Efforts underway to end race-based assessments of lung function

Multi-institutional team, including physicians and researchers who successfully proposed updates to national guidelines, share important next steps for reevaluating how occupational impairment is determined  

Last July, a team of physicians and researchers successfully proposed modifications to the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment, advocating against the use of race in lung function testing. In a new publication in The New England Journal of Medicine, the team describes the history of how race and pulmonary function testing have been used to quantify lung function impairment, which often determines disability and eligibility for worker’s compensation. They also outline a path forward toward more equitable evaluation and warn against the dangers of overreliance on “objective” cutoff-based criteria.

“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,” said lead author Rohan Khazanchi, MD, MPH, a resident physician in the Harvard Internal Medicine & Pediatrics combined residency program at Brigham and Women’s Hospital, Boston Children’s Hospital, and Boston Medical Center and 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.”

"After our group made the recommendation 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,” said Nirav Bhakta, MD, PhD, Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at the University of California, San Francisco (UCSF). “We were fortunate to be able to collaborate with the AMA on the proposed modifications to remove the bias of race-based equations."

The AMA Guides are used by the majority of U.S. states, U.S. federal employee compensation programs, and multiple multinational corporations and international government agencies as a “gold standard” for evaluating worker’s compensation claims. The most recent version of the Guides continues to recommend race-based reference equations for spirometry—a breathing test to evaluate a patient’s lung capacity and function. In their NEJM publication, the authors outline pitfalls in the original studies that led to race-adjusted interpretation of spirometry, many of which emphasized biological explanations for racial differences in readings while ignoring known environmental or social factors which predict lung-related health outcomes.

The authors’ proposals to eliminate race-based assessments from lung function testing will be reflected in the next update to the Guides, but the authors note that complex solutions will still be needed to ensure that pulmonary evaluations are equitable in the future.

 “The medical field should critically reevaluate the whole ecosystem surrounding pulmonary impairment evaluations — including and beyond the choice of reference equations,” the authors write.

The authors also emphasize the need for remedy of harms, especially for patients whose degree of lung function impairment – and thus, their disability ratings or worker’s compensation payments – may have been underestimated by race-based equations.

Mass General Brigham and UCSF recently removed race from their pulmonary function testing calculations, moving to the race-neutral Global Lung Function Initiative reference equation. Other healthcare systems have also been shifting to this race-neutral equation in accordance with the American Thoracic Society guidelines.

Authorship: In addition to Khazanchi, authors include Sanja Stanojevic, Stella E. Hines, and Nirav R. Bhakta.

Disclosures: Disclosure forms provided by the authors are available at NEJM.org.

Paper cited: Khazanchi R, et al. “Reform and Remedy for Imprecision and Inequity — Ending the Race-Based Evaluation of Occupational Pulmonary Impairment.” N Engl J Med 2025. 393(5):508-514. DOI: 10.1056/NEJMms2416661.

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