Health care disparities are pervasive in the United States, affecting care delivery and compromising patient safety1,2 A systematic review by Chauhan et al. showed that ethnic minorities are at a higher risk of patient safety events.3 Despite overall improvements in patient safety during the perioperative period, safe anesthetic care is not universal. For example, the odds of receiving general anesthesia for Cesarean delivery is higher for Black and Hispanic women compared to non-Hispanic White women.4 There are large disparities in morbidity and mortality by patient demographics5,6; for example, rates of maternal mortality in American Indian and Black women are twice that of non-Hispanic White women. Anesthesiologists should work at multiple levels – from individual patient care, to within health systems, to societies and governmental lobbying – to improve patient safety by diminishing inequities.7 In this article, we highlight the steps needed to diminish the health care gap (Table).

Table: Suggestions to decrease health care disparities.

Table: Suggestions to decrease health care disparities.
Table: Suggestions to decrease health care disparities.

Anesthesiology teams play a vital role in improving equity in perioperative patient safety. First, we need to assess for individual implicit biases based on race, ethnicity, socioeconomic status, and religion. We all have biases. It is important to be aware of these biases and intervene through education and training. This is vital to avoid stigmatizing patients, which can lead to inappropriate care for vulnerable populations. There are free tests online for implicit bias evaluation (i.e., Implicit Association Test) that can allow us to better identify these biases.8 

Anesthesiologists and members of the health care team also need to meet patients where they are. Equal care will not reduce disparities in patient safety; instead, we need to provide equitable care. Optimizing patient communication is paramount. For example, interpreters should be provided for patients not proficient in English. Preoperative instructions and discharge information should be culturally appropriate, available in multiple languages, and at a reading-level suitable for the patient. Poor communication between patients and their health care providers can result in errors and is a threat to patient safety.

Community outreach is another opportunity for anesthesiologists to advance health equity and to follow the American Medical Association (AMA) Declaration of Professional Responsibility.9 

Community outreach can take multiple forms. One example is physician-organized visits to underserved area schools encouraging students to pursue careers in health care.

Health systems are responsible for ensuring patient safety and addressing inequities in care delivery. Health systems that work toward equity require infrastructure that supports high performance, value-based care, and organizational excellence.10 Furthermore, health systems can foster a culture that recognizes and directly addresses disparities by creating an environment for health professionals to recognize, identify, and support system-wide solutions to reduce disparities in patient safety and quality.

There are three key strategic priorities health systems must pursue to achieve equity in patient safety: improving the collection of data and use of analytics, providing the infrastructure for systemwide quality improvement initiatives to reduce disparities in care, and intentionally recruiting diverse health care professionals who reflect the patient population.11 

  1. Systemwide investment in the accurate and comprehensive collection of data on race, ethnicity, language, religion, and gender with pronouns is an important foundational step. Without data and analytics on health care disparities, efforts to achieve health equity across patient safety domains will be limited.12 A strong foundation in data and analytics can be used to support systemwide quality improvement initiatives to reduce disparities in care.

  2. Health systems can integrate equity into their core values and support the infrastructure needed to improve patient outcomes and reduce disparities. Furthermore, systemwide implementation of standardized practice guidelines driven by evidence-based research and local health system practice data has been proven to reduce disparities in health care delivery.13 

  3. Health systems can intentionally recruit diverse professionals who reflect the diversity of patient populations. Diversifying our anesthesiology teams will help reduce personal biases, as we can learn about diverse cultures and perspectives. It will also allow for better physician-patient concordance, which is associated with increased patient satisfaction.14,15 The benefits of diverse care teams have included improved patient outcomes, team communications, and financial performance.16 

Structures to ensure the delivery of quality perioperative care are limited in under-resourced hospitals like safety-net hospitals – a fact that presents another opportunity to improve equity in patient safety. Safety-net hospitals often experience staffing issues and are unlikely to have dedicated perioperative services such as a regional anesthesia team.17 A study published in JAMA found that overlapping coverage by an anesthesiologist was associated with higher morbidity and mortality.18 The staffing of more than two rooms at a time was associated with higher failure-to-rescue rates and higher costs. This is also problematic for low-resource countries and rural communities.19 

Anesthesiologists, as safety leaders who care for patients across the entire health care system, are uniquely suited to lead organizations to move equity considerations into mainstream practice and operations.

Pursuing health equity is a priority for most American medical societies. There is collective interest in diversifying board memberships, giving opportunities to underrepresented physicians to serve in higher offices, providing education about racism, bias, and inclusion, and addressing member and patient concerns related to unequal treatment.

“Anesthesiology teams play a vital role in improving equity in perioperative patient safety. First, we need to assess for individual implicit biases based on race, ethnicity, socioeconomic status, and religion. We all have biases. It is important to be aware of these biases and intervene through education and training.”

