B58-25 A Mixed-Methods Study to Investigate the Clinical Impact of De-Implementing Race-Based PFT Equations Within Two Safety Net Hospitals in NYC

Introduction and Rationale

Obstructive lung disease is a leading cause of death in the United States.1 Historical biases in spirometry, particularly race-adjusted reference equations, have underestimated disease severity in Black, Hispanic/Latino, and Asian populations, delaying diagnosis and limiting eligibility for treatment and transplantation.2-8 In 2021, the American Thoracic Society (ATS) recommended removing race as a factor in pulmonary function tests (PFTs), prompting the adoption of race-neutral equations such as the Global Lung Function Initiative (GLI)-Global equation.8-10While prior studies have explored the clinical and financial implications of transitioning to race-neutral PFT equations, our study takes a broader approach by examining whether algorithmic reform alone is sufficient to improve care. We aim to assess clinician awareness of the new race-neutral PFT equation, their understanding of its rationale, and its impact on clinical decision-making in two safety-net hospitals in New York City

Methods

We are conducting a mixed-methods study across two safety-net hospitals. Qualitative data include focus groups and interviews administered to pulmonologists, primary care physicians, and trainees to assess their knowledge, attitudes, and perceptions related to the race-neutral PFT equation. Quantitative analyses (ongoing) use a retrospective pre-/post-implementation design utilizing electronic medical record (EMR) data to examine changes in clinical management within 90 days of an index PFT before versus after adoption of race-neutral reference equations. Primary outcomes include referral to pulmonology and treatment initiation or intensification. Descriptive analyses assess changes in obstructive lung disease diagnosis and severity. We use multivariable logistic regression to examine associations between equation status and inhaler receipt, including interaction terms to assess effect modification by physiological subgroup.

Results

Among 32 survey, focus group and interview participants, awareness of race-based PFT equations was limited; 61% reported little to no understanding of the rationale for the guideline change. While 63% reported interpreting PFTs at least occasionally, 37% reported rare or no interpretation in routine practice; treatment decisions were driven primarily by real-time clinical assessment rather than spirometric thresholds. Across roles, providers expressed discomfort proactively communicating equation changes to patients.

Conclusions

De-implementation of race-based PFT equations represents an important equity-driven policy change, but algorithmic reform alone is insufficient to transform care. Providers emphasized the need for targeted education, communication supports, and broader structural interventions to effectively translate race-neutral diagnostics into meaningful clinical and equity gains. Ongoing quantitative analyses will evaluate the impact on treatment patterns, referrals, and downstream clinical outcomes.

Funding Statement

This work was supported by the Doris Duke Foundation, Grant Number 2023-0138.

This abstract is funded by: Doris Duke Foundation