Original Article
Association Between Perceived Discrimination and Emergency Department Use Among Safety-Net Patients in the Southwestern United States
Abstract
Objectives: Patients’ perceptions of how they are treated in their interactions with the healthcare system represent important and valid measures of healthcare quality that may influence health utilization, outcomes, and costs. Perceived discrimination or the sense of being treated unfairly is an important patient perception known to adversely affect health, but the relation of such perceptions to health-seeking behaviors related to low-acuity emergency department (ED) use is unclear. The objectives of this exploratory study were to describe the prevalence and nature of perceived discrimination or perceived unfair treatment (PD/PUT), and to examine the association of PD/PUT with healthcare utilization among adult safety-net patients in the southwestern United States who sought ED treatment for low-acuity conditions.Methods: Cross-sectional survey data were collected via self-administered questionnaires completed by adult safety-net patients who were uninsured or covered by Medicaid and who sought ED treatment for low-acuity conditions (N = 310). We used descriptive statistics to describe PD/PUT in the healthcare experiences reported by study participants. We used logistic regression to examine the association between PD/PUT and participants’ likelihood to seek health care from ED and non-ED settings.
Results: Thirty-eight percent of study participants reported PD/PUT, most frequently attributed to insurance status (being uninsured or covered by Medicaid). Participants who reported PD/PUT in their ability to access medical care or to obtain health insurance were significantly more likely to be frequent (vs nonfrequent) ED users (odds ratio [OR] 3.80, P < 0.001) and to use multiple (vs 1) EDs (OR 3.79, P < 0.001) during a 12-month period. Participants who reported PD/ PUT while receiving medical care were more likely to have received care in ED and non-ED settings, as compared with EDs only (OR 2.02, P = 0.012).
Conclusions: A substantial proportion of this sample of adult safety-net patients in the Southwest reported experiencing PD/PUT in their healthcare interactions and most frequently attributed such perceptions to their insurance status. Although this study does not establish a causal link between PD/PUTand utilization of care in specific settings, it highlights the need to better understand the underlying causes of PD/PUT across multiple delivery settings and to clarify the extent to which such experiences may influence patients’ healthcare-seeking behaviors. Federal and state policies that aim to maintain or expand health insurance coverage for safety-net populations should consider the role of health insurance status in driving perceptions of being discriminated against or treated unfairly.
This content is limited to qualifying members.
Existing members, please login first
If you have an existing account please login now to access this article or view purchase options.
Purchase only this article ($25)
Create a free account, then purchase this article to download or access it online for 24 hours.
Purchase an SMJ online subscription ($75)
Create a free account, then purchase a subscription to get complete access to all articles for a full year.
Purchase a membership plan (fees vary)
Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.
References
1. Smedley BD, Stith AY, Nelson AR , eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: Institute of Medicine, National Academy Press; 2002.
2. Agency for Healthcare Research and Quality. 2014 National Healthcare Quality and Disparities Report. AHRQ Pub. No. 15-0007. Rockville, MD: Agency for Healthcare Research and Quality; 2015.
3. Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press; 2006.
4. Weech-Maldonado R, Hall A, Bryant T, et al. The relationship between perceived discrimination and patient experiences with health care. Med Care 2012;50(9 Suppl 2):S62-S68.
5. Rocque R, Leanza Y. A systematic review of patients’ experiences in communicating with primary care physicians: intercultural encounters and a balance between vulnerability and integrity. PLoS One 2015;10:e0139577.
6. Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence and needed research. J Behav Med 2009;32:20-47.
7. Shavers VL, Fagan P, Jones D, et al. The state of research on racial/ethnic discrimination in the receipt of health care. Am J Public Health 2012;102:953-966.
8. Krieger N. Discrimination and health inequities. Int J Health Serv 2014;44:643-710.
9. Blendon RJ, Buhr T, Cassidy EF, et al. Disparities in health: perspectives of a multi-ethnic, multi-racial America. Health Aff (Millwood) 2007;26:1437-1447.
10. Pascoe EA, Smart Richman L. Perceived discrimination and health: a meta-analytic review. Psychol Bull 2009;135:531-554.
