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ORIGINVAL COMMUNICATION AMBULATORY MEDICAL CARE AMONG ADULT BLAkCK AMERICANS: THE HOSPITAL EMERGENCY ROOM Harold W. Neighbors, PhD Ann Arbor, Michigan

This paper examines how sociodemographic factors (income, education, employment status, age, gender, insurance coverage, and place of residence) are related to the use of hospital emergency rooms for serious personal problems in a nationally representative sample of adult black Americans. Bivariate analyses indicated that low income, unemployed, and older respondents were most likely to use the emergency room. Gender, education, insurance coverage, and place of residence were not related to emergency room use. Multivariate analyses revealed that the relationship of age to utilization could be explained by the high prevalence of physical health complaints among the old. The poor and unemployed remained significantly more likely (than the non-poor and those with jobs) to use the emergency room when all other predictors were taken into account. The implications of these findings for health services delivery to the urban black poor and the general illness behavior of black Americans are discussed. From the University of Michigan Institute for Social Research (Program for Research on Black Americans), Ann Arbor, Michigan. Requests for reprints should be addressed to Dr. Harold W. Neighbors, Department of Community Health (Community Mental Health Program), University of Michigan, School of Public Health, 1090 South Observatory Street, Ann Arbor, Ml 48109.

Over the past 25 years, the nation has experienced a tremendous increase in the use of hospital outpatient departments, especially emergency rooms, by persons seeking medical care. ' This increase has been especially marked among the poor, the blacks, and those residing in central cities.2 The major reasons for this increased demand are: (1) the flight of private office-based physicians from inner-city areas during a time when Medicare and Medicaid increased demand (by decreasing financial access barriers) for health services among the elderly and urban poor; (2) the general tendency for the poor and blacks not to have a regular family physician; (3) the geographical proximity of hospitals to many urban dwellers; (4) the perception among some residents of medically underserved areas that hospitals provide a higher quality of medical care than neighborhood health centers; (5) the tendency of health insurance plans to provide reimbursement for hospital visits only; and (6) the tradition of free care within hospitals, which over the years may have taught many low income people to rely on hospitals as an inexpensive source of medical care.36 The fact that so much of the increased demand for hospital outpatient and emergency room care has occurred among blacks and the poor is an important policy issue because the quality of health care dispensed in such places is many times inferior to that provided in private physicians' offices.7 One goal of the Great Society's War on

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 78, NO. 4,1986

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AMBULATORY CARE AMONG BLACKS

Poverty (as well as the Civil Rights Movement) was to guarantee equitable access to quality health care for all Americans. While Medicaid and Medicare have facilitated utilization by decreasing financial barriers to physicians among the poor and the elderly, inequities in health care remain, especially when the source of physician contact (ie, private vs public agency) is taken into account.8 The bulk of empirical evidence suggests that many blacks, poor, and elderly persons have not yet moved into the "mainstream" of the United States health care system.9 There are other reasons for understanding the importance of the issue of the demand for hospital services. Many conditions seen in emergency departments are not urgent. Rather, they are the types of routine health problems that could be handled by other, supposedly more appropriate, ambulatory care sources.10 This fact coupled with the tendency to regard the illness behavior of blacks and the poor as suspect (because of their "inadequate" knowledge about what is the appropriate response to physical symptoms) has led some to argue that these groups are abusing hospital outpatient departments.11 This issue is especially relevant today because hospitals are the most expensive places to receive medical treatment. Thus, there are financial gains to be made if it is true that emergency rooms are being inappropriately used by the poor when less expensive alternatives are readily available and accessible. There is some indication that this is possible. One study found that the majority of conditions taken to a hospital emergency room could have been handled at a nearby neighborhood health clinic but that most of the respondents were unaware of the clinic's existence or preferred not to go there.4 The majority of the evidence, however, suggests that it is the structure of the medical system that influences blacks and the poor to use public medical facilities.8 Gibson,3 for example, argues strongly that the role of hospital emergency departments is dictated by the failure of other health care entry points to provide access for certain types of "undesirable" groups (black, young, poor, less-well-educated). In Gibson words, hospital emergency departments have become, "the twenty-four-hour rain barrel of ambulatory health

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care to collect everyone else's leaks."3 More research is needed in order to gain a better understanding about why certain groups tend to utilize hospital emergency rooms. As noted previously, emergency room use is particularly high among blacks and the poor. The stability of these relationships is evident when one inspects data on physician visits by source or place of care from the Health Interview Survey.2 In 1964 and for every year from 1972 to 1981, blacks have been twice as likely as whites to utilize hospital outpatient departments or emergency rooms for health care.2"12'15 The same data also show that lowincome respondents are significantly more likely to utilize these health resources. The question is whether the race effect can be explained by the fact that a disproportionate number of blacks (in comparison to whites) are poor. Such a question can be easily answered by simultaneously examining the relationships among race, income, and use. A review of the literature uncovered only one example of such an analysis. Kleinman et al,'6 using the 1976-1978 Health Interview Survey data, found that for both blacks and whites, the majority of physician visits took place in an office setting. Blacks, however, were twice as likely as whites to use hospital outpatient departments or emergency rooms at all levels of income. The fact that controlling for income did not eliminate this race differential means that the tendency for blacks to use hospital outpatient departments and emergency rooms more than whites cannot be attributed to a financial explanation alone. It is possible, however, that place of residence could explain these findings, as blacks are more likely than whites to reside in central cities where many hospital emergency rooms are also located. These results also suggest that cultural factors related to race may play an important role in explaining why blacks are predisposed to use emergency rooms for medical care. Brathwaite states that the history of racial segregation in the health care industry may have produced a preference among some blacks for public facilities where a person is less likely to be denied care because of skin color (N. Brathwaite, unpublished data, 1983). Blacks at all income levels may feel more socially distant from white physicians, and in-



