Clinical Practice Guidelines Miss Shot to Address Race, Ethnicity

(Reuters Health) – The vast majority of pediatric clinical practice guidelines fail to mention race or ethnicity, and most that include the terms do so in a way that could harm vulnerable and underrepresented groups, a new study finds.

“It’s really time to look at all of our guidelines, how race is being used, and how do we change the guidelines,” said lead author Dr. Courtney A. Gilliam, a pediatric hospital medicine fellow at Seattle Children’s Hospital at the University of Washington.

When guidelines note racial or ethnic differences, she told Reuters Health in a phone interview, “we need to go that next step and really explore that difference and not blame it on race.”

“Are we making these guidelines with a true equity lens?” Dr. Gilliam asked.

The answer is no, she and her colleagues conclude in JAMA Pediatrics. Most of the time, they found, pediatric clinical practice guidelines missed the opportunity to proactively address healthcare inequities.

Researchers examined 414 pediatric clinical practice guidelines issued from January 2016 through April 2021 and found only 126, or 30%, used the term race or ethnicity.

The team then used a critical race theory framework to assess the 126 guidelines that included the term race or ethnicity, and they classified each set of guidelines according to its potential to change racial inequities. Was, for example, race used as a genetic or biological marker?

They found that 58% of the guidelines used the terms race or ethnicity in ways that could exacerbate health inequities.

Only 12 clinical practice guidelines used race or ethnicity to discuss recommendations to close gaps in future research.

Two of the recommendations the researchers praised came from the U.S. Preventive Services Task Force (USPSTF). One on counseling to prevent skin cancer urges studies for people with skin types other than “fair.” Another on the prevention and cessation of tobacco use urges interventions tailored to subpopulations with elevated smoking rates, such as African American and LGBTQ youth.

“We’re asking for writers and developers to go the next step and explore the why,” Dr. Gilliam said. “It’s a lot more work. But the known healthcare inequities in this country are staggering, and it’s the work we need to do.”

One piece of the work is to include members from vulnerable racial and ethnic groups on the committees drafting guidelines, she said.

Karin Davidson, a psychologist and senior vice president for research at Northwell Health in New York, commended the study for sending clear, actionable messages to guideline-making organizations.

“I think it’s a call to action for guideline-making organizations to review their current guidelines and update them to review if they mean race as a proxy variable,” she said in a phone interview.

“Instead of measuring poverty, transportation difficulties, lack of primary care availability, we just measure the color of someone’s skin, and then we make causal attributions for that,” she said. “We need to look at the most likely causes of the inequities and fix those.”

Davidson, who also is a professor of medicine and psychiatry at the Zucker School of Medicine at Hofstra University and is past chair of the USPSTF, was not involved with the study.

The study points to the need for research that’s inclusive and representative of the population as well as for models and frameworks to support guideline-making organizations in thoughtfully integrating healthcare inequities, she said.

Davidson said she was surprised at how few clinical practice guidelines explicitly mentioned race and ethnicity and how many that did were judged to have the potential to widen health disparities.

“Default assumptions, often implicit assumptions, that race is a proxy variable for biology or genetics should be questioned and should not be acceptable without specific high-quality evidence to back up such a statement,” she said.

“The current evidence available to us is persuasive that racism and structural barriers to equitable care are far more likely explanatory variables for our current health inequities found in vulnerable subgroups,” she said. “The most important thing for clinicians to take away from this study is that they should consider carefully the guidelines they follow and whether they will ensure that everyone benefits.”

SOURCE: JAMA Pediatrics, June 6, 2022.

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