Our study demonstrates that compared to Caucasians, African-Americans are significantly more likely to select the ED for their usual place of care or report that they have no routine place of healthcare. Importantly, the racial disparity does not appear to result from differences in health insurance, barriers to primary care or patient perception of health. Uninsured patients similarly comprised a disproportionate share of patients who lack a usual place of care or use the ED routinely for medical concerns. After adjustment for age, gender, number of previous ED visits, and admission status, race and insurance remained significant, independent determinants of usual place of healthcare. Such findings highlight the complexity of healthcare reform and imply that insurance coverage for all individuals does not guarantee a change in patterns of access to care.
Our findings are in accordance with several studies, which found that African-Americans, and Medicaid and uninsured patients are less likely to have ongoing primary care.4,15,16
reaffirms previously published data that the ED serves as the chief medical provider for the uninsured. Such data emphasizes to healthcare policymakers the need for improved insurance coverage and its potential benefits on healthcare delivery. Also, similar to our results in , Baker et al.4
observed that African-Americans were more likely to identify the ED as their regular source of care, and Caucasians typically select a private physician as their routine provider. Previous research, however, cites traditional determinants of healthcare: age, health insurance, and access barriers as the basis for selecting the ED over a primary care facility, which our data did not support.4,15–17
Also, in contrast to our findings, several studies found a significantly higher number of ED visits reported by African-Americans, uninsured patients, and other payment groups.4,15,17,18
Such apparent inconsistencies may be explained by study design, specifically how one defines outcome variables. In our study, we defined barriers to primary care by measuring 3 common parameters: payment, transportation, and time off work; however, sociocultural factors, child care concerns, availability of local providers or, as 1 study demonstrated, distrust of healthcare providers can impede access to primary care and inform patients’ preference for site of care.9
In support of our findings, 1 survey study employed the same definition of access barriers and found that independent of race, patients reported difficulties in all parameters, yet African-Americans were more likely than Caucasians to report use of the ED for their health concerns.4
Moreover, Gornick et al19
showed that minorities, despite having Medicare, have higher use of acute care services than white patients with Medicare.
We can speculate the reasons underlying an association between site of care and patient populations. For uninsured patients, it seems plausible that the ED is the only alternative place for care. Indeed, the percentage of physicians providing charity care has dropped in recent years and the Emergency Medical Treatment and Active Labor Act (EMTALA) ensures that vulnerable populations receive medical care, regardless of ability to pay.20
The concept of usual place of healthcare in the African-American population is less clear. Our study could not explain the difference between races by health insurance, barriers to primary care, or patient perception of health; however, unmeasured factors must be considered. Reasons for frequent ED use cited previously include unmet medical needs, dissatisfaction with the choice of a primary care provider, and anticipated expediency.21
Physician supply in proximity to patient’s residence, the strength of the patient-physician relationship, and sociocultural factors may also account for racial differences in routine place of care.2,9
Moreover, disparity in patient presentation may contribute, as a recent study in Archives of Surgery
showed that after controlling for socioeconomic status, African-Americans were more likely than Caucasians to present with acute hernia complications requiring emergent surgery.22
Despite African-Americans disproportionately selecting the ED as their routine place of care, as noted in , the African-American patients in our study reported a similar frequency of ED visits in recent months as white patients. The most obvious explanation for this finding is that many factors in addition to preferred place of healthcare influence an individual’s frequency of ED use, including age, underlying illnesses, and health emergencies. These variables, as well as other unmeasured factors, may have narrowed any difference in ED use among African-Americans and whites in our study population. For 3 or more visits to the ED, the racial disparity widened, although not statistically significant, and the reason for this difference remains unclear. Perhaps, racial differences for frequency of ED visits are only statistically evident among patients who visit the ED at a rate greater than our study examined.