Advertisement

Journal of Urban Health

, Volume 93, Issue 3, pp 456–467 | Cite as

Race, Medical Mistrust, and Segregation in Primary Care as Usual Source of Care: Findings from the Exploring Health Disparities in Integrated Communities Study

  • M. J. Arnett
  • R. J. ThorpeJr.
  • D. J. Gaskin
  • J. V. Bowie
  • T. A. LaVeist
Article

Abstract

Compared to White Americans, African-Americans are less likely to use primary care (PC) as their usual source of care. This is generally attributed to race differences in socioeconomic status and in access to primary care services. Little is known about the relationship between race differences in medical mistrust and the usual source of care disparity. Using data from the Exploring Health Disparities in Integrated Communities (EHDIC) study, we examined the role of medical mistrust in choosing usual source of care in 1408 black and white adults who were exposed to the same healthcare facilities and low-income racially integrated community. Multinomial logistic regression models were estimated to examine the relationship between race, medical mistrust, and usual source of care. After adjusting for demographic and health-related factors, African-Americans were more likely than whites to use the emergency department (ED) (relative risk ratio [RRR] = 1.43 (95 % confidence interval (CI) [1.06–1.94])) and hospital outpatient department (RRR1.50 (95 %CI [1.10–2.05])) versus primary care as a usual source of care. When medical mistrust was added to the model, the gap between African-Americans’ and whites’ risk of using the ED versus primary care as a usual source of care closed (RRR = 1.29; 95 % CI [0.91–1.83]). However, race differences in the use of the hospital outpatient department remained even after accounting for medical mistrust (RRR = 1.67; 95 % CI [1.16–2.40]). Accounting for medical mistrust eliminated the ED-as-usual-source of care disparity. This study highlights the importance of medical mistrust as an intervention point for decreasing ED use as a usual source of care by low-income, urban African-Americans.

Keywords

Primary care Emergency department Usual source of care Medical mistrust Healthcare utilization Social context 

Notes

Acknowledgments

This work was supported by the National Center on Minority Health and Health Disparities of the National Institutes of Health (P60MD000214-01) and Pfizer, Inc.

