Racial and Ethnic Discrepancy in Pulse Oximetry and Delayed Identification of Treatment Eligibility Among Patients With COVID-19
Open accessAbstract
Importance: Pulse oximetry guides triage and therapy decisions for COVID-19. Whether reported racial inaccuracies in oxygen saturation measured by pulse oximetry are present in patients with COVID-19 and associated with treatment decisions is unknown. Objective: To determine whether there is differential inaccuracy of pulse oximetry by race or ethnicity among patients with COVID-19 and estimate the association of such inaccuracies with time to recognition of eligibility for oxygen threshold-specific COVID-19 therapies. Design, Setting, and Participants: This retrospective cohort study of clinical data from 5 referral centers and community hospitals in the Johns Hopkins Health System included patients with COVID-19 who self-identified as Asian, Black, Hispanic, or White. Exposures: Concurrent measurements (within 10 minutes) of oxygen saturation levels in arterial blood (SaO2) and by pulse oximetry (SpO2). Main Outcomes and Measures: For patients with concurrent SpO2 and SaO2 measurements, the proportion with occult hypoxemia (SaO2<88% with concurrent SpO2 of 92%-96%) was compared by race and ethnicity, and a covariate-adjusted linear mixed-effects model was produced to estimate the association of race and ethnicity with SpO2 and SaO2 difference. This model was applied to identify a separate sample of patients with predicted SaO2 levels of 94% or less before an SpO2 level of 94% or less or oxygen treatment initiation. Cox proportional hazards models were used to estimate differences by race and ethnicity in time to recognition of eligibility for guideline-recommended COVID-19 therapies, defined as an SpO2 level of 94% or less or oxygen treatment initiation. The median delay among individuals who ultimately had recognition of eligibility was then compared. Results: Of 7126 patients with COVID-19, 1216 patients (63 Asian [5.2%], 478 Black [39.3%], 215 Hispanic [17.7%], and 460 White [37.8%] individuals; 507 women [41.7%]) had 32 282 concurrently measured SpO2 and SaO2. Occult hypoxemia occurred in 19 Asian (30.2%), 136 Black (28.5%), and 64 non-Black Hispanic (29.8%) patients compared with 79 White patients (17.2%). Compared with White patients, SpO2 overestimated SaO2 by an average of 1.7% among Asian (95% CI, 0.5%-3.0%), 1.2% among Black (95% CI, 0.6%-1.9%), and 1.1% among non-Black Hispanic patients (95% CI, 0.3%-1.9%). Separately, among 1903 patients with predicted SaO2 levels of 94% or less before an SpO2 level of 94% or less or oxygen treatment initiation, compared with White patients, Black patients had a 29% lower hazard (hazard ratio, 0.71; 95% CI, 0.63-0.80), and non-Black Hispanic patients had a 23% lower hazard (hazard ratio, 0.77; 95% CI, 0.66-0.89) of treatment eligibility recognition. A total of 451 patients (23.7%) never had their treatment eligibility recognized, most of whom (247 [54.8%]) were Black. Among the remaining 1452 (76.3%) who had eventual recognition of treatment eligibility, Black patients had a median delay of 1.0 hour (95% CI, 0.23-1.9 hours; P = .01) longer than White patients. There was no significant median difference in delay between individuals of other racial and ethnic minority groups and White patients. Conclusions and Relevance: The results of this cohort study suggest that racial and ethnic biases in pulse oximetry accuracy were associated with greater occult hypoxemia in Asian, Black, and non-Black Hispanic patients with COVID-19, which was associated with significantly delayed or unrecognized eligibility for COVID-19 therapies among Black and Hispanic patients. This disparity may contribute to worse outcomes among Black and Hispanic patients with COVID-19.
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Overestimated SpO2 readings in patients with darker skin pigmentation lead to lower hospital admission, higher occult hypoxemia, delayed or no access to dexamethasone, therapeutic oxygen, and COVID-19 therapies, resulting in increased hospital readmission, organ dysfunction, and mortality.
“leading to lower hospital admission; higher occult hypoxemia; and delayed or no access to dexamethasone, therapeutic oxygen, and COVID-19 therapies, resulting in increased hospital readmission, organ dysfunction, and mortality [11-18].”
From Impact of skin pigmentation on pulse oximetry blood oxygenation and wearable pulse rate accuracy: systematic review and meta-analysis (2024) · cites this paper as [17]
Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredPatients with darker skin pigmentation are more likely than patients with lighter skin color to have overestimated SpO2 readings.
“Patients with darker skin pigmentation are more likely than patients with lighter skin color to have overestimated SpO2 readings”
From Impact of skin pigmentation on pulse oximetry blood oxygenation and wearable pulse rate accuracy: systematic review and meta-analysis (2024) · cites this paper as [17]
A retrospective study of 7126 patients with COVID-19 found that pulse oximetry overestimated arterial oxygen saturation among Asian, Black, and Hispanic patients compared to white patients, leading to a delay in guideline-based therapies.
“Similarly, a retrospective study of 7126 patients with COVID-19 found that pulse oximetry overestimated arterial oxygen saturation among Asian, Black, and Hispanic patients compared to white patients, leading to a delay in the initiation of guideline-based therapies [7].”
From Accuracy of heart rate measurement with wrist-worn wearable devices in various skin tones: a systematic review (2023) · cites this paper as [7]
A racial discrepancy has been established in pulse oximeters, which rely on transmission PPG.
“A racial discrepancy has been established in pulse oximeters, which rely on transmission PPG, a slightly different form of the technology.”
From Accuracy of heart rate measurement with wrist-worn wearable devices in various skin tones: a systematic review (2023) · cites this paper as [7]
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“…showing pulse oximeters significantly overestimating SpO 2 were expected for dark pigmentation and supported by findings on patient outcomes [11-15, 17 ], but Lastly, it should be noted that both SpO 2 and PR studies had lower between-study heterogeneity and higher within-study heterogeneity,…”
Influential
- Authors
- Fawzy, A., Wu, T. D., Wang, K., Robinson, M. L., Farha, J., Bradke, A., Golden, S. H., Xu, Y., & Garibaldi, B. T.
- Affiliations
- Johns Hopkins University (US)
- Michael E. DeBakey VA Medical Center (US)
- Rush University Medical Center (US)
- Corresponding author
- Fawzy, Ashraf
- ORCID
- Venue
- JAMA Internal Medicine
- Publisher
- American Medical Association (AMA)
- Published
- 2022-07-01
- Volume
- 182
- Issue
- 7
- Pages
- 730
- ISSN
- 2168-6106 (ISSN-L)
- PMC
- PMC9257583
- OpenAlex
- W4281757670
- Cited by
- 326
- References
- 40
- Citations by year
- 2026: 61 · 2025: 69 · 2024: 87 · 2023: 79 · 2022: 30
- FWCI
- 32.39
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA Internal Medicine (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Heart, Lung, and Blood Institute (K23HL151669, K23HL151758)
- Topics
- Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
- Physical Sciences › Engineering › Biomedical Engineering › Non-Invasive Vital Sign Monitoring
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Chronic Obstructive Pulmonary Disease (COPD) Research
- Keywords
- COVID-19 pandemic, pulse oximetry, racial and ethnic disparities, oxygen saturation, arterial oxygen saturation, racial disparities in health care, Black patients, Asian patients, Hispanic patients, Caucasian patients, triage decisions, health equity
- MeSH terms
- COVID-19, Hypoxia, Ethnicity, Female, Humans, Minority Groups, Oximetry, Oxygen, Retrospective Studies, Cohort Studies
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