Spring 2025 Issue

Race-Neutral Clinical Calculators
By Jennifer Lutz
For The Record
Vol. 37 No. 2 P. 20

Race-adjusted clinical calculators negatively impact patients 1; still, these detrimental tools are widely used—against the recommendations of scientific and academic bodies. The American Thoracic Society,2 the National Kidney Foundation, the American Society of Nephrology, the American Medical Association, CMS, and most recently, the National Academies of Sciences, Engineering, and Medicine1 all recommend switching to race-neutral calculators.

Why is the implementation of updated, race-neutral calculators so slow? Why are certain calculators corrected faster than others? What can professionals do to increase access and use of race-neutral clinical tools, improving patient care and clinical results? It requires working within a complex and decentralized system, but there are examples of success. In many ways, it’s about prioritizing patient outcomes, educating professionals, and choosing providers that prioritize updated clinical calculators.

Paving the Way
That process began in 2017 when Beth Israel in Boston was the first hospital to update their estimated glomerular filtration rate (eGFR) clinical calculator, measuring kidney function.3 The formula for estimating GFR previously used by most laboratories was developed by a group of physicians and researchers in 1999 based on observations from a study that included 1,304 white people and 197 Black people. The researchers were unable to explain the reason for the differences in kidney function between Black and non-Black people, but race-based assumptions led to a “race correction” for Black people.

Changing to a race-neutral calculator wasn’t easy—many proponents argued the race correction was science-based, while others insisted it promoted antiquated and racist ideologies, such as Black people being more muscular. The race correction has disadvantaged Black people for years—leading to misdiagnosis and underdiagnosis and delaying life-saving kidney transplants.

“We made the change officially in early 2017 after efforts in 2016,” says Melanie Hoenig, MD, course director for renal pathophysiology at Harvard Medical School. “Since then, the National Kidney Foundation and the American Society of Nephrology endorsed a newer formula that does not include race, so now, all laboratories in the United States should be using that formula. For those outliers that have not changed yet, there are resources4 to help them change,” Hoenig says.

Still, widespread implementation didn’t begin until late 2021 when laboratories across the United States, including Quest Diagnostics and LabCorp began using the updated race-neutral eGFR calculator in clinical practice.

“I thought the challenge would be convincing people to make the change. I wasn’t imaginative enough to realize that once the recommendation is made, it just starts the process,” says David S. Jones, MD, PhD, a professor of epidemiology at Harvard T.H. Chan School of Public Health Harvard University and author of “Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms.”5 “Part of it is a problem of the United States’ health care system being decentralized; there are over 6,000 hospitals in the country, and each one has to individually decide whether it’s going to make these changes. Some of these tools aren’t even confined to hospitals … there are clinics that have contracts with outpatient clinical laboratories, so it’s a complex process,” Jones says.

“I think it’s hard to change because it involves programming at the laboratory level … and then, just inertia,” Hoenig says. “But the computer issue at the laboratory is not a small thing, so it needs to be a priority to be changed.”

The inertia doesn’t match the science. Race has no biological impact on disease; Black people don’t have a lower lung capacity than white people, nor do they have significantly higher levels of creatinine in healthy populations.

“These categories of Black and white are baked so deeply into medical practice that people have a hard time understanding that the biggest problem with these clinical tools is that they’re nonevidence-based, nonscientific categories of Black vs white,” Jones says.

Calculator Corrections
The calculator for kidney function garnered the most attention over the years, but it’s just one of many calculators with a harmful race coefficient. A study identified 48 clinical calculators, out of which only seven had been modified to exclude race as a predictor (anemia in pregnancy, ASCVD Risk Calculator, MDRD GFR Equation, Kidney Donor Risk Index, Spirometry Reference Value Calculator, Vaginal Birth After Cesarean [VBAC] and UTICalc).6 The researchers created an online database for clinicians to check which calculations are race-based.7

Race correction not only hurts the patients being corrected but also causes providers to miss the underlying issues that are a factor. For example, expectant mothers don’t have higher risks during vaginal delivery because of their skin color, but high blood pressure is a factor. Because researchers assumed race was an issue, practitioners missed the opportunity to look at blood pressure and treat it.

