After-hours primary care and non-urgent emergency department use by adult patients from St. John's, Newfoundland & Labrador

Siromani, Jerome D. (2023) After-hours primary care and non-urgent emergency department use by adult patients from St. John's, Newfoundland & Labrador. Doctoral (PhD) thesis, Memorial University of Newfoundland.

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Abstract

Background: Wait times in Canadian Emergency Departments are among the highest in the industrialized world, and avoidable Emergency Department (ED) visits have been associated with greater costs. Primary Objective: Describe the relationship between after-hours care by Family Physicians (FPs) and low-acuity ED visits by adult patients from the St. John’s Metropolitan Area (SJMA), while controlling for non-modifiable patient characteristics. Methods: A retrospective cross-sectional observational study utilizing administrative data (2011-2015) was performed. Residents of the SJMA were assigned to their most frequent provider of primary care services according to Fee-For-Service (FFS) billings and patient records from university-affiliated Academic Family Physicians (AFPs). FPs practicing under the FFS model were categorized according to the percentage of their billings that included a supplementary after-hours fee code (i.e., <5%, 5-14.9%, 15-24.9%, and >25%), which served as a proxy for access to after-hours care. AFPs were in a distinct category because they practice in a unique model, which includes (a) 24/7 access to telephone triage, (b) follow-up that might include an after-hours visit, and (c) no FFS billings. Regression models included a categorical predictor variable, which comprised patients categorized via after-hours billings of FFS FPs, as well as patients of AFPs. To further clarify the relationship identified above, the relationship between after-hours billings and low-acuity ED visits was examined - with calendar date as the unit of analysis. Results: Differences in access to after-hours care among patients of FFS FPs were not associated with a difference in low-acuity ED visits, but patients of AFPs made significantly fewer low-acuity ED visits. With the reference category comprising patients of FFS FPs who had <5% of after-hours billings, the respective Rate Ratios (95% Confidence Intervals) were 0.99 (0.9-1.09) for the 5-14.9% category, 1.05 (0.88-1.27) for the 15-24.9% category, and 0.99 (0.83-1.18) for the >25% category, while it was 0.83 (0.7-0.99) for the category comprising AFPs. Per calendar date, more after-hours visits to FPs were associated with more low-acuity ED visits. Conclusion: After-hours care provided by FFS FPs was not associated with a reduction in low-acuity ED visits, but patients of AFPs appeared to make low-acuity ED visits less frequently.

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