Article Impact Level: HIGH Data Quality: STRONG Summary of New England Journal of Medicine, 393(5), 508–514. https://doi.org/10.1056/NEJMms2416661 Dr. Rohan Khazanchi et al.
Points
- Race has long been used inappropriately in lung function reference equations, potentially underestimating impairment for non-white patients and affecting their disability and compensation eligibility.
- A team of physicians successfully proposed modifications to the influential American Medical Association Guides to remove race-based bias in equations used to interpret pulmonary function test results.
- Leading health systems, such as Mass General Brigham and UCSF, are now adopting the race-neutral Global Lung Function Initiative equation in line with new guidelines from professional societies.
- The authors caution against replacing equations without reevaluating the entire ecosystem of pulmonary impairment assessment, as this could perpetuate inequities by using other objective cutoff criteria.
- There is a critical need to address and remedy past harms for patients whose lung function impairment may have been systematically underestimated by previous race-adjusted calculations.
Summary
A multi-institutional team of physicians and researchers has highlighted significant implementation gaps following the recent shift to race-neutral reference equations for pulmonary-function tests (PFTs). The authors note that while new guidelines from the American Thoracic Society and European Respiratory Society advocate against using race in lung function equations, the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment have only recently been slated for an update. These Guides, used by a majority of U.S. states and federal programs, have historically recommended race-based equations for spirometry, which risks perpetuating inequities in disability and workers’ compensation determinations. The source text does not contain specific numerical data such as patient cohort sizes, confidence intervals, or hazard ratios.
In a new publication, the authors detail their successful proposal from last July to modify the AMA Guides, which will remove race-based assessments in the next update. They critique the original studies that established race-adjusted spirometry, pointing out that these studies often emphasized biological explanations for racial differences while ignoring known social and environmental determinants of lung health. The authors caution against a simplistic substitution of equations without a broader reevaluation of the entire ecosystem surrounding pulmonary impairment, including the overreliance on objective cutoff-based criteria that may harbor other biases.
Leading health systems, including Mass General Brigham and the University of California, San Francisco (UCSF), have already de-implemented race-based calculations, adopting the race-neutral Global Lung Function Initiative (GLI) reference equation. The authors stress the urgent need for systemic remedy, particularly for patients whose degree of lung impairment, and therefore their disability ratings or compensation, may have been underestimated by the previous race-based standards. They call for a critical reevaluation of how occupational impairment is determined to ensure future assessments are truly equitable.
Link to the article: https://www.nejm.org/doi/10.1056/NEJMms2416661
References Khazanchi, R., Stanojevic, S., Hines, S. E., & Bhakta, N. R. (2025). Reform and remedy for imprecision and inequity—Ending the race-based evaluation of occupational pulmonary impairment. New England Journal of Medicine, 393(5), 508–514. https://doi.org/10.1056/NEJMms2416661
