Reply to “How to deconstruct ‘race’ and spirometry”

The authors appreciate the correspondence from Kelso1Kelso J.M. How to deconstruct “race” and spirometry.J Allergy Clin Immunol Pract. 2022; 10: 2488-2489Abstract Full Text Full Text PDF Scopus (1) Google Scholar regarding our Rostrum on deconstructing race-based reference equations in pulmonary function testing.2Ramsey N.B. Apter A.J. Israel E. Louisias M. Noroski L.M. Nyenhuis S.M. et al.Deconstructing the way we use pulmonary function test race-based adjustments.J Allergy Clin Immunol Pract. 2022; 10: 972-978Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Kelso raises several key points.Regarding the genetic differences associated with “race” categories, the variability among “races” is linked to ancestry, which leads to within-group inconsistencies, given the amount of admixture existing in racial groupings. However, these findings are merely associations, not evidence of causation. The genetic associations may merely be more common in a group that has had different environmental, social, and economic exposures.Creating race-neutral reference equations may have positive effects on persons who are symptomatic but cannot be given a diagnosis owing to the current unintended normalization of lower lung function. Recent studies that analyzed the Third National Health and Nutrition Examination Survey cohort identified increased mortality in patients who use a race-specific reference equation, versus a multiracial, mixed, or other; or White or Caucasian reference equation approach.3Gaffney A.W. McCormick D. Woolhandler S. Christiani D.C. Himmelstein D.U. Prognostic implications of differences in forced vital capacity in black and white US adults: findings from NHANES III with long-term mortality follow-up.EClinicalMedicine. 2021; 39101073Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,4McCormack M.C. Balasubramanian A. Matsui E.C. Peng R.D. Wise R.A. Keet C.A. Race, lung function, and long-term mortality in the National Health and Nutrition Examination Survey III.Am J Respir Crit Care Med. 2022; 205: 723-724Crossref PubMed Google Scholar Another study that reanalyzed the Multi-Ethnic Study of Atherosclerosis cohort found no improvement in clinical event prediction for chronic lower respiratory diseases such as asthma, chronic obstructive pulmonary disease (COPD), emphysema, and bronchitis when using race-specific reference equations.5Elmaleh-Sachs A. Balte P. Oelsner E.C. Allen N.B. Baugh A. Bertoni A.G. et al.Race/ethnicity, spirometry reference equations, and prediction of incident clinical events: the Multi-Ethnic Study of Atherosclerosis (MESA) lung study.Am J Respir Crit Care Med. 2022; 205: 700-710Crossref PubMed Google Scholar A fourth study reanalyzed a cohort of patients with COPD and at-risk for COPD using a multiracial, mixed, and other reference equation and showed that patients with Black race had the clinical severity of illness underestimated by race-specific reference equations.6Baugh A.D. Shiboski S. Hansel N.N. Ortega V. Barjakteravic I. Barr R.G. et al.Reconsidering the utility of race-specific lung function prediction equations.Am J Respir Crit Care Med. 2022; 205: 819-829Crossref PubMed Scopus (14) Google Scholar Overall, these data demonstrate several positive implications of reworking the current race-based approach.Nonetheless, we cannot neglect the potential unintended consequences for job or therapy eligibility if we switch to a race-neutral approach to reference equations in spirometry. Further investigation and consideration are required to determine the best way to move forward. Is spirometry critical for job or therapy eligibility in all cases? One path forward, if these spirometry standards are deemed necessary, is to adopt the new race-neutral equations as of a predetermined date and grandfather in anyone who was previously screened into a role or therapy plan. Although there may be some exclusion of persons who would otherwise be eligible for these roles and therapies, the question remains whether those who might be disqualified have lung compromise that might lead to increased susceptibility to occupational hazards and adverse effects of toxic medications. The investigations we cited in the prior paragraphs certainly suggest this to be the case.Looking ahead, we agree that the best option is to create reference values, while employing an individualized approach incorporating social determinants of health as well as environmental exposures, truncal height, and possibly even ancestry, as feasible. As a temporizing