Switch to race-neutral test fixes missed asthma among Black kids

Black children are more likely to have asthma than white children, yet it’s often overlooked—partly because of outdated lung-function equations. Historical use of an adjusted race correction essentially reduced the predicted lung function among Black patients, according to  Erica Ridley, MD, an allergist and immunologist at Henry Ford Health in Detroit. 

“We’re starting to realize that this is potentially leading to underdiagnosis of asthma in non-Caucasian patients, which may be contributing to delays in diagnosis and increased morbidity and mortality from untreated asthma,” said Dr. Ridley.

This is especially relevant to Henry Ford Health, which serves a large number of Black patients with high rates of asthma, especially in children. People living in central Detroit experience greater exposure to allergens such as cockroaches and pollution, as a result of residential segregation and other factors. Those factors contribute to the higher rates of asthma and increased severity of asthma among residents of these neighborhoods.

Henry Ford Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

In 2022, the Global Lung Initiative Network updated its lung function reference equations to exclude race to lessen the negative impact of using race-specific equations. A study that Henry Ford Health researchers conducted on the impact of spirometry race correction on preadolescent Black and white children in Detroit found that race neutral-spirometry was twice as effective in identifying asthma in Black patients as race-adjusted spirometry, with minimal to no change in identification of asthma among white patients. 

Researchers in Cincinnati arrived at similar conclusions in a broader study that compared race-specific and race-neutral equations in three different populations of children. Their results were published in JAMA Network Open in February.

The study included 1,533 Cincinnati-area children with asthma, ranging from infancy to 12 years old; 21% of the patients were Black children. Children underwent forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) tests. 

Compared with the race-specific equation, the race-neutral equation identified two- to fourfold more Black children with significant findings of airway obstruction who also had symptoms suggestive of asthma. 

“This is important because not only were the FEV1 values lower than what was predicted with the race-adjusted spirometry, but these patients also had clinical symptoms of asthma, which confirms the diagnosis of asthma in these patients,” said Dr. Ridley, who was not involved in the study.

This indicates that they were likely mischaracterized as having normal lung function, she added. Between 38% and 44% of Black children in the study cohorts respectively switched from ineligible to eligible for further diagnostic testing under the race-neutral equation. 

Comparatively, the race-specific equation failed to detect reduced percent predicted FEV1 in 55% and 41% of Black children with asthma in two of the pediatric asthma groups, respectively.

“Importantly, using the race-neutral equation on white children had no meaningful impact on the lung function tests,” says the JAMA Network Open study, whose authors recommended the universal use of the race-neutral equation. The anticipation is these results will boost diagnosis and treatment of asthma while tamping down on asthma-related health disparities, they wrote. 

To better serve its patients, Henry Ford Health is switching its spirometry calculations to the race-neutral equation. The pulmonology department has already started to implement this in their clinics, and the allergy department is in the process of making the change, said Dr. Ridley. 

“We do anticipate that after this we will likely detect more cases of asthma in Black children that we would have missed in the past,” she added. 

The change means educating patients and their parents about the nuances of spirometry testing, she added. 

“I suspect that many people aren’t aware that spirometry does have an adjustment for race. We do ask our patients what their race is when we do the spirometry, but I’m not quite sure if they realize that this factors into the calculation itself,” said Dr. Ridley. 

Henry Ford Health physicians will explain to patients that they may see some differences if they have done spirometry before, due to the adoption of the race-neutral calculations. Dr. Ridley also plans on explaining the history to them as well.

“Historically, race was used as the adjustment factor for FEV1 to promote this erroneous theory that the white population has a higher lung capacity,” Dr. Ridley explained. 

As noted in a 2023 article published in The Journal of Allergy and Clinical Immunology: In Practice, “early versions of the spirometer were built by plantation physician and slaveholder Dr. Samuel Cartwright, whose experiments were designed to justify slavery by comparing enslaved persons to white colonists.” 

Other groups such as patients who identify as Hispanic or Latino have a higher incidence of asthma. 

“It’s important to make sure that we are reaching patients in all of these different communities to make sure that they are getting the proper spirometry diagnosis of asthma along with their clinical symptoms,” said Dr. Ridley.

Physicians cannot control everything that happens in the environment, but there are things they can do to intervene. 

“If there is cockroach sensitization, we want to control the other diagnoses that tend to impact asthma control such as allergic rhinitis,” she said.

Making sure that patients have adequate access to health care and can afford asthma treatment is also extremely important, Dr. Ridley added. 

“Different inhalers do have different costs and hospitalizations related to asthma can all really add up. As a health care system, we need to start considering how we can help our patients improve the environment that they’re living in and what resources can we provide them to help them get the care and access that they need.” 

Patients in the past may have been told that they don’t have asthma; that their breathing tests have all been normal. But if there’s a high clinical suspicion, reevaluating the patient could help identify any missed diagnoses, Dr. Ridley advised. 

The latest edition of the AMA Guides^® to the Evaluation of Permanent Impairment also has been updated with similar changes related to pulmonary function, but focused on adults. 

A movement has been underway—as reflected in AMA policy—to address and correct clinical algorithms that mistakenly substitute and equate racial data for genetic and other information, leading to suboptimal care.

The estimated glomerular filtration rate (eGFR), a key measure for calculating kidney function, underwent a similar transformation to the asthma calculation. Previously, the eGFR was automatically adjusted to give Black patients a higher number, which underestimated disease. In 2021, the Chronic Kidney Disease Epidemiology Collaboration developed new equations that eliminated the automatic race adjustment. 

The AMA has warned federal regulators that improperly developed clinical guidelines carry the potential to introduce bias and racism that can threaten health and perpetuate inequities already experienced by historically marginalized communities. Efforts are underway across the AMA Federation of Medicine to eliminate harmful race-based clinical algorithms.

Learn more about the AMA Center for Health Equity and the AMA’s 2024–2025 strategic plan to advance health equity.