Physicians’ Perspectives on Race and Atherosclerotic Cardiovascular Disease (ASCVD) Risk Calculator

Context: The pooled cohort equations (used in the ASCVD risk calculator) are race-stratified equations that estimate an individual’s ten-year risk of ASCVD. However, using race to guide clinical decisions is now controversial, potentially impacting clinician use of this tool.

Objective: We sought to explore how clinicians viewed race as it relates to ASCVD risk and their perceptions of race in the ASCVD risk calculator.

Study design: Qualitative descriptive study conducted using ten 45-minute semi-structured interviews with primary care physicians in North Carolina between March and April 2022. Interview topics included race and ASCVD risk and the use of race in the calculator. Responses were analyzed using both deductive and inductive approaches to identify primary topics.

Setting: Video interviews, audio recorded and transcribed.

Population studied: Actively practicing North Carolina internal medicine and family medicine physicians.

Results: Five men and five women participated in the study. Of these, six identified as White, two as Black, and two as Asian. Three main topics emerged: perceptions of race as a biological; perceptions of race in the calculator; and understanding of race and ASCVD risk. Participants held varied perspectives on race: one viewed it as biological, five as sociobiological, and four as social. Most saw race as being presented as biological in the ASCVD risk calculator, which concerned them. Participants recognized increased ASCVD risk among Black patients, which they attributed to social and cultural factors. However, they did not discuss the inclusion of race in ASCVD risk estimates and rarely discussed with Black patients their increased risk of ASCVD. Proposed solutions for addressing race in the calculator were to provide race-neutral and race-specific estimates; offer solely race-neutral estimates; and use race for risk estimation while explicitly clarifying that racial risk is due to non-biological factors.

Conclusions: Greater transparency with patients regarding the role of race in ASCVD risk estimation may be needed. Additionally, contextualizing race-specific estimates by describing race as a social construct, along with providing supplemental information connecting structural racism to health, may increase clinicians’ willingness to engage in conversations with Black patients about how race is used in the calculator. This approach could also help clinicians discuss the relationship between race and ASCVD risk.