JMIR Publications

ABSTRACT

Background:

In Canada, 30% to 60% of patients presenting to emergency departments (ED) are ambulatory. This category has been labeled as a source of ED overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible and thereby lighten the load on EDs. Data in support of this approach remain scarce and equivocal.

Objective:

We aim to compare the value of the care received in EDs, walk-in clinics and primary care practices by ambulatory patients suffering from upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma or acute exacerbation of chronic obstructive pulmonary disease.

Methods:

A multicenter prospective cohort study will be performed in Ontario and Quebec. In phase 1, a time-driven activity-based costing method will be applied at each of 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead (eg, building maintenance) and physician charges to patient care. The cost of a care episode thus will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored in order to compare the care received in each setting. Patients shall be aged 18 years and over, ambulatory throughout the care episode and discharged to home with one of the targeted diagnoses mentioned above. The estimated sample size is 1,485 patients. The three types of care setting will be compared on the basis of primary outcomes in terms of (1) the proportion of return visits to any site 3 and 7 days after the initial visit, (2) the mean cost of care. The secondary outcomes measured will include: (1) scores on patient-reported outcome and experience measures, and (2) mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness.

Results:

Phase 1 will begin in 2021 and phase 2, in 2023. Results will be available in 2025.

Conclusions:

The endpoint of our program will be for deciders, patients and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative.