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Race-Neutral Equations and Pulmonary Function Test Interpretation in Two Pediatric Cohorts
George Doumat1, Geneva D Mehta2, Janice A Espinola1
1Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
Insights
New race-neutral lung function equations increase respiratory impairment prevalence and severity in Black children. These findings highlight disparities in spirometry interpretation and the need for equitable pediatric respiratory care.
Area of Science:
- Pediatric pulmonology
- Respiratory medicine
- Health equity
Background:
- Spirometry interpretation traditionally used race-specific equations.
- Recent shifts towards race-neutral equations aim for greater equity.
- The impact of these new equations on pediatric lung function predictions requires investigation.
Purpose of the Study:
- To evaluate changes in predicted lung function measurements in children using new Global Lung Initiative (GLI) race-neutral equations.
- To compare spirometry results interpreted with race-neutral versus race-specific GLI equations.
- To assess the association of race with respiratory impairment prevalence and severity under new guidelines.
Main Methods:
- Analysis of data from two prospective multicenter cohorts of healthy children and those with a history of severe bronchiolitis.
- Spirometry data from 677 children at their 6-year physical exam were analyzed using both new GLI Global and 2012 GLI equations.
- Multivariable logistic regression, adjusted for age, height, and sex, examined race's association with new or increased respiratory impairment (FEV1 z-score ≤ -1.645) per 2022 American Thoracic Society guidelines.
Main Results:
- Race-neutral equations increased predicted FEV1 and FVC in White children but decreased them in Black children.
- Obstruction prevalence rose by 21% in White children; possible restriction increased by 222% in Black children.
- Black race was significantly associated with higher prevalence (aOR 7.59) and severity (aOR 35.40) of respiratory impairments compared to White race.
Conclusions:
- The adoption of race-neutral spirometry reference equations resulted in increased prevalence and severity of respiratory impairments among Black children.
- These findings underscore the critical need to address racial disparities in respiratory health assessments.
- The study supports the removal of race from spirometry interpretation due to lack of biological justification and observed inequities.
Objective:
To investigate the changes in predicted lung function measurements when using race-neutral equations in children, based upon the new Global Lung Initiative (GLI) reference equations, utilizing a race-neutral approach in interpreting spirometry results compared with the 2012 race-specific GLI equations.
Study Design:
We analyzed data from 2 multicenter prospective cohorts comprised of healthy children and children with history of severe (requiring hospitalization) bronchiolitis. Spirometry testing was done at the 6-year physical exam, and 677 tests were analyzed using new GLI Global and 2012 GLI equations. We used multivariable logistic regression, adjusted for age, height, and sex, to examine the association of race with the development of new impairment or increased severity (forced expiratory volume in the first second (FEV1) z-score ≤ -1.645) as per 2022 American Thoracic Society (ATS) guidelines.
Results:
Compared with the race-specific GLI, the race-neutral equation yielded increases in the median forced expiratory volume in the first second and forced vital capacity (FVC) percent predicted in White children but decreases in these two measures in Black children. The prevalence of obstruction increased in White children by 21%, and the prevalence of possible restriction increased in Black children by 222%. Compared with White race, Black race was associated with increased prevalence of new impairments (aOR 7.59; 95%CI, 3.00-19.67; P < .001) and increased severity (aOR 35.40; 95%CI, 4.70-266.40; P = .001). Results were similar across both cohorts.
Conclusions:
As there are no biological justifications for the inclusion of race in spirometry interpretation, use of race-neutral spirometry reference equations led to an increase in both the prevalence and severity of respiratory impairments among Black children.
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