The VBAC calculator had a race adjustment that calculated a higher risk for Black women. Further research revealed that race was not a contributing risk factor, whereas high blood pressure was. The calculator was updated in 2021 and again in 2023. It’s available on the Maternal-Fetal Medicine Units Network8 official site, MDCalc.9 Still, use is not universal. “The American College of Obstetrics and Gynecology was amazing, and they updated all of their materials and the website immediately. It was a call to action,” Hoenig says. If practitioners are still using the old calculator, they’re out of date. They’re five years out of date—but that happens in medicine.”

A race-neutral spirometry10 (the tool used to measure pulmonary health by respiratory output) wasn’t recommended by the American Thoracic Society until 2023. The debate over its use and implications is ongoing. Many spirometers require clinicians to select a patient’s race and calculate a higher diagnostic threshold for Black people.

According to a 2024 study in the New England Journal of Medicine, “Among the 249 million persons in the United States between 6 and 79 years of age who are able to produce high-quality spirometric results, the use of GLI-Global equations may reclassify ventilatory impairment for 12.5 million persons, medical impairment ratings for 8.16 million, occupational eligibility for 2.28 million, grading of chronic obstructive pulmonary disease for 2.05 million, and military disability compensation for 413,000.”11 The differences varied across race. For example, classifications of nonobstructive ventilatory impairment may change dramatically, increasing 141% among Black people and decreasing among white people.

Even with these race-neutral calculators available, different hospitals are still using different computer systems and different clinical calculators. A patient’s lung function may be normal at a hospital that uses race-based calculators and abnormal at one that uses the upgraded, race-neutral model.

“The pulmonary function test is one of the hardest tests to update. The old spirometers had a mechanical switch for Black or white, and every time you used the spirometer, it had to be in one of those positions. Most of the modern spirometers require a software update—either way, first you have to change the spirometer,” Jones explains.

EHR Collaboration
Some major EHR providers like Epic, Cerner, and Allscripts, which have historically incorporated race-adjusted clinical calculators, are beginning to incorporate the updated, race-neutral calculators into their systems. Centralizing this would require collaboration with software vendors to remove outdated tools and implement universal changes.

Epic Systems acknowledged the error of race-adjusted calculators and works with hospital systems to update clinical calculators; in 2022, they worked with Ochsner Health Network to introduce the race-neutral calculator for kidney function.12 Allscripts describes their EHR system as customizable—the health care provider can decide to incorporate outdated race-adjusted calculators or the updated race-neutral version.13 Cerner, which is used by the Department of Defense and the VA, also allows systems to customize calculators. 14 Both provide clients a list of calculators, but it’s not always clear which calculator includes race and which does not.

The problem may seem overwhelming, but recent history proves it’s solvable. In seven years, the race-neutral calculator for kidney function has seen almost universal adoption.15 “A patient’s bloodwork should show how the estimated GFR was calculated. I lecture around the country, and I always tell primary care providers that if anyone’s laboratory is still using the old formula, email me and I’ll help support the change—I haven’t gotten an email in a few years,” Hoenig says.

“More and more tests are being outsourced, but that diminishes the hospital’s discretion; they could want to make a change, but it depends on whether the lab they contract with has updated their clinical calculators,” Jones says.

The Movement for Change
“The strategies that we used were just a lot of meetings with a lot of people. You’d meet with one group of people, and they would direct you to another group of people, and then we’d speak with them; at each juncture, the individuals I spoke with opened their minds to change. Because we don’t have centralized health care, each health care system has developed in its own way, which makes it much harder. I think the reason we were able to achieve this change at Beth Israel is that I had friends in the laboratory. In this day and age, when everyone is alone, people crave connecting, and yes, it has the potential to be a lot of work, but it’s work well spent. We all want the same thing—we want the best for our patients,” Hoenig says.

Should race be included in medical testing? “I think it should never be included,” Hoenig says. “I don’t know how to use it. What is race?”

Along with meetings at individual hospitals and clinics, there are movements, driven by practitioners and sometimes even insurers, that recognize the need for change. For example, in 2023, Philadelphia-area health organizations formed a Regional Coalition to Eliminate Race-Based Medicine in the area.16 The group was convened by Independence Blue Cross and is working to remove the race-adjustment from 15 different clinical support decision tools. The group will work together to phase out the use of race as a variable in some of the tools. They will also collaborate on alternative best practices, which do not reinforce a biological understanding of race. The Regional Coalition extends the work of Accelerate Health Equity,17 which many of the participants, including Independence, are members. These organizations collaborate across the Philadelphia region to combat systemic racism and barriers in health care.

