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Abstract. Objective: After a pilot study suggested that African American patients enrolled in managed care organizations (MCOs) were more likely than whites to be denied authorization for emergency department (ED) care through gatekeeping, the authors sought to determine the association between ethnicity and denial of authorization in a second, larger study at another hospital. Methods: A retrospective cohort design was used, with adjustment for triage score, age, gender, day and time of arrival at the ED, and type of MCO. Results: African Americans were more likely to be denied authorization for ED visits by the gatekeepers representing their MCOs even after adjusting for confounders, with an odds ratio of 1.52 (95% CI = 1.18 to 1.94). Conclusions: African Americans were more likely than whites to be denied authorization for ED visits. The observational study design raises the possibility that incomplete control of confounding contributed to or accounted for the association between ethnicity and gatekeeping decisions. Nevertheless, the questions that these findings raise about equity of gatekeeping indicate a need for additional research in this area. half of those ED visits are for nonurgent problems. 4,5 Because charges for ED care are typically higher than charges for care of comparable illnesses treated in traditional primary care settings 6 and because of a belief that patients may benefit from the enhanced continuity of care provided in a traditional primary care setting, some policy makers have advocated strategies to reduce ED use for nonurgent problems. [7][8][9][10]

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