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Results:Patient confidence in rapid access at their clinic decreases ER use (OR=0.73). Rural sites offer fewer walk-in services or on-site medical procedures and less proximity to laboratory and diagnostic services, but paradoxically, rural patients are more confident that their own physician will see them for a sudden illness. Patients from clinics offering a larger range of medical procedures on site have lower ER use (OR=0.92 per procedure). Rural physicians tend to divide their time between hospital and primary care; doing in-patient care increases ER use (OR=1.64). In Canada, emergency room (ER) crowding and waiting times have long made headlines. The ER is the safety net for emergency health problems, the last resort for accessing care. High rates of ER use often indicate problems elsewhere in the system, ranging from inadequate management of clinical problems to problems with access for many reasons (;;;;; ).In 2002, we conducted a survey of Quebec primary healthcare users and found that 41% reported using the ER in the last year: 51% in rural and 33% in urban areas.
We postulated that higher rural ER use was unlikely to be due to a higher proportion of “real” emergencies and that a higher probability of rural ER use is related to inadequate accessibility or availability of primary care clinics. We undertook a secondary analysis of the data to determine whether accessibility-related organizational characteristics predict ER use and could explain observed differences between urban and rural areas. Information collectedWe collected information about patients' care experiences, physicians' practice profiles and clinic organization using self-administered questionnaires. Research technicians administering the study on site made observations and obtained information from front-desk staff about clinic organization, physician availability, time to third-next appointment and the physician's preferred modalities for coping with urgent care needs. Each practice director or administrator reported on physical and human resources, governance and management structures and operational links with other healthcare establishments.
AnalysisThe main outcome was the probability of having used the ER in the last 12 months. Analysis was based only on patients whose regular source of care was the participating clinic. We described patient characteristics that might explain differences in ER use.
We also explored whether their perceptions of clinic accessibility were associated with ER use. We attempted to build a multilevel logistic regression model that would explain clinic and physician characteristics associated with likelihood of ER use among sampled patients; all variable selections were driven by hypothesized associations with clinic or physician practice. For valid comparisons, all models controlled for patient age, education level, perceived health status and number of primary care visits in the previous year. We used the HLM multilevel software , which takes into account the nesting of patients in physicians and of physicians in practice sites. We looked for modification of clinic effects by urban and rural area.Because organizational characteristics tend to be highly correlated (; ), it was often difficult to enter two related characteristics in the model. We ultimately selected variables that provided the most robust and global explanation of the phenomenon. ResultsTable gives the characteristics, ER use and reported care experience of the 2,725 eligible patients.
Likelihood and frequency of ER use are remarkably higher in rural than urban patients; use of primary care services is also slightly higher. Rural patients report less education and higher percentages of poor or fair health – factors reported among frequent ER users (;; ) – but these do not fully explain the observed differences in ER use. Paradoxically, rural patients provide higher ratings of their clinics' accessibility. Patients confident of rapid clinic access when ill were significantly less likely to have used the ER in the last year, compared to those who were not: odds ratios (ORs) were 0.78 (95% CI: 0.64–0.97) in rural areas and 0.69 (95% CI: 0.56–0.85) in urban areas.
Overalln=2725(100%)Urban areasn=1506(55.3%)Rural areasn=1219(44.7%)Test value ( p) for urban–rural differencePatient healthcare use in the past yearAt least one ER visit1117 (41.0%)490 (32.5%)627 (51.4%)χ 2 = 99.5(. The characteristics of the geographic areas where urban and rural clinics were located are described in Table.
Clinic and physician characteristics that we hypothesized to be associated with accessibility also differed significantly between rural and urban areas (Table ). While clinics did not differ on self-ratings of rapid-access culture, urban clinics showed a wider variation of opening hours, though none were open 24 hours day, 7 days a week, unlike community health centres in remote areas of Quebec. Most rural clinics (75%) either had no walk-in services or offered them only during the day. Urban clinics were more likely to offer walk-in services over longer periods and to have specialists, radiology and laboratory services in immediate proximity. In contrast, most rural clinics (82.5%) provided hospital care compared to 25% in urban areas, and rural physicians spent on average 70% of their time at the clinic compared to 90% among their urban counterparts.
While more rural physicians worked at the ER, urban physicians tended to be more available at the clinic on evenings and weekends. Finally, rural physicians expressed greater attachment to the clinic's community than urban physicians. 5Audiometry, refraction, ECG interpretation, pulmonary function testing, Pap smears, IUD insertion, D+C aspiration, lumbar puncture, musculoskeletal (includes joint) injection/aspiration, casting/splinting, anoscopy, needle aspiration (for diagnosis/biopsy), skin biopsy, suturingTable shows which clinic and physician variables are significantly associated with the likelihood of ER use.
Significant variables differ markedly between urban and rural settings. The only organizational variable associated with ER use in both settings was whether the clinic offered in-hospital follow-up. This increased the likelihood of ER use by 1.47 in urban and 1.57 in rural areas. We tried to fit a single model (overall model, Table ) with interaction terms between clinic factors and geographic location to account for expected effect modification by strata. After adjusting for age, health status, education and healthcare use, rural patients were almost five times more likely than urban patients to have used the ER in the last year.
