Low-acuity Emergency Department Research Articles

Redirection of low-acuity emergency department patients to nearby medical clinics using an electronic medical support system: effects on emergency department performance indicators

BackgroundOvercrowded emergency departments (EDs) are associated with higher morbidity and mortality and suboptimal quality-of-care. Most ED flow management strategies focus on early identification and redirection of low-acuity patients to primary care settings. To assess the impact of redirecting low-acuity ED patients to medical clinics using an electronic clinical decision support system on four ED performance indicators.MethodsWe performed a retrospective observational study in the ED of a Canadian tertiary trauma center where a redirection process for low-acuity patients was implemented. The process was based on a clinical decision support system relying on an algorithm based on chief complaint, performed by nurses at triage and not involving physician assessment. All patients visiting the ED from 2013 to 2017 were included. We compared ED performance indicators before and after implementation of the redirection process (June 2015): length-of-triage, time-to-initial-physician-assessment, length-of-stay and rate of patients leaving without being seen. We performed an interrupted time series analysis adjusted for age, gender, time of visit, triage category and overcrowding.ResultsOf 242,972 ED attendees over the study period, 9546 (8% of 121,116 post-intervention patients) were redirected to a nearby primary medical clinic. After the redirection process was implemented, length-of-triage increased by 1 min [1;2], time-to-initial assessment decreased by 13 min [-16;-11], length-of-stay for non-redirected patients increased by 29 min [13;44] (p < 0.001), minus 20 min [-42;1] (p = 0.066) for patients assigned to triage 5 category. The rate of patients leaving without being seen decreased by 2% [-3;-2] (p < 0.001).ConclusionImplementing a redirection process for low-acuity ED patients based on a clinical support system was associated with improvements in two of four ED performance indicators.

Emergency department visits as a potential opportunity to promote primary care attachment and modify utilization patterns – results of a pilot study in Berlin, Germany

BackgroundUtilization by low acuity patients contributes to emergency department (ED) crowding. Both knowledge deficits about adequate care levels and access barriers in primary care are important promoters of such presentations. Concurrently, not having a general practitioner (GP) increases the likelihood of low-acuity ED utilization. This pilot study thus investigated feasibility, acceptance, and potential effects of an ED-delivered intervention for low-acuity patients with no regular primary care provider, consisting of an educational leaflet on acute care options and an optional GP appointment scheduling service.MethodsLow-acuity ED consulters not attached to a GP were given an information leaflet about alternative care offers for acute health problems and offered optional personal appointment scheduling at a local GP practice. Patients were surveyed on demographics, medical characteristics, health care utilization, valuation of the intervention, and reasons for not being attached to a GP and visiting the ED. A follow-up survey was conducted after twelve months. Trends in health and health care utilization were evaluated.ResultsBetween December 2020 and April 2022, n = 160 patients were enrolled, n = 114 were followed up. The study population was characterized by young age (mean 30.6 years) and predominantly good general health. Besides good health, personal mobility was a central reason for not being attached to a GP, but general preference for specialists and bad experiences with primary care were also mentioned. Most frequently stated motives for the ED consultation were subjective distress and anxiety, a belief in the superiority of the hospital, and access problems in primary care. The interventional offers were favorably valued, 52.5% (n = 84) accepted the GP appointment scheduling service offer. At follow-up, GP utilization had significantly increased, while there were no significant changes regarding utilization of other providers, including ED. An additional practice survey showed a 63.0% take-up rate for the appointment service.ConclusionsWith this pilot study, we were able to show that a personalized appointment scheduling service seems to be a promising approach to promote GP attachment and increase primary care utilization in patients without a regular GP in a highly urbanized setting. Further larger-scale studies are needed to investigate potential quantitative effects on ED visits.Trial RegistrationGerman Clinical Trials Register (DRKS00023480); date 2020/11/27.

