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Ruchika Talwar: Hi everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar, and today I'm joined by Dr. Logan Galansky, who's a resident at Johns Hopkins University Hospital. Dr. Galansky is joining us today to discuss a very important topic of integrating race into our clinical algorithms. Dr. Galansky, we're super excited to chat with you. Thank you so much for being here with us.

Logan Galansky: Thank you Dr. Talwar and UroToday. I'm very excited to talk about this important topic. So in recent years, there has been much more attention in the medical community paid to how we are understanding diseases, patients, and health outcomes. And with that comes a greater emphasis on incorporating the entire context that may affect a patient's life, whether that be the social determinants of health, environmental factors, or in the case of the article that we're discussing today, race. And essentially there's been a push to move from the concept of race-based medicine to race-conscious medicine. And so what that means is that race-based medicine is an antiquated concept that has been defined as the system by which research characterizing race as an essential biologic variable translates into clinical practice. And so essentially in these cases, race is being used as a biologic proxy and it's been shown many times that this can lead to inequitable care.

The alternative is a framework called race-conscious medicine. And this is a potentially normative construct that is emerging in the medical literature in response to increased recognition of the possible unintended consequences of the deep-rooted race-based paradigm. So what race-conscious medicine does, is it aims to improve health equity by integrating pathophysiology and epidemiological data with a broader understanding of the effects of systemic racism on health outcomes. And so some medical organizations are really taking up the mantle and leading the pack in transitioning from race-based to race-conscious medicine. Particularly the American Academy of Pediatrics, which is led by Dr. Joseph Wright has been one of the leaders in this field. And all of this came about essentially when there was a groundbreaking commentary in the New England Journal of Medicine in August of 2020 which, if you'll remember, was at a time when race relations were very fraught. It was right after George Floyd was murdered and racial injustice was really at the forefront of the media and people's minds.

And this commentary, "Hidden in Plain Sight," was about reconsidering the use of race correction and clinical algorithms. And I think anyone who is involved with patient care knows that clinical algorithms are a diagnostic tool, that are used to help patients understand their risk and help guide providers in their decision-making process for treatment. And what "Hidden in Plain Sight" demonstrated to people was that the use of race in these clinical algorithms may actually exacerbate racial inequities and perpetuate health disparities in patient care. Probably the most well-known example in the public eye is in the use of kidney function and EGFR adjustments. And so there was a rationale developed decades ago by credible researchers that because Black individuals have greater muscle mass and creatinine production, there should be an adjustment to their renal function. And this was operationalized by using race as an input variable in clinical algorithms to predict kidney function and risk of who should get a nephrology referral and eventually a kidney transplant.

And this resulted in higher GFR estimates for Black patients, making it seem like they had better renal function because of this belief of their greater muscle mass and creatinine production. However, later studies have found that Black patients have had significantly greater delays in nephrology referrals, transplant listings, and overall outcomes because this assumption of muscle mass and creatinine was really rooted in systemic racism and did not have a good biologic basis. And so since then, the various societies involved in nephrology and transplant of kidneys have gotten together, and they've created a new algorithm using a much more rigorously defined scientific metric of cystatin C and creatinine clearance that eliminates the use of race. And has already shown more stabilization in the health inequities between Black and non-Black patients. And it's now encouraged widely across the nation to be using this new estimation of GFR.

Unfortunately, "Hidden in Plain Sight" also called out two urology metrics. One was for predicting kidney stone risk in patients who presented with flank pain, and one was predicting UTI in children. And both used race as a clinical output and both were shown to lead to worse outcomes for Black patients because they discourage clinicians from pursuing additional workups such as a CT scan or a catheterized urine sample. And both have been amended since then. One of the biggest consequences of this commentary was that it encouraged Congress in 2020 to ask the Agency of Healthcare Research and Quality to investigate this issue. And AHRQ for sure released their report in December of last year, December 2023. And it was a systematic review analyzing the impact of clinical algorithms on racial disparities in healthcare. They reviewed 18 algorithms and five were identified as reducing disparities, two of which were actually related to prostate cancer.

