Physicians End Race Bias in Lung Function Testing
Landmark Shift: Race-Based Lung Function Testing to Be Phased Out in Disability Evaluations
Boston, MA – A significant movement is underway to reform how lung function impairment is assessed, particularly in the context of disability evaluations and worker’s compensation claims. Leading medical institutions and professional societies are advocating for and beginning to implement the removal of race-based adjustments in pulmonary function testing, a practise long criticized for its flawed scientific basis and potential for inequity.
The American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment, a widely adopted standard across the United States for determining worker’s compensation claims, is set to update its guidelines to eliminate race-based reference equations for spirometry. Spirometry, a crucial breathing test that measures lung capacity and function, has historically used different reference equations based on race, a practice now being challenged for its perpetuation of racial bias.
“Race has long been inappropriately used as a proxy for biological traits in medical care and research,including in lung function testing reference equations used to evaluate how much someone’s lung function is impaired,” stated lead author Rohan Khazanchi,MD,MPH,a resident physician at Brigham and Women’s Hospital,Boston Children’s Hospital,and Boston Medical Center,and a research affiliate at the FXB Center for Health & Human Rights at Harvard University. “National guidelines from the American Thoracic Society and European Respiratory Society now advocate against the use of race in lung function equations, but there are significant barriers to de-implementation.”
The AMA Guides are considered a “gold standard” by the majority of U.S. states, federal employee compensation programs, and numerous multinational corporations and international government agencies. The current version of the guides still recommends race-based reference equations for spirometry. Though, the authors of a recent publication in the New England Journal of Medicine highlight critical flaws in the original studies that led to these race-adjusted interpretations. These studies often emphasized biological explanations for racial differences in lung function readings while overlooking crucial environmental and social factors that considerably predict lung-related health outcomes.”After our group made the proposal to remove race from pulmonary function reference equations, we quickly realized the need to address implementation not only in a clinical care setting but also in the area of disability evaluations,” explained Nirav Bhakta, MD, PhD, Professor of Medicine at the University of California, San Francisco. “we were fortunate to be able to collaborate with the AMA on the proposed modifications to remove the bias of race-based equations.”
The proposed changes to eliminate race-based assessments from lung function testing will be incorporated into the next update of the AMA Guides. However, the authors emphasize that more complete solutions are still necessary to ensure future pulmonary evaluations are truly equitable.
“The medical field should critically reevaluate the whole ecosystem surrounding pulmonary impairment evaluations - including and beyond the choice of reference equations,” the authors urged. They also stressed the importance of rectifying past harms, particularly for patients whose lung function impairment, and consequently their disability ratings or worker’s compensation payments, may have been underestimated due to race-based equations.
In line with the American Thoracic Society guidelines, prominent healthcare systems such as Mass General Brigham and UCSF have already transitioned to the race-neutral Global Lung Function Initiative reference equation for their pulmonary function testing calculations. This shift signifies a broader movement within the medical community towards more equitable and scientifically sound practices in assessing lung health.
Source:
Khazanchi, R.,et al. (2025) Reform and Remedy for Imprecision and Inequity – Ending the Race-Based Evaluation of Occupational Pulmonary impairment. New England Journal of Medicine. doi.org/10.1056/NEJMms2416661