Objective: This systematic review and meta-analysis primarily aimed to evaluate the accuracy of PPG-derived SpO₂ and PR by skin pigmentation. Secondarily, we aimed to evaluate statistical biases and the clinical relevance of PPG-derived SpO₂ and PR according to skin pigmentation.

Methods: We identified 23 pulse oximetry studies (n=59,684; 197,353 paired SpO₂-arterial blood observations) and 4 wearable PR studies (n=176; 140,771 paired PPG-electrocardiography observations). We evaluated accuracy according to skin pigmentation group by comparing SpO₂ accuracy root-mean-square values to the regulatory threshold of 3% and PR 95% limits of agreement values to +5 or –5 beats per minute (bpm), according to the standards of the American National Standards Institute, Association for the Advancement of Medical Instrumentation, and the International Electrotechnical Commission. We evaluated biases and clinical relevance using mean bias and 95% CI.

Results: For SpO₂, accuracy root-mean-square values were 3.96%, 4.71%, and 4.15%, and pooled mean biases were 0.70% (95% CI 0.17%-1.22%), 0.27% (95% CI –0.64% to 1.19%), and 1.27% (95% CI 0.58%-1.95%) for light, medium, and dark pigmentation, respectively. For PR, 95% limits of agreement values were from –16.02 to 13.54, from –18.62 to 16.84, and from –33.69 to 32.54, and pooled mean biases were –1.24 (95% CI –5.31 to 2.83) bpm, –0.89 (95% CI –3.70 to 1.93) bpm, and –0.57 (95% CI –9.44 to 8.29) bpm for light, medium, and dark pigmentation, respectively.

Conclusions: SpO₂ and PR measurements may be inaccurate across all skin pigmentation groups, breaching U.S. Food and Drug Administration guidance and industry standard thresholds. Pulse oximeters significantly overestimate SpO₂ for both light and dark skin pigmentation, but this overestimation may not be clinically relevant. PRs obtained from wearables exhibit no statistically or clinically significant bias based on skin pigmentation.