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Left without being seen in a hybrid point of service collection model emergency department
YAJEM-58249; No of Pages 6 American Journal of Emergency Medicine xxx (xxxx) xxx
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American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Left without being seen in a hybrid point of service collection model emergency department Eveline Hitti, M.D., M.B.A. a, Dima Hadid, M.A.P.H. a, Hani Tamim, Ph.D. b, Moustafa Al Hariri, Ph.D. a, Mazen El Sayed, M.D., M.P.H. a,⁎ a b
Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
a r t i c l e
i n f o
Article history: Received 28 January 2019 Received in revised form 14 May 2019 Accepted 16 May 2019 Available online xxxx Keywords: Leaving without being seen Point-of-service model Predictors Insurance Clinical outcomes Emergency department
a b s t r a c t Objective: This study identifies reasons and predictors of LWBS and examines outcomes of patients in a model that uses “point-of-service” (POS) collection for low acuity patients. Methods: This was a matched case-control study of all patients who left without being seen from the ED of a tertiary care center in Beirut Lebanon between June 2016 and May 2017. Matching was done for the ESI score, date and time (±2 h). A descriptive analysis and a bivariate analysis were conducted comparing patients who LWBS and those who completed their medical treatment. This was followed by a Logistic regression to identify predictors of LWBS. Results: 133 LWBS cases and 133 matched controls were enrolled in the study. Mean age for LWBS patients was (31.69 ± 15.29). The average reported wait time of LWBS patients was reported as 27.48 min (±25.09). Reasons for LWBS were; non-compensable status (66.9%), financial reasons (12.8%), long waiting times (12.8%), and others (8.3%). The majority of LWBS patients (81.2%) sought medical care after leaving the ED, and 8.3% of the LWBS patients represented to the ED after 48 h. Important predictors of LWBS included male gender, lower than undergraduate education level, waiting room time, non-compensable coverage status and fewer ED visits in the past year. Conclusion: In an ED setting with POS collection for low acuity patients, non-compensable coverage status was the strongest predictor for LWBS. Further studies are needed to assess the outcomes of patients who LWBS in this model of care. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Patients who leave the emergency department (ED) without being seen (LWBS) by a physician are at risk of poorer clinical outcomes than those who complete their ED assessment (e.g. patient satisfaction) [1]. This key operational metric is reportedly on the rise in many countries and ranges from 1% to 15% [2]. This rise is related to increased demand for ED services and overcrowding which in some countries has reached a critical state [3]. Studies that have looked at predictors of LWBS have found an association with ED overcrowding, dissatisfaction with the care provided and long waiting times, with the latter being the primary driver [4,5]. Specific patients' characteristics are also linked to LWBS. LWBS patients
⁎ Corresponding author at: American University of Beirut Medical Center, P.O. Box - 110236, Riad El Solh, Beirut 1107 2020, Lebanon. E-mail addresses: [email protected] (E. Hitti), [email protected] (D. Hadid), [email protected] (H. Tamim), [email protected] (M. Al Hariri), [email protected] (M. El Sayed).
are more likely to be young adults, male, uninsured, and have a lower triage acuity level. Studies examining outcomes (return visits, future hospitalization, and mortality) of LWBS patients showed that LWBS patients are more likely to be re-admitted to the ED, often seek alternative medical attention and exhibit rates of ongoing symptoms compared to those who complete their medical treatment [6]. In response to overcrowding as well as increasing operational challenges with collections, some emergency departments have started adopting point of service collections for urgent and non-urgent patients who can be cared for in lower cost settings. Instead of collecting charges after ED visit, collection of payments from low acuity patients is done at the time services are provided after providing medical screening, a practice known as “point-of-service (POS) collections” [7,8]. To our knowledge, no study has looked at LWBS in a POS collection model. In Lebanon, the prevailing model in EDs is POS collection for low acuity patient. Lebanon has N168 private hospitals (mostly in large cities) and around 10 public hospitals [9]. Nearly half (53%) of the population lack health insurance and receive support from the Ministry of Public Health. The national health expenditure per capita was reported to be
https://doi.org/10.1016/j.ajem.2019.05.034 0735-6757/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: E. Hitti, D. Hadid, H. Tamim, et al., Left without being seen in a hybrid point of service collection model emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.05.034
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E. Hitti et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
$460 in 2006 with nearly 44% from out of pocket contribution [9]. Out of those with medical coverage, only 23% have ED coverage [10,11]. Although there is no law to regulate medical stabilization of patients in Lebanon, common practice is for patients to be screened medically, and, if deemed to be low acuity, to pay prior to full service [12,13]. This study identifies reasons and predictors of LWBS in a model that uses POS collection for low acuity patients and examines outcomes of involved patients in order to improve access to emergency care.
was retrieved and their charts were included for review. The same list was used to select controls with a matching ESI, and arrival date and time in order to ensure that the matched pair faced similar hospital and ED conditions during their visits. Patients were contacted 8 days following their ED visit and were asked whether they are willing to participate in a ten-minute survey regarding their recent visit to the ED. Contacting patients within a limited time frame was done to guarantee that patients were able to remember details of the ED visit while allowing them sufficient time to seek alternative means of healthcare.
2. Methodology 2.4. Measurements 2.1. Study design and setting This was a matched case-control study of all patients who left without being seen from the emergency department (ED) between June 2016 and May 2017. The study was conducted at the ED of an academic tertiary care medical center in Lebanon with an annual ED census of 57,000 ED at the time of the study. Patients are triaged by trained nurses using the emergency severity index (ESI) [14]. ESI is a 5-level index used in emergency departments to rate patient's acuity from level 1 (most urgent) to level 5 (least urgent) based on an estimation of resources required [14]. The majority of our patients (80%) are triaged to an ESI score of 3 (intermediate acuity), while 15% have an ESI of 4 or 5 (low acuity), and only 5% are triaged to an ESI of 2 or 1 (high acuity). The ED is staffed by a mix of American board-certified Emergency Medicine physicians and residents with extensive experience in EM. The ED has a hybrid “point of service collection” model whereby patients with low acuity (ESI 4 or 5) are asked to cover an upfront facility and professional fee charge after medical screening while high and intermediate acuity patients (ESI 1, 2 or 3) are evaluated fully and stabilized prior to financial clearance with the option of financial counseling and charity care funds for those who are unable to cover the full cost of care. The study was approved by the Institutional Review Board (IRB) of the American University of Beirut (AUB).
