https://orcid.org/0009-0008-8029-9319
Figures
Abstract
Background
Racial and ethnic disparities in the delivery and outcomes of critical care are well documented. However, interventions to mitigate these disparities are less well understood. We sought to review the current state of evidence for interventions to promote equity in critical care processes and patient outcomes.
Methods
Four bibliographic databases (MEDLINE/PubMed, Web of Science Core Collection, CINAHL, and Embase) and a list of core journals, conference abstracts, and clinical trial registries were queried with a pre-specified search strategy. We analyzed the content of interventions by categorizing each as single- or multi-component, extracting each intervention component during review, and grouping intervention components according to strategy to identify common approaches.
Results
The search strategy yielded 11,509 studies. Seven-thousand seventeen duplicate studies were removed, leaving 4,491 studies for title and abstract screening. After screening, 93 studies were included for full-text review. After full-text review by two independent reviewers, eleven studies met eligibility criteria. We identified ten distinct intervention components under five broad categories: education, communication, standardization, restructuring, and outreach. Most examined effectiveness using pre-post or other non-randomized designs.
Conclusions
Despite widespread recognition of disparities in critical care outcomes, few interventions have been evaluated to address disparities in the ICU. Many studies did not describe the rationale or targeted disparity mechanism for their intervention design. There is a need for randomized, controlled evaluations of interventions that target demonstrated mechanisms for disparities to promote equity in critical care.
Citation: Ge S, Lappen H, Mercado L, Lamarche K, Iwashyna TJ, Hough CL, et al. (2025) Interventions to improve racial and ethnic equity in critical care: A scoping review. PLoS One 20(11): e0336922. https://doi.org/10.1371/journal.pone.0336922
Editor: De-Chih Lee, Dayeh University, TAIWAN
Received: November 5, 2024; Accepted: November 2, 2025; Published: November 25, 2025
Copyright: © 2025 Ge et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Disparities in the delivery and outcomes of critical care are well documented [1–5]. Black patients are less likely to receive timely or guideline-concordant antibiotics [6], Hispanic patients are more likely to receive deep sedation, and both Black and Hispanic patients are less likely to receive timely tracheostomy [7–9]. Black and Hispanic patients also have higher rates of sepsis and mortality from acute respiratory distress syndrome compared to White patients [10,11]. Furthermore, Black patients have higher incidence of venous thromboembolism and noncardiogenic respiratory failure [12–15].
Racial and ethnic disparities in outcomes of pediatric critical care are also well recognized. In the neonatal intensive care unit (NICU) setting, non-White infants have a two-fold greater risk of mortality related to intraventricular hemorrhage (IVH) and are less likely to survive necrotizing enterocolitis (NEC) [16,17]. Non-White infants are also less likely to be discharged on breastmilk feeding, which is associated with lower incidence of IVH, NEC, neurodevelopmental delays, late-onset sepsis, and chronic lung disease [18–23].
As the coronavirus disease 2019 pandemic disproportionately sickened Black, Hispanic, and Native American populations, awareness of inequities in critical care and interest in interventions to combat disparities increased [24,25]. However, despite longstanding recognition of disparities in outcomes of critical care and increasing urgency to address them, few interventions to reduce disparities have been routinely deployed in the critical care setting [2,3]. We therefore aimed to review existing and ongoing studies of interventions that target racial or ethnic disparities in the delivery or outcomes of ICU care. The objective of this scoping review is to consolidate the available knowledge regarding interventions and quality improvement initiatives to reduce racial and ethnic disparities in critical care.
Methods
Literature search
This scoping review addressed the question, “What is the current state of evidence for interventions to reduce racial and ethnic disparities in critical care processes and patient outcomes?” To answer this question, we developed a review protocol based on a framework by Visintini, Evidence Synthesis Coordinator at the Maritime SPOR SUPPORT Unit [26]. A research librarian (HL) was consulted in study design and results analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) standard was followed in reporting procedures and results [27,28] (S1 Checklist).
We included past and ongoing studies, trials, and initiatives with an interventional component that aimed to address racial/ethnic disparities in medical, surgical, and pediatric intensive care settings in the United States. We limited the scope of our review to the United States to enhance comparability of studies. Studies were excluded if they aimed only to detect the presence of a racial or ethnic disparity, lacked an intervention, were conducted outside the U.S., were not published in English, or did not take place in an intensive care setting or examine critical illnesses.
