Health care reform and emergency outpatient use of rural hospitals in Alberta, Canada

The Journal of Emergency Medicine, Vol 13, No 3, pp 415-421, 1995 Copyright 0 1995 Elsevier Science Ltd Printed in the USA. All rights reserved 0136-4679/95 $9.50 + .oo

Pergamon

0736~4679(95)00014-3

Canadian Perspectives HEALTH CARE REFORM AND EMERGENCY OUTPATIENT USE OF RURAL HOSPITALS IN ALBERTA, CANADA James M. Thompson,

MD, CCFP(EM)*

and Nora L. McNair esct

*Department of Family Medicine, The University of Calgary, Calgary, Canada tThe University of Alberta, Edmonton, Alberta, Canada Reprint Address: Dr. Jim Thompson, Bag 5, Sundre, Alberta, Canada TOM 1X0

0 Abstract-We describe Alberta’s publicly funded system of rural hospital emergency outpatient services just before the profound impact of major health care reforms. From a rural physician’s perspective, we descriptively analyze a unique government database that contains the number of emergency outpatient visits to all Alberta hospitals in the fiscal year 1992/93. We found that most people in rural Alberta had ready accessto an extensive system of physician-based rural hospital emergency outpatient services, that 50% of all emergency visits were made to rural hospitals, and that 70% of physicians providing hospitalbased emergency serviceswere rural. There were significant differences in the emergency outpatient use of large urban, regional urban, and rural hospitals, and between rural hospitals that were close, middle, or remote distances from tertiary or secondary care centers. We identify some clinically important factors that are not described by available data, but which should be considered by the reform movement.

will decide how health care services are to be funded, and reduction of rural hospital acute care services ( 1). The changes are being driven by powerful fiscal and political forces without research into clinical impact. In emergency medicine, the clinical issues are accurate diagnosis and safe, prompt patient management. Much of the literature on rural hospital services has used models based on population and distance criteria or economic factors, rather than clinical factors familiar to rural physicians (2-7). For example, without considering clinical factors, a Canadian economist concluded that physician-based rural hospital emergency departments (EDs) in Alberta could be replaced with ambulance services (5). Some proponents of downgrading rural hospital acute care services in Canada refer to “community care” and “wellness” models that do not seemto be connected to the clinical realities that a rural physician might believe to be important (2,4,8). We felt that a first step toward rationalizing these apparently disparate views of health care reform would be to describe rural hospital emergency department utilization over a large area. We undertook this study to describe rural emergency department (ED) usethrough the eyesof a rural physician. Development of a unique emergency services administrative database in 1992 by Alberta Health made it possible to analyze rural hospital emer-

0 Keywords-rural health; rural hospitals; hospital emergency services; health care reform; regional health planning

INTRODUCTION

In 1994 the Alberta provincial government began to make sweeping changes to Alberta’s publicly funded health care system. These changes included consolidating 104 autonomous rural hospital boards into 15 regional boards comprised of lay persons who RECEIVED: ACCEPTED:

Canadian Perspectives is coordinated by James Ducharme, MD, of the Canadian Association of Emergency Physicians(CAEP) and McGill University, Quebec,Canada 1 June 1994; FINAL SUBMISSION RECEIVED: 7 October 1994; 21 November 1994 415