The data collection was extracted from three sources: patient charts, a standardized phone survey and the ED administrative database. Patient charts were used to pull socio-demographic characteristics (age, gender, marital status, and educational status), clinical characteristics and administrative characteristics (ESI, chief complaint, insurance status, date of triage, and time of triage). Chief complaints were categorized based on the International Classification of Primary Care (ICPC-2). A standardized phone survey was used to extract the other variables including mode of arrival, referral source, number of ED visits in the past year, wait time before leaving without being seen, and wait time before being seen by a physician, ED access issues encountered (waiting time, financial barriers, unfriendly hospital staff and other), reasons for leaving before being seen by a physician, admission to the hospital during follow up period, 8- day mortality. ED wait times for LWBS patients were defined as the interval between the patient's arrival time to the ED and departure time. As for the patients who completed their treatment, the ED wait time was defined as the interval between the patient's arrival to the ED and time seen by a physician. Lastly, the volume of the patients presenting to ED during the study period was extracted from ED electronic business intelligence software QlikView. 2.5. Data analysis
2.2. Study population Patients who left before being seen by a physician were classified as LWBS cases. All patients who left the ED before being seen by a physician during the study period were considered eligible for inclusion in the study. Patients who were dead upon arrival or who died during their treatment or left against medical advice or transferred to specialty clinics or other hospital departments were excluded from the analysis. In addition, patients who were unreachable after 6 phone calls attempts and those who refused to enroll were also excluded. A total of 985 patients were identified with 692 patients excluded because they were not reachable. An addition 160 patients were excluded because they refused to participate. The remaining 133 patients were included in the study. Out of reach patients include those with a wrong phone number, those with a missing phone number from ED chart, and those who did not respond after 6 phone calls. Patients presenting to the ED undergo paper triage and the information collected on paper does not go automatically into patients charts until after the ED visit ends. As a result, many patients' charts have missing documentation. 2.3. Selection of participants The 133 LWBS cases were included and were matched with 133 controls cases. The control group included patients who presented to the ED during the same period and completed their treatment either to be discharged home afterwards or to be admitted to the hospital. Matching was done for the ESI score, date and time (±2 h). Using the emergency department's patient database, a list of all LWBS patients who presented to the emergency department during the study period
Statistical analyses were performed using SPSS 22 (Statistical Package for Social Sciences) for data cleaning, management and analyses. Descriptive statistics were summarized by presenting the frequencies and percentages for categorical variables and mean and standard deviation (SD) for continuous variables. In the bivariate analysis, the association between case control group and other categorical variables was carried out by using the chi-square and Fisher's exact test, as appropriate. Whereas, Student's t-test was used for the association with continuous variables. Multivariate regression analysis was used to adjust for potentially confounding variables. A stepwise multivariate logistic regression was conducted with all risk factors found to be significant in the bivariate analysis in addition to those considered as being clinically meaningful. p-Value of 0.05 was set for the entry of potential predictors into the model, whereas a p-value of 0.1 was set for removal from the model. The results were presented by the adjusted odds ratio (aOR) and 95% confidence interval (CI). p-Value of b0.05 was considered statistically significant. 3. Results A total of 985 potential eligible participants arrived to the ED during data collection period. 133 LWBS cases and 133 matched controls were enrolled in the study and completed the survey (Fig. 1). Table 1 presents a comparison between cases and controls in terms of baseline and demographic and clinical characteristics. Table 2 presents a comparison between the event characteristics for both cases and controls. The average for the reported waiting room time for patients who LWBS was lower compared to that of patients who completed their treatment (27.48 ± 25.09 vs 17.26 ± 15.13 min) (p b 0.0001).
Please cite this article as: E. Hitti, D. Hadid, H. Tamim, et al., Left without being seen in a hybrid point of service collection model emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.05.034
E. Hitti et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
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Potential ED patients (Presenting during data collection times) N= 56537
Eligible LWBS patients N= 985
Excluded (Out of Reach*) N= 692
Eligible patients N= 293
Excluded (Refused to participate) N= 160
Matched controls N= 133
Total Eligible LWBS cases N=133
Fig. 1. Study flow diagram of the selection process of cases and controls.
Factors contributing to LWBS are presented in Table 3. LWBS patients are more likely to have faced at least one ED access issue, with financial concerns being the most significant factor 10.5% as compared to 0.8% in controls, p-value b 0.001. Several reasons for leaving without being seen were elicited including in descending frequencies as follows; non-compensable status (without insurance coverage) (66.9%), financial reasons (12.8%), long waiting times (12.8%), and others (8.3%). With respect to clinical outcomes, 68.4% of the LWBS patients felt the same after leaving the ED as compared to 17.4% of those who completed treatment, p-value b 0.0001, and 17.3% felt worse after leaving the ED as compared to 3.0% of those who completed treatment, p-value b 0.0001. The majority of LWBS (81.2%) patients sought medical care after leaving the ED as compared to 14.3% of those who completed their treatment, pvalue b 0.0001, and 8.3% of the LWBS patients represented to the ED after 48 h, p-value = 0.0001. At 8 days follow-up, mortality rates between both groups were similar. The results of the stepwise multivariate logistic regression analyses for the predictors of LWBS are presented in Table 4. It was found that males were more likely to leave without being seen [aOR (95% CI): 2.87 (1.45–5.66), p = 0.002]. Moreover, for every 10 min increase in waiting room time, patients were 1.45 times more likely to leave without being seen [aOR (95% CI): 1.45 (1.20–1.74), p b 0.0001]. It was also found that patients with undergraduate or lower education level, as compared to those with graduate or higher education level, were more likely to leave without being seen [aOR (95% CI): 3.83 (1.70–8.62), p = 0.001]. Those who visited the ED once or more than twice over the past year, were less likely to leave without being seen [aOR (95% CI): 0.32 (0.14–0.71), p = 0.005; aOR (95% CI): 0.19 (0.08–0.47), p b 0.0001, respectively]. On the other hand, those who left without being seen were more likely to be self-payers (non-