An iterative search methodology was employed to optimize the comprehensiveness of our literature search. First, four bibliographic databases (MEDLINE/PubMed, Web of Science Core Collection, CINAHL, and Embase) were queried with pre-specified search strategies. Journals, conference abstracts, and clinical trial registries were hand-searched using the same criteria. All sources were searched from inception until December 31, 2023 (S1 Database).
Databases were searched using an iterative approach that began with a focused search strategy which included terms on improvement, reduction, and intervention to quickly identify relevant articles (S1 Database). Diseases and devices common to the ICU setting (acute respiratory distress syndrome (ARDS), respiratory failure, extracorporeal membrane oxygenation (ECMO), and sepsis) were incorporated into search strategy to ensure any studies related to critical care medicine were captured. This initial, focused strategy is shown to demonstrate the overall structure of the search strategies. The search strategies for each database and iteration are reported in S1 Database:
(race OR racial OR ethnic*)
AND
(disparity OR disparities OR inequality OR inequalities OR inequity OR inequities)
AND
(icu OR critical care OR intensive care OR intensive care units OR critical illness OR ARDS OR respiratory failure OR ECMO OR sepsis)
AND
(quality improvement OR improvement OR improve OR reduction OR reduce OR intervention OR intervene).
Though “inequity” has a distinct meaning from “inequality” or “disparity”, health equity depends on addressing inequalities and disparities [29,30]; thus, the search terms “inequity” and “inequities” were used to capture all possible articles relevant disparity research. Following the first focused search, the databases were queried again using broader search strategies that removed terms specifying an interventional component and also integrated subject headings and additional ICU-related keywords to ensure the search was comprehensive.
After surveying the databases, sources that report ongoing studies were hand-searched. These included ClinicalTrials.gov, NIH RePORTER, MedRXiv, and the Veterans Affairs (VA) Health Services Research and Development citations database. The VA database reports both past and ongoing studies. Journals and conference abstracts from Society of Critical Care Medicine and the American Thoracic Society were also hand-searched for reports of past or ongoing studies. The resulting literature was imported into Covidence systematic review software for deduplication, screening, and extraction [31]. The studies were screened by title and abstract by one reviewer (SG). The remaining literature was full-text reviewed by two team members (SG, MAH) independently. Conflicts within the full-text screening regarding study exclusion or the specific reason for exclusion were discussed between the two reviewers and a third reviewer (HL) and resolved by consensus or a tie-breaking vote by the third reviewer. The reasons for exclusion were recorded per PRISMA-ScR guidelines. The two reviewers (SG, MAH) then each independently extracted the included studies and compared the extractions to reach a final consensus.
Analysis
Both reviewers extracted detailed characterizations of the interventions evaluated in the included studies. Because there is heterogeneity in how race and ethnicity were characterized and measured by investigators, reviewers also recorded how each study defined its target disparity and how demographic data were collected. Next, reviewers catalogued each intervention component and distinguished between complex interventions that bundled together multiple intervention components and simple interventions that consisted of a single intervention component [32]. Reviewers then discussed each intervention component and organized them into a taxonomy of intervention types and elements. The taxonomy was developed by grouping similar intervention components under a broad category and then further categorizing the components into more granular, specific classifications. By creating a taxonomy, we could compare the different interventional approaches among the included studies and identify patterns in current and previous interventions aimed at disparities.
Results
Literature search
For the first focused search, bibliographic database queries and hand-searches yielded 1,406 studies (Fig 1, S1 Database). The broad search of the databases resulted in 5,021 articles, and the second broad search with subject headings and additional terms resulted in 5,072 articles. Seven thousand seventeen duplicates were removed, leaving 4,491 studies for title and abstract screening of which 4,398 studies were deemed irrelevant. One report was merged because it was the study protocol for another study already added for screening [33,34]. After full-text review of the remaining 93 studies by two independent reviewers, 11 studies met eligibility criteria.
