The emergency department for routine healthcare: Race/ethnicity, socioeconomic status, and perceptual factors

doi:10.1016/j.jemermed.2006.05.042

The Journal of Emergency Medicine

Volume 32, Issue 2, February 2007, Pages 149-158

Abstracts presented at the National ACEP Research Forum 2003, Boston, MA, October 13, 2003.

https://doi.org/10.1016/j.jemermed.2006.05.042 Get rights and content

Abstract

Our objective was to study the role of race/ethnicity and socioeconomic status (SES) in the use of the emergency department (ED) as a source of routine healthcare. Adult patients presenting to an urban ED were surveyed. We assessed demographics, race/ethnicity, SES, and perceptional factors related to choosing the ED for the current visit. Stepwise logistic regression analyses were used to explore whether SES accounted for racial/ethnic trends in ED use. Of 1375 patients, 936 (68%) were enrolled. After controlling for insurance status, income, employment status, and education, neither race nor ethnicity remained a strong predictor of routine ED use. Race/ethnicity-based disparities in routine ED use were due to the confounding effects of SES. Programs to reduce inappropriate ED use must be sensitive to an array of complex socioeconomic issues and may necessitate a substantial paradigm shift in how acute care is provided in low SES communities.

Introduction

Because the number of emergency department (ED) visits in the United States has increased significantly over the past decade, from nearly 90 million visits in 1992 to almost 110 million visits in 2001, many EDs are confronting problems with overcrowding (1, 2). Complicating matters, the ED often acts as a safety net for patients with non-urgent problems who have no other source of care (3, 4, 5). Although population-based studies have found that only 0.9%–2% of the United States population reports using the ED as their usual source of care, approximately 25% of patients visiting the ED at any given time state that it is their usual source of care (6, 7, 8, 9, 10). Moreover, an additional 15%–25% of people being treated in the ED report no source of usual care, presumably leaving the ED as the default site of care (7, 8, 9, 10).

If effective interventions to reduce reliance on the ED as a usual source of care are to be designed, it is important to understand the factors associated with such use. Several studies have reported that black and Hispanic patients are up to 3.5 times more likely than Whites to report receiving their routine healthcare in an ED (7, 8, 9, 10, 11, 12, 13). Although this trend is robust and has been replicated by investigators from different parts of the country and by using different research methods, the reasons underlying such racial/ethnic trends have not been sufficiently studied. It is illogical to say that skin color or ancestry, per se, causes a person to seek routine care in an ED. Rather, other factors that are associated with both race/ethnicity and routine ED use are probably to blame. Ostensibly, if we can better understand these confounding factors, we can better design interventions and policy to remediate these race/ethnic disparities.

One of the most likely factors confounding the relation between race/ethnicity and using the ED for routine or non-urgent healthcare is socioeconomic status (SES). Black and Hispanic patients may be more likely to be economically disadvantaged and uninsured, making them less likely to have a primary care provider (PCP) to turn to when they are ill (7, 9, 11, 12, 13, 14). However, most studies have not explicitly investigated whether SES accounts for race/ethnic ED use trends. Other factors linked to race/ethnicity, SES, or both may contribute to using the ED for routine care, such as racial/ethnic differences in perceptions of the quality, convenience, or efficiency of different healthcare venues (9, 10, 11, 15, 16, 17, 18, 19). We conducted a prospective surveillance study to further examine the role of race/ethnicity, SES, and perceptual factors in determining use of the ED for routine care.

Section snippets

Methods

Using a standardized survey, investigators at an urban, academic ED recruited participants for 5 weeks during peak volume hours (8:00 a.m. to 12:00 midnight), 7 days a week. Most other studies investigating routine ED use have used similar time periods (8, 9). Authors of these studies have noted that patients presenting during the early morning hours are often more ill, have altered mental status, or are sleeping, making it less likely they would be able to participate in the survey, therefore

Results

There were 1375 patients who presented during the hours of research assistant staffing. Of these, 936 (68%) were enrolled; 26 were of another race/ethnicity besides white, black, or Hispanic and were omitted for the present analyses. This left 910 (66% of presenting patients) for the analyses reported herein (Figure 1). This enrollment rate is similar to those obtained by others (8, 9).

Of those enrolled, 238 (26%) reported that the ED was their source of routine healthcare. As mentioned

Discussion

Overcrowding in the ED is a significant problem, with an increasing number of visits per year and a decreasing number of EDs nationwide as a result of economic forces (24). Presumably, ED overcrowding can have multiple adverse effects, such as poorer outcomes for patients, prolonged pain and suffering of some patients, longer waiting times, increased patient dissatisfaction, ambulance diversions, increased transport times, decreased physician productivity, increased frustration among medical

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Original contributionThe emergency department for routine healthcare: Race/ethnicity, socioeconomic status, and perceptual factors

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

J Emerg Nurs

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Chest

Am J Emerg Med

Trends in hospital emergency department utilization: United States, 1992–99

Vital Health Stat

National Hospital Ambulatory Medical Care Survey: 2001 emergency department summary

Adv Data

Variations among emergency room populations: a comparison of four hospitals in New York City

Med Care

Help?The hospital emergency unit as a community physician

Med Care

The use of hospital emergency departments for nonurgent health problems: a national perspective

Med Care Res Rev

The emergency department as usual source of medical care: estimates from the 1998 national health interview survey

Acad Emerg Med

Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department

JAMA

Ambulatory visits to hospital emergency departments: patterns and reasons for use

JAMA

Original contribution
The emergency department for routine healthcare: Race/ethnicity, socioeconomic status, and perceptual factors