Only the interaction term for rapid-access culture approached statistical significance, suggesting that such a culture reduces likelihood of ER use in rural but not in urban areas. We consequently fitted separate models by geographic location (see Table ). Odds ratio95% CIOverall Model (2,677 patients)Rural location4.741.78–12.60Number of medical procedures on site0.920.85–1.00Interaction term between rapid-access culture and rural location0.800.63–1.02Urban Model (1,473 patients)Offering in-patient follow-up1.641.11–2.41Number of medical procedures on site0.920.82–1.00Rural Model (1,204 patients)Culture of rapid access0.780.64–0.96Availability of evening walk-in services0.770.58–1.03Physician time spent in primary care site less than 50% (reference ≥ 90%)1.471.01–2.14. Only two variables predicted urban ER use: offering in-patient follow-up (OR=1.64) and offering a wider range of procedures on site (OR=0.92 per additional procedure, compared to the mean). Rural models were more complex to build because significant organizational variables tended to be highly correlated and could not be entered together. For instance, correlation between rapid-access culture and number of procedures available was 0.34.
Indeed, correlations between a practice culture of rapid access and key accessibility variables such as availability on evenings and weekends are stronger in rural than in urban clinics (data available on request). Our final model includes the variable of rapid-access culture, which we considered foundational in determining the clinic's organizational features. The mean importance attached to rapid access in clinics was 3.97 (on a scale of 1 to 5). In clinics that rated the importance of rapid access at 5, patients were 22% less likely to use the ER (OR=0.78). If their clinic also offered evening walk-in services, likelihood of ER use was 23% less than among patients of clinics that did not (OR=0.77). However, if their physician's working time at the clinic was less than 50%, likelihood of ER use was 47% higher (OR=1.47) compared to patients of physicians spending 90% of their time on site.
DiscussionThis study highlights not only the large difference in ER use between urban and rural primary healthcare clients, but also differences in primary care organization. Rural clinics have fewer accessibility-related features, and rural physicians spend less time at their clinics and offer less walk-in care (even though they work longer hours, overall). These factors reduce rapid-response capacity for urgent problems, which may partly account for higher rural ER use, especially since there are considerably fewer primary care alternatives in rural areas. When the usual clinic is not readily available, the ER may be the principal alternative for both minor and major urgent care needs. Lower clinical severity scores among rural ER users are found in Ontario , supporting the possibility that rural hospital ERs may be filling a primary care role in rural areas.
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Our interpretations should be accepted with caution because they are based on secondary analysis of data collected for another objective, and our findings are predicated on the assumption, which we had no way of testing, that higher ER use in rural areas does not reflect “true” emergencies.We found that when the clinic physicians also provide in-hospital services, their patients are more likely to use the ER. Again, this finding may be due to lower clinic accessibility and/or to a higher probability of patients' seeing their own physician in the ER. In rural areas, the ER can provide both continuity of care and accessible services.We found that patients' confidence in being seen rapidly at their clinic for sudden illness decreases their likelihood of using the ER, but rural patients expressed higher confidence levels than their urban counterparts.
Urgence Definition
This paradox may be explained by the fact that more rural physicians work in the local hospital. Clinic secretaries reported that almost a quarter of rural physicians managed urgent care for their regular patients by meeting them at the ER, whereas this situation was rare in urban areas. Rural patients and physicians also tend to belong to the same community network, and rural patients may know where to find their doctor, including at the ER, hence their confidence in being seen rapidly and their tendency to use the ER. This interpretation would need to be explored in future studies.These findings call for prudence in interpreting high or repeated ER use as an indicator of poor control of health problems (; ). Our study suggests ER use is more common in rural areas and may not constitute an ambulatory-care-sensitive indicator in studies using provincewide administrative data. Rather, it is possible the ER intentionally fulfills a slightly different function in rural areas, attending to both emergency and urgent primary care. Likewise, primary care clinics may fulfill a slightly different function, seemingly more oriented towards continuity and follow-up than acute episodic care, which is consistent with lower patient volume and fewer procedures on site.
The rural ER may be more integrated with the primary healthcare system, with physicians being the principal agents of integration through involvement in both areas.Still, high rural ER use is not necessarily alarm-free. Our study reinforces the association between poor primary care accessibility and ER use. And in rural areas with fewer alternatives, patients are very dependent on clinic organizational structures and their physician's practice style. Rural physicians may need to enhance their community practice accessibility or integrate more formally and transparently with the ER for walk-in care. In the open comments, patients expressed strong preferences to be seen by their own physician at their own clinic rather than going to the ER. Using the ER for acute and episodic care may indeed be an efficient way to organize scarce resources in rural and remote areas, but it should be part of a clear policy that maximizes efforts by both patients and health professionals.This study reinforces the notion that ER utilization is associated with problematic primary healthcare accessibility for urgent needs, especially in rural contexts where there are fewer primary care alternatives. However, it also provokes reflection on an expanded function of rural ERs and cautions against monolithic interpretation of ER rates.
In a 2004 five-country Commonwealth survey, Canada had the highest ER utilization rate. A high rate of non-urgent ER use is interpreted as an indicator of primary care system failure (; ), and the clear message is that primary healthcare accessibility in Canada must be enhanced, including appropriate integration with the ER in rural and remote areas.