Identifying Acuity Level-Based Adult Emergency Department Use Time Trends Across Demographic Characteristics

Homelessness and Emergency Department Use: Wait Time Disparities Across Triage Acuity Levels

Introduction Certain patient groups perceive specific barriers to accessing primary care, resulting in increased emergency department (ED) use for non-emergency conditions. There is evidence coming from other countries that homeless people are treated differently in accessing emergency services. Examination of ED wait time by demographic characteristics provides pertinent information to identify subgroups that are more subject to the consequences or causes of access block and delayed treatment.  Methods We analyzed five years of Emergency Department Information System (EDIS) visit records of the largest tertiary care center in Atlantic Canada. The wait time from triage to seeing a physician was the outcome, housing status was the main exposure, and age and gender were the predictors. Quantile regressions were carried out to identify the influence of homeless visits in meeting the Canadian Association of Emergency Physicians (CAEP) wait time benchmarks for each Canadian Triage and Acuity Scale (CTAS) level. The classification and regression tree method was used to quantify and classify the demographic subgroups contributing to wait time disparities across CTAS levels. Results Homeless visit median wait times that exceeded the three-hour CAEP benchmark were significantly longer for urgent (by 40 minutes, CI: 25-55), semi-urgent (by 31 minutes, CI: 17-45), and non-urgent (by 57 minutes, CI: 25-89) than acuity level-matched domiciled visit wait times. At the 50th percentile, one-hour benchmark homeless triaged as semi-urgent waited (median=20 minutes, CI: 12-28) longer, and no other triage-level differences were found at this benchmark. Homeless emergent-level visits that exceeded the three-hour benchmark were 28 minutes, on average, shorter than domiciled patients of the same acuity level. Homeless females above 40 stayed the longest for non-urgent care (mean=173 minutes), 82 minutes longer (p=0.0001) than age-gender-acuity level-matched domiciled patients. Homelessness was the most prominent ED wait time classifier for non-urgent, ED visits. Overall, homeless patients triaged as CTAS-5 waited 30 minutes longer (p=0.0001) than domiciled patients triaged as CTAS-5. Homeless male 16-20-year-olds waited the shortest time of 72 minutes.  Conclusion Homelessness-related wait time disparities exist in the low acuity non-urgent-level ED visits more than in the other levels, supporting the theory that lack of primary care access is a driver of ED use in this group. Our acuity level analysis supports that homeless people of a certain age (older) and gender groups (female) wait longer than their age-gender-matched domiciled patients to be seen by a physician in low acuity level presentations. Given the pattern of the homeless being seen earlier or statistically similar in emergent-level visits compared to matched domiciled patients and that 16-20-year-old homeless males were seen on average within 72 minutes (the shortest mean wait time reported for the triage level CTAS-5), we decline the notion of discrimination at the study site ED. If homeless patients' non-urgent needs were met elsewhere, pressure on the ED to meet benchmarks might be reduced.

Does the definition of preventable emergency department visit matter? An empirical analysis using 20 million visits in Ontario and Alberta

OBJECTIVES

This study had two objectives: (1) to estimate the prevalence of preventable emergency department (ED) visits during the 2016-2020 time period among those living in 19 large urban centers in Alberta and Ontario, Canada, and (2) to assess if the definition of preventable ED visits matters in estimating the prevalence.

METHODS

A retrospective, population-based study of ED visits that were reported to the National Ambulatory Care Reporting System from April 1, 2016, to March 31, 2020, was conducted. Preventable ED visits were operationalized based on the following approaches: (1) Canadian Triage and Acuity Scale (CTAS), (2) ambulatory care-sensitive conditions (ACSC), (3) family practice-sensitive conditions (FPSC), and (4) sentinel nonurgent conditions (SNC). The overall proportion of ED visits that were preventable was estimated. We also estimated the adjusted relative risks of preventable ED visits by patients' sex and age, fiscal year, province of residence, and census metropolitan area (CMA) of residence.

RESULTS

There were 20,171,319 ED visits made by 8,919,618 patients ages 1 to 74 who resided in one of the 19 CMAs in Alberta or Ontario. On average, there were 2.26 visits per patient over the period of 4 fiscal years; most patients made one (44.22%) or two ED visits (20.72%). The overall unadjusted prevalence of preventable ED visits varied by definition; 35.33% of ED visits were defined as preventable based on CTAS, 12.88% based on FPSC, 3.41% based on SNC, and 2.33% based on ACSC.

CONCLUSIONS

There is a substantial level of variation in prevalence estimates across definitions of preventable ED visits, and care should be taken when interpreting these estimates as each has a different meaning and may lead to different conclusions. The conceptualization and measurement of preventable ED visits is complex and multifaceted and may not be adequately captured by a single definition.