Article type
Abstract
Background: Some guidelines include special considerations for those in certain racial/ethnic groups, which may be based on evidence about disparities. Medical practice has moved toward an understanding that race is a social rather than a biological construct. However, clinicians and guideline developers are questioning when to include recommendations that differ by race/ethnicity, “race-aware” recommendations, because frequently it is unclear whether these recommendations will reduce or perpetuate disparities.
Objectives: To apply an equity-driven framework to assess race-aware recommendations in 3 guidelines to inform decisions about whether to modify, remove, or add race-aware recommendations
Methods: Using 4 guiding questions as an equity framework, guideline development teams assessed the race-aware recommendations in 3 guidelines that were updated in 2023 (colorectal cancer screening, hypertension, and osteoporosis), examining: 1) observed health disparities by race/ethnicity; 2) evidence to support race/ethnicity-specific recommendations; 3) the impact of including or excluding race-aware recommendations on health inequity; and 4) implementation considerations.
Results: In 2 guidelines, race-aware recommendations were removed based on the equity assessment. A colorectal cancer recommendation to begin screening African American/Black patients at an earlier age (45 years) was removed, since evidence for the general recommendation had recently expanded to start screening at age 45 for all. An evidence-based hypertension treatment recommendation to include thiazide diuretics or calcium channel blockers as initial treatment for African American/Black patients was also removed. Given current approaches in hypertension treatment, including the use of fixed-dose combination pills, the race-aware recommendation did not have clear benefit in helping African American patients reach their blood pressure goal. The third guideline, osteoporosis, did not have a race-aware recommendation, but it referenced a race-based risk calculator (Fracture Risk Assessment Tool [FRAX]) for the United States. The guideline development team applied the equity framework but recommended no changes at this time since other professional society efforts are ongoing to evaluate the equity implications of FRAX.
Conclusions: Guideline developers should routinely revisit race-aware recommendations using an equity-centric framework to help decide when to include or remove recommendations that may improve disparities and promote equity in clinical care.
Objectives: To apply an equity-driven framework to assess race-aware recommendations in 3 guidelines to inform decisions about whether to modify, remove, or add race-aware recommendations
Methods: Using 4 guiding questions as an equity framework, guideline development teams assessed the race-aware recommendations in 3 guidelines that were updated in 2023 (colorectal cancer screening, hypertension, and osteoporosis), examining: 1) observed health disparities by race/ethnicity; 2) evidence to support race/ethnicity-specific recommendations; 3) the impact of including or excluding race-aware recommendations on health inequity; and 4) implementation considerations.
Results: In 2 guidelines, race-aware recommendations were removed based on the equity assessment. A colorectal cancer recommendation to begin screening African American/Black patients at an earlier age (45 years) was removed, since evidence for the general recommendation had recently expanded to start screening at age 45 for all. An evidence-based hypertension treatment recommendation to include thiazide diuretics or calcium channel blockers as initial treatment for African American/Black patients was also removed. Given current approaches in hypertension treatment, including the use of fixed-dose combination pills, the race-aware recommendation did not have clear benefit in helping African American patients reach their blood pressure goal. The third guideline, osteoporosis, did not have a race-aware recommendation, but it referenced a race-based risk calculator (Fracture Risk Assessment Tool [FRAX]) for the United States. The guideline development team applied the equity framework but recommended no changes at this time since other professional society efforts are ongoing to evaluate the equity implications of FRAX.
Conclusions: Guideline developers should routinely revisit race-aware recommendations using an equity-centric framework to help decide when to include or remove recommendations that may improve disparities and promote equity in clinical care.