YNHHS Works To Eliminate Biased Tests and Procedures That Can Lead to Poor Outcomes

In August, Yale New Haven Health updated a standard approach to measuring kidney function that was based on methods used nationwide for the past 20 years.

Research has shown that the traditional methods of estimating glomerular filtration rate (eGFR) as part of kidney function may be inaccurate and are racially biased. Those who developed the methods in 1999 hypothesized that Black patients have more muscle mass than white patients, so they included a “racial modifier” in the eGFR test to better fit the racial disparities in the data they were seeing.

That means Black patients automatically have points added to certain values in the test, making their kidney function appear healthier than it is. Those skewed results likely lead to diagnostic and treatment delays for patients based solely on their race.

YNHHS’ updated approach to the eGFR test uses a new equation that removes race and is recommended by the National Kidney Foundation and American Society of Nephrology.

YNHHS and organizations nationwide have been working for years to eliminate healthcare disparities that can lead to differences in treatment and outcomes based on patients’ race, ethnicity, gender, socioeconomic status and other factors. A growing amount of research is revealing racially biased tests, procedures and other clinical processes that can lead to less-effective treatment and worse outcomes for all patients.

In addition to altering the eGFR test, YNHHS no longer uses race as a factor in predicting jaundice in newborns. According to research, many other, more relevant elements contribute to jaundice and related complications.

“Using race to predict higher or lower risks of jaundice can lead to unnecessary procedures or, conversely, inadequate treatment,” said Louis Hart, MD, a pediatric hospitalist, medical director of Health Equity for YNHHS and assistant professor of pediatrics at Yale School of Medicine.

These and numerous other clinical processes are often based on “racial biology,” a false assumption that someone’s race can be used to accurately predict their underlying genetics.

“Race is not a biological category that produces health disparities due to universal genetic differences; rather, it is a sociopolitical system used to support the continuation of structural racism,” Dr. Hart said. “We remain steadfast in our commitment to push forward on our journey to eliminate racial biology from medicine, here and beyond.”

More changes in the works

In the future, investigators from YNHHS and Yale School of Medicine will change a tool that uses a point scale to predict kidney stones when a patient comes to the emergency department. The more points, the more likely kidney stones are causing symptoms. The current tool automatically adds points for patients identified as white.

“This race-based statistical adjustment has been supported by numerous mathematical models,” Dr. Hart said. “However, there is no scientific basis for white patients having more kidney stones than non-white patients.”

This lack of scientific evidence, along with well-documented inequities patients of color face when accessing health care in the U.S., call into question whether race-based clinical models are inherently flawed, Dr. Hart said. Clinicians using a racially based tool might initially miss kidney stones in non-white patients, delaying proper treatment. Researchers are working to validate a new clinical variable that is biological, objective and more reliable.

Another change will involve how YNHHS clinicians interpret results from pulse oximeters, devices placed on patients’ fingers that use light to measure pulse and blood oxygen levels. A study found that many participating Black patients and others with darker skin tones showed normal pulse oximeter readings. But other tests revealed dangerously low oxygen in their blood. The Food and Drug Administration is examining how well the devices work for patients with different degrees of skin pigmentation.

New Epic fields will support health equity

YNHHS’ Office of Health Equity (OHE) is preparing to launch a “We Ask Because We Care” campaign in 2023. The campaign will support the continued collection of accurate patient demographic data and awareness of how these data are critical to efforts to eliminate healthcare disparities.

Through the campaign, YNHHS will continue inviting patients to share their race, ethnicity, preferred language, sexual orientation, gender identity and disability identity. Patients do not have to answer these questions, but information from those who do will be entered into updated fields in their Epic medical record.

The Office of Health Equity, working with the departments of Care Signature and Quality and Safety, will analyze the de-identified patient information to measure equity in patient access; use of healthcare services; transitions from one care setting to another; patient experience; and quality and safety clinical outcomes.

The OHE’s quality and organizational improvement work will help set a new standard for equitable care delivery and community impact that serves as a national model for implementation, said Darcey Cobbs-Lomax, OHE director. This work will also support state, federal and healthcare accrediting organizations’ efforts to reduce healthcare disparities.

“Most importantly, it will help us identify and eliminate unjust social disparities that exist within healthcare systems and guarantee that we are providing the highest-quality, safest and most accessible care possible to every patient, every time,” Dr. Hart said.

Watch for future communications about YNHHS systemwide equity, quality and safety efforts.