Study finds bias in classification of radiographs for black lung claims
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A new study found a strong association between payment source and physicians who review radiographs of coal miners with claims of black lung, researchers reported in the Annals of the American Thoracic Society.
The researchers found that the determinations of these physicians, who are known as B-readers and are certified by the National Institute for Occupational Safety and Health, were strongly associated with the party that hired them, according to a press release issued by the ATS.
“Certainly, we anticipated finding some bias, as there has been anecdotal evidence for some time and the Department of Labor has even taken action since 2013 to avoid such bias,” Lee S. Friedman, PhD, associate professor in the division of environmental and occupational health sciences at the School of Public Health at the University of Illinois, Chicago, said in the release. “But the degree of bias shown in this data is alarming.”
The study analyzed 63,780 radiograph classifications made by 264 physicians for black lung, or pneumoconiosis, claims filed to the Federal Black Lung Program from 2000 to 2013. The U.S. Department of Labor administers the Federal Black Lung Program, which manages claims by coal miners for workers’ compensation. Nearly half of the radiographs were read by 10 physicians; of those, six were hired predominantly by the U.S. Department of Labor. To evaluate financial conflicts of interest for each physician, researchers assessed 7,656 Federal Black Lung Program court decisions from 2002 to 2019. Researchers aimed to evaluate the direction and severity of the associations between financial conflicts of interest of participating physicians in the Federal Black Lung Program and radiograph classifications of pneumoconiosis.
The main outcome was classifications of radiographs for the absence of pneumoconiosis, simple pneumoconiosis and progressive massive fibrosis.
Of all radiographs, 31.4% were classified as positive for simple pneumoconiosis and 3.6% were classified as progressive massive fibrosis.
“There is a clear association between affiliation with a specific party and the proportion of classifications for an absence of opacities, simple pneumoconiosis and [progressive massive fibrosis],” the researchers wrote.
Readers who were identified as ever being hired by a coal miner’s employer read the images as negative for pneumoconiosis in 84.8% of the records. A lower percentage of the records were read as negative for pneumoconiosis by those hired by the U.S. Department of Labor or a minor — 63.2% and 51.3% of the records, respectively, according to the press release.
In addition, 64 physicians classified an absence of pneumoconiosis in 95% of their classifications, with the majority (93%) of classifications made by readers who were primarily hired by the employer. Most of these readers (n = 52) classified radiographs as having no evidence of pneumoconiosis in at least 99% of their readings, according to the results. There were 23 readers who identified simple pneumoconiosis in 95% of their classifications, with a minority (22%) of the classifications made by readers who were primarily hired by the claimnant miner. Of those, 18 readers classified simple pneumoconiosis in at least 99% of their readers, according to the release.
The results showed the adjusted odds of a negative reading of pneumoconiosis were 1.46 (95% CI, 1.44-1.47) per 10% increase in the proportion of court records that indicated a physician was hired by the employer, the researchers reported.
Further, the adjusted odds of a classification of simple pneumoconiosis were 1.51 (95% CI, 1.49-1.52) and odds of a classification of progressive massive fibrosis were 1.28 (95% CI, 1.26-1.3) per 10% increase in court records that indicated a physician was hired by a miner claimnant, the researchers reported.
“While there is evidence of bias on both sides, it is clear that the degree of bias is much heavier on the employer side, and this is twofold,” Robert A. Cohen, MD, with the division of environmental and occupational health sciences at the School of Public Health at the University of Illinois, Chicago, said in the release. “Not only are those hired by an employer much more likely to classify a chest X-ray as negative for black lung disease, but it is also much more likely that an employer will have the resources to hire its own expert — at a much higher fee — in the first place.”
The researchers said there is a need for substantial improvement in transparency, oversight and objectivity in the classification of radiographs for black lung claims.
“An investigative report in 2013 identified several hundred cases of disagreement between B-readers which led to rule changes affecting the [Federal Black Lung Program]. Our study provides the first systematic description of disagreement between B-readers, and we identified thousands of cases, not hundreds, where a B-reader reported an absence of pneumoconiosis in contrast with another B-reader indicating high profusion simple pneumoconiosis or PMF,” the researchers wrote.