Triage Discordance in an Academic Pediatric Emergency Department and Disparities by Race, Ethnicity, and Language for Care

Background Minoritized patients are disproportionately represented in low-acuity emergency department (ED) visits in the United States in part caused by lack of timely access to primary and urgent care. However, there is also the possibility that implicit bias during triage could contribute to disproportionate representation of minority groups in low-acuity ED visits. Triage discordance, defined as when ED resources used are different from initial triage score predictions, can be used as a proxy for triage accuracy. Recent data suggest that discordant triage may be common, although little is known about the interaction with race, ethnicity, and language for care. Objectives This study aims to determine the prevalence of discordant triage among moderate- and low-acuity pediatric ED encounters and the interaction with patient race, ethnicity, and language for care. Methods We performed a retrospective analysis of pediatric ED encounters from 2019 with Emergency Severity Index (ESI) scores of 3, 4, or 5 at an academic referral hospital. The primary outcome was triage discordance, encompassing overtriage (ESI 3 and 4) and undertriage (ESI 4 and 5). Logistic and multinomial regressions were used to assess discordant triage by race, ethnicity, and language group. Results Triage discordance occurred in 47% (n = 18,040) of encounters. Black and Hispanic patients had higher likelihood of undertriage for ESI 5 (adjusted odds ratio 1.21, 95% confidence interval [CI] 1.01–1.46 and 1.27, 95% CI 1.07–1.52, respectively), and Black patients were more likely to be overtriaged in ESI 3 (1.18, 95% CI 1.09–1.27). Those with a language other than English for care had higher proportions of overtriage for ESI 3 (1.08, 95% CI 1.04–1.12) and undertriage for ESI 5 (1.23, 95% CI 1.11–1.37). Conclusions We found high rates of triage discordance in our pediatric ED, with significant associations with race, ethnicity, and language for care. Future research should evaluate the source of triage discordance and develop quality improvement efforts to improve equitable care.

Identifying low acuity Emergency Department visits with a machine learning approach: The low acuity visit algorithms (LAVA).

To improve the performance of International Classification of Disease (ICD) code rule-based algorithms for identifying low acuity Emergency Department (ED) visits by using machine learning methods and additional covariates. We used secondary data on ED visits from the National Hospital Ambulatory Medical Survey (NHAMCS), from 2016 to 2020. We established baseline performance metrics with seven published algorithms consisting of International Classification of Disease, Tenth Revision codes used to identify low acuity ED visits. We then trained logistic regression, random forest, and gradient boosting (XGBoost) models to predict low acuity ED visits. Each model was trained on five different covariate sets of demographic and clinical data. Model performance was compared using a separate validation dataset. The primary performance metric was the probability that a visit identified by an algorithm as low acuity did not experience significant testing, treatment, or disposition (positive predictive value, PPV). Subgroup analyses assessed model performance across age, sex, and race/ethnicity. We used 2016-2019 NHAMCS data as the training set and 2020 NHAMCS data for validation. The training and validation data consisted of 53,074 and 9542 observations, respectively. Among seven rule-based algorithms, the highest-performing had a PPV of 0.35 (95% CI [0.33, 0.36]). All model-based algorithms outperformed existing algorithms, with the least effective-random forest using only age and sex-improving PPV by 26% (up to 0.44; 95% CI [0.40, 0.48]). Logistic regression and XGBoost trained on all variables improved PPV by 83% (to 0.64; 95% CI [0.62, 0.66]). Multivariable models also demonstrated higher PPV across all three demographic subgroups. Machine learning models substantially outperform existing algorithms based on ICD codes in predicting low acuity ED visits. Variations in model performance across demographic groups highlight the need for further research to ensure their applicability and fairness across diverse populations.

Understanding low acuity emergency department presentations in infancy: A cohort study.

