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Race-, Ethnicity-based Clinical Guidelines Miss the Mark: Study

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SAN DIEGO, California — Race-based recommendations and clinical algorithms may be doing more harm than good, according to a systematic review of databases and guidelines.

The study found examples of screening recommendations based on race or ethnicity that were likely misleading since these are social constructs that don’t reflect a patient’s individual risk, said Shazia Siddique, MD, who presented the study at the annual Digestive Disease Week (DDW). “Historically, we’ve made so many clinical decisions based on somebody’s race and ethnicity. We walk into a room, we don’t even ask people which racial or ethnic category they identify with. We just look at them and we say, ‘Their skin color looks black, and therefore we’re going to apply a different equation to them.’ ”

However, a patient’s risks and unique health circumstances are much more complicated than that. They may be related to genetics, environmental exposures, or level of access to quality healthcare. Race can often be inappropriately used as a stand-in for these and other factors, she explained.

“These [racial] categories are truly a social construct. It’s becoming very problematic that people are literally making decisions based on somebody’s skin color. That’s just not what the science supports. If there are specific genes or environmental factors, or differences in access to healthcare that then impact outcomes for certain racial or ethnic groups, we need to figure out what those are,” said Siddique, who is an assistant professor of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

Those messages are still entrenched in medical education. “I graduated medical school in 2012, and it was taught to me to use race and ethnicity in clinical decision-making. We need to start in medical education to shift the way that we’re thinking. On the research side, we really need to think about how we can replace or remove race and ethnicity and understand the consequences of that, so that over time we can make a shift,” said Siddique.

For example, Siddique discussed recommendations that suggest Asian heritage as a risk factor for hepatitis B screening, but that’s not a good factor to consider.

“People were saying that Asians should be screened at an earlier age, but it’s really people that were born and raised in Asian countries where it’s endemic or they may have gotten it from their mothers at birth. It’s a marker for how long you have had the disease and how much virus is in your bloodstream. It’s not because you’re Asian. If you’re born and raised in the United States, and you don’t have any of those risk factors, you shouldn’t be treated differently based on your identified racial and ethnic group,” said Siddique.

These questions have become even more important in recent years because of patients with multiracial identities and other considerations. “Now the proxy for which race was being used is even messier,” said Siddique.

So, how should physicians think about assessing a patient’s personalized risks? The key, said Siddique, is to look at each patient’s individual factors, such as healthcare access, environmental exposures from jobs or living conditions, or the country they emigrated from if they weren’t born in the United States. “Disease prevalences are different in different areas, and that changes your index of suspicion,” she said.

And when considering current guidelines that incorporate race or ethnicity, she recommends viewing them skeptically. “If there is a current algorithm in your health system or in a guideline that you’re reading that says you should be making a change based on race and ethnicity, you should look at that with a close eye and say, ‘What do I think it’s being used as a proxy for, and how can I elicit that from my patient?’ ”

The issues raised by Siddique’s study are important, but there also could be concerns in taking them too far, according to Gary Falk, MD, a professor of medicine at the University of Pennsylvania who comoderated the session where Siddique presented. He was not involved in the study, but was listed on Siddique’s acknowledgement slide.

Falk coauthored Barrett’s esophagus guidelines in 2016 that incorporated white race as a risk factor.

“There are certain clear ethnic factors or country of origin factors that impact one’s risk for cancer, and there are certain diseases that are more common in certain ethnic groups. I think that if we homogenize everybody, we may potentially hurt some people in the effort to be inclusive. That’s my only concern. I think it’s totally correct that we have to get out of our comfort zone, but I hate to see us reach too far on the other end, and homogenize things to the point that people who have increased risk are not being recognized for that reason,” said Falk.

He acknowledged that white race as a risk for Barrett’s is not easy to define given the uncertainty of the genetic risk, for example, in patients with mixed heritage. “This is all very provocative. We have to think about it carefully,” said Falk.

Siddique and Falk have disclosed no relevant financial relationships.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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