During full-text review, studies were excluded if they did not include a prospective assessment of an intervention (S1 Text). Eighty-two studies were excluded during full-text review, of which 34 studies (41%) were disqualified for ineligible study design. These studies lacked an intervention and either focused on investigating the mechanisms for disparities or discussed potential ways to address disparities without carrying out an evaluation. Twenty-one studies (26%) were excluded for “Formative research (no intervention)”, meaning they sought to detect or explore a racial/ethnic disparity but did not pilot an intervention to resolve the disparity. Two studies (2%) were omitted for “Wrong intervention” because the study intervention did not address a racial or ethnic disparity. In one study, investigators retrospectively assessed if a previously implemented protocol to reduce sepsis mortality had equitably benefited patients of racial or ethnic minority background, as opposed to designing and implementing an intervention to reduce a previously observed disparity [35]. The second excluded study examined how using a screening tool for social determinants of health in the NICU impacted patients and families, but did not directly address associated health disparities by race and ethnicity [36]. The 11 studies that remained after full-text review each had an interventional component to address a racial or ethnic disparity in care processes or outcomes in an intensive care setting in the United States.
Intervention targets and results
Table 1 summarizes the 11 included studies. Nine were single-center studies. Two were multicenter studies: the Massachusetts Human Milk QI Collaborative by Parker et al., a statewide QI initiative that involved all 10 level III NICUs in Massachusetts [37], and the Mayo Clinic Care Network (MCCN) Guiding Coalition by Linnander et al., a coalition-based leadership intervention across eight U.S. health systems and their surrounding communities [38]. Six studies (55%) were ongoing clinical trials [34,38–42]. Two studies (18%) employed interventions that continued to be implemented past the study period [37,43].
More than half of studies (six studies, 55%) evaluated interventions for pediatric or newborn populations, with four (36%) studies targeting disparities in mother’s-own-milk feedings in the NICU [34,37,42,43]. The two remaining pediatric studies targeted ICU mortality and parent-infant verbal interactions in the NICU, respectively [44,45]. In the five studies of interventions to reduce disparities in adults with critical illness (45%), four studies focused on improving communication between patients and providers for end-of-life care and shared-decision making [39–41,46]. Only one study targeted a clinical diagnosis, specifically sepsis [38]. Additionally, four out of five of the adult studies were ongoing at the time of analysis and had not yet reported any results [38–41].
Most studies focused on increasing salutary health behaviors for all patients in practices that have been shown to have race-based differences [34,37,39,43,44,46]. For example, Obaid et al.’s primary objective in their “Liquid Gold” intervention was to increase mother’s own milk feedings in the NICU for all patients and their secondary aim was to evaluate the impact of the intervention on disparities between African American, White, and Hispanic mother-infant pairs [43]. In contrast, only Anand et al.’s study sought to resolve disparities in patient outcomes, in particular, reducing mortality in a Latino pediatric population [45].
Five studies (45%) had a pre-intervention period in which they assessed sources or mechanisms of disparities in the target outcome to inform the design of the intervention (Table 1) [37,38,41,43,45]. For instance, in Linnander et al.’s ongoing initiative to address inequities in sepsis outcomes, coalitions comprised of hospital leadership, patient advocacy representatives, and community organizations are participating in forums and workshops to identify which inequity processes are present in their health system and ways to address them. Coalitions will then implement the strategies and continually evaluate and adjust their solutions over a 2.5-year study period [38].
Linnander et al.’s study was also unique because it targeted organizational change to reduce racial and ethnic disparities [38]. While most interventions were not based on behavioral theories, Chuang’s clinical trial cited transformational learning theory as the basis of its intervention [41].
Lastly, studies varied in how they defined race and collected race data on participants (Table 1). Patient race was generally obtained from medical records or self-reported by patients; however, some studies did not specify a data collection method.
Taxonomy analysis
Our analysis of the intervention elements that appeared across studies yielded a taxonomy of 10 intervention components under five broad categories (Tables 2 and 3). The categories were Education (e.g., education of healthcare providers and/or education of patients and families), Communication (e.g., facilitated communication between providers and patients and increasing number of bilingual staff/and or interpreter services), Standardization (e.g., creating an automatic clinical decision support tool within the electronic medical record and standardizing a protocol for a specific healthcare process), Restructuring (e.g., financial and/or material resources provided to patient and families and restructuring patients’ environment), and Outreach (e.g., outreach efforts to the community and help from government services). Seven studies (64%) included Education elements, six (55%) Communication, three (27%) Standardization, five (45%) Resourcing, and only two (18%) Outreach (Table 3).