compensable status) [aOR (95% CI): 3.05 (1.12–8.31), p = 0.03]. No specific presenting chief complaint was identified to be a significant predictor for LWBS. 4. Discussion This study is the first to examine the characteristics of patients, reasons for and predictors of LWBS in an ED of a tertiary care center that follows a hybrid point-of-service collection model. As EDs are challenged with increasing demand for emergency care, understanding the reasons and predictors for leaving without being seen, and examining associated clinical outcomes are important for other settings that are considering a similar model. In this hybrid POS collection model, patients who LWBS were relatively older than those who completed the ED assessment. Patients in both groups in this study were however relatively young with a mean age of 31.69 years and 26.61 years for cases and controls respectively. Previous studies that examined LWBS in EDs in the US and Australia revealed that LWBS patients tend to be younger when compared with those who completed their treatment [15,16]. Characteristics of patients who leave without being seen are associated with the reasons of LWBS and younger healthier patients are more prone to leaving without full medical evaluation when they experience prolonged waiting times [16]. Waiting time has been frequently cited as the main reason for LWBS in the literature [15,16]. In our study, even though waiting time was a predictor for LWBS with an aOR = 1.45 (95% CI 1.20–1.74) for every 10 min increase in wait times, waiting time was not the most common reason for LWBS. This could be explained by the relatively short average waiting times in our setting, with average reported waiting room time of patients who LWBS at 27.48 min vs a 17.26 min average waiting
Please cite this article as: E. Hitti, D. Hadid, H. Tamim, et al., Left without being seen in a hybrid point of service collection model emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.05.034
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E. Hitti et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
Table 1 Baseline and demographic characteristics for cases and controls Groups
Gender Male Female Age, mean (±SD) b18 18–24 25–34 35–44 45–54 ≥55 Marital status Single Married Education Lower than undergraduate Undergraduate and higher Triage days per time Day (8 AM to 3:30 PM) Evening (3:30 PM to 11 PM) Night (11 PM to 7:30 AM) Chief complaint General Neurological Gastrointestinal Cardiovascular/Respiratory Eye/ear Musculoskeletal/skin Urological/Gynecological Others ESI 2 3 4 Financial coverage Compensable Non-compensable
Table 2 Event characteristics for cases and controls. p-Value
Controls N = 133
Cases N = 133
42 (31.6) 91 (68.4) 26.61 ± 8.96 1 (0.8) 75 (56.4) 36 (27.1) 16 (12.0) 3 (2.3) 2 (1.5)
74 (55.6) 59 (44.4) 31.69 ± 15.29 16 (12.0) 32 (24.1) 33 (24.8) 29 (21.8) 10 (7.5) 13 (9.8)
b0.0001
101 (75.9) 32 (24.1)
75 (56.8) 57 (43.2)
0.001
14 (10.6) 118 (89.4)
48 (37.5) 80 (62.5)
b0.0001
55 (41.4) 65 (48.9) 13 (9.8)
50 (37.9) 71 (53.8) 11 (8.3)
15 (11.3) 11 (8.3) 35 (26.3) 24 (18.0) 6 (4.5) 35 (26.3) 6 (4.5) 1 (0.8)
18 (13.7) 11 (8.4) 11 (8.4) 14 (10.7) 16 (12.2) 58 (44.3) 2 (1.5) 1 (0.8)
1 (0.8) 103 (77.4) 29 (21.8)
1 (0.8) 103 (77.4) 29 (21.8)
122 (92.4) 10 (7.6)
101 (76.5) 31 (23.5)
Group Controls N = 133
0.001
b0.0001
0.76
0.55 0.97 b0.0001 0.09 0.02 0.002 0.28 1.00 1.00
b0.0001
room time before being seen by a provider reported by patients who completed their treatment. In comparison, prior studies, where the most common reason for leaving before being seen was long wait times, reported wait times of around 1–2 h [15-17]. There were several initiatives that were done gradually over the years prior to the study date which focused on reducing waiting time and door to physician time and consisted of a series of value-driven interventions using Lean methodology that were previously described [18]. Non-compensable status was the strongest predictor for leaving the ED before being seen by a physician with an aOR = 3.09 (95% CI 1.14–8.39). It was also identified as the main reason for LWBS (66.9%). This may reflect access barrier that hybrid POS collection models create for patients who are uninsured or whose insurances do not provide coverage for an ED visit for specific chief complaints. Financial coverage has been previously identified as a predictor for LWBS in other settings with different payment models [1,16] with LWBS patients being more likely to be non-compensable compared to those who completed their medical treatment [1]. Non-compensable status should not however prevent patients from seeking alternative care locations where insurance payers might reimburse visits. It also allows patients with minor chief complaints or low triage acuity to make an informed decision early on about their ED visit rather than complete service and be surprised with an unsettled ED bill. Other predictors such as male gender and lower than undergraduate education were also identified. Previous studies that examined LWBS in EDs in the US and Australia revealed that LWBS patients were more likely to be of male gender and high school or college graduates when compared with those who completed their treatment [16,19,20]. The relation between gender, educational status and LWBS is not well
Transport Ambulance EMS Others Self Taxi Walking Proximity to ED 1 2 3 4 5 Referral source Self-referred Other than self ED visits last year Uncompleted 0 1 Admitted 0 1 ≥2 Discharged 0 1 ≥2 Waiting room time (minutes), mean (±SD) Waiting room time (minutes) ≤10 11–20 21–30 31–40 41–50 51–60 ≥61
p-Value Cases N = 133
6 (4.5) 6 (100.0) 0 (0.0) 126 (94.7) 98 (77.8) 28 (22.2)
6 (4.5) 4 (66.7) 2 (33.3) 127 (95.5) 102 (80.3) 25 (19.7)
1.00
51 (38.3) 41 (30.8) 25 (18.8) 7 (5.3) 9 (6.8)
48 (36.1) 45 (33.8) 23 (17.3) 5 (3.8) 12 (9.0)
97 (72.9) 36 (27.1)
105 (78.9) 28 (21.1)
0.25
133 (100.0) 0 (0.0)
126 (95.5) 6 (4.5)
0.01
119 (89.5) 11 (8.3) 3 (2.3)
130 (98.5) 2 (1.5) 0 (0.0)
63 (47.4) 31 (23.3) 39 (29.3) 17.26 ± 15.13
97 (73.5) 21 (15.9) 14 (10.6) 27.48 ± 25.09
65 (50.8) 32 (25.0) 15 (11.7) 3 (2.3) 6 (4.7) 6 (4.7) 1 (0.8)
55 (44.4) 15 (12.1) 20 (16.1) 2 (1.6) 6 (4.8) 18 (14.5) 8 (6.5)
0.46 1.00 0.62
0.89
0.005
b0.0001
b0.0001
0.002
examined in the literature and can be the focus of future studies examining demographic characteristics of LWBS patients. Presenting chief complaint was not identified to be a significant predictor for LWBS. Previous studies from other settings reported that patients who LWBS had mainly musculoskeletal and gastrointestinal complaints [20]. In our setting, practices by insurance companies to deny ED coverage for illnesses that can be addressed in clinics and to pre-authorization practices are common. In fact, patients with low acuity chief complaints (ESI 4 or 5) with private insurance frequently require pre-authorization from their insurance companies prior to service delivery. Patients with high acuity chief complaint (ESI 1, 2 or 3) are medically stabilized before requesting pre-authorization. With regards to clinical outcomes, even though there were no mortalities in patients who LWBS, this group was more likely to seek medical care after leaving the ED and to represent to the ED after 48 h. A higher ED return visit among LWBS patients was expected as a result of their incomplete medical treatment. These findings are consistent with previous literature [6,15,16]. LWBS patients were more likely to seek further care within short time intervals or to re-presented to ED within 48 h [15,17]. When applied selectively to low acuity patients, POS collection models do not however seem to impact patient outcomes. In fact, the majority of patients who LWBS in our study were young and had low acuity triage levels and at follow up the majority (81.2%) of LWBS successfully sought alternate care (hospitals/primary care). Rates of hospital admission were also similar between the two groups and no mortality was recorded at follow up.