References

  1. 1.
    Gaskin DJ, Arbelaez JJ, Brown JR, et al. Examining racial and ethnic disparities in site of usual source of care. J Natl Med Assoc. 2007; 99: 22–30.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Gaskin DJ, Price A, Brandon DT, LaVeist TA. Segregation and disparities in health services use. Med Care Res Rev. 2009; 66: 578–589.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Lillie-Blanton M, Martinez RM, Salganicoff A. Site of medical care: do racial and ethnic differences persist? Yale J Health Policy Law Ethics Spring. 2001; 1: 15–32.Google Scholar
  4. 4.
    Moy E. Changes in usual source of medical care between 1987 and 1992. J Healthcare Poor U. 1998; 9(2): 126–139.CrossRefGoogle Scholar
  5. 5.
    Bureau of the Census. Statistical abstract of the United States: 2012. Table 168. Ambulatory care visits to physicians’ offices and hospital outpatient and emergency departments: 2008. U.S Census Bureau. http://www.census.gov/compendia/statab/2012/tables/12s0168.pdf. Accessed May 4, 2015.
  6. 6.
    U.S. National Center for Health Statistics. National health statistics reports; ambulatory care visits to physicians’ offices. 2003. www.census.gov/compendia/statab/2012/tables/12s0168.xls. Accessed April 17, 2015.
  7. 7.
    Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989; 27: S110–S127.CrossRefPubMedGoogle Scholar
  8. 8.
    Starfield B. Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012. Gac Sanit. 2012; 26(1): 20–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Marchlin, D.R. Expenses for a hospital emergency room Visit. 2003. Statistical Brief#111.January 2006. Agency for healthcare research and quality, Rockville, Md. http://meps.arhq.gov/mepsweb/data_files/publications/st111/stat111.shtml Accessed April 20,2012.
  10. 10.
    Hargraves JL, Hadley J. The contribution of insurance coverage and community resources to reducing racial/ethnic disparities in access to care. Health Serv Res. 2008; 38: 809–829.CrossRefGoogle Scholar
  11. 11.
    Weinick RM, Zuvekas SH, Cohen JW. Racial and ethnic differences in access to and use of health care services, 1977-1996. Medical Care Res Rev. 2000; 57: 35–54.CrossRefGoogle Scholar
  12. 12.
    King WD. Examining African Americans’ mistrust of the health care system: expanding the research question. Commentary on “race and trust in the health care system”. Public Health Rep. 2003; 118(4): 366–7.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Scheppers E, van Dongen E, Dekker J, Geertzen J. Potential barriers to the use of health services among ethnic minorities: a review. Fam Pract. 2006; 23: 325–348.CrossRefPubMedGoogle Scholar
  14. 14.
    LaVeist TA, Isaac L, Williams K. Mistrust of health care organizations is associated with underutilization of health services. Health Serv Res. 2009; 44: 2093–2105.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Doescher MP, Saver BG, Franks P, Fiscella K. Racial and ethnic disparities in perceptions of physician style and trust. Arch Fam Med. 2000; 9(10): 1156–63.CrossRefPubMedGoogle Scholar
  16. 16.
    LaVeist TA, Nickerson KJ, Bowie JV. Attitudes about racism, medical mistrust and satisfaction with care among African american and white cardiac patients. Med Care Res Rev. 2000; 57: 146–61.CrossRefPubMedGoogle Scholar
  17. 17.
    Hammond WP, Matthews D, Mohottige D, et al. Masculinity, medical mistrust, and preventive health services delays among community-dwelling African-american Men. J Gen Inten Med. 2010; 25: 1300–1308.CrossRefGoogle Scholar
  18. 18.
    White K, Haas JS, Williams DR. Elucidating the role of place in health disparities: the example of racial/ethnic residential segregation. Health Serv Res. 2012; 47(3Pt2): 1278–99.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Massey D, White M, Voon-Chin P. The dimensions of segregation revisited. Sociol Method Res. 1996; 25: 172–206.CrossRefGoogle Scholar
  20. 20.
    Cummins S, Curtis S, Diez-Roux AV, et al. Understanding and representing ‘place’ in health research: a relational approach. Soc Sci Med. 2007; 65: 1825–1838.CrossRefPubMedGoogle Scholar
  21. 21.
    Gaskin DJ, Dinwiddie GY, Chan KS, et al. Residential segregation and the availability of primary care physicians. Health Serv Res. 2012; 47(6): 2353–76.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Kershaw KN, Diez Roux AV, Burgard SA, et al. Metropolitan-level racial residential segregation and Black-White disparities in hypertension. Am J Epidemiol. 2011; 174(5): 537–45.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    White K, Borrell LN. Racial/ethnic residential segregation: framing the context of health risk and health disparities. Health Place. 2011; 17: 438–448.CrossRefPubMedGoogle Scholar
  24. 24.
    Massey D, Fong E. Segregation and neighborhood quality: blacks, Hispanics, and Asians in the San Francisco metropolitan area. Soc Forces. 1990; 69:15–32.CrossRefGoogle Scholar
  25. 25.
    Massey DS, Gross AH, Eggers ML. Segregation, the concentration of poverty, and the life chances of individuals. So Sci Res. 1991; 20:397–420.Google Scholar
  26. 26.
    Greene J, Blustein J, Weitzman BC. Race, segregation, and Physicians’ participation in medicaid. Milbank Q. 2006; 84: 239–272.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Massey D, Fischer M. How segregation concentrates poverty. Ethnic Racial Stud. 2000; 23: 670–691.CrossRefGoogle Scholar