Low acuity presentations (LAPs) contribute to large numbers of ED presentations and carry numerous consequences. The present study sought to improve the understanding of regional infant LAPs by analysing temporal patterns of presentation, discharge diagnoses and potential predictive factors. This retrospective observational study examined ED presentations among children less than 12 months old (infants) to the Royal Prince Alfred Hospital between 2017 and 2019. Descriptive statistics were used to identify temporal patterns of presentation and common discharge diagnoses among LAPs. Multivariable logistic regression was used to determine the association between early life, demographic and perinatal factors and low acuity presenters. Of 6881 infant ED presentations, 19.8% were LAPs, occurring disproportionately on weekdays (82.2%) and during hours of 08.00-17.00 (69.9%). Respiratory tract infections and gastrointestinal complaints were most common overall, though non-allergic rash, feeding difficulties, eczema and developmental concerns contributed substantially among LAPs. Socio-economic status (SES) (odds ratio [OR] 1.71), overseas maternal nationality (OR 1.25) and Medicare ineligible maternal financial class (OR 0.49) were associated with low acuity presenters. Low appearance, pulse, grimace, activity and respiration score (OR 3.53), low SES (OR 3.26), complicated delivery (OR 1.64), maternal multiparity (OR 0.50), maternal partner presence (OR 0.40) and obstetric complications (OR 0.37) were associated with repeat, multi-low acuity presenters (multi-LAPs). A substantial minority of infant ED presentations are LAPs. Targeted interventions may benefit from focusing on families with a background of socioeconomic disadvantage, social isolation, cultural and linguistic diversity and perinatal complications, with a view to strengthening engagement with community-based services among these groups.

Is the emergency department used as a substitute or a complement to primary care in Medicaid?

Policies to decrease low-acuity emergency department (ED) use have traditionally assumed that EDs are a substitute for unavailable primary care (PC). However, such policies can exacerbate ED overcrowding, rather than ameliorate it, if patients use EDs to complement, rather than substitute, their PC use. We tested whether Medicaid managed care enrolees visit the ED for nonemergent and PC treatable conditions to substitute for or to complement PC. Based on consumer choice theory, we modelled county-level monthly ED visit rate as a function of PC supply and used 2012-2015 New York Statewide Planning and Research Cooperative System (SPARCS) outpatient data and non-linear least squares method to test substitution vs complementarity. In the post-Medicaid expansion period (2014-2015), ED and PC are substitutes state-wide, but are complements in highly urban and poorer counties during nights and weekends. There is no evidence of complementarity before the expansion (2012-2013). Analyses by PC provider demonstrate that the relationship between ED and PC differs depending on whether PC is provided by physicians or advanced practice providers. Policies to reduce low-acuity ED use via improved PC access in Medicaid are likely to be most effective if they focus on increasing actual appointment availability, ideally by physicians, in areas with low PC provider supply. Different aspects of PC access may be differently related to low-acuity ED use.

The effectiveness and decay of public health policy actions on infection-control behaviour in the general public: Evidence from a low-COVID prevalence jurisdiction.

Public health policies designed to influence individuals' infection-control behaviour are a tool for governments to help prevent the spread of disease. Findings on the impacts of policies are mixed and there is limited information on the effects of removing restrictions and how policies impact behavioural trends. We use low-acuity emergency department visits from 12 hospitals in New Brunswick, Canada, (January 2017 -October 2021) as a proxy for infection-control behaviour and provide insight into the effects of the COVID-19 virus on a population with a low prevalence of cases. Quasi-experimental techniques (event studies) are applied to estimate the magnitude and persistence of effects of specific events (e.g., policy changes), to control for COVID-19 cases and vaccines, and to explore how the effectiveness of policy changes during the pandemic as more policies are introduced. Initial tightening of restrictions on March 11, 2020 reduced low-acuity emergency department visits by around 60% and reached a minimum after 30 days. Relaxing policies on social gatherings and personal services gradually increased low-acuity emergency department visits by approximately 50% after 44 days. No effects were found from policies lifting all restrictions, and reinstating a state of emergency on July 31, 2021, and September 24, 2021. These results suggest that policy interventions are less likely to be effective at influencing infection control behaviour with time and more policies introduced, and that tracking and publicly reporting case numbers can influence infection control behaviour.