Please cite this article as: E. Hitti, D. Hadid, H. Tamim, et al., Left without being seen in a hybrid point of service collection model emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.05.034
E. Hitti et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
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Table 3 Reasons for LWBS and clinical outcomes. Group Controls N = 133 ED access issues None At least one of the below Waiting time Financial barriers Unfriendly hospital staff Others Reasons for leaving Too long Too ill Feel better Health insurance coverage Cost Problem could wait Other Health status after leaving ED Worse Better Same Seek care after leaving Patients who have a family doctor Patients who would seek care in AUBMC emergency department in the future Patients who have re-presented to ED within 48 h Patients who have been admitted to hospital within 8 days Mortality status after 8 days, alive
4.1. Limitations The results of our study should be considered in the light of its limitations. We were unable to follow up on all LWBS patients as many did not have contact information documented at triage. This may have limited our ability to detect statistically significant predictors or to observe a difference in outcomes such as mortality. Patients who were missed might have had different experiences, however, each case was adequately matched. Additionally, although not assessed by our study, the impact of cost of care on LWBS rates may be different in our setting compared with other community hospitals in Lebanon with similar payment model since the costs at tertiary care centers are usually higher. Our hospital is one of the largest tertiary care centers in Lebanon and benefits from a large catchment area and the results of this study may be generalizable to hospitals in other settings with similar payment model.
p-Value Cases N = 133
77 (57.9) 56 (42.1) 19 (14.3) 1 (0.8) 1 (0.8) 40 (30.1)
56 (42.1) 77 (57.9) 20 (15.0) 14 (10.5) 5 (3.8) 42 (31.6)
– – – – – – –
17 (12.8) 1 (0.8) 5 (3.8) 89 (66.9) 17 (12.8) 4 (3.0) 11 (8.3)
4 (3.0) 105 (79.5) 23 (17.4) 19 (14.3) 59 (44.4) 124 (93.2) 0 (0.0) 5 (3.8) 133 (100.0)
23 (17.3) 19 (14.3) 91 (68.4) 108 (81.2) 45 (33.8) 77 (57.9) 11 (8.3) 5 (3.8) 133 (100.0)
0.01 0.86 0.001 0.21 0.79 NA
b0.0001 b0.0001 0.10 b0.0001 0.001 1.00 NA
than undergraduate education level, non-compensable coverage status. Financial coverage was the strongest predictor for LWBS. Larger studies are needed to better assess outcomes of patients who LWBS in a POS collection model. Funding source This work was supported by The American University of Beirut Medical Practice Plan grant number MPP 11.320083. XXXXX.11465.720.9999.0000. Funding body agreements and policies: Elsevier has established a number of agreements with funding bodies which allow authors to comply with their funder's open access policies. Some funding bodies will reimburse the author for the gold open access publication fee. Details of existing agreements are available online.
5. Conclusion
Ethics approval statement
In conclusion, in a hybrid POS collection model, patients who leave without being seen are more likely to be of male gender, have lower
The study was approved by the Institutional Review Board (IRB) of the American University of Beirut (AUB).
Table 4 Stepwise multivariate logistic regression of predictors of LWBS (Reference: LWBS = No), Goodness of fit test = 0.44. Variables Gender (Ref: Female) Age Waiting room time Marital status (Ref: Single) Education (Ref: Graduate or higher) Chief complaint (Ref: General)
Financial coverage (Ref: Compensable) ED access issues (Ref: None) Discharged ED visits in the preceding (1 year) (Ref: 0)
Male Increase by 10 units Increase by 10 units Married Undergraduate or lower Neurological Gastrointestinal Cardiovascular/Respiratory Eye/Ear Urological/Gynecological MSK/Skin Non-compensable At least one access issues (waiting time, financial barriers; unfriendly hospital staff or others) 1 ≥2
aOR (95% CI)
p-Value
2.87 (1.45–5.66) 1.18 (0.86–1.64) 1.45 (1.20–1.74) 1.84 (0.82–4.15) 3.83 (1.70–8.62) 0.67 (0.17–2.63) 0.26 (0.08–0.84) 0.55 (0.18–1.73) 3.60 (0.90–14.44) 0.16 (0.02–1.19) 1.09 (0.43–2.76) 3.09 (1.14–8.40) 1.52 (0.81–2.87)
0.002 0.3 b0.0001 0.14 0.001 0.57 0.03 0.31 0.07 0.07 0.86 0.03 0.19
0.32 (0.14–0.71) 0.19 (0.08–0.47)
0.005 b0.0001
Please cite this article as: E. Hitti, D. Hadid, H. Tamim, et al., Left without being seen in a hybrid point of service collection model emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.05.034
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Declaration of Competing Interest None declared. Acknowledgement Not applicable. Clinical trial registration Not applicable. Grants This work was supported by the Medical Practice Plan (MPP) grant [MPP 11.320083.XXXXX.11465.720.9999.0000]. License statement I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined in the below author license), an exclusive license and/or a non-exclusive license for contributions from authors who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY license shall apply, and/or iii) in accordance with the terms applicable for US Federal Government officers or employees acting as part of their official duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd. (“BMJ”) its licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the Work in Emergency Medicine Journal and any other BMJ products and to exploit all rights, as set out in our license. References
[2] Clarey A, Cooke M. Patients who leave emergency departments without being seen: literature review and English data analysis. Emerg Med J 2012;29(8):617–21. [3] Ioannides KL, Blome A, Schreyer KE. Impact of a direct bedding initiative on left without being seen rates. J Emerg Med 2018;55(6):850–60. [4] Rowe BH, et al. Characteristics of patients who leave emergency departments without being seen. Acad Emerg Med 2006;13(8):848–52. [5] Weiss SJ, et al. Relationship between the National ED Overcrowding Scale and the number of patients who leave without being seen in an academic ED. Am J Emerg Med 2005;23(3):288–94. [6] Mohsin M, et al. A population follow-up study of patients who left an emergency department without being seen by a medical officer. Emerg Med J 2007;24(3):175–9. [7] Boyer, D.F. and W.E. Hammersla III, Point of service third party financial management vehicle for the healthcare industry. 2001, Google Patents. [8] Forrest CB, et al. Self-referral in point-of-service health plans. Jama 2001;285(17): 2223–31. [9] Country cooperation strategy for WHO and Lebanon 2010–2015. Available from http://www.who.int/countryfocus/cooperation_strategy/ccs_lbn_en.pdf. [10] Magauran BG. Risk management for the emergency physician: competency and decision-making capacity, informed consent, and refusal of care against medical advice. Emergency Medicine Clinics 2009;27(4):605–14. [11] Crilly J, et al. Patients who presented to an Australian emergency department and did not wait or left against medical advice: a prospective cohort follow-up study. Adv Emerg Nurs J 2012;34(4):357–68. [12] Bitterman RA. EMTALA and the ethical delivery of hospital emergency services. Emergency Medicine Clinics 2006;24(3):557–77. [13] Hyman DA, Studdert DM. Emergency Medical Treatment and Labor Act: what every physician should know about the federal antidumping law. Chest 2015;147(6): 1691–6. [14] Eitel DR, et al. The emergency severity index triage algorithm version 2 is reliable and valid. Acad Emerg Med 2003;10(10):1070–80. [15] Fraser J, et al. A comparative study of patient characteristics, opinions, and outcomes, for patients who leave the emergency department before medical assessment. Canadian Journal of Emergency Medicine 2017;19(5):347–54. [16] Tropea J, et al. Patients who leave without being seen in emergency departments: an analysis of predictive factors and outcomes. Acad Emerg Med 2012;19(4):439–47. [17] Arendt KW, et al. The left-without-being-seen patients: what would keep them from leaving? Ann Emerg Med 2003;42(3):317-IN2. [18] El Sayed M, et al. Discharge against medical advice from the emergency department: results from a tertiary care hospital in Beirut, Lebanon. Medicine 2016;95(6). [19] Weissberg MP, Heitner M, Lowenstein SR, Keefer G. Patients who leave without being seen. Ann Emerg Med 1986;15(7):813–7. [20] Carron P-N, et al. Missed opportunities: evolution of patients leaving without being seen or against medical advice during a six-year period in a Swiss tertiary hospital emergency department. Biomed Res Int 2014;2014.
