Epidemiological Assessment and Inference in Race-Based Clinical Algorithms: A Narrative Review and Health Policy Analysis Focused on Living Kidney Donation.

Background: Minoritized racial and ethnic groups in the United States face long-standing disparities in a variety of health outcomes, owing to inequitable distribution of social and structural determinants of health along racial and ethnic lines. Although the existence of such disparities has long been a topic of scientific inquiry, there has been a dearth of investigations regarding their underlying mechanisms and potential remedies. This presents a challenge to those creating evidence-based and equity-focused health policy. Methods: We conducted an evidence-based, equity-focused narrative review about living kidney donor eligibility using salient literature about donor eligibility and racial and ethnic disparities in kidney transplantation and donation in the United States. We sought to examine the rigor and reproducibility of the evidence base regarding race- and ethnicity-based living kidney donation policies. Results: Our review identified several threats to scientific validity in the evidence base, including ambiguity in the operationalization of race and ethnicity variables, instances of type III error and racial essentialist biases, and causal inferences made using underpowered or scientifically unsubstantial subgroup analyses. We also identified structural barriers to the interpretation of this evidence to advance health equity, including barriers to the practices of clinical equipoise and shared medical decision-making. Conclusions: Threats to scientific validity and inferential errors in the evidence base about health inequities may forestall progress toward equity. We provide recommendations for addressing such barriers using standards applied in other clinical and research domains.