Clinical algorithms guide many decisions in health care every day. They help clinicians estimate kidney function, interpret lung capacity, and make treatment choices. These tools aim to bring consistency and reduce uncertainty, but when the assumptions underlying them are flawed, the results can deepen inequities in care.
One of the most pressing issues in recent years has been the use of race-based adjustments in clinical algorithms. For decades, race modifiers have been part of tests such as the estimated glomerular filtration rate (eGFR) for kidney function and the pulmonary function test (PFT) for lung capacity. These adjustments were introduced based on the idea that biological differences exist among racial groups for instance, claims that Black patients have greater muscle mass or different lung volumes. Research now shows that these assumptions are not sufficiently supported and can cause harm (Eneanya et al., 2019; Moffett et al., 2023).
How Race Adjustments Affect Care
When race is built into an equation, it can change how a diagnosis is made. For example, under race-adjusted eGFR equations, Black patients may appear to have better kidney function because the algorithm raises the estimated value, even when their condition may already require medical attention (Zelnick et al., 2021). This can delay referral to specialists or eligibility for needed treatments.
Similarly, in lung testing, race-based reference equations can mask early disease in people whose true lung function is lower than the “normal” values adjusted for race would suggest. A cross-sectional study found that when race-neutral equations were used instead of race-specific ones, there was a significant increase in the number of Black individuals classified as having restrictive and nonspecific lung impairments (Moffett et al., 2023).
These are not just academic problems. They affect who gets care, when they get it, and how seriously a patient’s symptoms are addressed.
Why Safety Net Hospitals Should Lead
The need to review and remove race adjustments is especially urgent in safety net hospitals because these hospitals serve large numbers of patients of color and those with limited access to care. When the diagnostic tools used there misclassify disease risk, it widens existing health inequities.
Safety net hospitals also shape standards for the broader medical workforce. They train clinicians and set community care practices. By leading the effort to adopt race-neutral clinical algorithms, they can show how to align evidence-based care with equity.
The Path Forward
Removing race as a variable in algorithms is not simply deleting a line of code. It requires validation studies, redesigning algorithms, and retraining for clinicians who have relied on older equations for years. Progress is underway: several major health systems and professional societies now support race-neutral equations for kidney and lung function (Delgado et al., 2021; Bonner et al., 2023).
For safety net hospitals, the next step is implementing these changes consistently and ensuring clinicians understand why they matter. It also means communicating clearly with patients, many of whom may not know that race has ever been a factor in interpreting their test results.
A Moment for Trust and Accountability
Updating clinical algorithms is both a scientific correction and a moral commitment. It shows that medicine is willing to question outdated assumptions and align its tools with both scientific integrity and ethical care. For safety net hospitals, this is an opportunity to lead with integrity to ensure that every patient, regardless of race, receives care that reflects their true health needs and full humanity.
References
- Delgado C, et al. Reassessing the Inclusion of Race in Diagnosing Kidney Diseases: An Interim Report From the NKF-ASN Task Force. 2021.
- Eneanya ND, et al. Reconsidering the Consequences of Using Race to Estimate Kidney Function. 2019.
- Moffett AT, et al. Global Race-Neutral Reference Equations and Pulmonary Function Test Interpretation. JAMA Network Open. 2023.
- Zelnick LR, et al. eGFR With vs Without a Race Coefficient and Time to Eligibility for Kidney Transplant. JAMA Network Open. 2021.
- Bonner SN, et al. Clinical Implications of Removing Race Correction in Pulmonary Function Tests for African American Patients Requiring Surgery for Lung Cancer. JAMA Surgery. 2023.