And so these specific algorithms were able to reduce healthcare disparities among Black patients because of the way they were developed. Meaning that when these algorithms were conceived of, they were based off of studies that prospectively designed their methods to assess differences by race, by comparing the frequency of avoided biopsies to missed clinically significant prostate cancer between racial groups. And so as such, it was including race as part of the greater context that we've known for a long time, that there's been a disparity in prostate cancer care in which Black men are receiving more low yield prostate biopsies. And so instead of just including race as a proxy variable, they included sort of the broader context of it and were able to create an algorithm that then led to more high yield biopsies for all men with less racial disparity. The main takeaway from the ARHQ report was that this concept of understanding how race is used in a greater context is how we mitigate healthcare inequities when we are creating clinical algorithms.

So where does that take us? Basically, this is a call to action that there are other medical societies that are starting to do this shift, as I mentioned. And it is a real moment that urologists can step up and work on redefining how we are understanding data and educating our patients and coming up with treatment plans to have more equitable outcomes. This will include things like having better studies that are more inclusive of marginalized populations. Making sure that our healthcare workforce reflects the racial and ethnic identities of the patients we serve since that's been shown time and again, to improve health outcomes, greater transparency in the actual creation of clinical algorithms. Something I learned in the process of this work was that when algorithms are using proprietary data by EHR vendors, insurance payers, private health systems, there's very little empiric rationale that can be found as to why certain variables are included. And yet the risk predictions that are the outputs of these algorithms are used for determining insurance coverage and reimbursement rates, things that greatly affect patients.

And so like anything with healthcare and policy, we as doctors have to add our voice to the conversation. And that's the best way we can advocate for our patients and for our specialty.

Ruchika Talwar: Thank you so much, Dr. Galansky. What a rich, rich discussion this really generates because you've presented a lot of compelling evidence. I just want to focus on one point that I think is really important here. It's not about not using race and ethnicity at all. So let's dive into that a little more. I want you to explain to me one of your wrap-up points about it really is the fact that we need to use race and ethnicity in a way that is advancing care for the patient. So tell me more about that.

Logan Galansky: Absolutely. I think that for people who are new to this concept, the tendency might be to believe well, let's just eliminate race completely and not include it. And that's going to do just as much of a disservice to our patients as it would be to continue to practice race-based medicine. And essentially what the idea of race-conscious medicine is proposing, is that race is a very important variable in healthcare outcomes. For better or worse, there are certain systemic environmental and socioeconomic factors that are tied to race that affect health outcomes. And in some cases, there are actual pathophysiologic and epidemiologic reasons that we see where, for example, prostate cancer is shown to be more aggressive and present earlier in Black men. But the problem is when we reduce it to just this proxy where we're calling race the cause of health outcomes without contextualizing it. And I think that's what we're trying to encourage is creating just a broader view of how race fits into the whole patient care picture, in order to make a more accurate risk assessment and advise our patients as best as we can.

Ruchika Talwar: Absolutely. I couldn't agree more on all points. Now, obviously you've outlined the work ahead for our medical societies, our specialty societies, and our guidelines committees. But as we wrap up here, tell me what can we as individual urologists do to ensure that we are adopting the practice of race-conscious medicine?

Logan Galansky: That's a great question, and I think there are a few key areas. The first is actually in our interdisciplinary collaboration with other healthcare providers. Urology is unique in that we don't have a medical counterpart of our specialty, but we do rely heavily on PCPs and other practitioners to do things like PSA screening or working up hematuria or things like that. And something we can do is we can help discuss and educate with other providers that race is a variable that should be understood in the context of greater risk for certain urologic diseases. And so they should be screening their Black male patients sooner for prostate cancer or things like that. And sort of empowering our colleagues in other fields to practice race-conscious medicine, so that we're not perpetuating delays in care for Black or other marginalized patients. Another way that we can do this as urologists is just to be more intentional about how we're conducting research, how we are advising our patients. And instead of including race as this kind of single biologic proxy, as I've said, to really have it be more of a composite variable that has an intentional research question.

As the ARHQ report showed, when race and understanding health inequities are driving the discussion because of a known disparity, that's when it can really be used to help patients. And that's sort of what race consciousness is all about.

Ruchika Talwar: Absolutely. Again, couldn't agree more on all points there. Thank you so much for enlightening us with this important commentary. I'm really excited to be able to share it with our broader UroToday audience because I think that it is a shift that is long overdue. And I'm so glad that we're having these sorts of conversations, so we really appreciate your time.

Logan Galansky: Absolutely. Thank you so much. As I said, other physicians and medical societies are participating in this. I think that it is a great moment for urologists and urologic societies to join the discussion and not be left behind in it.

Ruchika Talwar: Yeah. So here's everyone's call to action. To our audience, thank you so much for joining. We'll see you next time.