416

J. M. Thompson and N. L,. McNair

gency outpatient visits for the entire province. Previous wide-area Canadian hospital databases did not contain sufficient detail to conduct comprehensive analyses of emergency visits to hospitals over large rural regions of Canada (9-11). We provide a baseline snapshot of the system using the government database before rural hospital ED serviceswere affected by governmental intervention, and explore limitations of that database from a clinical perspective. METHODS We obtained the number of outpatient visits to each hospital from the Acute Care Funding Plan (ACFP) program of Alberta Health for the fiscal year April 1992-March 1993. Beginning April 1992, Alberta Health required that ACFP data collection be done by all Alberta hospitals. The hospitals were told to report the number of unscheduled emergency outpatient visits, providing the first systematic accounting of emergency outpatient visits for the Province. Each visit was sorted into one of five nursing workload scores (NWS) in an effort to measure the cost of the casemix of patients seenby each hospital. The emergency services NWS was developed by a multidisciplinary ACFP committee comprised of managers, health records staff, nurses, and emergency physicians from both rural and urban hospitals. The five-tiered system assumed that all diagnosesassigned to a tier consumed, on average, the same number of nursing minutes: level 1 corresponded to 25 minutes, level 2 to 38 min, level 3 to 75 min, level 4 to 130 min, and level 5 to 150 min. The NWS system assumed that hospital resource consumption, and therefore required funding, was directly proportional on average to the number of nursing minutes required for the patient. Using a comprehensive list of several hundred diagnoses derived from the diagnostic classification suggested by the American College of Emergency Physicians (12), the committee debated the score for each diagnosis based on collective personal experience. During data collection, the NWS was assigned by health records technicians in the hospital. The technicians compared the physician’s discharge diagnosis with the master list of diagnoses produced by the committee. The latest government publications were used to estimate hospital bed sizes for 1989, and populations for 1992 (13-15). Total hospital expenditures were for the 1991-92 fiscal year (16). The number of physicians with active privileges covering the emergency department in each hospital was determined by a tele-

phone survey of the administrators or local physicians on June 28-29, 1993. For simplicity in this study, we refer to all of these physicians as “emergency physicians.” The two largest urban cities (Edmonton and Calgary) had ten tertiary teaching and secondary care hospitals with EDs. We called these “large urban.” Five smaller cities, which we termed “regional urban” centers (Red Deer, Lethbridge, Medicine Hat, Fort McMurray, and Grande Prairie), had five secondary care hospitals with EDs. Outside these communities, there were 104 hospitals with EDs. We called all of the 104 hospitals “rural.” They ranged in size from eight to 135 acute care beds in towns with populations less than 14,000, except one community (St. Albert), which had a population of 42,000 (very close to Edmonton). We divided the rural hospitals into three groups based on air distance to the seven urban centers. They were “rural close” if the hospital was within 50 km, “rural middle” if between 50-200 km, and “rural remote” if further than 200 km. Fifty km was chosen becauseit has been suggestedin Alberta that multiple trauma patients should be taken directly to the nearest hospital for stabilization, unless a higher level of care is available within 30 minutes by ground (roughly 50 km). Two hundred km was chosen because that is the outer limit of range without refueling for the BK117 helicopter providing outreach air ambulance service from tertiary care in southern Alberta. This corresponds to a ground transport time of about 2.5 hours. RESULTS Table 1 summarizes our findings. There were about 1.5 million emergency outpatient visits to Alberta hospitals, of which 50% were made to the rural hospitals. The rural hospitals accounted for 22% of total acute care hospital expenditures in 1992, and 36% of acute care beds in 1989. There were 101 hospitals smaller in size than 100 acute care beds with ED services (85% of all hospitals). There were 540 physicians covering the 104 rural emergency departments in a variety of on-call systems. This accounted for 70% of all 772 full or part time emergency physicians in the Province. Four hundred and ninety-one (64% ) provided emergency care in the hospitals smaller than 100 acute care beds. The sizes of emergency medical staffs are shown in Figure 1. There were two clusters of communities, each consisting of three small hospitals, where the medical staff shared call after hours at one facility,

Emergencies

417

in Rural Alberta Hospitals

Table 1. Characteristics

of Alberta Hospitals Providing Emergency Outpatient Services

Hospitals Acute Care Beds Resident Population Emergency Visits Total Hospital Expenditurest (million $) Medical staff covering the ED (number of physicians) Mean Distance to secondary or tertiary care (km)