[1] Moe J, Belsky JB. Comparing patients who leave the ED prematurely, before vs after medical evaluation: a National Hospital Ambulatory Medical Care Survey analysis. Am J Emerg Med 2016;34(5):830–3.
Please cite this article as: E. Hitti, D. Hadid, H. Tamim, et al., Left without being seen in a hybrid point of service collection model emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.05.034
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Left without being seen in a hybrid point of service collection model emergency department Eveline Hitti, M.D., M.B.A. a, Dima Hadid, M.A.P.H. a, Hani Tamim, Ph.D. b, Moustafa Al Hariri, Ph.D. a, Mazen El Sayed, M.D., M.P.H. a,⁎ a b
Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
a r t i c l e
i n f o
Article history: Received 28 January 2019 Received in revised form 14 May 2019 Accepted 16 May 2019 Available online xxxx Keywords: Leaving without being seen Point-of-service model Predictors Insurance Clinical outcomes Emergency department
a b s t r a c t Objective: This study identifies reasons and predictors of LWBS and examines outcomes of patients in a model that uses “point-of-service” (POS) collection for low acuity patients. Methods: This was a matched case-control study of all patients who left without being seen from the ED of a tertiary care center in Beirut Lebanon between June 2016 and May 2017. Matching was done for the ESI score, date and time (±2 h). A descriptive analysis and a bivariate analysis were conducted comparing patients who LWBS and those who completed their medical treatment. This was followed by a Logistic regression to identify predictors of LWBS. Results: 133 LWBS cases and 133 matched controls were enrolled in the study. Mean age for LWBS patients was (31.69 ± 15.29). The average reported wait time of LWBS patients was reported as 27.48 min (±25.09). Reasons for LWBS were; non-compensable status (66.9%), financial reasons (12.8%), long waiting times (12.8%), and others (8.3%). The majority of LWBS patients (81.2%) sought medical care after leaving the ED, and 8.3% of the LWBS patients represented to the ED after 48 h. Important predictors of LWBS included male gender, lower than undergraduate education level, waiting room time, non-compensable coverage status and fewer ED visits in the past year. Conclusion: In an ED setting with POS collection for low acuity patients, non-compensable coverage status was the strongest predictor for LWBS. Further studies are needed to assess the outcomes of patients who LWBS in this model of care. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Patients who leave the emergency department (ED) without being seen (LWBS) by a physician are at risk of poorer clinical outcomes than those who complete their ED assessment (e.g. patient satisfaction) [1]. This key operational metric is reportedly on the rise in many countries and ranges from 1% to 15% [2]. This rise is related to increased demand for ED services and overcrowding which in some countries has reached a critical state [3]. Studies that have looked at predictors of LWBS have found an association with ED overcrowding, dissatisfaction with the care provided and long waiting times, with the latter being the primary driver [4,5]. Specific patients' characteristics are also linked to LWBS. LWBS patients
⁎ Corresponding author at: American University of Beirut Medical Center, P.O. Box - 110236, Riad El Solh, Beirut 1107 2020, Lebanon. E-mail addresses: [email protected] (E. Hitti), [email protected] (D. Hadid), [email protected] (H. Tamim), [email protected] (M. Al Hariri), [email protected] (M. El Sayed).
are more likely to be young adults, male, uninsured, and have a lower triage acuity level. Studies examining outcomes (return visits, future hospitalization, and mortality) of LWBS patients showed that LWBS patients are more likely to be re-admitted to the ED, often seek alternative medical attention and exhibit rates of ongoing symptoms compared to those who complete their medical treatment [6]. In response to overcrowding as well as increasing operational challenges with collections, some emergency departments have started adopting point of service collections for urgent and non-urgent patients who can be cared for in lower cost settings. Instead of collecting charges after ED visit, collection of payments from low acuity patients is done at the time services are provided after providing medical screening, a practice known as “point-of-service (POS) collections” [7,8]. To our knowledge, no study has looked at LWBS in a POS collection model. In Lebanon, the prevailing model in EDs is POS collection for low acuity patient. Lebanon has N168 private hospitals (mostly in large cities) and around 10 public hospitals [9]. Nearly half (53%) of the population lack health insurance and receive support from the Ministry of Public Health. The national health expenditure per capita was reported to be
https://doi.org/10.1016/j.ajem.2019.05.034 0735-6757/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: E. Hitti, D. Hadid, H. Tamim, et al., Left without being seen in a hybrid point of service collection model emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.05.034
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E. Hitti et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
$460 in 2006 with nearly 44% from out of pocket contribution [9]. Out of those with medical coverage, only 23% have ED coverage [10,11]. Although there is no law to regulate medical stabilization of patients in Lebanon, common practice is for patients to be screened medically, and, if deemed to be low acuity, to pay prior to full service [12,13]. This study identifies reasons and predictors of LWBS in a model that uses POS collection for low acuity patients and examines outcomes of involved patients in order to improve access to emergency care.
was retrieved and their charts were included for review. The same list was used to select controls with a matching ESI, and arrival date and time in order to ensure that the matched pair faced similar hospital and ED conditions during their visits. Patients were contacted 8 days following their ED visit and were asked whether they are willing to participate in a ten-minute survey regarding their recent visit to the ED. Contacting patients within a limited time frame was done to guarantee that patients were able to remember details of the ED visit while allowing them sufficient time to seek alternative means of healthcare.