Changes in low-acuity patient volume in an emergency department after launching a walk-in clinic.

Unscheduled low-acuity care options are on the rise and are often expected to reduce emergency department (ED) visits. We opened an ED-staffed walk-in clinic (WIC) as an alternative care location for low-acuity patients at a time when ED visits exceeded facility capacity and the impending flu season was anticipated to increase visits further, and we assessed whether low-acuity ED patient visits decreased after opening the WIC. In this retrospective cohort study, we compared patient and clinical visit characteristics of the ED and WIC patients and conducted interrupted time-series analyses to quantify the impact of the WIC on low-acuity ED patient visit volume and the trend. There were 27,211 low-acuity ED visits (22.7% of total ED visits), and 7,058 patients seen in the WIC from February 26, 2018, to November 17, 2019. Low-acuity patient visits in the ED reduced significantly immediately after the WIC opened (P=0.01). In the subsequent months, however, patient volume trended back to pre-WIC volumes such that there was no significant impact at 6, 9, or 12 months (P=0.07). Had WIC patients been seen in the main ED, low-acuity volume would have been 27% of the total volume rather than the 22.7% that was observed. The WIC did not result in a sustained reduction in low-acuity patients in the main ED. However, it enabled emergency staff to see low-acuity patients in a lower resource setting during times when ED capacity was limited.

Identification of low-acuity attendances in routine clinical information documented in German Emergency Departments

IntroductionIt has not yet been possible to ascertain the exact proportion, characterization or impact of low-acuity emergency department (ED) attendances on the German Health Care System since valid and robust definitions to be applied in German ED routine data are missing.MethodsInternationally used methods and parameters to identify low-acuity ED attendances were identified, analyzed and then applied to routine ED data from two EDs of the tertiary care hospitals Charité—Universitätsmedizin Berlin, Campus Mitte (CCM) and Campus Virchow (CVK).ResultsBased on the three routinely available parameters `disposition´, `transport to the ED´ and `triage´ 33.2% (n = 30 676) out of 92 477 presentations to the two EDs of Charité—Universitätsmedizin Berlin (CVK, CCM) in 2016 could be classified as low-acuity presentations.ConclusionThis study provides a reliable and replicable means of retrospective identification and quantification of low-acuity attendances in German ED routine data. This enables both intra-national and international comparisons of figures across future studies and health care monitoring.

English- and Spanish-preferring patient perspectives on managing acute care needs at two disparate health systems.

1524 Background: Although nearly every participating provider group in Medicare’s Oncology Care Model sought to reduce emergency department (ED) use by their patients with cancer, few achieved this. Despite growing spread of specialized oncology urgent care clinics (OUCC) as an ED-alternative to treat commonly anticipated treatment-related symptoms, these clinics are underused. The University of Texas Southwestern (UTSW) and Dallas County Safety-net (Parkland Health) have run OUCCs since 2015. Parkland patients use the ED twice as often as UTSW patients in the first 6 months after cancer diagnosis. Utilizing semi-structured interviews, we investigated oncology patient perspectives on acute care needs and ED decision-making in both systems among English and Spanish-preferring patients. Methods: We interviewed 24 UTSW and 16 Parkland oncology patients (5 English-preferring, 11 Spanish-preferring). UTSW is an urban regional academic referral center serving nearly 8 million people with a cancer patient population that is 35% nonwhite and 7% Medicaid or uninsured. Parkland serves patients in Dallas County including a cancer patient population that is 77% nonwhite and 80% with Medicaid or county charity care (uninsured). Translated transcripts were analyzed using iterative thematic analysis and the constant comparative method. We evaluated decision-making, attitudes, beliefs, and barriers to access that influenced decisions to present to the ED across a diverse patient population. Results: Patients in both health systems endorsed that they did not receive adequate information about expected side effects from cancer treatment. UTSW patients described direct access (e.g., personal cell phone numbers) to their oncologist, whereas Parkland patients commonly relied on non-clinician family to triage symptoms. Parkland patients reported experiencing barriers to outpatient care (lack of insurance, language barriers, and limited access to outpatient care), and described an acculturation to visiting the ED for acute care needs. When patients called a clinician for triage advice, they were often referred to the ED. Overall, patients were largely unaware of OUCCs and a 24/7 telephone triage line, but were very interested in accessing the OUCC to avoid prolonged wait times and exposure to infectious pathogens in the ED. Conclusions: Among ED-visiting patients with cancer, we found notable disparities in rapid informal access to clinicians between oncology patients receiving care through UTSW compared to Parkland. Highlighting the available 24/7 phone line as part of patient counseling on treatment side-effects might mitigate this disparity in access, increase utilization of the OUCCs, and reduce low-acuity ED visits in both health systems. Patient perspectives provide valuable insights on how to better integrate care delivery innovations for this high-risk population.

