYC Health + Hospitals drops use of two race-based clinical assessments

The nation’s largest public health system will stop using clinical assessments for kidney function and vaginal delivery after C-sections that use race-based calculations for determining illness severity and risk. These assessments can result in people of color not receiving the diagnoses and treatments they need.

In an effort to boost equitable care, the country’s largest public health system will no longer use two race-based clinical assessments.

NYC Health + Hospitals launched its Medical Eracism initiative Monday that aims to address racial biases in clinical care, including in assessments and algorithms used. To begin with, the New York City-based health system will stop using two common diagnostic tests — one for kidney disease and another for vaginal birth after a cesarean delivery — that include embedded race-based calculations for determining the severity of illness and risk.

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For decades, providers have used race as a proxy to calculate kidney function. The kidney function test, known as glomerular filtration rate, is adjusted for Black Americans and categorizes all patients as Black or non-Black. This can minimize the severity of illness in Black patients, resulting in delayed referrals for treatment and disqualification for transplants.

The second race-based assessment to be eliminated is the risk calculation for vaginal birth after cesarean section, or VBAC. This is used to estimate the risk and potential success of labor for a vaginal delivery after undergoing a C-section in a previous pregnancy. The calculation includes several risk factors, such as age, body mass index and clinical history of delivery, along with whether the patient is Black or Hispanic.

NYC Health + Hospitals, which includes 11 acute care facilities, decided to first eliminate these two assessments because of the large impact it is likely to have on the demographically diverse patients they serve, said Dr. Louis Hart, director of equity, quality and safety at the health system, in a phone interview.

But the health system does not plan to stop at just those two. Next, they will examine lung function testing and the use of diagnostic calculators to gauge the risk of urinary tract infections in children between 2 and 23 months, he said. These take race into account and are based on dated prevalence studies.

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Further, NYC Health + Hospitals is planning to use an article published in the New England Journal of Medicine — which identified 13 different race-based assessments and algorithms — as a guide for which assessments to tackle after these initial four, Hart added.

Race-based assessments and equations tend to use different coefficients, so the calculations provide a different result after taking race into account, he explained. Some take individual races into account and provide differentiated outcomes or reference ranges for what is considered normal, and others provide binary results — like the aforementioned test for kidney function, which provides one result for Black patients, and another for non-Black.

“When we look at race-based medicine or race-based equations, we realize that race is not the risk factor for inequities — we believe it’s actually racism,” he said. “Or the ways in which our society has structured opportunities and privilege.”

The Medical Eracism initiative is being led by the health system’s Office of Quality & Safety and its new Equity & Access Council, which is focusing on four target areas: workforce diversity, workforce inclusion, equity of care and monitoring and evaluation.

“[We have] to play a leading role in [health equity], just given the fact of our scale and given the demographics of our patient population,” Hart said. “Given we are the largest public safety-net system in our country, the disparities and inequities that could either occur in our four walls or that we could remain ignorant [about due to] the status quo, could [cause] hurt on a larger [scale].”

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