Organized medicine’s advocacy has shown effectiveness in reducing health inequity in general and the misuse of race in clinical algorithms in particular. That is especially true with moving beyond a once widely used formula for calculating kidney function that automatically underestimated the severity of kidney disease in Black patients. The changes have cut kidney-transplant waitlist times for thousands—with a median drop of 1.7 years.
“As part of broader efforts to transform health care through coordinated and collective action, the AMA and Council of Medical Specialty Societies are convening professional societies around foundational actions to advance equity, including the elimination of harmful race-based clinical algorithms and other organizational-level contributors to inequitable access to health services,” says a research letter published in JAMA Network Open.
The research details findings from the inaugural “Health Equity in Organized Medicine” survey (PDF) of the state medical associations and national specialty societies that make up the AMA Federation of Medicine. The survey report highlights how the American Academy of Family Physicians adopted policy to eliminate race as a proxy for biology or genetics in clinical evaluation, while the Medical Society of Delaware adopted policy advocating for the elimination of race as a factor in the measurement of kidney function—that is, the estimated glomerular filtration rate (eGFR).
The Medical Society of Delaware then worked with the state hospital association, local hospitals and all laboratories in the state to eliminate the use of the eGFR and other harmful race-based algorithms.
The race-based algorithms don’t “have any basis in genetics and biology,” said Emily Cleveland Manchanda, MD, MPH, director of social justice education and implementation at the AMA Center for Health Equity and lead author of the JAMA Network Open research letter.
“So when we were talking about using harmful race-based algorithms in the measurement of how kidneys, lungs or reproductive-organ function—it’s profoundly problematic,” she said.
According to the AMA survey, 47% of the physician organizations polled undertook at least one action to advance health equity. That work included advocating to eliminate harmful race-based clinical algorithms relating to kidney function, vaginal birth after cesarean, and spirometry/pulmonary function testing.
The examples described in the JAMA Network Open letter “highlight the ways in which societies that play different roles in medicine can all have a part in addressing harmful racial essentialism, the biologicalization of race,” Dr. Cleveland Manchanda said. “That's created support for clinicians, researchers and others at health care institutions around the country to eliminate these harmful algorithms from use.”
Thousands of lives changed
The race-based eGFR calculations had long been automatically adjusted to give Black patients a higher number, which led to underestimating the severity of their kidney disease. That meant delays in access to medication, specialist referral, nutrition therapy, disease education, dialysis and transplantation.
New equations eliminating the automatic race adjustment, developed by the Chronic Kidney Disease Epidemiology Collaboration, were published in 2021. The United Network for Organ Sharing adopted new policy in 2023 to adjust waiting times for Black kidney-transplant patients whose place in line was negatively affected by the race-based calculation.
That change in policy has already had a dramatic effect, according to the United Network for Organ Sharing. The organization reported that in the first six months of 2023:
- 6,103 Black patients had their waitlist time modified.
- Median time given back to Black patients was 1.7 years.
- 491 Black patients with a waitlist modification got a deceased donor kidney transplant.
- 15 Black patients with a waitlist modification received a living donor transplant.
The changes mean “that patients are getting both the medical and surgical interventions to treat kidney disease at the appropriate time,” Dr. Cleveland Manchanda said.
A second survey of Federation of Medicine associations has already been conducted and the data is being reviewed for use in a follow-up report.
Data from the surveys is also being used to develop content and programming in the Rise to Health Coalition, which seeks to coordinate health care organization actions to create a strong national impact on breaking down barriers to achieving health equity.
