Removing race from the lung test will not have a major impact on disability STAT

VEeterans Affairs officials said Monday they have launched a study to determine how removing race from commonly used lung function tests could affect disability benefits for veterans, and they expect the impact will be much smaller than predicted in a report published earlier this year study.

They also said veterans who may have heard of the issue should not worry about sudden changes to their benefits. Any change, said Olumayowa Famakinwa, who oversees the implementation of the VA’s disability rating scheme, would come with ample notice and the opportunity for veterans to appeal.

“If I were talking to a veteran, I would say give us some time, but we will definitely work it out and you can continue to trust that you will get the benefits you have earned,” he said.

In response to the outcry that the use of race in pulmonary function tests may underestimate the extent of the disease in black patients, and to a lesser extent in Asian patients, the American Thoracic Society released new guidelines in 2023 stating that the use of race contributed to the health. inequalities and they must end. A breed-based comparison had long been used to guide the interpretation of spirometry test results and was built into the machines’ software over time.

The tests are used to diagnose lung diseases and guide treatment decisions, as well as in determining disability benefits.

A study published in May in the New England Journal of Medicine analyzed how a race-free comparison could affect patients. Using data from a large population survey, the authors estimate that the change could affect more than 400,000 veterans and lead to a redistribution of nearly $2 billion dollars, with a total of 17% more going to black veterans and just over 1% less to white veterans.

In an interview with STAT, veterans officials said they believed the study had vastly overestimated the number of veterans eligible for benefits and the amount benefits could change for individuals because the researchers did not use VA figures but extrapolated from data on the entire population. .

“To my knowledge, there was no VA involvement in that manuscript,” said David Au, a pulmonologist who directs the Veterans Health Administration’s Center for Care and Payment Innovation. “We would have liked to make a contribution.”

Au said he appreciated the attention the study paid to the issue, but hoped the study could be corrected or revised or that the authors would work with the VA in the future to provide more accurate estimates.

The study’s lead author, Arjun Manrai, an assistant professor of biomedical informatics at Harvard, said he appreciated the VA’s comments and agreed that the populations were not as accurate as they would have been if the authors had used VA data directly.

But he said he believed in the broader finding, that black veterans might gain additional benefits if pulmonary function tests, or PFTs, used race-free comparisons were unlikely to change. “Ultimately, we are confident in our estimates of the direction and magnitude of changes we expect with widespread adoption of race-neutral PFTs,” he told STAT, adding that he would like to see the VA’s data.

VA officials said potential changes in disability benefits likely won’t be as large as the study estimated for a number of reasons. First, lung function tests are only one factor in diagnosing lung function disorders. It also uses a wide range of tests and other factors, such as whether people need bronchodilators to control asthma or whether they are prescribed outpatient oxygen.

Additionally, Famakinwa said, most disability claims include some service-connected disabilities, so changing the amount of pulmonary disability among numerous other claims could reduce or increase a disability benefit very little, if at all.

The VA began studying the issue after the ATS recommendation was released and it hopes to determine a new policy by September 2025, said Au, who added that he was fully on board with the larger issue of removing race from clinical algorithms, but said removing it in the lung diseases won’t be easy used to be. “This is really an implementation problem,” Au said. “It’s messy and complex.”

He said VA officials don’t want to make a change that could introduce new health inequities. “Ten years ago, fifteen years ago, there were disparities in the delivery of care in the VA. The most recent data has shown that we have eliminated most treatment and outcome disparities between black and white veterans,” he said. “What we were concerned about was that if we implemented this large-scale implementation, we would create new inequities.”

He mentioned as an example a JAMA Surgery paper Published last year showing that black patients were less likely to receive a more aggressive and effective surgical option for lung cancer if their lung function was assessed using race-neutral comparisons. “That was alarming for us,” Au said.

Another concern is that if relatively simple PFT tests are replaced with more complex tests that are not offered at every VA hospital, it could create access barriers for veterans with transportation issues or other complications. “Every time you add a layer of complexity to testing, you drop a population,” Au said.

Au said decisions about whether to administer the tests were up to the individual VA centers, and that 30% had started using the race-free equation while the rest did not, causing problems for continuity of care. The VA has paused implementation of the changes for now, he said. “We really want it [changes] to be consistent and fair throughout the system,” he said.

The VA moved faster to implement race-free testing for kidney function, but Au said that was an easier decision because nephrologists in that case had a gold standard test and data modeling showed that a race-free comparison had similar performance. Pulmonary function tests, he said, have no gold standard or new data analytics and are influenced by a wide variety of factors, including ancestry, poverty and air pollution, making the issue much less clear. “I wish we were nephrologists,” he said.