2. Methodology 2.4. Measurements 2.1. Study design and setting This was a matched case-control study of all patients who left without being seen from the emergency department (ED) between June 2016 and May 2017. The study was conducted at the ED of an academic tertiary care medical center in Lebanon with an annual ED census of 57,000 ED at the time of the study. Patients are triaged by trained nurses using the emergency severity index (ESI) [14]. ESI is a 5-level index used in emergency departments to rate patient's acuity from level 1 (most urgent) to level 5 (least urgent) based on an estimation of resources required [14]. The majority of our patients (80%) are triaged to an ESI score of 3 (intermediate acuity), while 15% have an ESI of 4 or 5 (low acuity), and only 5% are triaged to an ESI of 2 or 1 (high acuity). The ED is staffed by a mix of American board-certified Emergency Medicine physicians and residents with extensive experience in EM. The ED has a hybrid “point of service collection” model whereby patients with low acuity (ESI 4 or 5) are asked to cover an upfront facility and professional fee charge after medical screening while high and intermediate acuity patients (ESI 1, 2 or 3) are evaluated fully and stabilized prior to financial clearance with the option of financial counseling and charity care funds for those who are unable to cover the full cost of care. The study was approved by the Institutional Review Board (IRB) of the American University of Beirut (AUB).
The data collection was extracted from three sources: patient charts, a standardized phone survey and the ED administrative database. Patient charts were used to pull socio-demographic characteristics (age, gender, marital status, and educational status), clinical characteristics and administrative characteristics (ESI, chief complaint, insurance status, date of triage, and time of triage). Chief complaints were categorized based on the International Classification of Primary Care (ICPC-2). A standardized phone survey was used to extract the other variables including mode of arrival, referral source, number of ED visits in the past year, wait time before leaving without being seen, and wait time before being seen by a physician, ED access issues encountered (waiting time, financial barriers, unfriendly hospital staff and other), reasons for leaving before being seen by a physician, admission to the hospital during follow up period, 8- day mortality. ED wait times for LWBS patients were defined as the interval between the patient's arrival time to the ED and departure time. As for the patients who completed their treatment, the ED wait time was defined as the interval between the patient's arrival to the ED and time seen by a physician. Lastly, the volume of the patients presenting to ED during the study period was extracted from ED electronic business intelligence software QlikView. 2.5. Data analysis
2.2. Study population Patients who left before being seen by a physician were classified as LWBS cases. All patients who left the ED before being seen by a physician during the study period were considered eligible for inclusion in the study. Patients who were dead upon arrival or who died during their treatment or left against medical advice or transferred to specialty clinics or other hospital departments were excluded from the analysis. In addition, patients who were unreachable after 6 phone calls attempts and those who refused to enroll were also excluded. A total of 985 patients were identified with 692 patients excluded because they were not reachable. An addition 160 patients were excluded because they refused to participate. The remaining 133 patients were included in the study. Out of reach patients include those with a wrong phone number, those with a missing phone number from ED chart, and those who did not respond after 6 phone calls. Patients presenting to the ED undergo paper triage and the information collected on paper does not go automatically into patients charts until after the ED visit ends. As a result, many patients' charts have missing documentation. 2.3. Selection of participants The 133 LWBS cases were included and were matched with 133 controls cases. The control group included patients who presented to the ED during the same period and completed their treatment either to be discharged home afterwards or to be admitted to the hospital. Matching was done for the ESI score, date and time (±2 h). Using the emergency department's patient database, a list of all LWBS patients who presented to the emergency department during the study period
Statistical analyses were performed using SPSS 22 (Statistical Package for Social Sciences) for data cleaning, management and analyses. Descriptive statistics were summarized by presenting the frequencies and percentages for categorical variables and mean and standard deviation (SD) for continuous variables. In the bivariate analysis, the association between case control group and other categorical variables was carried out by using the chi-square and Fisher's exact test, as appropriate. Whereas, Student's t-test was used for the association with continuous variables. Multivariate regression analysis was used to adjust for potentially confounding variables. A stepwise multivariate logistic regression was conducted with all risk factors found to be significant in the bivariate analysis in addition to those considered as being clinically meaningful. p-Value of 0.05 was set for the entry of potential predictors into the model, whereas a p-value of 0.1 was set for removal from the model. The results were presented by the adjusted odds ratio (aOR) and 95% confidence interval (CI). p-Value of b0.05 was considered statistically significant. 3. Results A total of 985 potential eligible participants arrived to the ED during data collection period. 133 LWBS cases and 133 matched controls were enrolled in the study and completed the survey (Fig. 1). Table 1 presents a comparison between cases and controls in terms of baseline and demographic and clinical characteristics. Table 2 presents a comparison between the event characteristics for both cases and controls. The average for the reported waiting room time for patients who LWBS was lower compared to that of patients who completed their treatment (27.48 ± 25.09 vs 17.26 ± 15.13 min) (p b 0.0001).
Please cite this article as: E. Hitti, D. Hadid, H. Tamim, et al., Left without being seen in a hybrid point of service collection model emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.05.034
E. Hitti et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
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Potential ED patients (Presenting during data collection times) N= 56537
Eligible LWBS patients N= 985
Excluded (Out of Reach*) N= 692
Eligible patients N= 293
Excluded (Refused to participate) N= 160
Matched controls N= 133
Total Eligible LWBS cases N=133
Fig. 1. Study flow diagram of the selection process of cases and controls.
