Racial bias in pulse oximetry measurement
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Pulse oximetry has documented skin-pigmentation-linked measurement errors.
“Related work on pulse oximetry, which relies on the same optical principles, has also documented skin-pigmentation-linked measurement errors [14,15]”
From PPG-Based Heart Rate Accuracy in Hispanic Adults with Fitzpatrick III–V Skin Tones: An Evaluation of Body Composition and Skin-Tone Effects (2026) · cites this paper as [15]
In the main text (page not provided), the study reports that pulse oximetry missed occult hypoxemia nearly three times as often in Black patients as in White patients. This documents a race-associated measurement error, but the study classified patients by self-identified race; it did not measure skin pigmentation or establish that pigmentation caused the difference. (LLM, conf=0.84)
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 [11]
In “Racial Bias in Pulse Oximetry Measurement,” the authors report that Black patients were more likely than White patients to have occult hypoxemia despite SpO2 readings of 92–96%. The study compared self-identified racial groups, not measured skin pigmentation, so it does not directly establish the claim’s darker-versus-lighter-skin comparison. (LLM, conf=0.86)
Experimental — accuracy not yet measuredOverestimated 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 [11]
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 measuredA large study including 1333 white patients and 276 black patients indicated that the incidence of hypoxemia can be 3 times higher among patients self-reported as Black versus White because oxygen saturation readings of black patients tend to be overestimated at a low SpO2 range.
“Results from a large study [17] that includes 1333 white patients and 276 black patients indicated that the incidence of hypoxemia can be 3 times higher among patients self-reported as Black vs White because the oxygen saturation readings of black patients tend to be overestimated at a low SpO2 range.”
From Investigating the accuracy of blood oxygen saturation measurements in common consumer smartwatches (2023) · cites this paper as [17]
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredRacial bias can lead to undetected hidden hypoxemia.
“For example, racial bias can lead to undetected hidden hypoxemia.”
From Investigating the accuracy of blood oxygen saturation measurements in common consumer smartwatches (2023) · cites this paper as [17]
Black patients are three times more likely to suffer from an occult hypoxemia that remains undetected by pulse oximeters compared with white patients.
“As a result, Black patients are three times more likely to suffer from an occult hypoxemia that remains undetected by pulse oximeters compared with white patients.”
From Addressing bias in big data and AI for health care: A call for open science (2021) · cites this paper as [1]
Imbalanced samples are a form of bias that the medical community has historically and still currently struggles to address.
“Imbalanced samples are a form of bias that the medical community has historically and still currently struggles to address [42].”
From Bias in medical AI: Implications for clinical decision-making (2024) · cites this paper as [42]
Bias in clinical parameters such as glomerular filtration rate, pulse oximetry (with undiagnosed hidden hypoxemia for historically underserved patients), and differences in ICU severity scoring shape radiology data sets for machine learning through a cascade effect as they affect ordering patterns for medical images.
“Bias in clinical parameters such as glomerular filtration rate, pulse oximetry (with undiagnosed hidden hypoxemia for historically underserved patients), 35 differences in ICU severity scoring 36 shape radiology data sets for machine learning through a cascade effect as they affect ordering patterns for medical images.”
From AI pitfalls and what not to do: mitigating bias in AI (2023) · cites this paper as [35]
People of colour are consistently misclassified by health sensors such as oximeters as they were validated on predominantly white populations.
“At the same time, people of colour are consistently misclassified by health sensors such as oximeters as they were validated on predominantly white populations [191].”
From Human-centred artificial intelligence for mobile health sensing: challenges and opportunities (2023) · cites this paper as [191]
Pulse oximeters have increased error rates based on skin tone.
“there is evidence that pulse oximeters also have increased error rates based on skin tone11,12”
From Response To: Investigating sources of inaccuracy in wearable optical heart rate sensors (2021) · cites this paper as [12]
M.W. Sjoding et al. found overestimations in dark-skinned patients with an increased risk of occult hypoxemia.
“Besides, they found overestimations in dark-skinned patients with an increased risk of occult hypoxemia [50].”
