3 results
P017: A time-driven activity-based costing method to estimate health care costs in the emergency department
- S. Berthelot, M. Mallet, L. Baril, P. Dupont, L. Bissonnette, H. Stelfox, M. Émond, S. Blais, A. Vezo, M. Létourneau, S. Côté, G. Bécotte, M. Lafrenière, L. Moore
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 19 / Issue S1 / May 2017
- Published online by Cambridge University Press:
- 15 May 2017, p. S83
- Print publication:
- May 2017
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Introduction: Poor physicians’ knowledge of health care costs has been identified as an important barrier to improving efficiency and reducing overuse in care delivery. Moreover, costs of tests and treatments estimated with traditional costing methods have been shown to be imprecise and unreliable. We estimated the cost of frequent care activities in the emergency department (ED) using the time-driven activity-based costing (TDABC) method. Methods: We conducted a TDABC study in the ED of the CHUL, Québec city (77000 visits/year). We estimated the cost of all potential care activities (e.g. triage) provided to adult patients with selected urgent (e.g. pulmonary sepsis) and non urgent (e.g. urinary tract infection) conditions frequently encountered in the ED. Following Lean management principles, process maps were developed by a group of ED care providers for each care activity to identify human resources, supplies and equipment involved, and to estimate the time required to complete each process. Resource unit cost (e.g. cost per minute of a nurse) and overhead rate were calculated using financial information from fiscal year 2015-16. Estimated cost of each care activity (e.g. chest X-ray) including physicians’ charges was calculated by summing overhead allocation and the cost of each process (e.g. disinfection of the X-ray machine) as obtained by multiplying the resource unit cost by the time for process completion. Results: Process maps were developed for 14 conditions and 68 ED care activities. We estimated the costs of activities (CAN$) related to nursing (e.g. urinalysis and culture triage ordering $14.70), clerk tasks (e.g. patient registration $3.40), physicians (e.g. FAST scan $20.90), laboratory testing (e.g. CBC $6.30), diagnostic imaging (e.g. abdominal CT scan $146.50), therapy (e.g. 5 mg of iv morphine $20.40), and resuscitation (rapid sequence intubation with ketamine and succinylcholine $146.40). Overall, emergency physicians’ charges, personnel salaries and overheads accounted for 38%, 22% and 16% of all ED care costs, respectively. Conclusion: Our results represent an important step toward increasing emergency physicians’ awareness on the real cost of their interventions and empowering them to adopt more cost-effective practice patterns.
GD02: An international consensus study to identify quality indicators for ambulatory emergency care
- S. Berthelot, E. Lang, M. Émond, M. Mallet, H. T. Stelfox, R. Lavergne, F. Légaré, L. Bissonnette, S. Blais, J-C Forest, E. Mercier, C. Guimont, L. Moore
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 19 / Issue S1 / May 2017
- Published online by Cambridge University Press:
- 15 May 2017, pp. S62-S63
- Print publication:
- May 2017
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Introduction: Redirecting low acuity patients from emergency departments to primary care walk-in clinics has been identified as a priority by many health authorities. Promoting family physicians for the management of ambulatory patients with urgent health concerns reflects the assumption that primary care facilities can offer high-quality and more affordable ambulatory emergency care. However, no performance assessment framework has been developed for ambulatory emergency care and consequently, quality of care provided in these alternate settings has never been formally compared. Primary objective: To identify structure, process and outcome indicators for ambulatory emergency care. Methods: We will identify and develop quality indicators (QIs) for ambulatory emergency care using a RAND/UCLA Appropriateness Method (RAM) composed of three different steps. First, we will perform a scoping literature review to inventory 1) all previously recommended QIs assessing care provided to ambulatory emergency patients in the ED or the primary care settings; 2) all conditions evaluated with the retrieved QIs; and 3) all outcomes measured by the same QIs. Second, a steering committee composed of the research team and of international experts in performance assessment in emergency and primary care will be presented with the lists of QI-related conditions and outcomes. They will be asked to identify potential outcome indicators for