Race and Ethnicity in Pulmonary Function Test Interpretation: An Official American Thoracic Society Statement

Abstract

Current American Thoracic Society (ATS) standards promote the use of race and ethnicity-specific reference equations for pulmonary function test (PFT) interpretation. There is rising concern that the use of race and ethnicity in PFT interpretation contributes to a false view of fixed differences between races and may mask the effects of differential exposures. This use of race and ethnicity may contribute to health disparities by norming differences in pulmonary function. In the United States and globally, race serves as a social construct that is based on appearance and reflects social values, structures, and practices. Classification of people into racial and ethnic groups differs geographically and temporally. These considerations challenge the notion that racial and ethnic categories have biological meaning and question the use of race in PFT interpretation. The ATS convened a diverse group of clinicians and investigators for a workshop in 2021 to evaluate the use of race and ethnicity in PFT interpretation. Review of evidence published since then that challenges current practice and continued discussion concluded with a recommendation to replace race and ethnicity-specific equations with race-neutral average reference equations, which must be accompanied with a broader re-evaluation of how PFTs are used to make clinical, employment, and insurance decisions. There was also a call to engage key stakeholders not represented in this workshop and a statement of caution regarding the uncertain effects and potential harms of this change. Other recommendations include continued research and education to understand the impact of the change, to improve the evidence for the use of PFTs in general, and to identify modifiable risk factors for reduced pulmonary function.

Keywords: PFT; ethnicity; interpretation; race.

Figure 1.

Influence of environmental exposures on lung growth and aging depending on the time of life when exposure occurred. Examples of early-life events affecting lung growth are prematurity and its consequences, as well as exposure to secondhand smoke, poor air quality, and infections. Discrimination is associated with differential risk of prematurity and exposures. Reprinted by permission from reference (42).

Figure 2.

Influence of race-specific equations compared with a single reference equation in the interpretation of pulmonary function and the association with survival. The predicted survival for a 55-year-old, non–tobacco-smoking woman living at two times the federal income-poverty ratio is displayed for Black and White participants using each approach (top). Histograms demonstrate the distribution of FEV₁ z-scores applying race-specific equations compared with a single reference equation (Global Lung Function Initiative reference equations) (bottom). Reprinted from reference (86).

Figure 3.

Pulmonary function versus symptoms in the Sub-Populations and InteRmediate Outcome Measures In Chronic Obstructive Pulmonary Disease (COPD) Study. For each patient-reported outcome (St. George’s Respiratory Questionnaire and COPD Assessment Test), participants’ scores are plotted against percent predicted FEV₁. Separate univariable linear regressions for each self-identified racial group are superimposed. The relationships between symptoms and pulmonary function are more consistent with a universally applied single reference equation (GLI Other). AA = African American; GLI = Global Lung Function Initiative; NHW = non-Hispanic White. Reprinted from reference (88).