Factors contributing to LWBS are presented in Table 3. LWBS patients are more likely to have faced at least one ED access issue, with financial concerns being the most significant factor 10.5% as compared to 0.8% in controls, p-value b 0.001. Several reasons for leaving without being seen were elicited including in descending frequencies as follows; non-compensable status (without insurance coverage) (66.9%), financial reasons (12.8%), long waiting times (12.8%), and others (8.3%). With respect to clinical outcomes, 68.4% of the LWBS patients felt the same after leaving the ED as compared to 17.4% of those who completed treatment, p-value b 0.0001, and 17.3% felt worse after leaving the ED as compared to 3.0% of those who completed treatment, p-value b 0.0001. The majority of LWBS (81.2%) patients sought medical care after leaving the ED as compared to 14.3% of those who completed their treatment, pvalue b 0.0001, and 8.3% of the LWBS patients represented to the ED after 48 h, p-value = 0.0001. At 8 days follow-up, mortality rates between both groups were similar. The results of the stepwise multivariate logistic regression analyses for the predictors of LWBS are presented in Table 4. It was found that males were more likely to leave without being seen [aOR (95% CI): 2.87 (1.45–5.66), p = 0.002]. Moreover, for every 10 min increase in waiting room time, patients were 1.45 times more likely to leave without being seen [aOR (95% CI): 1.45 (1.20–1.74), p b 0.0001]. It was also found that patients with undergraduate or lower education level, as compared to those with graduate or higher education level, were more likely to leave without being seen [aOR (95% CI): 3.83 (1.70–8.62), p = 0.001]. Those who visited the ED once or more than twice over the past year, were less likely to leave without being seen [aOR (95% CI): 0.32 (0.14–0.71), p = 0.005; aOR (95% CI): 0.19 (0.08–0.47), p b 0.0001, respectively]. On the other hand, those who left without being seen were more likely to be self-payers (non-
compensable status) [aOR (95% CI): 3.05 (1.12–8.31), p = 0.03]. No specific presenting chief complaint was identified to be a significant predictor for LWBS. 4. Discussion This study is the first to examine the characteristics of patients, reasons for and predictors of LWBS in an ED of a tertiary care center that follows a hybrid point-of-service collection model. As EDs are challenged with increasing demand for emergency care, understanding the reasons and predictors for leaving without being seen, and examining associated clinical outcomes are important for other settings that are considering a similar model. In this hybrid POS collection model, patients who LWBS were relatively older than those who completed the ED assessment. Patients in both groups in this study were however relatively young with a mean age of 31.69 years and 26.61 years for cases and controls respectively. Previous studies that examined LWBS in EDs in the US and Australia revealed that LWBS patients tend to be younger when compared with those who completed their treatment [15,16]. Characteristics of patients who leave without being seen are associated with the reasons of LWBS and younger healthier patients are more prone to leaving without full medical evaluation when they experience prolonged waiting times [16]. Waiting time has been frequently cited as the main reason for LWBS in the literature [15,16]. In our study, even though waiting time was a predictor for LWBS with an aOR = 1.45 (95% CI 1.20–1.74) for every 10 min increase in wait times, waiting time was not the most common reason for LWBS. This could be explained by the relatively short average waiting times in our setting, with average reported waiting room time of patients who LWBS at 27.48 min vs a 17.26 min average waiting
Please cite this article as: E. Hitti, D. Hadid, H. Tamim, et al., Left without being seen in a hybrid point of service collection model emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.05.034
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Table 1 Baseline and demographic characteristics for cases and controls Groups
Gender Male Female Age, mean (±SD) b18 18–24 25–34 35–44 45–54 ≥55 Marital status Single Married Education Lower than undergraduate Undergraduate and higher Triage days per time Day (8 AM to 3:30 PM) Evening (3:30 PM to 11 PM) Night (11 PM to 7:30 AM) Chief complaint General Neurological Gastrointestinal Cardiovascular/Respiratory Eye/ear Musculoskeletal/skin Urological/Gynecological Others ESI 2 3 4 Financial coverage Compensable Non-compensable
Table 2 Event characteristics for cases and controls. p-Value
Controls N = 133
Cases N = 133
42 (31.6) 91 (68.4) 26.61 ± 8.96 1 (0.8) 75 (56.4) 36 (27.1) 16 (12.0) 3 (2.3) 2 (1.5)
74 (55.6) 59 (44.4) 31.69 ± 15.29 16 (12.0) 32 (24.1) 33 (24.8) 29 (21.8) 10 (7.5) 13 (9.8)
b0.0001
101 (75.9) 32 (24.1)
75 (56.8) 57 (43.2)
0.001
14 (10.6) 118 (89.4)
48 (37.5) 80 (62.5)
b0.0001
55 (41.4) 65 (48.9) 13 (9.8)
50 (37.9) 71 (53.8) 11 (8.3)
15 (11.3) 11 (8.3) 35 (26.3) 24 (18.0) 6 (4.5) 35 (26.3) 6 (4.5) 1 (0.8)
18 (13.7) 11 (8.4) 11 (8.4) 14 (10.7) 16 (12.2) 58 (44.3) 2 (1.5) 1 (0.8)
1 (0.8) 103 (77.4) 29 (21.8)
1 (0.8) 103 (77.4) 29 (21.8)
122 (92.4) 10 (7.6)
101 (76.5) 31 (23.5)
Group Controls N = 133
0.001
b0.0001
0.76
0.55 0.97 b0.0001 0.09 0.02 0.002 0.28 1.00 1.00
b0.0001
room time before being seen by a provider reported by patients who completed their treatment. In comparison, prior studies, where the most common reason for leaving before being seen was long wait times, reported wait times of around 1–2 h [15-17]. There were several initiatives that were done gradually over the years prior to the study date which focused on reducing waiting time and door to physician time and consisted of a series of value-driven interventions using Lean methodology that were previously described [18]. Non-compensable status was the strongest predictor for leaving the ED before being seen by a physician with an aOR = 3.09 (95% CI 1.14–8.39). It was also identified as the main reason for LWBS (66.9%). This may reflect access barrier that hybrid POS collection models create for patients who are uninsured or whose insurances do not provide coverage for an ED visit for specific chief complaints. Financial coverage has been previously identified as a predictor for LWBS in other settings with different payment models [1,16] with LWBS patients being more likely to be non-compensable compared to those who completed their medical treatment [1]. Non-compensable status should not however prevent patients from seeking alternative care locations where insurance payers might reimburse visits. It also allows patients with minor chief complaints or low triage acuity to make an informed decision early on about their ED visit rather than complete service and be surprised with an unsettled ED bill. Other predictors such as male gender and lower than undergraduate education were also identified. Previous studies that examined LWBS in EDs in the US and Australia revealed that LWBS patients were more likely to be of male gender and high school or college graduates when compared with those who completed their treatment [16,19,20]. The relation between gender, educational status and LWBS is not well
Transport Ambulance EMS Others Self Taxi Walking Proximity to ED 1 2 3 4 5 Referral source Self-referred Other than self ED visits last year Uncompleted 0 1 Admitted 0 1 ≥2 Discharged 0 1 ≥2 Waiting room time (minutes), mean (±SD) Waiting room time (minutes) ≤10 11–20 21–30 31–40 41–50 51–60 ≥61
p-Value Cases N = 133
6 (4.5) 6 (100.0) 0 (0.0) 126 (94.7) 98 (77.8) 28 (22.2)
6 (4.5) 4 (66.7) 2 (33.3) 127 (95.5) 102 (80.3) 25 (19.7)
1.00
51 (38.3) 41 (30.8) 25 (18.8) 7 (5.3) 9 (6.8)
48 (36.1) 45 (33.8) 23 (17.3) 5 (3.8) 12 (9.0)
97 (72.9) 36 (27.1)
105 (78.9) 28 (21.1)
0.25
133 (100.0) 0 (0.0)
126 (95.5) 6 (4.5)
0.01
119 (89.5) 11 (8.3) 3 (2.3)
130 (98.5) 2 (1.5) 0 (0.0)
63 (47.4) 31 (23.3) 39 (29.3) 17.26 ± 15.13
97 (73.5) 21 (15.9) 14 (10.6) 27.48 ± 25.09
65 (50.8) 32 (25.0) 15 (11.7) 3 (2.3) 6 (4.7) 6 (4.7) 1 (0.8)
55 (44.4) 15 (12.1) 20 (16.1) 2 (1.6) 6 (4.8) 18 (14.5) 8 (6.5)
0.46 1.00 0.62
0.89
0.005
b0.0001
b0.0001
0.002
examined in the literature and can be the focus of future studies examining demographic characteristics of LWBS patients. Presenting chief complaint was not identified to be a significant predictor for LWBS. Previous studies from other settings reported that patients who LWBS had mainly musculoskeletal and gastrointestinal complaints [20]. In our setting, practices by insurance companies to deny ED coverage for illnesses that can be addressed in clinics and to pre-authorization practices are common. In fact, patients with low acuity chief complaints (ESI 4 or 5) with private insurance frequently require pre-authorization from their insurance companies prior to service delivery. Patients with high acuity chief complaint (ESI 1, 2 or 3) are medically stabilized before requesting pre-authorization. With regards to clinical outcomes, even though there were no mortalities in patients who LWBS, this group was more likely to seek medical care after leaving the ED and to represent to the ED after 48 h. A higher ED return visit among LWBS patients was expected as a result of their incomplete medical treatment. These findings are consistent with previous literature [6,15,16]. LWBS patients were more likely to seek further care within short time intervals or to re-presented to ED within 48 h [15,17]. When applied selectively to low acuity patients, POS collection models do not however seem to impact patient outcomes. In fact, the majority of patients who LWBS in our study were young and had low acuity triage levels and at follow up the majority (81.2%) of LWBS successfully sought alternate care (hospitals/primary care). Rates of hospital admission were also similar between the two groups and no mortality was recorded at follow up.