  28. 28.
    Gaskin DJ, Dinwiddie GY, Chan KS, McCleary RR. Residential segregation and disparities in health care services utilization. Med Care Res Rev. 2011; 69: 158–175.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Kirby JB, Kaneda T. Neighborhood socioeconomic disadvantage and access to health care. J Health Soc Behav. 2005; 46(1): 15–31.CrossRefPubMedGoogle Scholar
  30. 30.
    Smith DB. The politics of racial disparities: desegregating the hospitals in Jackson. Mississippi Milbank Q. 2005; 83(2): 247–269.CrossRefPubMedGoogle Scholar
  31. 31.
    Ko M, Ponce NA. Community residential segregation and the local supply of federally qualified health centers. Health Serv Res. 2013; 48(1): 253–270.CrossRefPubMedGoogle Scholar
  32. 32.
    Uslaner EM. Trust, diversity, and segregation in the United States and the united kingdom. Int J Comp Sociol. 2011; 10: 221–247.CrossRefGoogle Scholar
  33. 33.
    Laveist TA, Thorpe RJ, Bowen-Reid T, et al. Exploring health disparites in integrated communities: overview of the EHDIC study. J Urban Health. 2008; 85: 11–21.CrossRefPubMedGoogle Scholar
  34. 34.
    Bernstein AB, Hing E, Moss AJ, Allen KF, Siller AB, Tiggle RB. National center for health statistics: health care in America: trends in utilization. Hyattsville, Maryland: 2003. Available: http://www.cdc.gov/nchs/data/misc/healthcare.pdf. Accessed May 4, 2015.
  35. 35.
    Hosmer DW, Lemeshow S. Applied logistic regression. 2nd ed. New York: Wiley; 2000.CrossRefGoogle Scholar
  36. 36.
    StataCorp. Stata statistical software: release 11. College Sation, TX: StataCorp LP; 2009.Google Scholar
  37. 37.
    Sarver JH, Cydulka RK, Baker DW. Usual source of care and Nonurgent emergency department use. Acad Emerg Med. 2002; 9(9): 916–23.CrossRefPubMedGoogle Scholar
  38. 38.
    Hammond WP. Psychosocial correlates of medical mistrust among African American Men. Am J Community Psychol. 2010; 45(1-2): 87–106.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Brandon DT, Isaac LA, LaVeist TA. The legacy of Tuskegee and trust in medical care: is Tuskegee responsible for race differences in mistrust of medical care? J Natl Med Assoc. 2005; 97(7):951–6.PubMedPubMedCentralGoogle Scholar
  40. 40.
    Saeugling S. Showing up: the power of building trust with parents. Best Babies Zone website. http://www.bestbabieszone.org/Showing-Up-The-Power-Of-Building-Trust-With-Parents. August 26, 2015. Accessed December 28, 2015.
  41. 41.
    Pies C, Hussey W, Merrell S, Strouse C. Best babies zones- A new approach to reducing infant mortality. NAACHO Exchange. 2014; 13(1):17–19.Google Scholar
  42. 42.
    Gibbons MC. A historical overview of health disparities and the potential of eHealth solutions. J Med Internet Red. 2005; 7(5): e50.CrossRefGoogle Scholar
  43. 43.
    Christopher Gibbons M. Use of health information technology among racial and ethnic underserved communities. Perspect Health Inf Manag. 2011; 8: 1f.PubMedPubMedCentralGoogle Scholar
  44. 44.
    Nundy S, Dick JJ, Solomon MC, Peek ME. Developing a behavioral model for mobile phone-based diabetes interventions. Patient Educ Couns. 2013; 90: 125–32.CrossRefPubMedGoogle Scholar
  45. 45.
    Markwick L, McConnochie K, Wood N. Expanding telemedicine to include primary care for the urban adult. J Health Care Poor Underserved. 2015; 26(3): 771–6.CrossRefPubMedGoogle Scholar
  46. 46.
    Smedley BD, Stith AY, Nelson AR. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, D.C: National Academies Press; 2003: 199–212.Google Scholar
  47. 47.
    Weissman JS, Betancourt J, Campbell EG, et al. Resident physicians’ preparedness to provide cross-cultural care. J Am Med Assoc. 2005; 294: 1058–1067.CrossRefGoogle Scholar
  48. 48.
    Beach MC, Cooper LA, Robinson KA, et al. Strategies for improving minority healthcare quality. Rockville (MD): agency for healthcare research and quality (US); Evidence reports/technology Assessments, No. 90. http://archive.ahrq.gov/downloads/pub/evidence/pdf/minqual/minqual.pdf. Published January 2004. Accessed September 20, 2015.
  49. 49.
    Bronstein JM, Johnson VA, Fargason CA Jr. Impact of care setting on cost and quality under Medicaid. J Health Care Poor Underserved. 1997; 8(2): 202–13.CrossRefPubMedGoogle Scholar
  50. 50.
    American Hospital Association. Hospital outpatient department costs higher than physician offices due to additional capabilities, regulations. 2014. http://www.aha.org/research/policy/infographics/pdf/info-hopd.pdf. Accessed Dec 26,2015.
  51. 51.
    Shi L, Lebrun LA, Hung L, Zhu J, Tsai J. US primary care delivery after the health center growth initiative. J Ambulatory Care Manag. 2012; 35(1): 60–74.CrossRefGoogle Scholar
  52. 52.
    Rothkopf J, Brookler K, Wadhwa S, Sajovetz M. Medicaid patients seen at federally qualified health centers use hospital services less than those seen by private providers. Health Aff (Millwood). 2011; 30(7): 1335–42.CrossRefGoogle Scholar

Copyright information

© The New York Academy of Medicine 2016

Authors and Affiliations

  • M. J. Arnett
    • 1
    • 2
  • R. J. ThorpeJr.
    • 2
  • D. J. Gaskin
    • 2
  • J. V. Bowie
    • 2
  • T. A. LaVeist
    • 2
  1. 1.Perelman School of Medicine at the University of PennsylvaniaPhiladelphiaUSA
  2. 2.Hopkins Center for Health Disparities SolutionsJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA

Personalised recommendations