Clinical and economic impact of a community-based, hybrid model of in-person and virtual care in a Canadian rural setting: a cross-sectional population-based comparative study

ObjectivesTo determine the clinical and economic impact of a community-based, hybrid model of in-person and virtual care by comparing health-system performance of the rural jurisdiction where this model was implemented...

Exploring the views of low-acuity emergency department consulters on an educational intervention and general practitioner appointment service: a qualitative study in Berlin, Germany

ObjectivesLow-acuity patients presenting to emergency departments (EDs) frequently have unmet ambulatory care needs. This qualitative study explores the patients’ views of an intervention aimed at education about care options and...

Maternal Emergency Department Use Before Pregnancy and Infant Emergency Department Use After Birth

Maternal emergency department (ED) use before or during pregnancy is associated with worse obstetrical outcomes, for reasons including preexisting medical conditions and challenges in accessing health care. It is not known whether maternal prepregnancy ED use is associated with higher use of the ED by their infant. To study the association between maternal prepregnancy ED use and risk of infant ED use in the first year of life. This population-based cohort study included all singleton livebirths in all of Ontario, Canada, from June 2003 to January 2020. Any maternal ED encounter within 90 days preceding the start of the index pregnancy. Any infant ED visit up to 365 days after the index birth hospitalization discharge date. Relative risks (RR) and absolute risk differences (ARD) were adjusted for maternal age, income, rural residence, immigrant status, parity, having a primary care clinician, and number of prepregnancy comorbidities. There were 2 088 111 singleton livebirths; the mean (SD) maternal age was 29.5 (5.4) years, 208 356 (10.0%) were rural dwelling, and 487 773 (23.4%) had 3 or more comorbidities. Among singleton livebirths, 206 539 mothers (9.9%) had an ED visit within 90 days before the index pregnancy. ED use in the first year of life was higher among infants whose mother had visited the ED before pregnancy (570 per 1000) vs those whose mother had not (388 per 1000) (RR, 1.19 [95% CI, 1.18-1.20]; ARD, 91.1 per 1000 [95% CI, 88.6-93.6 per 1000]). Compared with mothers without a prepregnancy ED visit, the RR of infant ED use in the first year was 1.19 (95% CI, 1.18-1.20) if its mother had 1 prepregnancy ED visit, 1.18 (95% CI, 1.17-1.20) following 2 visits, and 1.22 (95% CI, 1.20-1.23) after at least 3 maternal visits. A low-acuity maternal prepregnancy ED visit was associated with an adjusted odds ratio (aOR) of 5.52 (95% CI, 5.16-5.90) for a low-acuity infant ED visit, which was numerically higher than the pairing of a high-acuity ED use between mother and infant (aOR, 1.43, 95% CI, 1.38-1.49). In this cohort study of singleton livebirths, prepregnancy maternal ED use was associated with a higher rate of ED use by the infant in the first year of life, especially for low-acuity ED use. This study's results may suggest a useful trigger for health system interventions aimed at reducing some ED use in infancy.