Please cite this article as: E. Hitti, D. Hadid, H. Tamim, et al., Left without being seen in a hybrid point of service collection model emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.05.034
E. Hitti et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
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Table 3 Reasons for LWBS and clinical outcomes. Group Controls N = 133 ED access issues None At least one of the below Waiting time Financial barriers Unfriendly hospital staff Others Reasons for leaving Too long Too ill Feel better Health insurance coverage Cost Problem could wait Other Health status after leaving ED Worse Better Same Seek care after leaving Patients who have a family doctor Patients who would seek care in AUBMC emergency department in the future Patients who have re-presented to ED within 48 h Patients who have been admitted to hospital within 8 days Mortality status after 8 days, alive
4.1. Limitations The results of our study should be considered in the light of its limitations. We were unable to follow up on all LWBS patients as many did not have contact information documented at triage. This may have limited our ability to detect statistically significant predictors or to observe a difference in outcomes such as mortality. Patients who were missed might have had different experiences, however, each case was adequately matched. Additionally, although not assessed by our study, the impact of cost of care on LWBS rates may be different in our setting compared with other community hospitals in Lebanon with similar payment model since the costs at tertiary care centers are usually higher. Our hospital is one of the largest tertiary care centers in Lebanon and benefits from a large catchment area and the results of this study may be generalizable to hospitals in other settings with similar payment model.
p-Value Cases N = 133
77 (57.9) 56 (42.1) 19 (14.3) 1 (0.8) 1 (0.8) 40 (30.1)
56 (42.1) 77 (57.9) 20 (15.0) 14 (10.5) 5 (3.8) 42 (31.6)
– – – – – – –
17 (12.8) 1 (0.8) 5 (3.8) 89 (66.9) 17 (12.8) 4 (3.0) 11 (8.3)
4 (3.0) 105 (79.5) 23 (17.4) 19 (14.3) 59 (44.4) 124 (93.2) 0 (0.0) 5 (3.8) 133 (100.0)
23 (17.3) 19 (14.3) 91 (68.4) 108 (81.2) 45 (33.8) 77 (57.9) 11 (8.3) 5 (3.8) 133 (100.0)
0.01 0.86 0.001 0.21 0.79 NA
b0.0001 b0.0001 0.10 b0.0001 0.001 1.00 NA
than undergraduate education level, non-compensable coverage status. Financial coverage was the strongest predictor for LWBS. Larger studies are needed to better assess outcomes of patients who LWBS in a POS collection model. Funding source This work was supported by The American University of Beirut Medical Practice Plan grant number MPP 11.320083. XXXXX.11465.720.9999.0000. Funding body agreements and policies: Elsevier has established a number of agreements with funding bodies which allow authors to comply with their funder's open access policies. Some funding bodies will reimburse the author for the gold open access publication fee. Details of existing agreements are available online.
5. Conclusion
Ethics approval statement
In conclusion, in a hybrid POS collection model, patients who leave without being seen are more likely to be of male gender, have lower
The study was approved by the Institutional Review Board (IRB) of the American University of Beirut (AUB).
Table 4 Stepwise multivariate logistic regression of predictors of LWBS (Reference: LWBS = No), Goodness of fit test = 0.44. Variables Gender (Ref: Female) Age Waiting room time Marital status (Ref: Single) Education (Ref: Graduate or higher) Chief complaint (Ref: General)
Financial coverage (Ref: Compensable) ED access issues (Ref: None) Discharged ED visits in the preceding (1 year) (Ref: 0)
Male Increase by 10 units Increase by 10 units Married Undergraduate or lower Neurological Gastrointestinal Cardiovascular/Respiratory Eye/Ear Urological/Gynecological MSK/Skin Non-compensable At least one access issues (waiting time, financial barriers; unfriendly hospital staff or others) 1 ≥2
aOR (95% CI)
p-Value
2.87 (1.45–5.66) 1.18 (0.86–1.64) 1.45 (1.20–1.74) 1.84 (0.82–4.15) 3.83 (1.70–8.62) 0.67 (0.17–2.63) 0.26 (0.08–0.84) 0.55 (0.18–1.73) 3.60 (0.90–14.44) 0.16 (0.02–1.19) 1.09 (0.43–2.76) 3.09 (1.14–8.40) 1.52 (0.81–2.87)
0.002 0.3 b0.0001 0.14 0.001 0.57 0.03 0.31 0.07 0.07 0.86 0.03 0.19
0.32 (0.14–0.71) 0.19 (0.08–0.47)
0.005 b0.0001
Please cite this article as: E. Hitti, D. Hadid, H. Tamim, et al., Left without being seen in a hybrid point of service collection model emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.05.034
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Declaration of Competing Interest None declared. Acknowledgement Not applicable. Clinical trial registration Not applicable. Grants This work was supported by the Medical Practice Plan (MPP) grant [MPP 11.320083.XXXXX.11465.720.9999.0000]. License statement I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined in the below author license), an exclusive license and/or a non-exclusive license for contributions from authors who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY license shall apply, and/or iii) in accordance with the terms applicable for US Federal Government officers or employees acting as part of their official duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd. (“BMJ”) its licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the Work in Emergency Medicine Journal and any other BMJ products and to exploit all rights, as set out in our license. References
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Please cite this article as: E. Hitti, D. Hadid, H. Tamim, et al., Left without being seen in a hybrid point of service collection model emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.05.034