measure, to avoid the negative effects currently in place, we suggest using the Global Lung Initiative “other” reference equations or the raw spirometry values in context. Using the Caucasian reference equation warrants additional considerations for inclusive, accurate interpretations. This decision should be made by interdisciplinary stakeholders with a comprehensive consideration of the data and their implications.Moreover, we must also recognize that self-characterization and provider characterizations of race may not match the established formulas applied because of either misidentification or mixed racial identities that do not fit into the prescribed, limiting racial selections that lack the depth and breadth of the actuality of our human diversity.The authors contend that the pros of moving to a race-neutral approach until a more individualistic approach can be reached should be carefully weighed against the worsened mortality and clinical severity of COPD, and the underestimation of disease burden, all of which have been noted with our current practice. The authors suggest that the next best step in working toward an equitable solution is to convene an interdisciplinary workshop with stakeholders, including but not limited to allergists, pulmonologists, oncologists, occupational health professionals, representatives from the armed forces, firefighters associations, workers’ compensation, and spirometer manufacturers. We echo the sentiment of Kelso1Kelso J.M. How to deconstruct “race” and spirometry.J Allergy Clin Immunol Pract. 2022; 10: 2488-2489Abstract Full Text Full Text PDF Scopus (1) Google Scholar about prioritizing eliminating medical racism, fully understanding the implications of our current way of interpreting pulmonary function tests and understanding the unintended consequences of any alterations that will be proposed for this important but necessary change. The authors appreciate the correspondence from Kelso1Kelso J.M. How to deconstruct “race” and spirometry.J Allergy Clin Immunol Pract. 2022; 10: 2488-2489Abstract Full Text Full Text PDF Scopus (1) Google Scholar regarding our Rostrum on deconstructing race-based reference equations in pulmonary function testing.2Ramsey N.B. Apter A.J. Israel E. Louisias M. Noroski L.M. Nyenhuis S.M. et al.Deconstructing the way we use pulmonary function test race-based adjustments.J Allergy Clin Immunol Pract. 2022; 10: 972-978Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Kelso raises several key points. Regarding the genetic differences associated with “race” categories, the variability among “races” is linked to ancestry, which leads to within-group inconsistencies, given the amount of admixture existing in racial groupings. However, these findings are merely associations, not evidence of causation. The genetic associations may merely be more common in a group that has had different environmental, social, and economic exposures. Creating race-neutral reference equations may have positive effects on persons who are symptomatic but cannot be given a diagnosis owing to the current unintended normalization of lower lung function. Recent studies that analyzed the Third National Health and Nutrition Examination Survey cohort identified increased mortality in patients who use a race-specific reference equation, versus a multiracial, mixed, or other; or White or Caucasian reference equation approach.3Gaffney A.W. McCormick D. Woolhandler S. Christiani D.C. Himmelstein D.U. Prognostic implications of differences in forced vital capacity in black and white US adults: findings from NHANES III with long-term mortality follow-up.EClinicalMedicine. 2021; 39101073Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,4McCormack M.C. Balasubramanian A. Matsui E.C. Peng R.D. Wise R.A. Keet C.A. Race, lung function, and long-term mortality in the National Health and Nutrition Examination Survey III.Am J Respir Crit Care Med. 2022; 205: 723-724Crossref PubMed Google Scholar Another study that reanalyzed the Multi-Ethnic Study of Atherosclerosis cohort found no improvement in clinical event prediction for chronic lower respiratory diseases such as asthma, chronic obstructive pulmonary disease (COPD), emphysema, and bronchitis when using race-specific reference equations.5Elmaleh-Sachs A. Balte P. Oelsner E.C. Allen N.B. Baugh A. Bertoni A.G. et al.Race/ethnicity, spirometry reference equations, and prediction of incident clinical events: the Multi-Ethnic Study of Atherosclerosis (MESA) lung study.Am J Respir Crit Care Med. 2022; 205: 700-710Crossref