Large Urban

Regional Urban

Rural Close

Rural Middle

Rural Remote

Total Number

10 8% 5,811 52% 1,335,328 51% 557,889 37% $1,245 85% 177 23% -*

5 4% 1,283 12% 228,830 9% 193,837 13% $232 12% 55 7%

18 15% 881 8% 208,420* 8%* 158,540 11% $81 4% 140 18% 31

77 85% 2,911 27% 284,842* lo%= 529,146 35% 3101 6% 355 46% 115

9 8% 307 3% 48,570’ 2%* 58,939 4% 34 2% 45 6%

119

-$

240

10,773 2,607,220 1,496,351 $1,902 772 -*

*These figures do not locate the 521,230 persons who live outside a city,town, or village (20.0% of the population). TFor acute care hospitals providing emergency outpatient service. *All secondary or tertiary care hospitals were in the urban communities.

but each of these hospitals still offered local physician-based ED emergency services for part of the day. Aside from a few very small communities that were understaffed, we heard of no hospitals having problems covering the emergency department on a 24 hour basis in Alberta. One hospital had no medical staff. If rural physicians were involved in every visit during our study period, then each rural physician was responsible for 1,357 visits/yr, on average. This

0

1

2

3

4

5

6

7

volume was more than one-third the average for urban emergency physicians ( 3,196 visitdyr ) . The number of emergency visits to each rural hospital is shown in Figure 2, and distance to secondary or tertiary care in Figure 3. There were eleven rural hospitals with less than 1,500 emergency outpatient visits per year. A spreadsheet listing all of the data for each hospital is available from the authors. Figure 4 shows the NWS profiles for each of the

6

9

10

11

12

13

14

15

16

Number of ED Physicians in Each Rural Hospital Figure 1. Number of ED physicians per rural hospital.

17

18

19

J. M. Thompson and N. L. McNair

418

r

0

50

100

150

Numberof Acute Care Beds (Rural Hospitals) Figure 2. Emorgsnoy outpatlent volumes.

24

2 0

:

Flgure 3. RUMI hoapltal dlstrnce from secondwy or

twtlary

awe.

Emergencies in Rural Alberta Hospitals

419

Lx NWS 1

n NWSZ HNWS3

q NWS4 NWS 5

Large Urban

Regional Urban

Rural Close

Rural Middle

Figure 4. Nursing workload scores (NWS) by locality. Lower NWS are proportionate

hospital groups. There was an increase in the proportion of low resource consumption visits (low NWS) in progressively more remote hospitals, and a decrease in the proportion of high consumption visits (high NWS). Since these are total counts of populations, not estimates, statistical descriptions of sampling variability were not necessary.

Rural Remote

to lower resource consumption visits.

boards consisting of lay persons who will be evaluating competing proposals from other groups of health care providers. Our results show that the new Alberta Health database provides an important overview of the system, but we were not able to find answers to many clinical issuesthat seemimportant to us.

Role of the Rural Hospital ED DISCUSSION Our results describe the system of 24-hr physicianbased hospital emergency outpatient service in rural Alberta as it existed just before major legislative and fiscal reforms began in 1994. These results reveal only indirectly the needs of patients for this type of health care (about 750,000 visits), and the cost of delivering that care (an unknown portion of 420 million dollars in total rural hospital acute care expenditures). To move health care reform forward in a realistic manner, system managers and tax-paying health care consumers must have an accurate understanding of emergency patient care in rural Canada. This is crucial now that health care spending decisions will be made in many Canadian provinces by regional

Like urban hospitals, rural hospital emergency outpatient services exist primarily to provide 24-hr service during private clinic hours for serious or potentially serious problems, and after hours for all patients who think they need urgent medical care. Their role in providing a reliable, disciplined and high quality access point to the health care system has not been clarified and compared to alternatives, but our data suggest that there are fundamental differences between the role of an ED in urban and rural communities. We found that an unexpectedly large proportion of all emergency outpatient visits in Alberta, 50% or 744,625 visits, were made to rural hospitals (Table l), and that small hospitals had large volumes (Fig-

