Racial bias and reproducibility in pulse oximetry among medical and surgical inpatients in general care in the Veterans Health Administration 2013-19: multicenter, retrospective cohort study
Open accessAbstract
Objectives: To evaluate measurement discrepancies by race between pulse oximetry and arterial oxygen saturation (as measured in arterial blood gas) among inpatients not in intensive care. Design: Multicenter, retrospective cohort study using electronic medical records from general care medical and surgical inpatients. Setting: Veteran Health Administration, a national and racially diverse integrated health system in the United States, from 2013 to 2019. Participants: Adult inpatients in general care (medical and surgical), in Veteran Health Administration medical centers. Main outcomes measures: Occult hypoxemia (defined as arterial blood oxygen saturation (SaO 2 ) of <88% despite a pulse oximetry (SpO 2 ) reading of ≥92%), and whether rates of occult hypoxemia varied by race and ethnic origin. Results: A total of 30 039 pairs of SpO 2 -SaO 2 readings made within 10 minutes of each other were identified during the study. These pairs were predominantly among non-Hispanic white (21 918 (73.0%)) patients; non-Hispanic black patients and Hispanic or Latino patients accounted for 6498 (21.6%) and 1623 (5.4%) pairs in the sample, respectively. Among SpO 2 values greater or equal to 92%, unadjusted probabilities of occult hypoxemia were 15.6% (95% confidence interval 15.0% to 16.1%) in white patients, 19.6% (18.6% to 20.6%) in black patients (P<0.001 v white patients, with similar P values in adjusted models), and 16.2% (14.4% to 18.1%) in Hispanic or Latino patients (P=0.53 v white patients, P<0.05 in adjusted models). This result was consistent in SpO 2 -SaO 2 pairs restricted to occur within 5 minutes and 2 minutes. In white patients, an initial SpO 2 -SaO 2 pair with little difference in saturation was associated with a 2.7% (95% confidence interval −0.1% to 5.5%) probability of SaO 2 <88% on a later paired SpO 2 -SaO 2 reading showing an SpO 2 of 92%, but black patients had a higher probability (12.9% (−3.3% to 29.0%)). Conclusions: In general care inpatient settings across the Veterans Health Administration where paired readings of arterial blood gas (SaO 2 ) and pulse oximetry (SpO 2 ) were obtained, black patients had higher odds than white patients of having occult hypoxemia noted on arterial blood gas but not detected by pulse oximetry. This difference could limit access to supplemental oxygen and other more intensive support and treatments for black patients.
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Patients 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 [12]
The Results (Probability of occult hypoxemia) show that Black inpatients were more likely than white inpatients to have SpO2 readings that masked low arterial oxygen saturation. But the Discussion (Strengths and limitations) says skin color was not recorded and race was used as a surrogate, so the study does not directly establish the comparison by skin pigmentation stated in the claim. (LLM, conf=0.88)
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 [12]
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 measuredBlack patients were at much higher risk of having occult hypoxemia due to overestimation of blood saturation by PO, thereby limiting access to supplemental oxygen.
“A recent study comparing arterial blood gas (invasive) with PO showed that Black patients were at much higher risk of having occult hypoxemia (an arterial oxygen blood saturation of <88%) due to overestimation of blood saturation by PO thereby limiting access to supplemental oxygen for Black patients.137”
From Effect of skin color on optical properties and the implications for medical optical technologies: a review (2024) · cites this paper as [137]
Skin pigmentation affects the accuracy of PO.
“A recent flurry in publications identifies that skin pigmentation affects the accuracy of PO.11,134–140”
From Effect of skin color on optical properties and the implications for medical optical technologies: a review (2024) · cites this paper as [137]
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- Authors
- Valbuena, V. S. M., Seelye, S., Sjoding, M. W., Valley, T. S., Dickson, R. P., Gay, S. E., Claar, D., Prescott, H. C., & Iwashyna, T. J.
- Affiliations
- University of Michigan (US)
- VA Center for Clinical Management Research (US)
- Corresponding author
- Iwashyna, Theodore J
- ORCID
- Venue
- BMJ
- Publisher
- BMJ
- Published
- 2022-07-06
- Volume
- 378
- Pages
- e069775
- ISSN
- 1756-1833 (ISSN-L)
- PMC
- PMC9254870
- OpenAlex
- W4283833691
- Cited by
- 127
- References
- 27
- Citations by year
- 2026: 19 · 2025: 27 · 2024: 38 · 2023: 31 · 2022: 12
- FWCI
- 7.85
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- BMJ (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Funders
- National Institute on Aging (T32AG000221)
- National Heart, Lung, and Blood Institute (K01HL136687, R01HL158626, R01HL144599, K23HL140165)
- Topics
- Physical Sciences › Engineering › Biomedical Engineering › Non-Invasive Vital Sign Monitoring
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Race, Genetics, and Society
- Health Sciences › Medicine › Physiology › Clinical Laboratory Practices and Quality Control
- Keywords
- pulse oximetry, racial bias, arterial oxygen saturation, arterial blood gases, hospitalized patients, veterans, racial disparities, non-Hispanic Black patients, general care, reproducibility, hypoxemia detection, Veterans Health Administration, electronic health records, non-Hispanic White patients
- MeSH terms
- Adult, Hypoxia, Humans, Inpatients, Oximetry, Retrospective Studies, Reproducibility of Results, Veterans Health, Racism
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