Simon Berthelot: The right care to the right patient at the right time from the right provider: Value-based comparison of the management of ambulatory respiratory diseases in a primary care walk-in clinic and an emergency department

Introduction: In Canada, 30 to 60% of patients presenting to emergency departments (ED) are ambulatory, i.e. not requiring an observation stretcher. This population has been controversially tagged as a source of ED overcrowding and overuse, threatening quality of care and increasing costs. Many Canadian jurisdictions have recently tried to redirect this population outside the ED. Policies promulgated in many health regions seem to suggest that walk-in clinics (WIC) and primary care physician practices (PCP) are better options than EDs, presumably offering equivalent care at a lower cost to ambulatory emergency patients. As reasonable as this approach may appear, data supporting it are scarce and contradictory.

Objectives: We will compare the quality and cost of the care given in EDs, WICs andPCPs for ambulatory patients suffering from an upper respiratory tract infection, sinusitis, bronchitis, influenza, pneumonia, acute asthma or acute exacerbation of chronic obstructive pulmonary disease.

Methods/Expertise: We will perform a multicentred prospective cohort study in four Canadian provinces. This trial will sequentially be composed of 2 phases: 1) A time-driven activity-based costing method in each study site. This method uses time as a cost driver to allocate to patient care all direct costs (e.g., medication), consumable expenditures (e.g., needle), overheads (e.g., building maintenance) and physician charges. The longer a patient spends time receiving care, the more expensive the episode of care will be. After this phase, a list of costs of all care processes (e.g. triage) will be generated and used to calculate the cost of each consultation during the next phase. 2) A prospective cohort of patients for comparing EDs, WICs and PCPs. Participants will be identified by the clinical teams. Data will be collected through local electronic medical records by research assistants and linked with provincial databases. Follow up phone calls will be made to all recruited patients, weeks 1 and 6 after the index visit. We will include the following patients: 1) aged 2 years and over; 2) ambulatory throughout the care episode; 3) with one of the targeted discharge diagnoses mentioned above; and 4) sent home for treatment. The primary outcomes for which we will compare the three settings will be: 1) the adjusted proportion of return to any ED, WIC or PCP 3 and 7 days after the index visit; 2) the adjusted mean cost of care. The secondary outcome measures will be: 1) scores on patient-reported outcome and experience measures; 2) adjusted mean costs borne by patients themselves; 3) adjusted incidence proportions of mortality and admission to hospital and intensive care within 30 days following the index visit; 4) Proportion of compliance to guidelines on respiratory diseases. Risk adjustment models will be derived for all outcome measures, controlling for age, sex, comorbidities, number of regular medications, poverty index, and vital signs. To carry out this study, we have assembled a strong research team with expertise in emergency and primary care, performance assessment, biostatistics, health economics, patient-centred research, knowledge transfer and administration.

Outcomes: The endpoint of our program will be for decision-makers, patients and care providers to be able to determine the most appropriate care setting for the management of respiratory ambulatory emergency conditions, based on each alternative’s quality and cost of care.


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