PubMed Google Scholar A fourth study reanalyzed a cohort of patients with COPD and at-risk for COPD using a multiracial, mixed, and other reference equation and showed that patients with Black race had the clinical severity of illness underestimated by race-specific reference equations.6Baugh A.D. Shiboski S. Hansel N.N. Ortega V. Barjakteravic I. Barr R.G. et al.Reconsidering the utility of race-specific lung function prediction equations.Am J Respir Crit Care Med. 2022; 205: 819-829Crossref PubMed Scopus (14) Google Scholar Overall, these data demonstrate several positive implications of reworking the current race-based approach. Nonetheless, we cannot neglect the potential unintended consequences for job or therapy eligibility if we switch to a race-neutral approach to reference equations in spirometry. Further investigation and consideration are required to determine the best way to move forward. Is spirometry critical for job or therapy eligibility in all cases? One path forward, if these spirometry standards are deemed necessary, is to adopt the new race-neutral equations as of a predetermined date and grandfather in anyone who was previously screened into a role or therapy plan. Although there may be some exclusion of persons who would otherwise be eligible for these roles and therapies, the question remains whether those who might be disqualified have lung compromise that might lead to increased susceptibility to occupational hazards and adverse effects of toxic medications. The investigations we cited in the prior paragraphs certainly suggest this to be the case. Looking ahead, we agree that the best option is to create reference values, while employing an individualized approach incorporating social determinants of health as well as environmental exposures, truncal height, and possibly even ancestry, as feasible. As a temporizing measure, to avoid the negative effects currently in place, we suggest using the Global Lung Initiative “other” reference equations or the raw spirometry values in context. Using the Caucasian reference equation warrants additional considerations for inclusive, accurate interpretations. This decision should be made by interdisciplinary stakeholders with a comprehensive consideration of the data and their implications. Moreover, we must also recognize that self-characterization and provider characterizations of race may not match the established formulas applied because of either misidentification or mixed racial identities that do not fit into the prescribed, limiting racial selections that lack the depth and breadth of the actuality of our human diversity. The authors contend that the pros of moving to a race-neutral approach until a more individualistic approach can be reached should be carefully weighed against the worsened mortality and clinical severity of COPD, and the underestimation of disease burden, all of which have been noted with our current practice. The authors suggest that the next best step in working toward an equitable solution is to convene an interdisciplinary workshop with stakeholders, including but not limited to allergists, pulmonologists, oncologists, occupational health professionals, representatives from the armed forces, firefighters associations, workers’ compensation, and spirometer manufacturers. We echo the sentiment of Kelso1Kelso J.M. How to deconstruct “race” and spirometry.J Allergy Clin Immunol Pract. 2022; 10: 2488-2489Abstract Full Text Full Text PDF Scopus (1) Google Scholar about prioritizing eliminating medical racism, fully understanding the implications of our current way of interpreting pulmonary function tests and understanding the unintended consequences of any alterations that will be proposed for this important but necessary change. How to deconstruct “race” and spirometryThe Journal of Allergy and Clinical Immunology: In PracticeVol. 10Issue 9PreviewTo the Editor:In their recent Rostrum article, Ramsey et al1 note that the Global Lung Initiative (GLI) found “that presumed normal lung function in ethnic groups is 13% to 14% less for Black, 0.7% to 2.7% less for North East Asian, and 9.7% to 13.7% less for South East Asian persons compared with White lung function.”1,2 More specifically, the GLI found that “FEV1 and FVC between ethnic groups differed proportionally from that in Caucasians, such that FEV1/FVC remained virtually independent of ethnic group.”2 Guidelines from the American Thoracic Society recommend that separate GLI predictive equations be used for those who identify as being in these groups. Full-Text PDF