ambulatory emergency care by generating any relevant combinations of one condition and one outcome (e.g. acute asthma exacerbation/re-consultation). Committee members will be given the latitude to use and pair any conditions or outcomes not included in the lists as long as they think the resulting indicators are compatible with the study objectives. Using a structured nominal group approach, they will combine their suggestions and refine the list of potential QIs. This list of potential outcome indicators composed of pairs “condition/outcome” will be merged with the list of already published QIs identified during the literature review. Third, as per the RAM standards, we will assemble an international multidisciplinary panel (n=20) of patients, emergency and primary care providers, researchers and decision makers, after recommendations from international emergency and primary care associations, and from the Canadian Strategy for Patient-Oriented Research (SPOR) Support Units. Through iterative rounds of ratings using both web-based survey tools and videoconferencing, panelists will independently assess all candidate QIs. They will be asked to rate on a nine-level scale to what extent each QI is a relevant and useful measure of ambulatory emergency care quality. From one round to the next, QIs with a median panelist rating score of one to three will be excluded. Those with a median score of seven or more will be automatically included in the final list. QIs with median score of four to six will be retained for future deliberations among the panelists. Rounds of ratings will be conducted until all QIs are classified. Impact: The QIs identified will be used to develop a performance assessment framework for ambulatory emergency care. This will represent an essential step toward testing the assumption that EDs and primary care walk-in clinics provide equivalent care quality to low acuity patients.
LO085: Canadian in-hospital mortality for patients with emergency-sensitive conditions
- S. Berthelot, E. Lang, H. Quan, H. Stelfox
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 18 / Issue S1 / May 2016
- Published online by Cambridge University Press:
- 02 June 2016, p. S59
- Print publication:
- May 2016
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Introduction: The emergency department (ED) hospital standardized mortality ratio (ED-HSMR) measures risk-adjusted mortality for patients admitted to hospital with conditions for which ED care may improve outcomes (emergency-sensitive conditions). This study aimed to describe in-hospital mortality across Canadian provinces using the ED-HSMR. Methods: Data were extracted from hospital discharge databases from April 2009 to March 2012. The ED-HSMR was calculated as the ratio of observed deaths among patients with emergency-sensitive conditions in a hospital during a year (2010-11 or 2011-12) to the expected deaths for the same patients during the reference year (2009-10), multiplied by 100. The expected deaths were estimated using predictive models fitted from the reference year for different hospital peer-groups (teaching, large, medium and small hospitals) adjusted for comorbidities, age, diagnosis, and hospital length of stay. Thirty-seven validated emergency-sensitive conditions were included (e.g., stroke, sepsis, shock). Aggregated provincial ED-HSMR values were derived from patient-level probabilities of death. A HSMR above or below 100 respectively means that more or fewer deaths than expected occurred in hospital within a province. Results: During the study period, 1,335,379 patients were admitted to 629 hospitals across 11 provinces and territories with an emergency-sensitive condition as the most responsible diagnosis, of which 8.9% died. More in-hospital deaths (95% confidence interval) than expected were respectively observed for the years 2010-11 and 2011-12 in Newfoundland [124.3 (116.3-132.6) & 117.6 (110.1-125.5)] and Nova Scotia [116.4 (110.7-122.5) & 108.7 (103.0-114.5)], while mortality was as expected in Prince Edward Island and Manitoba, and less than expected in other provinces and territories [Territories 67.3 (48.3-91.3) & 73.2 (55.0-95.5); New Brunswick 87.7 (82.5-93.1) & 90.4 (85.2-95.8); British Columbia 92.0 (89.6-94.4) & 87.1 (84.9-89.3); Saskatchewan 92.3 (87.1-97.4) & 90.8 (86.2-95.6); Ontario 94.0 (92.6-95.4) & 88.0 (86.6-89.3); Alberta 94.1 (91.1-97.2) & 91.0 (88.2-93.9); Québec 95.7 (93.8-97.6) & N/A]. Conclusion: Our study revealed important variation in risk-adjusted mortality for patients admitted to hospital with emergency-sensitive conditions among Canadian provinces. The results should trigger more in-depth evaluations to identify the causes for these regional variations.