Algorithms identifying low-acuity emergency department visits: A review and validation study.

To characterize and validate the landscape of algorithms that use International Classification of Disease (ICD) codes to identify low-acuity emergency department (ED) visits. Publicly available ED data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). We systematically searched for studies that specify algorithms consisting of ICD codes that identify preventable or low-acuity ED visits. We classified ED visits in NHAMCS according to these algorithms and compared agreements using the Jaccard index. We then evaluated the performance of each algorithm using positive predictive value (PPV) and sensitivity, with the reference group specified using low-acuity composite (LAC) criteria consisting of both triage and clinical components. In sensitivity analyses, we repeated our primary analysis using only triage or only clinical criteria for reference. We used the 2011-2017 NHAMCS data, totaling 163,576 observations before survey weighting and after dropping observations missing a primary diagnosis. We translated ICD-9 codes (years 2011-2015) to ICD-10 using a standard crosswalk. We identified 15 papers with an original list of ICD codes used to identify preventable or low-acuity ED presentations. These papers were published between 1992 and 2020, cited an average of 310 (SD 360) times, and included 968 (SD 1175) codes. Pairwise Jaccard similarity indices (0=no overlap, 1=perfect congruence) ranged from 0.01 to 0.82, with mean 0.20 (SD 0.13). When validated against the LAC reference group, the algorithms had an average PPV of 0.308 (95% CI [0.253, 0.364]) and sensitivity of 0.183 (95% CI [0.111, 0.256]). Overall, 2.1% of visits identified as low acuity by the algorithms died prehospital or in the ED, or needed surgery, critical care, or cardiac catheterization. Existing algorithms that identify low-acuity ED visits lack congruence and are imperfect predictors of visit acuity.

258EMF Urgent Care Centers Deter Some Emergency Department Visits But, On Net, Increase Spending

Urgent care clinics (UCCs) have been proliferating rapidly and have the potential to alter many aspects of unscheduled care delivery. These clinics offer low wait times and convenient sites of care. Therefore they could lower emergency department (ED) utilization, but may also increase the total number of visits for minor ailments, offsetting these cost savings. Little is known about their impact on emergency department visits or overall health care utilization. We utilize claims from a large, national insurer involving 14.1 million urgent care clinic visits and 9.8 million ED visits from 2008 to 2018. We use a differences-in-differences framework to study how low acuity ED visits in each ZIP code change when low acuity UCC visits increase. We combine these estimates with the insurer’s cost data to determine how out-of-pocket and overall costs changed in the difference-in-differences framework. Population studied: All individuals covered by a single insurer across 50 states in ZIP codes with greater than 30 enrollees any year in the study period. Values were weighted by the number of enrollees. We confirm a secular decrease in low acuity ED visits and increase in UCC claims over the study period. Overall, mean UCC visits per 1,000 enrollees increased from 56.1 to 129.9 between the early period (2008-2011) and the later period (2015-2018), representing a 73.8 [(73.0, 74.7) 95% CI] increase in visits per 1,000 enrollees. ED visits dropped from 63.7 to 59.9 per 1,000 enrollees, representing a -3.8 [(-4.1, -3.5) 95% CI] decrease. At the ZIP code level, there were 3,895 ZIP codes with a decline or no change in the number of UCC visits, and 20,272 with an increase. In ZIP codes with a decline in UCC visits, ED visits per 1,000 enrollees increased from 55.4 to 57.0 (change of 1.6 per enrollee [(0.7, 2.5) 95% CI]). ZIP codes with an increase in UCC visits experienced 81.8 more UCC visits per 1,000 enrollees but fewer ED visits: from 64.3 per 1,000 enrollees to 60.0 (change of -4.2 per enrollee [(-4.5, -3.9) 95% CI]). Lower acuity ED visits have declined in areas where urgent care visits have increased. However, urgent care visits have expanded much more rapidly than lower acuity emergency department visits have declined. Implications for policy or practice: Unlike retail clinics and telemedicine, urgent care clinics offer the possibility of offsetting some emergency department visits for lower acuity diagnoses. Their impact on the total costs of unscheduled care visits may be more ambiguous.

