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BACKGROUND Residential segregation is a spatial manifestation of structural racism. Racial disparities in emergency department (ED) utilization mirror social inequity in the larger community. We evaluated associations between residential segregation and ED utilization in a community with known disparities and geographically concentrated social and health risk. METHODS Cross-sectional data were collected from electronic medical records of 101 060 adult ED patients living in Mecklenburg County, North Carolina in 2017. Community context was measured as residential segregation using the dissimilarity index, categorized into quintiles (Q1-Q5) using 2013-2017 American Community Survey estimates, and residency in a public health priority area (PHPA). The outcome was measured as total ED visits during the study period. Associations between community context and ED utilization were modeled using Anderson's behavioral model of health service utilization, and estimated using negative binomial regression, including interaction terms by race. RESULTS Compared to areas with the lowest proportions of Black residents (Q1), living in Q4 was associated with higher rates of ED utilization among Black/Other (AME = 0.11) and White (AME = 0.23) patients, while associations with living in Q5 were approximately equivalent (AME = 0.12). PHPA residency was associated with higher rates of ED utilization among Black/Other (AME = 0.10) and White patients (AME = 0.22). LIMITATIONS Associations should not be interpreted as causal, or be generalized to the larger community without ED utilization. Health system leakage is possible but limited. CONCLUSIONS Residential segregation is associated with higher rates of ED utilization, as are PHPA residency and other individual-level determinants., (© 2022 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Objective: To examine whether and how avoidable emergency department (ED) utilization is associated with ambulatory or primary care (APC) utilization, insurance, and interaction effects., Design and Sample: A cross-sectional analysis of electronic health records from 70,870 adults residing in Mecklenburg County, North Carolina, who visited an ED within a large integrated healthcare system in 2017., Methods: APC utilization was measured as total visits, categorized as: 0, 1, and > 1. Insurance was defined as the method of payment for the ED visit as: Medicaid, Medicare, private, or uninsured. Avoidable ED utilization was quantified as a score (aED), calculated as the sum of New York University Algorithm probabilities multiplied by 100. Quantile regression models were used to predict the 25th, 50th, 75th, 95th, and 99th percentiles of avoidable ED scores with APC visits and insurance as predictors (Model 1) and with an interaction term (Model 2)., Results: Having >1 APC visit was negatively associated with aED at the lower percentiles and positively associated at higher percentiles. A higher aED was associated with having Medicaid insurance and a lower aED was associated with having private insurance, compared to being uninsured. In stratified models, having >1 APC visit was negatively associated with aED at the 25th percentile for the uninsured and privately insured, but positively associated with aED at higher percentiles among the uninsured, Medicaid-insured, and privately insured., Conclusions: The association between APC utilization and avoidable ED utilization varied based on segments of the distribution of ED score and differed significantly by insurance type., Competing Interests: Declaration of Competing Interest The authors report no conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)