Written by Clay Smith
Spoon Feed
Race was strongly associated with UTI risk, with non-Black children having 2-4 times greater odds of infection. However, replacement of race with 2 other variables resulted in similar diagnostic accuracy for the UTICalc tool.
Why does this matter?
We previously covered UTICalc, which scored, “age, temperature, race, sex, circumcision status, and presence of another source for fever to estimate the probability of UTI; if the calculated probability was 2% or higher (ie, the testing threshold that led to detection of 95% of UTIs), it recommended obtaining a urine sample for testing.” Non-Black children were at increased risk in the previous iteration. However, race may be a proxy for other confounding factors. Does race really change risk of UTI? If race was replaced with non-race based variables, how would UTICalc perform?
Recalculating UTICalc
The authors performed a systematic review and meta-analysis to determine whether race was associated with UTI. They found a very strong association of non-Black race with greater odds of UTI, OR 2.44. When only the highest quality studies, with the lowest risk of bias were included, the association was even stronger, OR 4.84. They discussed whether implicit bias or structural racism could have played a role and concluded this was highly unlikely. However, the authors said, “Although available data suggest that race and UTI are associated, we were compelled to search for other factors that could replace race in UTICalc.” By removing race and adding history of prior UTI and duration of fever, the diagnostic accuracy was nearly the same when applied to the original UTICalc cohort. Importantly, the current version of UTICalc does not include race. Authors note that this change will likely result, “in an 18% increase in testing of Black children,” without finding more UTIs. I think I understand why the authors felt compelled to make this change. Race can be hard to pin down and is a social construct, though this, “does not mean that racial classifications are free of consequence or tangible effects.” For example, how do we consider race in a risk calculator if one parent is Black and one is not; if one is Hispanic, and one is Asian? There are pros and cons, but it seems like this is a reasonable modification to UTICalc.
Source
Reassessment of the Role of Race in Calculating the Risk for Urinary Tract Infection: A Systematic Review and Meta-analysis. JAMA Pediatr. 2022 Apr 18. doi: 10.1001/jamapediatrics.2022.0700. Online ahead of print.
“Authors note that this change will likely result, “in an 18% increase in testing of Black children,” without finding more UTIs.”
Insanity. So the outcome will be that black children are exposed to more invasive testing (catheterization), false positives, unnecessary antibiotics, but at least the woke authors can pat themselves on the back and feel morally superior. The world is on its head.
I certainly understand this can be frustrating. I questioned whether this change was an improvement on my first reading. I also acknowledge that ideology may have been a driver in the authors’ decision. But as I thought more about it, I think there are solid reasons why this change might be a good idea. My family has a new and precious foster-care member, and we are not even sure what ‘race’ she is. As I consider how race is a socially defined label based on phenotypic features, manner of speaking, and even a person’s name, I can understand why the authors wanted to move away from it. What skin tone or phenotypic features ‘define’ who is or is not Black? What about a person who appears phenotypically White but has a parent who is Black? How should they be scored on UTICalc? Race is just not as simple as it seems on its face. To be sure, there are pros and cons to adding or removing race as a variable, and I don’t think this issue is settled. It will be important for these authors to do implementation studies to see if this does, if fact, result in overtesting of patients whose parents list their race as Black. However, it seems best to take a generous view of this and consider that the authors are trying to do the right thing.