The ASA Committee on Professional Diversity and the American Board of Anesthesiology (ABA) have published documents addressing health care disparities.20 Since 2018, the ABA has taken steps to increase diversity in its leadership, performed bias training among staff, and developed a diversity, equity, and inclusion (DEI) task force. The ABA also included the subjects of DEI in health care and health care disparities in the content outline of its current certification exams.21 

The role of the federal government in health care includes research, legislation, and the administration and funding of public medical insurance programs like Medicare and Medicaid. The Agency for Healthcare Research and Quality (AHRQ) annually publishes the “National Healthcare Quality and Disparities Report,” which provides a summary of trends in access to health care and patient safety and disparities related to ethnicity, income, and other social determinants of health.22 

The federal government, via the Centers for Medicare & Medicaid Service (CMS), is the nation's largest health insurer. Often, the policies and regulations implemented in the public sector are followed by the private sector. The fact that CMS released a document prioritizing health equity is a significant step in helping to decrease the health gap in the U.S. A priority of the CMS Framework for Health Equity 2022–2032 is to reduce gaps by assessing causes of disparities within CMS programs and addressing inequities in policies and operations. The CMS Innovation Center designed a project to help Medicare Advantage plans identify disparities among their enrollees and effect measures to advance health equity.23 

The Hospital Inpatient Quality Reporting Program is required for hospitals that are paid by CMS. Three equity measures are included in this program. The first measure assesses a hospital's commitment to establishing a culture of equity, including data collection and analysis, strategic planning, quality improvement, and leadership engagement. The other two are designed to capture screening and identification of patient-level, health-related social needs (i.e., social determinants of health) such as housing instability.24 CMS has also established a “Birthing-Friendly” designation on the publicly available Care Compare website. This allows hospitals and health care systems to show patients and insurers their commitment to improving maternal health outcomes through participation in maternity quality activities.

Reports of pulse oximetry inaccuracies among individuals with darker skin are of particular interest to anesthesiologists.25 The Food and Drug Administration (FDA) has issued a safety communication in response to this information. In February 2024, the FDA held a committee panel hearing to discuss this issue. This is a step toward ensuring greater safety and potentially better outcomes for the entire population.26 

The collection of taxes and the use of revenues to support social programs are other ways the government can impact global equity.27 The mega-rich call to global leaders at the Davos meeting in January 2024 to “tax their extreme wealth” is a welcome step toward equity from the private sector.28 

Health care is a crucial component of efforts to promote the general welfare of the people.29 Many generations have observed the uneven distribution of health care in this country, and many individuals have suffered the effects of bias during health care interactions. We must act toward decreasing health care disparities and educating the next generation of health leaders to achieve global equity in health delivery and patient safety. We will need the collective efforts of all members of our society to eradicate health inequities and promote good physical and mental health.

Disclosures: Dr. Fermin is a volunteer question editor for the American Board of Anesthesiology Basic Exam. Dr. Tan is a grant recipient of the Foundation for Anesthesia Education and Research, Anesthesia Patient Safety Foundation, and Southern California Environmental Health Sciences Center, as well as a consultant for GE HealthCare and Edwards Lifesciences.

Lilibeth Fermin, MD, MBA, ASA Committee on Patient Safety and Education, ASA Committee on Problem-Based Learning Discussions, Society of Cardiovascular Anesthesiologists Quality, Safety and Value Committee, Clinical Associate Professor of Anesthesiology, Cleveland Clinic Lerner College of Medicine, and Cardiothoracic Anesthesiologist and Intensivist, Cleveland Clinic, Weston, Florida.

Lilibeth Fermin, MD, MBA, ASA Committee on Patient Safety and Education, ASA Committee on Problem-Based Learning Discussions, Society of Cardiovascular Anesthesiologists Quality, Safety and Value Committee, Clinical Associate Professor of Anesthesiology, Cleveland Clinic Lerner College of Medicine, and Cardiothoracic Anesthesiologist and Intensivist, Cleveland Clinic, Weston, Florida.

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Jonathan M. Tan, MD, MPH, MBI, FASA, ASA Committee on Performance and Outcomes Measurement, ASA Committee on Informatics and Information Technologies, Vice Chair of Analytics and Clinical Effectiveness, and Assistant Professor of Clinical Anesthesiology and Spatial Sciences, Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, Spatial Sciences Institute, University of Southern California, Los Angeles, California. @jonathan_tan

Jonathan M. Tan, MD, MPH, MBI, FASA, ASA Committee on Performance and Outcomes Measurement, ASA Committee on Informatics and Information Technologies, Vice Chair of Analytics and Clinical Effectiveness, and Assistant Professor of Clinical Anesthesiology and Spatial Sciences, Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, Spatial Sciences Institute, University of Southern California, Los Angeles, California. @jonathan_tan

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P. Grace Harrell, MD, MPH, ASA Committee on Patient Safety and Education, Medical Director of Anesthesia, and Associate Clinical Professor of Anesthesia, City of Hope Orange County, Irvine, California.

P. Grace Harrell, MD, MPH, ASA Committee on Patient Safety and Education, Medical Director of Anesthesia, and Associate Clinical Professor of Anesthesia, City of Hope Orange County, Irvine, California.

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Candace Chang, MD, MPH, ASA Committee on Patient Safety and Education, ASA Committee on Global Health, Clinical Associate Professor, and Director of Non-Operating Anesthesia, University of Utah, Salt Lake City, Utah.

Candace Chang, MD, MPH, ASA Committee on Patient Safety and Education, ASA Committee on Global Health, Clinical Associate Professor, and Director of Non-Operating Anesthesia, University of Utah, Salt Lake City, Utah.

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Adam J. Milam, MD, PhD, FASE, ASA Committee on Professional Diversity, ASA Committee on Cardiovascular and Thoracic Anesthesia, ASA Cardiac Education Subcommittee, Professor of Anesthesiology, and Associate Professor of Epidemiology, Mayo Clinic, Phoenix, Arizona.

Adam J. Milam, MD, PhD, FASE, ASA Committee on Professional Diversity, ASA Committee on Cardiovascular and Thoracic Anesthesia, ASA Cardiac Education Subcommittee, Professor of Anesthesiology, and Associate Professor of Epidemiology, Mayo Clinic, Phoenix, Arizona.

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