Resource Utilization During Low-Acuity Pediatric Emergency Department Visits.

The aims of the study were to estimate testing and treatment rates among pediatric low-acuity emergency department (ED) visits and to compare testing and treatment patterns at general and pediatric-specific EDs. We performed a cross-sectional study of triage level 4 or 5 pediatric visits from a complex survey of nonfederal US EDs from 2008 to 2017. We analyzed demographics, vital signs, disposition, testing, and treatment. We calculated proportions for each data element and used χ2 tests to determine differences between general and pediatric EDs. There were an estimated 306.2 million pediatric visits with 129.1 million acuity level 4 or 5 visits (57.2%; 95% confidence interval, 55.4%-58.9%), with diagnostic testing performed in 47.1% and medications administered in 69.6% of the visits. Most low-acuity visits (82.0%) were to general EDs. Tests performed more frequently in general EDs compared with pediatric EDs included radiographs (25.8% vs 15.7%, P < 0.01), complete blood count (6.4% vs 3.9%, P < 0.01), electrolytes (11.6% vs 3.7%, P < 0.01), and glucose (2.0% vs 0.9%, P < 0.01). Ultrasound was used less frequently in general EDs (0.5 vs 0.7, P < 0.01). There were similar rates of intravenous fluid and overall medication administration and a higher proportion of patients receiving antibiotics in general EDs (28.7% vs 23.8%, P < 0.01). More than half of pediatric visits to the ED are low acuity. Although general EDs relied on more imaging, blood testing and antibiotics, and pediatric EDs on ultrasound, overall resource utilization was high in this population across both ED types and can likely be reduced.

Low-acuity emergency department use among patients in different primary care models in Hamilton and Ontario.

Jurisdictions such as Hamilton, Ontario, where most primary care practices participate in patient enrolment models with enhanced after-hours access, may demonstrate overall improved health equity outcomes. Non-urgent Emergency Department (ED) use has been suggested as an indicator of primary care access; however, the impact of primary care access on ED use is uncertain and likely varies by patient and contextual factors. This population-based, retrospective study investigated whether or not different primary care models were associated with different rates of non-urgent ED visits in Hamilton, a city with relatively high neighbourhood marginalization, compared to the rest of Ontario from 2014/2015 to 2017/2018. In Ontario, enrolment capitation-based practices had more non-urgent ED visits than non-enrolment fee-for-service practices. In Hamilton, where most of the city’s family physicians are in enrolment capitation-based practices, differences between models were minimal. The influence of primary care reforms may differ depending on how they are distributed within regions.

Workload and patterns of care in the Timmins Family Health Team in Ontario.

