Hamilton Health Sciences changes to race-neutral lung evaluation practices to support Black patients
Hamilton Health Sciences (HHS) is making strides in health equity by updating its clinical standards for testing lung health. This change comes in response to new guidelines from the American Thoracic Association. Race-based adjustments in lung health assessments have negatively affected Black and other racialized patients. The initiative reflects HHS’s commitment to providing the best possible care for all patients, regardless of race.
The problem with race-adjusted pulmonary function testing
Historically, HHS, like many other health-care organizations, used race-adjusted algorithms as part of evaluating the health of someone’s lungs. Patients were required to identify their race or ethnicity, and respiratory therapists would enter a corresponding code into the system. We now know this method was not based on representative evidence and often resulted in Black and other racialized patients being undiagnosed or underdiagnosed, limiting their access to appropriate care and treatments.
Now, a patient’s lung capacity is only compared against averages for other people of the same height, age and sex. One of the standard tests used is called spirometry, which measures how much air a patient breathes in and out, and how strongly or easily they breathe. These measurements help determine if someone’s lungs are working well or not.
Dr. Duong
“In the past, the standards were to deduct about 10 to 15 percent from the white value and bring down the ‘normal’ value for non-white patients,” says Dr. MyLinh Duong, an HHS respirologist working on the project. “And that’s how we were missing a lot of people who were non-white, because they could have symptoms, but their lung function was considered to be normal compared to their reference, but their reference was actually artificially lowered by this deduction.”
“Spirometry is just one measure that we use in a diagnosis,” says Duong. “I think spirometry is extremely useful, but interpreting it is complex – the standards have been all over the map. We need to consider the results of all the lung tests we have, and the context of the patient’s environment, employment, and overall health.”
The shift to race-agnostic standards
The American Thoracic Society (ATS) recently released a position statement and an academic publication advocating for race-agnostic equations in pulmonary function testing. These new standards do not factor in race, ensuring more accurate and equitable assessments for all patients. HHS is now adopting these standards, and updating our clinical processes and systems to reflect the best available evidence.
Stephanie Shiplo, RT
Stephanie Shiplo, manager of diagnostic services, emphasized the importance of this change.
“The guidelines that were previously in place used to disadvantage many different ethnicities by adjusting predictive values and thresholds for lung disease,” she says. “By moving to race-agnostic standards, we are ensuring that all our patients receive the most accurate diagnoses and treatments. This is a crucial step in our commitment to health equity.”
Technical and process changes
Implementing these new standards required technical changes and reconfigurations on the devices used by respiratory therapists. Additionally, updates to the electronic health record system, Epic, were necessary to support the new standards.
“This was simply an adjustment in our software system done with the vendor,” says Shiplo. “It was like flipping a switch in the background. It required uploading the race-neutral predictive values and setting them as the new default. After the reboot of our systems, it was in place across all our sites.”
HHS is also collaborating with St. Joseph’s Healthcare Hamilton to ensure a city-wide approach to these changes so that results are the same, no matter what organization a patient visits.
Commitment to equity, diversity, and inclusion
These changes are a testament to HHS’s dedication to equity, diversity, and inclusion.
Fatima Sheikh
Fatima Sheikh, HHS health equity specialist, says, “In many ways, this initiative highlights our commitment to health equity for all patients accessing care at HHS, and the importance of responding to patient and staff concerns as they arise. As an academic health sciences center, our ability to understand, integrate, and implement the best available evidence in a timely fashion reflects our commitment to evidence-informed health equity efforts.”
Duong agrees. “It’s a welcome change,” she says. “Because by attributing low lung function to race, we completely dismiss what is the underlying root causes for lung health differences. At the end of the day, there are differences that should not be there. We need to figure that out.”
Black health initiative
As HHS moves forward with these changes, the organization is also celebrating Black History Month and recognizing the importance of ongoing efforts to support Black patients. The successful acquisition of funding specifically to support Black Health for the current and next fiscal years will further enhance these initiatives.
The decision to adopt race-agnostic pulmonary function testing marks an important moment in the organization’s journey toward health equity. By eliminating race-based adjustments, HHS is taking a crucial step in providing fair and accurate care for all patients, particularly those who have been historically marginalized.
Additional reading:
Health Quality Ontario – COPD Website
