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How Skin Color May Put Your Health at Risk

Recent studies suggest some modern medical devices add to racial disparities in health care

spinner image close-up shot of doctor applying pulse oximeter on patients finger during appointment
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If you’ve been a patient at a hospital or health clinic, you likely have had a pulse oximeter clipped to your finger to measure your blood oxygen level and had a handheld device pointed at your forehead to read your temperature. Doctors rely on these modern medical devices to provide fast and accurate measurements to guide them in your care, and they’ve proven reliable — at least for the most part.

Concerns that darker skin pigmentation could throw off the readings from pulse oximeters and temporal artery thermometers have been voiced for years, but evidence that such imprecisions were significant enough to affect treatment provided to patients was missing. Newly published research, however, suggests these modern medical devices are not as accurate as needed to ensure all individuals with darker complexions receive proper care.

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Now, the Food and Drug Administration has announced that it will convene a panel of experts Nov. 1 to “discuss ongoing concerns that the pulse oximeters may be less accurate in individuals with darker skin pigmentations.” The advisory panel “will also discuss factors that may affect pulse oximeter accuracy and performance, the available evidence about the accuracy of pulse oximeters, recommendations for patients and health care providers, and the amount and type of data that should be provided by manufacturers to assess pulse oximeter accuracy and to guide other regulatory actions as needed.”

What studies have shown

In a December 2020 letter published in The New England Journal of Medicine, researchers at the University of Michigan Medical School reported that among a broad sample of hospitalized adults they found wider variations in pulse oximeter readings among Black patients than white patients.

Black patients, they reported, had nearly three times the frequency of “occult hypoxemia” than white patients. Occult hypoxemia was defined as having an arterial blood oxygen saturation (SaO2) of less than 88 percent despite a pulse oximetry (SpO2) reading greater than or equal to 92 percent. Oxygen saturation levels of 96 percent and higher are considered normal.

“Given the widespread use of pulse oximetry for medical decision making, these findings have some major implications, especially during the current coronavirus disease 2019 (COVID-19) pandemic. Our results suggest that reliance on pulse oximetry to triage patients and adjust supplemental oxygen levels may place Black patients at increased risk for hypoxemia,” the authors wrote. Hypoxemia, an abnormally low concentration of oxygen in the blood, can be life-threatening, according to the Cleveland Clinic.

Several additional studies published in recent months have amplified the Michigan study.

Research led by Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center in Boston found pulse oximeters less reliable in measuring oxygen saturation levels for Black, Hispanic and Asian patients treated in the intensive care unit than for white patients. Those patients also received less supplemental oxygen than white patients, according to a July 2022 report published in JAMA Internal Medicine.

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“It’s important to keep in mind that pulse oximeters give us an estimate, but it’s more than just a number. We use that estimate to make clinical decisions, such as how much supplemental oxygen to give a patient,” study author Eric Gottlieb, M.D., said in a statement. “It has real meaning for the patients that we care for because we can track back racial disparities in treatment to these differences in measurements.”

JAMA Internal Medicine published a separate study led by researchers at Johns Hopkins University School of Medicine in May 2022 of 7,126 patients with COVID-19. Among them, the researchers found a greater likelihood of occult hypoxemia among Asians (30.2 percent), Blacks (28.5 percent) and non-Black Hispanics (29.8 percent) than whites (17.2 percent). Further analysis found this disparity was associated with “significantly delayed or unrecognized eligibility for COVID-19 therapies among Black and Hispanic patients,” according to the report.

Beyond pulse oximeters

A study led by researchers at Emory University in Atlanta has also raised concerns about the accuracy of the temporal artery thermometer in measuring body temperature for patients with darker complexions that could lead to delays in “antibiotic and medical care” for Black patients whose fever is missed.

“Although the absolute difference between oral and temporal temperatures was small, the findings suggest that this discrepancy combined with commonly used fever cutoffs may lead to fever going undetected in many Black patients,” the investigators wrote in a September 2022 research letter published in JAMA.

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The researchers noted that the thermometer used in the study “has been evaluated in more than 100 clinical studies.”

Improving medical devices

In an editorial accompanying the Hopkins pulse oximeter study, Valeria S.M. Valbuena, a general surgery resident at Michigan Medicine, suggests health care providers need to insist that medical devices not be designed using white patients as the standard.

“The next generation of oxygen monitors should be designed and tested to work equally on all patients. However, this is an unlikely scenario without market pressure. Hospital systems, medical practitioners, and regulatory entities need to press for regulatory scrutiny and design equity by limiting purchasing choices to devices with equal performance for patients of all skin tones,” Valbuena wrote.

Meanwhile, she notes that options already exist for more accurate pulse oximeters.

“The design flaws of the pulse oximeter have been corrected in some devices. These improved devices use more wavelengths of light and perform equally for different skin tones; they have been used in limited settings but have not been widely produced or distributed,” Valbuena wrote.

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