Health equity - Beyond equations for CKD

Health equity is the state in which all individuals have a similar opportunity to enjoy a long and healthful life. Achieving health equity is a moral imperative, may be the most impactful and efficient way of improving the health of our patient populations, and would alleviate a significant contributor to healthcare costs (1). As laboratorians, we do not have standard practices for monitoring and ensuring fairness in our laboratory processes or how our decisions affect health equity. This may be a result of our field historically perceiving itself as an ancillary service rather than a clinical service directly driving patient care decisions. However, as illustrated by the example of racially-corrected estimated glomerular filtration rate (eGFR) equations, decisions made by the laboratory can have a profound impact on health equity. 

eGFR is a metric of renal function that is used to diagnose kidney disease and allocate life-saving advanced therapies. In 2009, the equations used to calculate eGFR were re-derived and included a racial correction factor (2). The intention was to improve accuracy across racial subgroups; however, this decision had the unintended consequence of exacerbating the existing disparity in access to treatment and patient outcomes (3). As a result, the equations have once again been re-derived, this time without a racial correction factor (4). 

One lesson that should be learned from the eGFR story is that laboratory medicine needs to move away from racialized medicine. Race is a societal construct that does not reflect human biology and has been historically used to justify poor treatment of racialized minority populations (5). In addition to this important point, there are other lessons that can help us to improve our practice of laboratory medicine. 

In general, laboratorians need to take a more proactive and intentional approach to health equity because the decisions within the laboratory can have a major effect on patient outcomes. Laboratories could take a concrete step by developing formal quality management programs for ensuring health equity. To facilitate these efforts, the field of laboratory medicine should work to develop guidelines, recommendations, and standards on how to benchmark and correct unfairness in laboratory practices.

Education on the importance and concepts of health equity should be integrated into curricular programs for all roles within the laboratory. Research is needed to understand how laboratory decisions contribute to health inequities. While race-based eGFR estimation highlighted the importance of the analytic and post-analytic phases, additional issues might arise at each step of the total laboratory testing process. For example, unfair access to laboratory services could be conceptualized as a (pre-) pre-analytical error that contributes to health disparities.  

Another lesson of race-based eGFR estimation is that equitable laboratory decisions require considering broader patient context. Currently, this is challenging because the laboratory only has access to limited data sources. Laboratories should invest in integrating additional data streams that capture patient outcomes, socioeconomic and demographic factors (6), environmental stresses, and patient preferences. In addition, new analytic tools are needed to integrate and process these complex data streams and bring forth relevant insights. At the same time, special consideration should be given to algorithmic fairness to ensure that the adoption of advanced tools like artificial intelligence and machine learning does not result in the amplification of existing societal biases (7).

Finally, laboratories should establish collaborations with external subject matter experts, including clinicians, public health practitioners, and social workers.

There is a lot of work to be done to improve equity in our laboratory services. However, with increasing recognition of the impact of healthcare disparities, and improving digital and informatics maturity, there has never been a more opportune time to address these issues. Investment in these efforts has the potential to greatly increase the contributions of the laboratory to improving patient care. 

References

1. Marmot, Michael. Achieving health equity: from root causes to fair outcomes. The Lancet 370.9593 (2007): 1153-1163.
2. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, et al; CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009 May 5;150(9):604-12.
3. Zelnick LR, Leca N, Young B, Bansal N. Association of the Estimated Glomerular Filtration Rate With vs Without a Coefficient for Race With Time to Eligibility for Kidney Transplant. JAMA Netw Open. 2021;4(1):e2034004.
4. Inker LA, Eneanya ND, Coresh J, Tighiouart H, Wang D, et al; Chronic Kidney Disease Epidemiology Collaboration. New Creatinine- and Cystatin C-Based Equations to Estimate GFR without Race. N Engl J Med. 2021 Nov 4;385(19):1737-1749.
5. Pierre CC. New Consensus Report Recommends against the Use of Race in Genetic Research. Clin Chem. 2023 Aug 2;69(8):941-942. doi: 10.1093/clinchem/hvad076. PMID: 37531562.
6. Azimi V, Jackups R Jr, Farnsworth CW, Budelier MM. Use of laboratory data for illicit drug use surveillance and identification of socioeconomic risk factors. Drug Alcohol Depend. 2022 Jul 1;236:109499.
7. Azimi V, Zaydman MA. Optimizing Equity: Working towards Fair Machine Learning Algorithms in Laboratory Medicine. J Appl Lab Med. 2023 Jan 4;8(1):113-128.