420 ure 2). This seemsdisproportionate to the population distribution, since not more than 40% of Albertans live in rural communities, and an undetermined number of those probably accessurban emergency health care facilities directly. Rural hospitals might be the only source of after-hours health care in most rural communities, whereas in urban settings there are many alternatives, including private walk-in clinics and family medicine clinics with late and weekend hours. Secondly, many urban residents travel to rural areas for work and recreation. Some of these tourists will visit rural hospitals when they require emergency health care. Thirdly, some rural physicians might see nonemergent patients in the hospital, for a variety of reasons unique to the rural context. These issuesneed further study. Figure 4 seems to show that more remote rural hospitals might serve less acute patients. It is important to recognize, however, that the nursing workload score described in our methods section was devised by Alberta Health to be a measure of resource utilization ( 17). The score therefore only indirectly reflects clinical acuity. In an earlier study of one rural hospital, we found that 82% of emergency outpatients were perceived by the ED nursing and physician staff in Sundre Hospital to require physician serviceswithin 12hours, information not evident in Figure 4 (18). The difference between these perspectives needs to be resolved with further research, recognizing that the whole issue of perceived acuity is highly controversial. Optimum Dispersal of Rural Hospital EDs There is little information on which to base recommendations regarding optimum dispersal of rural hospital EDs over a wide region. Our results can be compared to one other Canadian study, showing that variation exists in Canada. Rourke ( 10,ll) studied Ontario hospitals smaller than 100 acute care beds. He found that the system of 88 small hospitals in that Province (versus Alberta’s 104 rural hospitals) served a larger resident population per rural hospital ( 11,788 vs. our 10,029), had a larger average size (48 beds vs. 37), a larger ratio of population per acute care bed (245 vs. 135-176), and a larger number of physicians covering the ED (613 vs. 540). Data available to Rourke on the number of emergency visits (1,239,085) combined other types of outpatient visits, whereas our number (744,625) was for unscheduled emergency visits only, so the volumes are difficult to compare. Alberta seemed to have more hospital ED coverage for its rural geography and population than Ontario, but data for rural Ontario hospitals larger than 100 beds, if there were any, were not given.

J. M. Thompson and N. L. McNair

Rural Physician Issues We found that the majority of rural emergency physicians were general practitioners, as in the United States (19). Many worked in association with small call groups (Figure 1). We found that rural emergency physicians encountered on average just less than half the number of emergency patients encountered by urban emergency physicians, but our study did not account for the hundreds of thousands of patient visits managed by rural physicians in their private clinics, the emergenciesthey managed among rural hospital inpatients, nor the fact that the first on-call physician frequently consulted another rural colleague regarding emergency assessmentand management. The unique practice style, emergency training, and capabilities of rural physicians over a large Canadian region still are not documented. Rourke studied rural emergency physician staffing in a Canadian region ( 11). Rural physicians in Ontario are increasingly reluctant to staff local EDs after hours, particularly without financial compensation. This phenomenon was rare in Alberta during the period of our study, but also is commonly reported in American studies (20). Data Caveats There are important caveats about the administrative data we used in this study. We know from an Alberta Health audit of the database that some hospitals used different definitions for “emergency visit” to separate out scheduled, nonemergency visits during this first year of data collection, in part to attract optimum funding. As a result, some under- and over-reporting of emergency visits might have occurred. There is no wide-area data on the clinical problems encountered in rural hospitals in Alberta, except data collected for billing. The data do not give information about the role of ambulance services, the role of nonphysician health care providers in caring for the patients who made the visits we are reporting, variations in practice, nor the outcome of patients managed in rural hospitals by physicians and others. We found that in Alberta the majority of visits to rural hospitals were at small hospitals a significant distance from secondary or tertiary care (Figure 3). The ability of a rural hospital ED to manage emergency outpatients can be measured in terms of staff competency, drug formulary, equipment inventory, and ED team organization. There is no wide-area information on these issues for rural hospital EDs in Canada. The clinical and fiscal outcomes of closing 24-hr physician-based rural hospital EDs or replacing

