Including race in clinical algorithms can both reduce and increase health inequities – it depends on what doctors use them for

Health practitioners are increasingly concerned that because race is a social construct, and the biological mechanisms of how race affects clinical outcomes are often unknown, including race in predictive algorithms for clinical decision-making may worsen inequities.

For example, to calculate an estimate of kidney function called the estimated glomerular filtration rate, or eGFR, health care providers use an algorithm based on age, biological sex, race (Black or non-Black) and serum creatinine, a waste product the kidneys release into the blood. A higher eGFR value means better kidney health. These eGFR predictions are used to allocate kidney transplants in the U.S.

Based on this algorithm, which was trained on actual GFR values from patients, a Black patient would be assigned a higher eGFR than a non-Black patient of the same age, sex and serum creatinine level. This implies that some Black patients would be considered to have healthier kidneys than otherwise similar non-Black patients and less likely to be assigned a kidney transplant.

Biased clinical algorithms can lead to inaccurate diagnoses and delayed treatment.

In 2021, however, researchers found that excluding race in the original eGFR equations could lead to larger discrepancies between estimated and actual GFR values for both Black and non-Black patients. They also found adding an additional biomarker called cystatin C can improve predictions. However, even with this biomarker, excluding race from the algorithm still led to elevated discrepanies across races.

I am a health economist and statistician who studies how unobserved factors in data can result in biases that lead to inefficiencies, inequities and disparities in health care. My recently published research suggests that excluding race from certain diagnostic algorithms could worsen health inequities.

Different approaches to fairness

Researchers use different economic frameworks to understand how society allocates resources. Two key frameworks are utilitarianism and equality of opportunity.

A purely utilitarian outlook seeks to identify what features would get the most out of a positive outcome or reduce the harm from a negative one, ignoring who possesses those features. This approach allocates resources to those with the most opportunities to generate positive outcomes or mitigate negative ones.

A utilitarian approach would always include race and ethnicity to improve the prediction power and accuracy of algorithms, regardless of whether it’s fair. For example, utilitarian policies would aim to maximize overall survival among people seeking organ transplants. They would allocate organs to those who would survive the longest from transplantation, even if those who may not survive the longest due to circumstances outside their control and need the organs most would die sooner without the transplant.

Although utilitarian approaches do not…

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