“The health care system has a legacy of treating race as a biological fact, rather than a social construct,” says Seun Ross, DNP, CRNP-F, NP-C, executive director of health equity at Independence Blue Cross. “As a result, race has inappropriately become a component of many clinical decision tools in use today. We need to address it now so that all patients, no matter their background, have the best possible health outcomes.”

Change can be slow, especially when large and decentralized systems are involved. Some calculators are still being updated, and access to newer race-neutral clinical tools isn’t universal. In the interim, patients suffer.

To facilitate the change to race-neutral calculators, clinicians can familiarize themselves with the updated tools. They can also work with their hospital and lab systems to update outdated tools. Many successful initiatives began with medical students. The tools we use to measure have a direct impact on the success of treatment and the future of patients.

— Jennifer Lutz is a freelance journalist who covers health, politics, and travel. Her writing has appeared in The Guardian, The Independent, New York Daily News, BuzzFeed Politics, The Local ES, HealthCentral, Today’s Geriatric Medicine, Medscape, Pittsburgh City Paper, and more.

 

References
1. Rethinking race and ethnicity in biomedical research. National Academies website. https://nap.nationalacademies.org/catalog/27913/rethinking-race-and-ethnicity-in-biomedical-research. Published 2025.

2. ATS publishes official statement on race, ethnicity and pulmonary function test interpretation. American Thoracic Society website. https://site.thoracic.org/about-us/news/ats-publishes-official-statement-on-race-ethnicity-and-pulmonary-function-test-interpretation. Published 2023.

3. Balch B. Confronting race in diagnosis: Medical students call for reexamining how kidney function is estimated. AAMC website. https://www.aamc.org/news/confronting-race-diagnosis-medical-students-call-reexamining-how-kidney-function-estimated. Published September 24, 2020.

4. eGFR calculator. National Kidney Foundation website. https://www.kidney.org/professionals/gfr_calculator

5. Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight — reconsidering the use of race correction in clinical algorithms. N Engl J Med. 2020;383(9):874-882.

6. Visweswaran S, Sadhu EM, Morris MM, Vis AR, Samayamuthu MJ. Online database of clinical algorithms with race and ethnicity [published online July 6, 2023, and February 3, 2025]. medRxiv [Preprint]. doi: 10.1101/2023.07.04.23292231. Update in: Sci Rep. 2025;15(1):10913.

7. Clinical Algorithms with Race and Ethnicity website. https://www.clinical-algorithms-with-race-and-ethnicity.org

8. Vaginal Birth After Cesarean calculator. Maternal-Fetal Medicine Units Network website. https://mfmunetwork.bsc.gwu.edu/web/mfmunetwork/vaginal-birth-after-cesarean-calculator?. Updated November 2023.

9. Vaginal Birth After Cesarean (MFMU). MDCalc website. https://www.mdcalc.com/calc/10433/vaginal-birth-after-cesarean-vbac?

10. Spotlight: achieving health equity through race-neutral spirometry. California Academy of Family Physicians website. https://www.familydocs.org/news-spotlight-achieving-health-equity-through-race-neutral-spirometry/. Published August 12, 2024.

11. Diao JA, He Y, Khazanchi R, et al. Implications of race adjustment in lung-function equations. N Engl J Med. 2024;390(22):2083-2097.

12. New in EPIC: race-neutral diagnostic formula for kidney. Ochsner Health Network website. https://www.ochsnerhealthnetwork.org/post/new-in-epic-race-neutral-diagnostic-formula-for-kidney. Published September 1, 2022.

13. Allscripts EHR: game-changing healthcare software. Clarity website. https://www.clarity-ventures.com/hipaa-ecommerce/allscripts-ehr-healthcare-software. Updated November 26, 2024.

14. Cerner EHR overview. EHR Guide website. https://ehrguide.org/top-ehr-software/cerner-ehr/

15. McFarling UL, Palmer K. Embedded bias: inside the bruising battle to purge race from a kidney disease calculator. STAT website. https://www.statnews.com/2024/09/05/embedded-bias-part-3-kidney-disease-egfr-blood-test-racial-bias-kidney-transplant-list/. Published September 5, 2024,

16. Philadelphia-area health organizations form Regional Coalition to Eliminate Race-Based Medicine. Independence Blue Cross website. https://news.ibx.com/regional-coalition/. Published August 10, 2023.

17. Accelerate Health Equity website. https://ahephl.org