Known as “race essentialism,” the belief in innate biological differences between racial groups has been debunked by decades of scientific advancements. And yet, these race-as-biology theories are still used as a basis for many clinical algorithms that help guide screening, diagnosis, and treatment decisions for patients.
“Despite the fact that we have seen scientific evidence that shows that there aren’t differences across races, we continue to hold onto these racialized concepts of health and biology,” said Toni Eyssallenne, MD, PhD, deputy chief medical officer with the New York City Department of Health and Mental Hygiene (DOHMH). “This misuse of race in clinical algorithms is not based in any evidence, it’s based on, honestly, the history of racism in this country.”
Speaking at UHF’s Quality Leaders Forum in November, Dr. Eyssallenne detailed an important city effort to eliminate these "race modifiers” known as The NYC Coalition to End Racism in Clinical Algorithms (CERCA).
CERCA, formed in 2021, includes nine New York City health systems who have pledged to end race adjustment in one of three race-based clinical algorithms chosen by the coalition. The chosen algorithms include an equation used to estimate kidney health, lung function tests, and a risk calculator for having a successful vaginal birth after a caesarean section.
Race modifiers in each of these algorithms have been shown to negatively affect treatment and care for people of color, according to the coalition. For example, an assumption built into the lung function test that Black and Asian patients have a smaller lung capacity than white patients can lead to underdiagnosis and undertreatment of respiratory issues. Similarly, a healthier “adjusted” value ascribed to Black patients’ kidney health can delay diagnoses and care, including kidney transplants. In the case of the Vaginal Birth After Cesarean (VBAC) Risk Calculator, race modifiers have led to an increased likelihood of a repeat cesarean section for Black and Latino pregnant people, which could exacerbate birth inequities. Research has demonstrated that birth outcomes are better with vaginal births than with repeat C-sections
Given these impacts, the coalition’s work has extended well beyond simply removing race modifiers from each clinical algorithm, Dr. Eyssallenne said. Health systems are now focused on educating patients whose care may have been affected by the race modifiers and, in the case of the kidney health algorithm, tackling an increase in patients in need of treatment, including transplants, given corrected diagnoses.
“We’ve really built a circle of distrust with our patients, so that’s going to take time and investment...to gain that trust back,” Dr. Eyssallenne said of patient engagement efforts.
After Dr. Eyssallenne’s presentation on CERCA’s work, QLF attendees listened to a “fireside chat” with Dr. Eyssallenne, UHF Senior Medical Officer Anne-Marie J. Audet, MD, MSc, SM, and Michelle Morse, MD, MPH, chief medical officer and deputy commissioner for DOHMH’s Center for Health Equity and Community Wellness.
The panel highlighted the importance of raising awareness about how race adjustment contributes to racial health inequities. Such awareness can not only prevent race modifiers from being used in future clinical algorithms but can also help shift focus toward true causes of health inequities, like social determinants of health, the speakers said.
“Differences in health outcomes are not for any biological reason, but because of the social conditions,” said Dr. Morse, noting that housing, education, income, and other social determinants of health contribute to inequitable health outcomes. “If your algorithm is considering race a biological issue rather than looking at some of these social factors by race, you end up with the wrong solutions.”
Recognizing and addressing such health inequities will depend on the robust and accurate collection of race and ethnicity data in health care, the speakers said.
“We don’t want color blindness—we’re talking about using race and ethnicity data to eliminate inequities, not exacerbate them,” Dr. Eyssallenne said.
The Quality Leaders Forum is a group of emerging and established health quality leaders committed to improving the delivery of high-quality care in the greater New York area. Members include alumni from the UHF/GNYHA Clinical Quality Fellowship Program and honorees from UHF’s Tribute to Excellence in Health Care. Members are invited to network and discuss current issues in health care quality with nationally recognized quality leaders and to pursue opportunities for sharing best practices.
Past Forum summaries can be found here.
UHF is grateful to Elaine and David Gould, whose generosity supports the Quality Leaders Forum.
See below for a video and audio recording of Dr. Eyssallenne and Dr. Morse's presentation and fireside chat.