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 (PCP) and walk-in clinics (WIC) 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, WICs and PCPs 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 Québec. 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 (e.g. medication), consumable expenditures (e.g. needles), overhead (e.g. 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 EDs, WICs and PCPs. 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 be: 1) scores on patient-reported outcome and experience measures; 2) mean costs borne wholly by patients; 3) incidence proportions of mortality and admission to hospital and intensive care within 30 days following the initial visit; 4) the proportion of compliance with guidelines on the treatment of respiratory diseases.

Results:

Data collection for phase 1 will begin in 2021 and recruitment for phase 2 will begin in 2023. We expect results to 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.