From Skin pigmentation influence on pulse oximetry accuracy: a systematic review and bibliometric analysis (2022) · cites this paper as [50]
In M.W. Sjoding et al., the probability of dark-skinned patients with SpO2 reading between 92% and 96% having arterial oxygen saturation less than 88% was 3 times higher (11.7%) than light-skinned patients (3.6%) with the same SpO2 measurement.
“An important finding of this study is that the probability of dark-skinned patients with SpO2 reading between 92% and 96% having an arterial oxygen saturation of less than 88% was 3 times higher (11.7%) than light-skinned patients (3.6%) with the same SpO2 measurement.”
From Skin pigmentation influence on pulse oximetry accuracy: a systematic review and bibliometric analysis (2022) · cites this paper as [50]
M.W. Sjoding et al. conducted a study in two large cohorts at the University of Michigan Hospital comparing SpO2 and arterial blood gas measurements in over 10,000 people with 14-20% dark-skinned patients in both cohorts.
“They conducted this study in two large cohorts at the University of Michigan Hospital comparing measurements of SpO2 and arterial blood gas of a sample of over 10,000 people with 14–20% of dark-skinned patients in both cohorts.”
From Skin pigmentation influence on pulse oximetry accuracy: a systematic review and bibliometric analysis (2022) · cites this paper as [50]
More recent studies have revealed that dark skin pigmentation influences the accuracy and performance of pulse oximeter devices, resulting in overestimations, with increased incidence in the risk for occult hypoxemia (SO2<88% despite normal SpO2>92%).
“More recent studies have also revealed that dark skin pigmentation influences the accuracy and performance of pulse oximeters devices, resulting in overestimations [17,49,50,51,52,53] with increased incidence in the risk for occult hypoxemia (SO2<88% despite normal SpO2>92%) [54,55].”
From Skin pigmentation influence on pulse oximetry accuracy: a systematic review and bibliometric analysis (2022) · cites this paper as [50]
Recent studies have shown a positive bias in oxygen saturation measurements in patients with darkly pigmented skin, particularly under low saturation conditions.
“Recent studies have shown a positive bias in oxygen saturation measurements in patients with darkly pigmented skin, particularly under low saturation conditions.”
From Skin pigmentation influence on pulse oximetry accuracy: a systematic review and bibliometric analysis (2022) · cites this paper as [50]
Other subjective scales were employed in 13 studies (35.14%).
“and other subjective scales were employed in 13 studies (35.14%) [30,42,43,44,45,50,52,56,72,78,80,87,88].”
From Skin pigmentation influence on pulse oximetry accuracy: a systematic review and bibliometric analysis (2022) · cites this paper as [50]
In Sjoding et al.'s second cohort (n = 37,308), 17.0% of Black patients had undetected hypoxemia compared to 6.2% of white patients.
“Specifically, in the first cohort (n = 10,789), 11.4% Black patients had undetected hypoxemia (pulse oximetry > 92% and arterial oxygen saturation < 88%), compared to 3.6% white patients, and in the second cohort (n = 37,308), 17.0% Black patients had undetected hypoxemia, compared to 6.2% white patients.”
From Accuracy of heart rate measurement with wrist-worn wearable devices in various skin tones: a systematic review (2023) · cites this paper as [6]
Sjoding et al. found that compared to white patients, Black patients had a threefold increased frequency of undetected hypoxemia when using pulse oximeters.
“A recent study by Sjoding et al. found that when compared to white patients, Black patients had a threefold increased frequency of undetected hypoxemia when using pulse oximeters [6].”
From Accuracy of heart rate measurement with wrist-worn wearable devices in various skin tones: a systematic review (2023) · cites this paper as [6]
In Sjoding et al.'s first cohort (n = 10,789), 11.4% of Black patients had undetected hypoxemia compared to 3.6% of white patients.
“Specifically, in the first cohort (n = 10,789), 11.4% Black patients had undetected hypoxemia (pulse oximetry > 92% and arterial oxygen saturation < 88%), compared to 3.6% white patients, and in the second cohort (n = 37,308), 17.0% Black patients had undetected hypoxemia, compared to 6.2% white patients.”
From Accuracy of heart rate measurement with wrist-worn wearable devices in various skin tones: a systematic review (2023) · cites this paper as [6]
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 [6]
A recent US study found that people described as Black had nearly three times the frequency of occult hypoxemia not detected by pulse oximetry as those described as White.
“Results showed people described as Black had ‘nearly three times the frequency of occult hypoxemia that was not detected by pulse oximetry’ as those described as White [7].”
From The effects of skin pigmentation on the accuracy of pulse oximetry in measuring oxygen saturation: a systematic review and meta-analysis (2022) · cites this paper as [7]
Two recent diagnostic studies provide evidence on clinical implications resulting from the bias in pulse oximetry for blood oxygen saturation levels.
“Two recent diagnostic studies provide evidence on clinical implications resulting from the bias in pulse oximetry for blood oxygen saturation levels [7, 57].”
From The effects of skin pigmentation on the accuracy of pulse oximetry in measuring oxygen saturation: a systematic review and meta-analysis (2022) · cites this paper as [7]
At least two studies used diagnostic accuracy design and only presented proportions of participants with specific ranges of SpO2 in relation to specific SaO2 values, rather than SpO2 and SaO2 data.
“At least two studies used diagnostic accuracy design and only presented proportions of participants with specific ranges of SpO2 in relation to specific SaO2 values, again rather than SpO2 and SaO2 data [7, 57].”
From The effects of skin pigmentation on the accuracy of pulse oximetry in measuring oxygen saturation: a systematic review and meta-analysis (2022) · cites this paper as [7]
In these studies, people described as Black had a higher risk of occult hypoxemia that was not detected by pulse oximetry compared with those described as White.
“In these studies, people described as Black had a higher risk of ‘occult hypoxemia that was not detected by pulse oximetry’ compared with those described as White [7].”
From The effects of skin pigmentation on the accuracy of pulse oximetry in measuring oxygen saturation: a systematic review and meta-analysis (2022) · cites this paper as [7]
Racial bias has been observed in the measurement of oxygen saturation level by pulse oximetry devices.
“Racial bias has been observed in the measurement of oxygen saturation level by pulse oximetry devices.”
From Unlocking Tomorrow’s Health Care: Expanding the Clinical Scope of Wearables by Applying Artificial Intelligence (2024) · cites this paper as [48]
Because of the greater presence of melanin, Black patients have falsely elevated peripheral oxygen saturation detected via pulse oximetry compared with arterial oxygen saturation measured in arterial blood gas.
“Because of the greater presence of melanin, Black patients have falsely elevated peripheral oxygen saturation detected via pulse oximetry compared with arterial oxygen saturation measured in arterial blood gas.48”
From Unlocking Tomorrow’s Health Care: Expanding the Clinical Scope of Wearables by Applying Artificial Intelligence (2024) · cites this paper as [48]
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- [1]Moran-Thomas A How a popular medical device encodes racial bias. Boston Review. 8 5, 2020 (http://bostonreview.net/science-nature-race/amy-moran-thomas-how-popular-medical-device-encodes-racial-bias).
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- Authors
- Sjoding, M. W., Dickson, R. P., Iwashyna, T. J., Gay, S. E., & Valley, T. S.
- Affiliations
- University of Michigan (US)
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2020-12-17
- Volume
- 383
- Issue
- 25
- Pages
- 2477-2478
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- PMC
- PMC7808260
- OpenAlex
- W3111737151
- Cited by
- 1,114
- References
- 3
- Citations by year
- 2026: 191 · 2025: 182 · 2024: 193 · 2023: 227 · 2022: 209 · 2021: 109 · 2020: 1
- FWCI
- 42.90
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Health Services Research and Development (IIR 17-045)
- National Heart, Lung, and Blood Institute (K01 HL136687, K12 HL138039, K23 HL140165, R01 HL144599)
- U.S. National Library of Medicine (R01 LM013325)
- Topics
- Physical Sciences › Engineering › Biomedical Engineering › Non-Invasive Vital Sign Monitoring
- Social Sciences › Safety Research › Ethics and Social Impacts of AI
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Race, Genetics, and Society
- Keywords
- pulse oximetry, racial bias, skin pigmentation, oxygen saturation measurement, measurement error, racial disparities in health care
- MeSH terms
- Adult, Hypoxia, Black or African American, Female, Humans, Male, Oximetry, Oxygen, White People, Organ Dysfunction Scores, Racism
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