Department of Surgery, University of Michigan, Ann Arbor.
Center for Health Outcomes and Policy, University of Michigan, Ann Arbor.
JAMA Surg. 2023 Oct 1;158(10):1061-1068. doi: 10.1001/jamasurg.2023.3239.
Removal of race correction in pulmonary function tests (PFTs) is a priority, given that race correction inappropriately conflates race, a social construct, with biological differences and falsely assumes worse lung function in African American than White individuals. However, the impact of decorrecting PFTs for African American patients with lung cancer is unknown.
To identify how many hospitals providing lung cancer surgery use race correction, examine the association of race correction with predicted lung function, and test the effect of decorrection on surgeons' treatment recommendations.
DESIGN, SETTING, AND PARTICIPANTS: In this quality improvement study, hospitals participating in a statewide quality collaborative were contacted to determine use of race correction in PFTs. For hospitals performing race correction, percent predicted preoperative and postoperative forced expiratory volume in 1 second (FEV1) was calculated for African American patients who underwent lung cancer resection between January 1, 2015, and September 31, 2022, using race-corrected and race-neutral equations. US cardiothoracic surgeons were then randomized to receive 1 clinical vignette that differed by the use of Global Lung Function Initiative equations for (1) African American patients (percent predicted postoperative FEV1, 49%), (2) other race or multiracial patients (percent predicted postoperative FEV1, 45%), and (3) race-neutral patients (percent predicted postoperative FEV1, 42%).
Number of hospitals using race correction in PFTs, change in preoperative and postoperative FEV1 estimates based on race-neutral or race-corrected equations, and surgeon treatment recommendations for clinical vignettes.
A total of 515 African American patients (308 [59.8%] female; mean [SD] age, 66.2 [9.4] years) were included in the study. Fifteen of the 16 hospitals (93.8%) performing lung cancer resection for African American patients during the study period reported using race correction, which corresponds to 473 African American patients (91.8%) having race-corrected PFTs. Among these patients, the percent predicted preoperative FEV1 and postoperative FEV1 would have decreased by 9.2% (95% CI, -9.0% to -9.5%; P < .001) and 7.6% (95% CI, -7.3% to -7.9%; P < .001), respectively, if race-neutral equations had been used. A total of 225 surgeons (194 male [87.8%]; mean [SD] time in practice, 19.4 [11.3] years) were successfully randomized and completed the vignette items regarding risk perception and treatment outcomes (76% completion rate). Surgeons randomized to the vignette with African American race-corrected PFTs were more likely to recommend lobectomy (79.2%; 95% CI, 69.8%-88.5%) compared with surgeons randomized to the other race or multiracial-corrected (61.7%; 95% CI, 51.1%-72.3%; P = .02) or race-neutral PFTs (52.8%; 95% CI, 41.2%-64.3%; P = .001).
Given the findings of this quality improvement study, surgeons should be aware of changes in PFT testing because removal of race correction PFTs may change surgeons' treatment decisions and potentially worsen existing disparities in receipt of lung cancer surgery among African American patients.
鉴于种族修正不当地将种族（一种社会建构）与生物学差异混为一谈，并错误地假设非裔美国人的肺功能比白人差，因此优先考虑去除肺功能测试（PFT）中的种族修正。然而，对于患有肺癌的非裔美国患者，纠正 PFT 的影响尚不清楚。
确定提供肺癌手术的医院中有多少家使用种族修正，检查种族修正与预测肺功能的关联，并测试修正对外科医生治疗建议的影响。
设计、地点和参与者：在这项质量改进研究中，联系了参加全州质量合作的医院，以确定其在 PFT 中使用种族修正的情况。对于进行种族修正的医院，使用种族修正和非种族修正方程计算了 2015 年 1 月 1 日至 2022 年 9 月 31 日期间接受肺癌切除术的非裔美国患者的术前和术后用力呼气量（FEV1）的百分比预测值。然后，美国心胸外科医生被随机分配到一个临床病例中，该病例根据全球肺功能倡议方程的使用情况有所不同：（1）非裔美国患者（术后 FEV1 的百分比预测值，49%）；（2）其他种族或多种族患者（术后 FEV1 的百分比预测值，45%）；（3）非种族患者（术后 FEV1 的百分比预测值，42%）。
使用 PFT 进行种族修正的医院数量、基于非种族或种族修正方程的术前和术后 FEV1 估计值的变化以及外科医生对临床病例的治疗建议。
共有 515 名非裔美国患者（308 名女性[59.8%]；平均[SD]年龄，66.2[9.4]岁）纳入研究。在研究期间对非裔美国患者进行肺癌切除术的 16 家医院中的 15 家（93.8%）报告称使用了种族修正，这对应于 473 名非裔美国患者（91.8%）进行了种族修正的 PFT。在这些患者中，如果使用非种族修正方程，术前 FEV1 的百分比预测值和术后 FEV1 的百分比预测值将分别下降 9.2%（95%CI，-9.0%至-9.5%；P < .001）和 7.6%（95%CI，-7.3%至-7.9%；P < .001）。共有 225 名外科医生（194 名男性[87.8%]；平均[SD]从业年限，19.4[11.3]年）成功随机分组并完成了关于风险感知和治疗结果的病例项目（完成率为 76%）。随机分到非裔美国人种族修正 PFT 病例的外科医生更有可能建议行肺叶切除术（79.2%；95%CI，69.8%-88.5%），而随机分到其他种族或多种族修正（61.7%；95%CI，51.1%-72.3%；P = .02）或非种族修正 PFT 病例的外科医生（52.8%；95%CI，41.2%-64.3%；P = .001）。
鉴于这项质量改进研究的结果，外科医生应该意识到 PFT 测试的变化，因为去除种族修正的 PFT 可能会改变外科医生的治疗决策，并可能加剧非裔美国患者接受肺癌手术的现有差异。