stitutional settings may diminish these feelings. He also suggests that any poor treatment received would not be seen as racially motivated because such places are known to provide low-quality care to everyone. It is possible that even though some blacks have moved up the socioeconomic scale, they have retained some of the illness behavior associated with a previously lower status. Jackson17 argues that many of the black elderly may prefer clinics to private settings because they use the visit as a social event, making frequent appointments in order to visit with friends who also utilize the clinic. Furthermore, Jackson suggests these blacks gain a sense of importance in being welcomed by the medical staff at the clinics. The point is that we need to know more about factors that predict hospital outpatient utilization among black Americans. A number of writers have pointed out the advantages of conducting health research on large, representative samples of population subgroups known to be important targets for health services, a designation which is certainly appropriate for black Americans. 17'18 Thus, it is the purpose of this paper to examine the utilization of hospital emergency departments in a nationally representative sample of adult black Americans.

METHOD

Sample The analyses to be reported were conducted on a nationally representative cross-section of the adult (18 years old and older) black population living in the continental United States. The sample was drawn according to a multi-stage, area probability procedure designed to ensure that every black household had the same probability of being selected for the study. Based on the 1970 census distribution of the black population and stratified by degree of racial composition and income, 76 primary areas were selected. Actual sampling and interviewing were conducted in smaller geographical areas (called "clusters") generally representing city blocks or groups of

blocks. Professionally trained interviewers listed all habitable black households in each cluster. Within each selected black household, a single person was randomly chosen to be interviewed. All interviewing was conducted by professionally trained black interviewers. This sampling and interviewing procedure19 resulted in 2,107 completed interviews conducted during 1979 and 1980.

Variables Respondents were asked to report one situation they had experienced that had caused them a significant amount of distress and how they adapted to this stressful life event. Of the 2,107 blacks interviewed in this study, 1,322 (64 percent) were willing to talk about a serious personal problem. Each respondent who said he or she had experienced a problem was asked the following question: "Thinking about the last time you felt this way, what was the problem about?" This question was designed to ascertain how the respondent conceptualized the nature of the distress experienced. The answer to this question represents the specific locus to which the respondent attributed the cause of his or her personal distress. For analysis purposes, responses to this question were categorized into five problem categories: (1) physical health problems, (2) interpersonal difficulties (marital problems, problems with the opposite sex, and interpersonal relationships in general), (3) emotional adjustment problems (references to mood disturbances, self-doubt and personal adjustment issues in general), (4) death of a loved one, and (5) economic difficulties. Respondents who had experienced a problem were also presented with a list of professional helping facilities and asked if they had gone to any of the places listed for help. That list included the following professional help sources: hospital emergency room, social services, mental health center, private mental health therapist, doctor's office, minister, lawyer, police, school, and employment agency. In this paper, professional help utilization is operationalized by a dichotomous variable indicating the number of respondents with a problem who sought help from a hospital emergency room. Persons who indicated they had


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TABLE 1. DEMOGRAPHICS AND EMERGENCY ROOM USE

Sociodemographics Family Income* Under $5,000 $5,000-$9,999

$10,000-$19,999 $20,000 and above Education 0-11 years High school grad Some college College grad Employment Status** Working Not working Age*** 18-34 35-54 55 and above Sex Male Female Health Insurance Yes No Residence U rban Rural

Percentage Using Emergency Room

n

36.6 28.4 14.3 16.5

153 134 140 121

26.3 28.7 15.9 20.9

266 181 113 67

17.4 32.0

322 309

16.3 25.8 37.8

263 225 143

24.6 24.6

183 448

23.7 27.9

493 129

24.0 27.0

520 111

X2== 25.28, df 3, P < .001 X2 18.26, df= 1, P < .001 X2= 23.20, df = 2, P < .001 =

sought professional help were allowed to mention as many places contacted up to a limit of four. As a result, the analysis combines multiple mentions if a particular respondent contacted more than one professional help source. A respondent is coded as having used an emergency room regardless of whether emergency room was mentioned first, second, third, or fourth. Any respondent mentioning emergency room more than once (across the four mentions) was counted only once in the category indicating use of help. By creating a di-

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TABLE 2. PROBLEM TYPE AND EMERGENCY ROOM USE

Type of problem* Physical Interpersonal Emotional Death Economic

X2= 62.64, df

=

4, P