The characterization of intervention components captured the multifactorial approaches investigators used to address disparities (Tables 2 and 3). Six studies (55%) employed complex “bundled” interventions, which combined two or more intervention components to achieve a desired outcome (Table 2) [37,40,43–46]. The pediatric studies combined more intervention components than adult studies. The four pediatric studies with complex interventions (36%) had a range of three to seven components in their bundles [37,43–45]. In contrast, the two adult studies (18%) evaluating complex interventions each included two intervention components [40,46]. The adult studies also did not include any Standardization, Resourcing, or Outreach elements. Across studies, the most commonly deployed intervention component was education of healthcare professionals (six studies, 55%) and facilitated communication between providers and patients and families (six studies, 55%), followed by financial and/or material resources provided to patient and families (four studies, 36%).
Discussion
In this scoping review, we described and analyzed existing interventions to reduce racial or ethnic disparities in critical care settings. Despite decades of evidence identifying racial and ethnic disparities in ICU care [1], our findings suggest that very few interventions to address these recognized disparities in the ICU have been systematically evaluated. After searching databases of peer-reviewed articles, conference abstracts, and ongoing study registries, our review yielded only 11 intervention studies. Previous systematic reviews suggest that comparatively more attention has been paid to identifying disparities in critical care than to evaluating interventions to reduce disparities. To illustrate, Soto et al. and McGowan et al. found 38 and 25 studies, respectively, that identified disparities in adult ICU care [1,2]. Sigurdson et al. found 41 studies that identified disparities in neonatal ICU care [3]. Soto et al. noted also that no studies had yet aimed to reduce disparities at the time of publishing in 2013, and similarly, the other two groups did not describe intervention studies [1–3].
Kilbourne et al. organized health disparities research into three phases: detecting disparities, understanding the underlying mechanism of a disparity, and designing interventions to reduce and eliminate disparities [47]. The relative scarcity of intervention-oriented studies found in our study compared to the large number of observational studies found in prior reviews demonstrates that ICU disparities research has largely remained in the detection phase. Though research focused on detecting disparities has demonstrated significant differences in ICU care and outcomes by race and ethnicity, interventions designed to reduce or eliminate disparities remain troublingly rare. Even using a broad definition of intervention, we found only 11 intervention studies aiming to reduce racial or ethnic disparities in outcomes or delivery of critical care, with eight studies being from the last five years. These include reports for six ongoing randomized, controlled trials (RCTs) of interventions to reduce disparities in critical care settings [34,38–42].
One possible explanation for this stall is that researchers have yet to closely study mechanisms underlying disparities in critical care outcomes. Many studies did not describe the interventions they evaluated as designed around an empirically grounded theory or formative mechanistic research linking a particular barrier (e.g., clinician knowledge) to a specific patient outcome (e.g., increased rates of infants receiving mother’s own milk). Though some investigators designed interventions in response to observations during a pre-intervention period, assessments from the pre-study period and rationale for the associated intervention component were not consistently reported. Most studies clearly identified disparities and then proposed a bundle of intervention components that might reduce disparities through multiple pathways. For example, in Anand et al.’s study to reduce mortality of Latino PICU patients, investigators conducted a pre-intervention assessment and subsequently employed a bundle intervention, but did not elaborate the reasoning behind each intervention component [45]. Consequently, it is difficult to distinguish effective intervention components from ineffective components. Moreover, interventions designed using behavior change frameworks are more effective than interventions designed without frameworks [48,49]. Only Chuang’s study cited a behavioral theory for the basis of the intervention [41]. Future research should review the state of knowledge regarding mechanisms driving critical care disparities to develop theoretically and empirically grounded interventions.
Our scoping review did not seek to assess the quality of study designs because we aimed to survey current knowledge on reducing disparities in the ICU and, as our review demonstrates, research to reduce disparities is at an early state [28]. There is a breadth of study types among the included literature, including RCTs, pre-post studies, and QI initiatives (Table 1). Thus, it would not have been reasonable to evaluate study quality. It is, however, notable that most studies relied on pre-post designs rather than RCT designs. There are many barriers to carrying out randomized, controlled evaluations of interventions to reduce disparities. Most interestingly, many interventions to reduce disparities are organizational and must be delivered at the level of the ICU or the hospital rather than at the level of the patient. Stepped-wedge and other cluster-randomized, controlled trials are appropriate for evaluating such interventions, but they are resource-intensive. Nonetheless, more than half of the studies included in our analysis are currently ongoing trials, which suggests that controlled trials of interventions to reduce inequalities in critical care are growing rapidly.
