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A value-based comparison of the management of respiratory diseases in walk-in clinics and emergency departments

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Abstract

Objectives

Our aim was to compare some of the health outcomes and costs associated with value of care in emergency departments (ED) and walk-in clinics for ambulatory patients presenting with an acute respiratory disease.

Methods

A health records review was conducted from April 2016 through March 2017 in one ED and one walk-in clinic. Inclusion criteria were: (i) ambulatory patients at least 18 years old, (ii) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. Primary outcome was the proportion of patients returning to any ED or walk-in clinic within three and seven days of the index visit. Secondary outcomes were the mean cost of care and the incidence of antibiotic prescription for URTI patients. The cost of care was estimated from the Ministry of Health’s perspectives using time-driven activity-based costing.

Results

The ED group included 170 patients and the walk-in clinic group 326 patients. The return visit incidences at three and seven days were, respectively, 25.9% and 38.2% in the ED vs. 4.9% and 14.7% in the walk-in clinic (adjusted relative risk (arr) of 4.7 (95% CI 2.6–8.6) and 2.7 (1.9–3.9)). The mean cost ($Cdn) of the index visit care was 116.0 (106.3–125.7) in the ED vs. 62.5 (57.7–67.3) in the walk-in clinic (mean difference of 56.4 (45.7–67.1)). Antibiotic prescription for URTI was 5.6% in the ED vs. 24.7% in the walk-in clinic (arr 0.2, 0.01–0.6).

Conclusions

This study is the first in a larger research program to compare the value of care between walk-in clinics and the ED. The potential advantages of walk-in clinics over EDs (lower costs, lower incidence of return visits) for ambulatory patients with respiratory diseases should be considered in healthcare planning.

Résumé

Objectifs

Notre objectif était de comparer certains des résultats sanitaires et des coûts associés à la valeur des soins dans les services d'urgence et les cliniques sans rendez-vous pour les patients ambulatoires souffrant d'une maladie respiratoire aiguë.

Méthodes

Une revue des dossiers médicaux a été réalisée d'avril 2016 à mars 2017 dans un service d'urgence et une clinique sans rendez-vous. Les critères d’inclusion étaient les suivants : (i) patients ambulatoires âgés d’au moins 18 ans, (ii) renvoyés chez eux avec un diagnostic d’infection des voies respiratoires supérieures (IVRS), de pneumonie, d’asthme aigu ou d’exacerbation aiguë de la maladie pulmonaire obstructive chronique. Le résultat primaire était la proportion de patients retournant à un service d'urgence ou à une clinique sans rendez-vous dans les trois et sept jours suivant la visite de référence. Les résultats secondaires étaient le coût moyen des soins et l'incidence de la prescription d'antibiotiques pour les patients atteints d'IVRS. Le coût des soins a été estimé à partir des perspectives du ministère de la santé, en utilisant la méthode de calcul des coûts par activité en fonction du temps.

Résultats

Le groupe des urgences comprenait 170 patients et le groupe des cliniques sans rendez-vous 326 patients. Les incidences des visites de retour à trois et sept jours étaient respectivement de 25,9 % et 38,2 % dans le service des urgences contre 4,9 % et 14,7 % à la clinique sans rendez-vous (risque relatif ajusté (arr) de 4,7 (IC à 95 % 2,6 à 8,6) et 2,7 (1,9-3,9)). Le coût moyen ($CAN) de la visite de référence était de 116,0 (106,3-125,7) aux urgences contre 62,5 (57,7-67,3) dans la clinique sans rendez-vous (différence moyenne de 56,4 (45,7-67,1)). La prescription d'antibiotiques pour l’IVRS était de 5,6 % aux urgences contre 24,7 % dans la clinique sans rendez-vous (arr 0,2, 0,01-0,6).

Conclusions

Cette étude est la première d'un programme de recherche plus vaste visant à comparer la valeur des soins entre les cliniques sans rendez-vous et les urgences. Les avantages potentiels des cliniques sans rendez-vous par rapport aux services d'urgence (coûts moindres, incidence plus faible des visites de retour) pour les patients ambulatoires souffrant de maladies respiratoires devraient être pris en compte dans la planification des soins de santé.

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Data availability

All data requests should be submitted to the corresponding author (Dr S. Berthelot) for consideration. Access to anonymised data may be granted for non-commercial research at the discretion of the corresponding author.

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Funding

This study was supported by the Réseau de recherche en santé respiratoire du Québec (RSRQ), the Fonds de recherche du Québec-Santé (FRQS), the Centre de recherche du CHU de Québec-Université Laval, the Canadian Association of Emergency Physicians (CAEP), and the Département de médecine familiale et de médecine d’urgence de l’Université Laval.

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Authors and Affiliations

  1. Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada

    Tania Marx, Lynne Moore, Jason R. Guertin, Narcisse Singbo, David Simonyan, Jeanne Lavallée, Nawid Zada, Shaghayegh Shahrigharahkoshan, Benoit Huard, Pascale Olivier, Myriam Mallet & Simon Berthelot

  2. Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada

    Patrick M. Archambault & Simon Berthelot

  3. Clinical and Organizational Performance Department of the CHU de Québec-Université Laval, Québec, QC, Canada

    Philippe Lachapelle, Sébastien Blais & Mélanie Létourneau

  4. Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada

    Lynne Moore, Denis Talbot & Jason R. Guertin

  5. Centre de Recherche du Centre Intégré de Santé et de Services Sociaux de Chaudière-Appalaches, Lévis, QC, Canada

    Patrick M. Archambault

  6. Clinique La Cité Médicale, Québec, QC, Canada

    Michel Lafrenière

  7. VITAM - Centre de Recherche en Santé Durable, Université Laval, Québec, QC, Canada

    Patrick M. Archambault

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  1. Tania Marx
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Contributions

SB, PMA, MM and LM designed the study. SB, MM and ML supervised its conduct. MM, TM, JL, NZ, SS, PO, BH, PL, SBl and ML collected the financial, organizational, and clinical data. SB, TM, NS, DS, DT, LM and JRG carried out the statistical analyses and interpreted them. TM drafted the initial manuscript. All authors proofread the manuscript and approved its submitted version. SB assumes responsibility for the integrity of the data used in this study and the accuracy of its analysis.

Corresponding author

Correspondence to Simon Berthelot.

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Conflict of interest

SB, LM, DT, PMA and JRG reports grant money FRQS research scholarships. TM, PLa, SBl, NS, DS, JL, NZ, SS, BH, PO, MM, MLe, MLa report no conflict of interest.

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Marx, T., Moore, L., Talbot, D. et al. A value-based comparison of the management of respiratory diseases in walk-in clinics and emergency departments. Can J Emerg Med 25, 394–402 (2023). https://doi.org/10.1007/s43678-023-00481-7

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  • DOI: https://doi.org/10.1007/s43678-023-00481-7

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