Lung Function Tests: End of Racial Adjustments Could Have Wide Impact

Lung Function Tests: End of Racial Adjustments Could Have Wide Impact

— Millions in the U.S. may be reclassified, changing work eligibility, disability compensation

by Randy Dotinga, Contributing Writer, MedPage Today

SAN DIEGO – The elimination of race adjustments in lung-function testing could affect millions of people in the U.S. as they lose or gain eligibility for jobs and benefits due to reclassification of their pulmonary health, a new longitudinal analysis finds.

If race-neutral equations were applied to everyone aged 6-79, the number of cases of nonobstructive ventilatory impairment alone may shoot up by 141% among Black people while falling 69% among white people, reported Arjun Manrai, PhD, of Harvard Medical School, and colleagues here at the international conference of the American Thoracic Society (ATS).

On the other hand, more 754,000 Blacks may become ineligible for firefighting jobs due to exposure to dust or fumes, while 1.27 million whites may gain eligibility. Annual disability payments on Black veterans may increase by more than $1 billion as they decrease by $500 million among white veterans.

Study results were simultaneously published in The New England Journal of Medicine.

“There are profound clinical, financial, and occupational consequences to how race is used in lung-function equations,” Manrai told MedPage Today. “We were surprised by how large the effects were with millions of clinical reclassifications and billions of dollars at stake.”

In recent years, researchers have rethought the use of race-based adjustments in lung function tests, and both the ATS and European Respiratory Society (ERS) have discouraged their use, the study authors write.

“The decision to reconsider the use of race in lung function testing arose from a larger conversation about the use of race in clinical algorithms broadly,” co-author James A. Diao, M.Phil., also of Harvard Medical School, told MedPage Today. “Race-based calibration made Asian and Black patients appear less sick and Hispanic and white patients appear more sick relative to a race-neutral approach.”

Among other concerns, there’s been worry that race-based adjustments would obscure underlying disease in racial minorities and present challenges when the patient’s race does not fit one of the specified categories or when doctors incorrectly assume the patient’s race.

It’s not clear how many medical institutions have adopted race-neutral lung function tests.

The researchers estimate if racial categories are eliminated and everyone aged 6-79 was re-evaluated using new race-neutral criteria, various groups would be reclassified:

  • 12.5 million people for ventilatory impairment status
  • 8.16 million for medical impairment ratings
  • 2.28 million for occupational eligibility
  • 2.05 million for grading of chronic obstructive pulmonary disease
  • 413,000 for military disability compensation

The researchers also found that race-based and race-neutral lung-function equations had “similar discriminative accuracy” in regard to factors such as healthcare utilization, new-onset disease, and death related to respiratory disease.

Moving forward, “we believe hospitals should standardize their interpretation of lung function with the current ATS/ERS recommendations, policymakers should continue to re-evaluate guidelines and thresholds in light of new data, and researchers should continue to seek out and operationalize more precise measures of lung function as we move away from crude heuristics like race,” Manrai said.

In an accompanying commentary, Meredith McCormack, MD, and David A. Kaminsky, MD, of Johns Hopkins University School of Medicine in Baltimore, and University of Vermont Larner College of Medicine in Burlington, respectively, write that the study relies on data sets with “impressive breadth.”

The findings “show the vulnerability of applying threshold lung-function values as stringent cutoff points,” they write. “The findings also show how a relatively small proportionate change can have a large practical effect,” such as a redistribution of $1.94 billion in annual VA disability compensation.

The commentary authors urge medical professionals to not just rely on lung function tests but instead “consider all aspects of the patient’s presentation … For too long, such determinations have relied on simple measures, such as forced expiratory volume, that are susceptible to differences in interpretation on the basis of patient-reported race. We need new approaches that apply equally to everyone to assess an individual person’s functional capacity or ability to perform jobs and other activities.”

The researchers studied data such as spirometry results from 369,077 participants in several U.S. and U.K. databases and projected changes in clinical, occupational, and financial outcomes if race-neutral lung function criteria were put into place.

Among other findings, authors reported that classifications of moderate-to-severe chronic obstructive pulmonary disease would grow by 428,000 among Black people but fall by 1.1 million among white people. And 638,000 Black adults may get increased payments for impairment-based compensation due to work-related exposures to dust or fumes.

The study authors note limitations including the fact that spirometry results don’t independently determine clinical diagnoses. In addition, “reclassifications may also be overestimated owing to the inclusion of persons who would not be materially affected by reclassifications (e.g., disqualification from firefighting attributed to persons not considering the occupation).”

  • author['full_name']

    Randy Dotinga is a freelance medical and science journalist based in San Diego.


The National Heart, Lung, and Blood Institute and National Institute of Environmental Health Sciences funded the study.

Manrai disclosed grants to his institution from the National Heart, Lung, and Blood Institute and the National Institute of Environmental Health Sciences. Diao had no disclosures.

Kaminsky discloses consulting (Methapharm, Vitalograph), speaker fees (MGC Diagnostics), and royalties (UpToDate, Elsevier). McCormack had no disclosures.

Primary Source

The New England Journal of Medicine

Source Reference: Diao JA, et al “Implications of race adjustment in lung-function equations” N Engl J Med 2024; DOI: 10.1056/NEJMsa2311809.

Secondary Source

The New England Journal of Medicine

Source Reference: McCormack M, Kaminsky DA “Beyond diagnostics — removing race from lung-function test interpretation” N Engl J Med 2024; DOI: 10.1056/NEJMe2403770.

Shout Out!!!

Related articles