Date of Award

January 2018

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Brita Roy

Second Advisor

Marcella Nunez Smith


The purpose of the study is to investigate whether higher prevalence of place-based structural determinants of health inequity is directly associated with frequent utilization of services in the emergency department. Chi-square and t-test analyses found that compared to non-frequent ED users, frequent ED users were older (mean age 43.18 vs. 35.23, p<0.001), more commonly Black or African American (65.13% vs. 52.36%, p<0.001), more commonly covered by public insurance [Medicaid (50.62% vs. 36.66%, p<0.001) or Medicare (15.45% vs. 11.41%, p<0.001)] and more commonly unemployed (41.04% vs. 33.09%, p<0.001). Multivariate logistic regression analysis demonstrated that several person-level factors, age of sixty years and older (OR: 3.57; CI [3.38-3.77]), female gender (OR: 1.40; CI [1.32-1.48]), and history of chronic pain (OR: 1.30; CI [1.13-1.50]) significantly increased the likelihood of being diagnosed in the ED with an ACSC (Table 9). Finally, multivariate logistic regression analysis also demonstrated that both person-level factors—homelessness (OR: 3.74; CI [2.35-5.95]), history of abuse (OR: 1.79; CI [1.54-2.09]), and history of substance use disorder (OR: 1.53; CI [1.37- 1.69])—and place-level factors with housing instability (1.36; CI [1.33-1.39]) were associated with frequent ED utilization. Using multilevel analysis, compared to within census tracts, the variance between census tracts was found to be greater (3.29 vs. 0.046). In conclusion, there is some evidence that residing in an area with greater prevalence of a social need domain, specifically housing instability, is associated with increased utilization of ED services.


The student author of this thesis is grateful for all the guidance and support provided by both faculty and community mentors. She is thankful for the time of Mark Abraham, Executive Director of DataHaven, who expressed faith in this project and its potential to inform subsequent initiatives in community-based interventions targeting structural determinants of health in the Greater New Haven area. She is also appreciative of the unwavering optimism and patience provided by Elizabeth Samuels, MD, MPH from the conception of this project. The author is grateful for the guidance and time of her thesis advisor, Brita Roy, MD, MPH, MHS, throughout the entire process of working on this thesis.

Research reported in this publication was supported by National Heart, Lung And Blood Institute of the National Institutes of Health. The content is solely the responsibility of the author’s and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health under Award Number T35HL007649. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.


This thesis is restricted to Yale network users only. It will be made publicly available on 05/29/2021