11. Braveman P, Gottlieb L. The social determinants of health: it’ time to consider the causes of the causes. Public Health Rep 2014;129(Suppl 2):19-31.
12. Burgess DJ, Ding Y, Hargreaves M, et al. The association between perceived discrimination and underutilization of needed medical and mental health care in a multi-ethnic community sample. J Health Care Poor Underserved 2008;19:894-911.
13. Jacobs EA, Rathouz PJ, Karavolos K, et al. Perceived discrimination is associated with reduced breast and cervical cancer screening: the Study of Women’ Health Across the Nation (SWAN). J Womens Health (Larchmt) 2014;23:138-145.
14. Benjamins MR. Race/ethnic discrimination and preventive service utilization in a sample of whites, blacks, Mexicans, and Puerto Ricans. Med Care 2012;50:870-876.
15. Sorkin DH, Ngo-Metzger Q, De Alba I. Racial/ethnic discrimination in health care: impact on perceived quality of care. J Gen Intern Med 2010;25:390-396.
16. Tajeu GS, Cherrington AL, Andreae L, et al. “' get to you when we get to you”: exploring potential contributions of health care staff behaviors to patient perceptions of discrimination and satisfaction. Am J Public Health 2015;105:2076-2082.
17. Sue DW, Capodilupo CM, Torino GC, et al. Racial microaggressions in everyday life: implications for clinical practice. Am Psychol 2007;62:271-286.
18. Sommers BD, Gunja MZ, Finegold K, et al. Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act. JAMA 2015;314:366-374.
19. Sommers BD, Blendon RJ, Orav EJ, et al. Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance. JAMA Intern Med 2016;176:1501-1509.
20. Sommers BD, Gourevitch R, Maylone B, et al. Insurance churning rates for low-income adults under health reform: lower than expected but still harmful for many. Health Aff (Millwood) 2016;35:1816-1824.
21. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood) 2008;27:759-769.
22. Agency for Healthcare Research and Quality. Emergency Severity Index (ESI): a triage tool for emergency department. https://www.ahrq.gov/professionals/systems/hospital/esi/index.html. Accessed April 30, 2017.
23. Enard KR, Ganelin DM. Reducing preventable emergency department utilization and costs by using community health workers as patient navigators. J Healthc Manag 2013;58:412-428.
24. Allen H, Wright BJ, Harding K, et al. The role of stigma in access to health care for the poor. Milbank Q 2014;92:289-318.
25. Han X, Call KT, Pintor JK, et al. Reports of insurance-based discrimination in health care and its association with access to care. Am J Public Health 2015;105(Suppl 3):S517-S525.
26. Breland HL, Ellis C. Perceived discrimination in healthcare settings among Latinos with limited English proficiency in South Carolina. South Med J 2015;108:203-206.
27. Calo WA, Cubillos L, Breen J, et al. Experiences of Latinos with limited English proficiency with patient registration systems and their interactions with clinic front office staff: an exploratory study to inform community-based translational research in North Carolina. BMC Health Serv Res 2015;15:570.
28. Pines JM, Asplin BR, Kaji AH, et al. Frequent users of emergency department services: gaps in knowledge and a proposed research agenda. Acad Emerg Med 2011;18:e64-e69.
29. Widmer AJ, Basu R, Hochhalter AK. The association between office-based provider visits and emergency department utilization among Medicaid beneficiaries. J Community Health 2015;40:549-554.
30. Garfield R. The coverage gap: uninsured poor adults in states that do not expand Medicaid-an update. http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/. Published January 21, 2016. Accessed August 24, 2016.
31. US Census Bureau. QuickFacts Texas, United States. http://www.census.gov/quickfacts/table/PST045215/48,00. Accessed August 24, 2016.
32. Passel JS, Cohn D. Unauthorized immigrant totals rise in 7 states, fall in 14: decline in those from Mexico fuels most state decreases. http://www.pewhispanic.org/files/2014/11/2014-11-18_unauthorized-immigration.pdf. Published November 18, 2014. Accessed February 24, 2016.
33. LaVeist TA, Rolley NC, Diala C. Prevalence and patterns of discrimination among U.S. health care consumers. Int J Health Serv 2003;33:331-344.
