Effects of Race, Income, and Psychological Well-being on HIV Patient Decisions about Emergency Department (ED) Use

Gifford AL, Collins R, Timberlake D, Bozzette S, Shapiro M, Schuster MA, Kanouse D. Effects of Race, Income, and Psychological Well-being on HIV Patient Decisions about Emergency Department (ED) Use. Paper presented at: VA HSR&D National Meeting; 1999 Feb 24; Washington, DC.

Objectives: Veterans with HIV often choose the ED for care of both non-urgent and urgent symptoms, however ED care is expensive, and quality of care may suffer due to poor integration of ED care with primary care. To understand what determines HIV patient decisions to go to the ED or to their usual source of primary care (USOC), we interviewed a probability sample of both veteran and non-veteran HIV patients in the U.S. to determine how they would seek care in response to several symptom scenarios. Methods: A nationally representative probability sample of all U.S. HIV+ adults in care underwent detailed structured interviews. Three brief clinical scenarios describing headache, respiratory, and other HIV-related symptoms were asked of each subject. Different scenarios were asked of early stage (non-AIDS) and late stage (AIDS) patients. Scenario response options included 'I would go to the emergency room' and 'I would go to the doctorÆs office the same day.' Sociodemographic (SD), access to care, health status, psychological, and knowledge/attitude/belief (KAB) variables were also assessed. Weights were used to adjust for the sampling design, and non-response; linearization methods corrected for weights and multistage sample design. Proportional logit models to identify independent predictors of propensity to seek ED care were estimated separately for early and late stage patients. A hypothesis-driven regression approach was used to evaluate the relative contributions of SD, access, health, and KAB variables to propensity to choose ED care (among those who would seek immediate care).Results: Data were collected from 1245 non-AIDS and 1612 AIDS patients representing 86,800 and 126,420 HIV patients respectively nationwide. In a full multivariate model of those with AIDS, African-American race was the strongest independent predictor of propensity to use the ED (Adjusted odds ratio [AOR] compared with white 2.87, p < .0001), even with adjustment for all other SD, access, health, psychological, and KAB variables. Other independent predictors were low income (AOR 1.64, p < .04), low psychological well-being (AOR 1.08, p < .02), cognitive denial coping (AOR 1.01, p < .05), and several access (travel time to USOC, usually see the same person at USOC, length of time with same USOC provider) and attitude (prefer doctor to make decisions) variables. Among HIV+ patients without AIDS, African-American race was again the strongest independent predictor of propensity to use the ED (AOR 3.73, p < .0001), again with adjustment for all other variables; Hispanic ethnicity was also a predictor (AOR 2.17, p < .005), as was female gender (AOR 1.45, p < .03). Other predictors were again low income (AOR 2.00, p < .009), low psychological well-being (AOR 1.11, p < .02), and access (wait time for appointment date, wait time at appointment) variables. Health insurance category was not associated with propensity to use the ED in either model. Conclusions: African-American race is a significant, independent predictor of propensity to use the ED across stages of disease, even after adjustment for access, income, insurance, and other variables. Income, psychological well-being, and access variables are also important.Impact: Cultural preferences or habits that go beyond socioeconomic and access issues may influence propensity to use the ED among African-Americans.