Emergencies

421

in Rural Alberta Hospitals

them with a lower level of emergency care cannot be estimated from our results. We were unable to locate precisely the 20% of residents who live outside cities, towns, and villages. An undetermined proportion of these live close enough to urban centers that they probably obtained medical care there. The population of rural Albertans who might use rural hospital emergency services in their home communities therefore is less than 40070,but the exact proportion needs to be clarified. We were also unable to determine the proportion of ED visits made by transient urban and rural visitors to each hospital, which is a very significant group in many rural hospitals during seasonal periods of work and recreation. CONCLUSIONS We found that most people living and traveling in rural Alberta enjoy ready accessto an extensive system of physician-based rural hospital emergency ser-

vices. There are more rural hospital ED services spaced closer together than in Ontario, suggesting that considerable variation in ED dispersal exists in Canada’s publicly funded health care system. Although the administrative database developed by the Alberta government is an important tool for understanding rural hospital emergency service over a wide area, key clinical factors are not being captured. Health care reform decisions based on fiscal or political considerations alone could lead to inappropriate decisions.

Acknowledgments- We thank the many Alberta

Health employees and consultants who assisted us, and the administrators, nurses, and physicians of rural Alberta hospitals who gave freely of their time and knowledge. Dr. James Rourke and Dr. Hugh Hindle made helpful suggestions during the study. Ms. McNair’s work was funded by the Rural Physician Action Plan, a joint project of Alberta Health and the Department of Family Medicine at The University of Alberta.

REFERENCES 1. Healthy Albertans living in a healthy Alberta-a three year business plan. Alberta Health. Edmonton, Alberta 1994;29p. 2. Teixeira CA. Community health centers in Saskatchewan. Health Management Forum. 1987;8(3):13-19. 3. Samuels S, Cunningham JP, Choi C. The impact of hospital closures on travel time to hospitals. Inquiry. 1991;28:194-199. 4. Moscovice I, Rosenblatt RA. A Prognosis for the rural hospital Part I: what is the role of the rural hospital? J Rural Health. 1985;1(1):29-40. 5. Brown M. Do physicians locate as spatial competition models predict? Evidence from Alberta. Can Med Assoc J. 1993;148: 1301-1307. 6. Howard RA. Rural hospitals and community health. Health Management Forum. 1985;6(1):26-32. 7. Chown E. Responding to community needs: alternative models for rural health services. Report submitted to the Advisory Committee for the Rural Health Services Project. Alberta Health. Edmonton, Alberta. 1992;43p. 8. Weatherill JL. Beyond four walls: ideas and applications on regional planning of health care services. Healthcare Management Forum. 1992;5(4):48-53. 9. Heylar C. Comparative Analysis of the HMRI Database. HMRI. Toronto. 1992:96p. 10. Rourke J. Small hospital medical services in Ontario. Part I: overview. Can Fam Phys. 1991;37:1589-1594. 11. Rourke J. Small hospital medical services in Ontario. Part 2: emergency medical services. Can Fam Phys. 1991;37:17201724.

12. Brouch K. Diagnosis coding for emergency medicine. Published by American College of Emergency Physicians. Dallas Texas. 1989:140p. 13. Alberta Health. Hospital Care in Alberta, Statistical Supplement for Year Ended March 31, 1989.Government of Alberta. Edmonton. 1991:72p. 14. Government of Alberta. Official Population List 1992. Alberta Municipal Affairs, Municipal Services Branch. Edmonton. 1993:16p. 15. Government of Canada. Alberta Band Population as per Ottawa Register Change Report of April 1, 1992. Indian and Northern Affairs. Ottawa. 1993. 16. Government of Canada. 1991192annual return of health care facilities-hospitals-part one ( HFl ). Statistics Canada (as supplied by Alberta Health, Hospital Services Branch). Ottawa. 17. Philippon DJ, Odegard, LW. Alberta’s acute care funding plan. Financial Services. Canadian Health Care Management. 1991;12:1-7. 18. Thompson JM, Ratcliff M. Use of emergency outpatient services in a small rural hospital. Can Fam Phys. 1992;38:23222331. 19. Haskins RJ, Kallail KJ. Staffing small rural hospital emergency rooms: dependence on community family physicians. Fam Pratt Res J. 1994;14(1):67-75. 20. Williamson HA, Rosenblatt RA, Hart LG. Physician staffing of small rural hospital emergency departments: rapid change and escalating cost. J Rural Health. 1992;8(3):171-177.