To characterize primary care physician and nurse practitioner ("GP") workload and availability, and any relationship with daytime, low-acuity emergency department (ED) and after-hours walk-in clinic (WIC) visit counts. Retrospective database review. Timmins, Ont, with 5 family health team (FHT) office sites, 1 after-hours FHT WIC, and 1 ED. An anonymous data set representing 21 voluntarily enrolled GPs comprising 33 211 office appointments among 15 908 patients, plus 2043 ED visits and 2713 WIC visits, over 18 months. Roster size corrections for inactive ("dormant") patients, nursing supports, and patient complexity (age and sex). Availability of GPs was defined as the corrected number of office visits per patient per year. Linear and nonlinear relationships between GP availability and each roster's chronic disease burden (congestive heart failure, chronic obstructive pulmonary disease, and diabetes); ED visit count per patient; and WIC visit count per patient. Corrections for dormant patients and then for each of relative nursing support and patient complexity changed roster sizes by a mean (SD) of -8.4% (14.5%), -7.1% to 5.6% (median -1.6%), and 32.0% (18.2%), respectively. Combining these corrections increased effective roster size by a mean (SD) of 18.4% (7.3%). Larger rosters were not proportionately more dormant. In the Timmins FHT, GPs saw unique patients about 2.05 times per year (range 1.39 to 3.81). Availability of GPs did not change with increasing numbers of patients with congestive heart failure, chronic obstructive pulmonary disease, or diabetes in the roster. The ED diversion model had low explanatory power and was likely unreliable. The WIC diversion model was more robust, predicting 0.08 fewer WIC visits per patient per year if GP availability increased from 2.0 to 3.0 visits per patient per year (relative risk reduction of 41%). Sampled GPs manage a more complex patient population on average than their uncorrected roster sizes imply. There was no evidence that larger rosters or those with more patients with comorbid conditions reduced GP availability. Increasing physician availability might decrease WIC attendance.

Examination of Caregiver Social Factors and Its Influence on Low-Acuity Pediatric Emergency Department Utilization.

Social factors, such as adverse childhood experiences (ACEs), often influence health care utilization. Our study explores the association between caregiver social factors and low-acuity pediatric emergency department (ED) utilization, with the hypothesis that caregivers with high ACE exposure may use ED services more frequently for low-acuity complaints. In this case-control study, we performed surveys of caregivers with children aged 1 to 12 years registered for care in our pediatric ED. We defined high utilizers (cases) as those children with ≥3 low-acuity visits in the previous year and low utilizers (controls) as having no prior low-acuity visits, exclusive of the current visit. We compared the proportion of high ACE exposure (≥4 ACEs) between both groups. We enrolled 114 cases and 134 controls. We found no association between number of ACEs and odds of being a case or control (ED utilization). Demographics were significantly different between the 2 groups (ie, caregiver age, race, education, and household income); caregiver ACE exposure was high in both groups (20.2% cases vs 29.1% controls with [≥4 ACEs]). Although we did not find an association between caregiver ACEs and frequent low-acuity pediatric ED utilization, our data shed light on the overall prevalence of caregiver ACEs in families that seek care in our pediatric ED, even for the first time. Our findings emphasize the risk of conscious bias that can lead to inaccuracy: assuming that it is only high utilizers who experience social stressors. Future work should explore the contribution of structural inequities that influence caretakers' decisions to seek care for their children for low-acuity complaints, and consider types of interventions that could address and mitigate these inequities.

Impact of the COVID-19 Pandemic on the Loading and Quality of an Emergency Department in Taiwan: Enlightenment from a Low-Risk Country in a Public Health Crisis.

The impact of the coronavirus disease 2019 (COVID-19) pandemic on health-care quality in the emergency department (ED) in countries with a low risk is unclear. This study aimed to explore the effects of the COVID-19 pandemic on ED loading, quality of care, and patient prognosis. Data were retrospectively collected from 1 January 2018 to 30 September 2020 at the ED of Tri-service general hospital. Analyses included day-based ED loading, quality of care, and patient prognosis. Data on triage assessment, physiological states, disease history, and results of laboratory tests were collected and analyzed. The number of daily visits significantly decreased after the pandemic, leading to a reduction in the time to examination. Admitted patients benefitted from the pandemic with a reduction of 0.80 h in the length of stay in the ED, faster discharge without death, and reduced re-admission. However, non-admitted visits with chest pain increased the risk of mortality after the pandemic. In conclusion, the COVID-19 pandemic led to a significant reduction in low-acuity ED visits and improved prognoses for hospitalized patients. However, clinicians should be alert about patients with chest pain due to their increased risk of mortality in subsequent admission.