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Health Department Expands Work To Confront Racism in Medical Algorithms

Doris Duke Foundation grants nearly $3 million to support the examination of race adjustment in clinical algorithms, which are used by health care providers to guide decision-making in medical care

First phase of the effort, which focused on kidney function, lung function, and vaginal births after cesarians, resulted in seven health systems improving racial equity in algorithms

Next phase will expand algorithm focus areas to include hypertension

December 11, 2023 — The Health Department celebrates the two-year anniversary of the Coalition to End Racism in Clinical Algorithms (CERCA). CERCA was formed to support and speed up ongoing work by some New York City health systems to end the misuse of race in some clinical algorithms. Since the Coalition’s start, seven health systems have adopted changes in their clinical algorithms which improve racial equity; some institutions have ended the use of more than one of the three algorithms in the coalition’s focus area. CERCA has announced it will continue to work on the existing three focus areas and expand its work to include addressing the use of the hypertension algorithm. A key philanthropic partner has been the Doris Duke Foundation, which provided $2.9 million for the Health Department to partner with safety net hospitals to document the impact of replacing medical algorithms on health services.

“Medicine has not been immune to the legacy of racism, and it has infected the way we care for minoritized communities across this city and this nation for too long,” said Health Commissioner Dr. Ashwin Vasan. “Confronting that history and promoting the health of all New Yorkers is no small feat and compels us to look at the kind of care that people receive. Improving care, promoting equity and removing harmful practices and building trust in public health makes our entire city a healthier place.”

“The use of race-based algorithms to make clinical decisions is a practice that is behind the times,” said Chief Medical Officer and Deputy Commissioner, Dr. Michelle Morse. “Decades of research has shown that race is not biology. CERCA’s impact and ongoing work is critical to transforming our healthcare system to be fairer and more equitable in the twenty-first century.”

Hypertension is a leading cause of early deaths for many people across our country, especially for Black New Yorkers,” said Deputy Chief Medical Officer, Dr. Toni Eyssallenne. “Ending race-based prescribing in hypertension helps to support the important message that using race as a biological factor in clinical management decisions and the tools that accompany these decisions is incorrect and must end."

Clinical algorithms are tools used by clinicians to guide their decision-making in medical care of patients. Clinical algorithms using race norming — also called “race adjustment”— often negatively impacts the treatment and care for persons of color. For example, the “adjustment” factor for Black patients, in reference to kidney function, calculates Black kidney function levels to be healthier than white patients for the same measured result, sometimes delaying needed care.

Over the past two years, nine health systems and organizations participated in CERCA and they worked on the following goals:

1) End race modifier use in at least one of the three priority clinical algorithms

glomerular filtration rate (eGFR) for kidney function;

spirometry/pulmonary function testing (PFT)

Vaginal birth after Cesarean section (VBAC) calculator).

2) Evaluate the impact of using algorithms without race on health inequities in patient outcomes; 3) Create and implement initiatives for patient engagement among patients whose care may have been impacted by race modifiers.

CERCA will continue to work towards its three initial algorithms of focus as well as expand to include race-based hypertension prescribing. This expanded focus on hypertension is necessary to develop race conscious approaches to prescribing blood pressure medication that do not rely on harmful unscientific claims that race is biological. Hypertension is also linked to kidney and maternal health outcomes, both of which are focus areas of CERCA.

The need to end the use of race adjustment in clinical algorithms is increasingly recognized as a necessary step to improving population health and health equity. A recent special issue in the journal Health Equity entitled “Race Adjustment in Clinical Algorithms and Other Clinical Decision-making Tools” has nine newly published articles that highlight the need to end this practice which perpetuates health inequities.

The continuation of CERCA is also made possible through the following partnerships:

Fund for Public Health NY

Josiah Macy Jr. Foundation

New York Academy of Medicine

Robert Wood Johnson Foundation

CERCA members also completed an inaugural report that highlighted their progress up until that point. The Health Department and Doris Duke Foundation celebrated the two-year anniversary of CERCA on Friday, December 8, 2023 at the Doris Duke Center.

“CERCA has made tremendous strides in working with healthcare systems to eliminate race-based algorithms from clinical practice,” said NYC Health + Hospitals Vice President and Chief Population Health Officer Nichola Davis, MD, MS. “We cannot achieve population health without health equity, and removing race-based practices in medicine is one critical step. We have been proud to partner with CERCA in elimination of race-based algorithms at NYC Health + Hospitals for the past two years, and look forward to continuing this work with them.”

“No movement to eradicate the pernicious role of race in medicine will succeed without the support of clinicians on the frontlines of care,” said Doris Duke Foundation President and CEO Sam Gill. “We are proud to support New York City's CERCA coalition and applaud their courage and leadership in demonstrating a more just path forward.”

“In just two years CERCA has generated much needed attention to the improper use of race in the design of clinical algorithms,” said Sara Gardner, CEO of the Fund for Public Health NYC. “Thanks to the visionary support of the Doris Duke Foundation, this conversation and work toward corrective measures is expanding beyond clinicians and researchers to be a collaborative movement that also includes patients, philanthropy, and public health entities.”

“We are proud to lend our support to CERCA’s work, which marks a vital step toward ensuring equitable health and health care for all,” said Holly J. Humphrey, President of the Josiah Macy Jr. Foundation. “By shining a light on the inequitable care and patient outcomes that emanate from using these unsupported clinical tools, CERCA is contributing to a new era of medicine that benefits patients and enhances the educational experience for those training to become the next generation of health care providers.”

“We are glad to partner with the New York City Department of Health and Mental Hygiene, Doris Duke Foundation and participating safety-net hospitals and to provide our research expertise on this initiative that puts equity at the forefront—addressing and removing racist biases that have historically led to inaccurate diagnoses and treatment in healthcare,” said NYAM President Dr. Ann Kurth. “This is the overdue opportunity to improve bias-based diagnosing protocols that have historically kept many patients from receiving best and appropriate care.”

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