Simon Berthelot

Years since first academic appointment: Less than 5 years

Title: The right care to the right patient at the right time from the right provider: new quality indicators for a value-based comparison of primary and emergency department care

Authors: Berthelot S, Blais S, Bissonnette L, Légaré F, Moore L, Lavergne R, Émond M, Lang E, Stelfox HT, Mercier E, Guimont C, Forest JC

Protocol: In November of 2015, Bill 20 was adopted by the National Assembly of Québec to improve patient access and loyalty to family physicians and reduce avoidable emergency department (ED) visits. The Ministry of Health Care has also launched a program to create 50 family medicine super-clinics around the province to divert urgent ED visits that could be treated in a non-ED setting. Promoting family physicians as the primary access point to the health care system for urgent health concerns reflects the government’s assumption that primary care facilities offer high-quality and more affordable ambulatory emergency care. To our knowledge, this assumption has never been formally tested.

By developing accurate costing methods and ambulatory emergency care quality indicators (QI), our research program, to which this research project is attached, will compare primary care clinics to EDs for non-urgent cases, using a value-based approach. Value is defined as health outcomes per dollar spent and is best represented by the formula V=P/C, where V represents value; P represents performance, measured with different clinical outcome indicators; and C is the incurred costs to obtain such outcomes. This approach promotes the best care at the lowest cost.

This study proposal specifically aims to identify and validate performance indicators for ambulatory emergency care (P in V=P/C). We will derive new indicators using the concept of ambulatory emergency sensitive conditions that could be defined as conditions for which care provided to similar patients in either primary care clinics or EDs may have an impact on patient outcomes.

Our primary objectives are: 1) To develop indicators for ambulatory emergency sensitive conditions; 2) To test the availability, the reliability, and the construct validity of these indicators.

To reach those objectives, we propose a 3-year research project composed of two phases.

Phase 1: RAND/UCLA Appropriateness Method to identify QIs for ambulatory emergency care. This phase will include a scoping review to develop a list of potential QIs; a deliberative process with a steering committee and a panel of experts; a minimum of three rounds of ratings and a video conference.

Phase 2: Retrospective cohort study to validate selected QIs. We will test and validate the retained QIs in an ED and a primary care clinic of Québec city. Data will be obtained from administrative databases through automated data extraction or manual chart reviews.

By seeking to improve our knowledge on the complex interactions between primary care clinics, our results will help health system stakeholders to 1) determine the function that primary care clinics and EDs should have on the continuum of care; 2) define the most appropriate ambulatory emergency care paths based on patient needs, quality of care and costs; and 3) ensure that the right patient receives the right services at the right time by the right provider.


What would be the best approach to develop a countrywide collaboration that would have the goal to 1) further validate the developed QIs and 2) compare value of care between EDs and primary care walk-in clinics?