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Ann Am Thorac Soc
Ann Am Thorac Soc
AnnalsATS
Annals of the American Thoracic Society
2329-6933
2325-6621
American Thoracic Society

39212421
202407-676ED
10.1513/AnnalsATS.202407-676ED
Editorials
Framing the Consequences of Implementing Race-Neutral Interpretation of Spirometry
https://orcid.org/0000-0002-2135-7012
Bhakta Nirav R. 1
Taylor Aaron 2
1 University of California, San Francisco, San Francisco, California; and
2 University of Arizona, Tucson, Arizona
1 9 2024
1 9 2024
1 9 2024
21 9 12491250
Copyright © 2024 by the American Thoracic Society
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0. For commercial usage and reprints, please e-mail Diane Gern.
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pmcA small number of studies have examined the impact of changing to race-neutral spirometry reference equations on clinical decisions such as historical position on lung transplantation waiting lists (1, 2) and treatment for pulmonary fibrosis (3). One study reported the potential impact on administrative decisions, including the assessment of occupational eligibility for firefighting and of pulmonary impairment for disability benefits, by scaling estimates from research and population survey cohorts (2). However, the results, including dollar amounts, are expected to be different when using data from the specific populations on which decisions are actually made because distinct backgrounds, exposures, and health will alter the distribution of pulmonary function relative to that from general populations.

In this issue of AnnalsATS, the study by Spece and colleagues (pp. 1272–1280) is unique in that the authors used a large dataset from the U.S. Department of Veterans Affairs to quantitate the impact on a few key threshold-based decisions in patients with chronic obstructive pulmonary disease (COPD): lung cancer resection risk, candidacy for lung volume reduction surgery, and disability benefits (4). A key strength of this cohort is the ability to expand the dialog around spirometry beyond a Black–White dichotomy. Because of underenrollment in many cohorts used in analyses on this topic, consequences for Asian and other population groups have been heretofore underconsidered. Good policymaking requires understanding the impact across all Americans, not solely those most affected. We should acknowledge that although African Americans were a particularly focal target of discrimination in the United States, the broader concerns about inequality that could affect lung function logically apply to many groups. The authors are to be commended for the use of actual veterans, who are a unique population deserving separate characterization.

Future work could further enhance specificity. Both NETT (National Emphysema Treatment Trial), for lung volume reduction surgery, and the lobectomy guidelines suggest criteria for diffusing capacity of the lung for carbon monoxide as well as for forced expiratory volume in 1 second, but only the latter were used in this study (5, 6). The impact might differ after accounting for those who were already disqualified by these criteria. Regarding lobectomy, like other recent work (7), the authors assumed that all participants would lose an equal number of lung segments. In contrast, guidelines recommend the use of postoperative predictive lung function, recognizing the variable impact of surgical treatment on the basis of the actual amount of tissue resected (5).

The authors rightly note the opportunity to revise clinical guidelines. However, an alternatively useful framing is that these guidelines needed updating regardless. In the time since NETT, new evidence has suggested greater safety and efficacy for those with low diffusing capacity of the lung for carbon monoxide and homogeneous emphysema (8, 9). Endobronchial lung volume reduction, which is equally efficacious, can be applied to those with extremely low forced expiratory volume in 1 second (10, 11). More recent work in surgical approaches to early-stage lung cancer suggest that sublobar resection might be equally efficacious as lobectomy (12). Apart from unresolved questions about surgical safety, this evidence in favor of a lung-sparing approach might recast the meaning of recent findings that thoracic surgeons presented with race-neutral interpretation are more likely to recommend wedge resections to Black patients (13). The underlying data for each of these still active recommendations were based on cohorts that were overwhelmingly White (5, 6). Pulmonary function criteria for the safety of lung cancer resection might have limited performance in COPD (5). In short, advances made these guidelines difficult to interpret long before the advent of race-neutral spirometry interpretation. The distance between new discoveries and current guidelines also increases the likelihood of nonadherence, muddying our estimates of consequences.

Furthermore, there is a need to consider more than just the impact of changing to race-neutral reference equations. Most thresholds use percentage of predicted lung function, which, compared with a z-score, leads to the proportion of the reference population above or below the threshold to vary with age and height, a bias that must be considered when developing thresholds. Some applications of spirometry might perform better without reference equations (14, 15).

There is an inherent limitation in scope. The authors provide details on the financial impact of a transition on veterans with COPD and examine access to therapies. In contrast, the recent American Thoracic Society statement recommending a change to race-neutral interpretation of pulmonary function testing (PFT) results also highlighted the potential contributions of race-specific reference equations to provide false assurance on diagnosis, risk, and prognosis of underserved and underrepresented minority populations (16). Evidence of this more subtle influence of PFT reference equation choice on clinician attitudes and care pathways is much needed but would require different research methodologies. Studies on the risk of respiratory events and relationships of pulmonary function to lung pathology, symptoms, walk distance, and survival already favor race-neutral interpretation of spirometry. Beyond the interpretation of PFT results, many other sources of inequitable respiratory care and outcomes in the medical system require investigation and intervention.

By examining real-world consequences with increased inclusivity and specificity relative to prior efforts, Spece and colleagues (4) provide quantitative data that are critical to inform policy changes. Their findings defy simple characterization, offering effects that trend in both directions for every group examined. Money shifts away from White groups and toward non-White groups, which will be very impactful to the individuals affected but represents a very small portion of the Department of Veterans Affairs disability budget (2). Yet a focus on the changes should ignore neither the imprecision of race categories applied to individuals nor how the application hides rather than reveals differences. The authors note the importance of making policy changes with input from multiple stakeholders, including patients. If these deliberations find a role to include race in clinical or administrative algorithms to partially capture the effects of social and occupational experiences, this can no longer be done at the level of PFT reference equations. Doing so claims an understanding of the relationship between race and pulmonary function, a uniform relationship for all uses of PFT, and that race is a genetic variable, none of which is true. Race and racism must be acknowledged and studied, but any careful use in research or clinical algorithms must also be transparent by their incorporation as downstream as possible rather than hidden upstream in the reporting and interpretation of PFT results.

Whatever the consequences from a change in reference equations, we must rise to the challenges of dismantling structural racism. Strategies to manage consequences will include clearer articulation of the questions being answered by the measurement of pulmonary function for any specific use, review of existing and generation of new data to determine how well the questions are answered by PFT, increased application of baseline testing, education of clinicians and patients, and equitable increases in complementary evaluations such as exercise testing, imaging, and expert consultation. Discussion should also be open to the possibility of implementing a period during which access to treatment, employment, or compensation can occur through either old or new criteria if there is no evidence of increased harm, and a retroactive period during which to change the course in cases in which access was previously denied.

Author disclosures are available with the text of this article at www.atsjournals.org.
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