In U.S. health care, the most commonly reported type of discrimination is racially based. Racial discrimination imposes a particular burden on Black patients, whose receipt of less appropriate care than white patients is associated with higher mortality.

Anish Agarwal
Anish Agarwal, MD, MPH

Most health systems assess patient experience with surveys, but the questions do not ask about racism. A new study by LDI Senior Fellows Anish Agarwal, Raina Merchant, David Asch, Eugenia South, and colleagues used text messaged-based surveys to assess patient emergency department experience, including the impact of race.

We asked lead author Dr. Agarwal about the study. Answers were edited for length and clarity.

What motivated this study?

There has been an enormous focus on health care quality and safety by health care organizations. Even though organizations try to measure patient experience as part of these efforts, they rarely directly measure patient experiences of racism in health care and within clinical settings. Inequity—specifically across race—has led to significant disparities in patient care and outcomes that persist in health care. We need to find ways to measure experiences of racism and address it. In our study, we used automated text messaging after visits to the emergency department to assess patient experience and the impact of race on care.

What are the study’s key findings?

First, patients are willing to respond to text messages and talk about the intersection of racism and health care. Next, when asked, 1 in 10 Black patients note that their race negatively impacted their care. In contrast, fewer than 2 in 100 white patients reported that race had a negative effect on their care. Black patients reported that race most heavily affected quality of care, respect, and communication.

What are the study’s implications for improving clinical care?

Dismantling structural racism across society, and within health care, requires specific attention. We currently do not have ways to directly address or even investigate this critical aspect of health care. Our study shines light on the nuanced challenges of asking necessary, direct questions related to racism using patient-experience surveys.

We used a simple, text messaged-based survey to connect with patients. The early insights reveal that a text message survey can collect patient-reported experiences, including about racism, and Black patients reported more race-related negative effects in emergency care than white patients.

What are the implications for hospital care and quality measures?

If we are truly going to move the needle toward equity in patient care, we must understand how important communication, trust, and respect are in health care. To ignore the complexities of how race affects interactions between patients and clinicians would be short-sighted. It would limit our ability to think of patient-centered methods to improve the quality of care, including experiences of racism.

We believe health systems should be specifically seeking out patients’ care experiences related to race. However, they can’t stop there, health care organizations need to use this information to take action on the roots of racism in their own systems. 

What questions remain about this topic?

Our study is just the beginning. We need deeper and larger dives into understanding experiences across clinical settings (e.g., inpatient, emergency department, clinic). We need to start building larger information systems on patient experiences of racism in care so we can identify key areas where work to reduce the negative impact of race will have a high impact.

We need to build systems that continuously pay attention to racism in health care and provide actionable data for leaders to address. What might this look like? In my opinion, this could involve including questions related to race and health care experiences in routine patient experience surveys. Teams could incorporate the resulting metrics into ongoing quality improvement and operational measures. Our team is also digging deeper into patient experiences through qualitative methods to gain more understanding to help guide leaders and clinicians.

The study, Assessing Experiences of Racism Among Black and white Patients in the Emergency Department, was published on December 21, 2022 in Journal of the American College of Emergency Physicians Open. Authors include Anish K. Agarwal, Charlotte Sagan, Rachel Gonzales, Sally Nijim, Raina M. Merchant, David A. Asch, and Eugenia C. South.


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