We found that many of the interventions included in this review focused on standardizing delivery of care with the aim of reducing disparities in patient outcomes. Structured care processes can reduce bias in care and clinical decision-making. However, the instruments and measures used to deliver standardized care may themselves need to be re-evaluated to avoid re-inscribing structural bias. For example, the incorporation of race into the equation of estimated glomerular filtration rate (eGFR) is debated because the formula assigns higher eGFR values to Black patients without substantial empirical data. Inflating the kidney function of Black patients affects medication doses and restricts patients from receiving timely nephrology referrals, participating in clinical trials, and obtaining life-saving kidney transplants [50]. Due to these implications, many health institutions now mandate calculation of eGFR using a formula without a race parameter. In addition, studies have also shown that pulse oximeters produce biased measures of oxygen saturation for patients with darker skin tone [51]. Care processes that make use of biased instruments may worsen quality of care and endanger minority patients even when clinicians themselves do not exercise bias in clinical decision-making.
We also found that the adult interventions to reduce disparities in adult critical care used a relatively narrow range of strategies. Interventions for adult critical care focused on educating providers regarding culturally competent care and facilitating communication with patients. In contrast, the studies seeking to reduce disparities in pediatric critical care employed more intervention types, including strategies that extended beyond the ICU such as Outreach and Resourcing to address structural sources of disparities. This difference may be attributed to the fact that parents or other adult guardians are typically surrogate decision makers for pediatric patients, and so pediatric intensivists are more confronted by their patients’ social contexts. The more varied approach of the pediatric studies highlights possible new approaches for interventions in adult critical care.
Finally, methodology for collecting race and ethnicity data was not consistently reported across studies. The American Medical Association guidance for reporting race and ethnicity recommends that authors report in their Methods an explanation describing both how race and ethnicity data were collected and why they were collected in this way [52]. Future studies should report the method and rationale for identifying the race and ethnicity of participants.
Our review possessed several strengths. We systematically searched a wide variety of databases to identify both completed and ongoing research, as well as research that may have been carried out but never reported in peer-reviewed venues. Furthermore, our approach to extraction of intervention targets and components for each study enabled us to identify the most common strategies across a broad range of interventions to reduce disparities. Finally, our methods relied on multiple independent reviewers to improve rigor and reliability.
Our scoping review also had some limitations. First, we were unable to identify ongoing studies not registered in Clinicaltrials.gov or NIH RePORTER. Privately funded studies or quality improvement initiatives may be missing from our analysis if they were not reported in a peer-reviewed journal. Second, due to the small number of studies and our objective of providing a comprehensive review of all critical care interventions, we included interventions targeting age-diverse populations, from neonates to adults. The NICU is a unique care setting and the barriers and facilitators to equal care delivery and outcomes in this setting may differ substantially from those in pediatric or adult critical care. In addition, our review only included studies conducted in the United States, so interventions employed outside of the U.S. or published in non-English may have been overlooked. We did not include non-U.S studies because the U.S. has a distinct landscape of racial and ethnic disparities in healthcare, shaped by its history, policies, and sociocultural dynamics. Studies outside the U.S. would likely address disparities within different sociopolitical and healthcare contexts, making direct comparisons challenging [25,53–55].
Conclusion
Despite the widespread recognition of racial and ethnic disparities in critical care, there is little evidence of rigorous efforts to address them through interventions. This is the first study to comprehensively examine interventions addressing racial and ethnic disparities in critical care processes and patient outcomes. Of the few interventions that have been evaluated, many did not describe the rationale or targeted disparity mechanism for their intervention design. Interventions should be developed based on theories that address recognized mechanisms of disparities. There is a need for randomized, controlled evaluations of theory-informed interventions to reduce racial and ethnic disparities in critical care.
Supporting information
S1 Checklist. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.
https://doi.org/10.1371/journal.pone.0336922.s001
(DOCX)
S1 Text. Studies Excluded in Full-Text Review.
https://doi.org/10.1371/journal.pone.0336922.s003
(DOCX)
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