• Madison Coots, Soroush Saghafian, David M Kent, and Sharad Goel.
• Harvard University, Cambridge, Massachusetts (M.C., S.S., S.G.).
• Ann. Intern. Med. 2024 Dec 3.

BackgroundAccounting for race and ethnicity in estimating disease risk may improve the accuracy of predictions but may also encourage a racialized view of medicine.ObjectiveTo present a decision analytic framework for considering the potential benefits of race-aware over race-unaware risk predictions, using cardiovascular disease, breast cancer, and lung cancer as case studies.DesignCross-sectional study.SettingNHANES (National Health and Nutrition Examination Survey), 2011 to 2018, and NLST (National Lung Screening Trial), 2002 to 2004.PatientsU.S. adults.MeasurementsStarting with risk predictions from clinically recommended race-aware models, the researchers generated race-unaware predictions via statistical marginalization. They then estimated the utility gains of the race-aware over the race-unaware models, based on a simple utility function that assumes constant costs of screening and constant benefits of disease detection.ResultsThe race-unaware predictions were substantially miscalibrated across racial and ethnic groups compared with the race-aware predictions as the benchmark. However, the clinical net benefit at the population level of race-aware predictions over race-unaware predictions was smaller than expected. This result stems from 2 empirical patterns: First, across all 3 diseases, 95% or more of individuals would receive the same decision regardless of whether race and ethnicity are included in risk models; second, for those who receive different decisions, the net benefit of screening or treatment is relatively small because these patients have disease risks close to the decision threshold (that is, the theoretical "point of indifference"). When used to inform rationing, race-aware models may have a more substantial net benefit.LimitationsFor illustrative purposes, the race-aware models were assumed to yield accurate estimates of risk given the input variables. The researchers used a simplified approach to generate race-unaware risk predictions from the race-aware models and a simple utility function to compare models.ConclusionThe analysis highlights the importance of foregrounding changes in decisions and utility when evaluating the potential benefit of using race and ethnicity to estimate disease risk.Primary Funding SourceThe Greenwall Foundation.

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