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Emergency rooms in British Columbia : a pilot project to validate current data and describe users McKendry, Rachael; Reid, Robert J.; McGrail, Kimberlyn; Kerluke, K.J. 2002

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 Centre for Health Services and Policy Research     Emergency Rooms in British Columbia: A pilot project to validate current data  and describe users   Rachael McKendry Robert J. Reid Kimberlyn M. McGrail Kerry J. Kerluke    HPRU 02:16D December 2002    Health Policy Research Unit Research Reports             THE  UNIVERSITY  OF  BRITISH  COLUMBIA    The Centre for Health Services and Policy Research was established by the Board of Governors of the University of British Columbia in December 1990.  It was officially opened in July 1991.  The Centre’s primary objective is to co-ordinate, facilitate, and undertake multidisciplinary research in the areas of health policy, health services research, population health, and health human resources.  It brings together r searchers in a variety of disciplines who are committed to a multidisciplinary approach to research, and to promoting wide dissemination and discussion of research results, in these areas.  The Centre aims to contribute to the improvement of population health by being responsive to the research needs of those responsible for health policy.  To this end, it provides a research resource for graduate students; develops and facilitates access to health and health care databases; sponsors seminars, workshops, conferences and policy consultations; and distributes Discussion Papers, Research Reports and publication reprints resulting from the research programs of Centre faculty.  The Centre’s Health Policy Research Unit Discussion Paper series provides a vehicle for the circulation of (pre-publication) work of Centre faculty, staff and associates.  It is intended to promote discussion and to elicit comments and suggestions that might be incorporated within revised versions of these papers. The analyses and interpretatio s, and any errors in the papers, are those of the listed authors.  The Centre does not review or edit the papers before they are released.  A complete list of available Health Policy Research Unit Discussion Papers and Reprints, along with an address to which requests for copies should be sent, appears at the back of each paper.            Emergency Rooms in British Columbia:  A pilot project to validate current data and describe users        Final report to the BC Medical Services Foundation Project number BCM00- 18    Rachael McKendry Robert J. Reid Kimberlyn M. McGrail Kerry J. Kerluke     The Centre for Health Services and Policy ResearchDecember 2002      1Emergency Rooms in British Columbia:  A pilot project to validate current data and describe users  A. BACKGROUND   Emergency departments have been given considerable media attention over the last few years, characterized by a 'chronic shortage' of either staff or funding. What is not clear is whether emergency departments themselves are under-funded or under-staffed, or whether the situation in the emergency department is a symptom of a system-wide misallocation of resources. There has been work, for example, that suggests that many individuals occupying acute care beds do not actually require acute care services (Wright, Cardiff and Kilshaw; 1997). Discharge from an acute care setting may be impossible, however, if alternative levels of care that are more appropriate (in the community or in long term care facilities, for example) are not availabl  (McGrail et al.; 1998). The occupation of acute care beds by people not actually requiring that level of service prevents people who do need acute-level care from being admitted, thereby potentially backing up other areas of the health care system, such as emergency departments.  Evaluation of the functioning of a health care system is contingent on an extensive knowledge about the breadth of services encompassed in that system. Emergency departments (EDs) are understood to be an important aspect of health servic s, as they represent both a source of care for urgent medical needs and a source of primary care when GP offices are closed (Mustard et al., 1998). Use of EDs accounts for anywhere from 5% (Mustard et al., 1998) to 11% (Schappert, 1998) of ambulatory care. While a good deal of research has concentrated on whether services provided in the ED are an efficient use of health care resources (Franco, Mitchell and Buzon, 1997; Green and Dale, 1992; Leydon et al., 1998), less time has been spent describing the users of EDs, and how that use fits in an overall pattern of health care service utilisation.  There were nearly 1.6 million visits to British Columbia EDs in fiscal year 1998/99 (BC Ministry of Health, 1998), or approximately 39 visits per 100 persons. This rate of use is similar to the 35.5 visits per 100 person years reported in Manitoba (Mustard et al., 1998). The total number of visits is based on aggregate numbers of ED visits reported by hospitals on an annual basis to the Ministry of Health. These numbers, however, do not provide information on who the users are, for what reasons they present, or what the outcomes of care were.  Considering the full continuum of ambulatory care, females are, in most age groups, higher overall users of ambulatory services, but are less likely than males to present with   2problems in an ED setting. Males are slightly higher users than females in proportionate terms (Schappert, 1998), but female adolescents age 16-20 re slightly higher users of EDs than males of the same age (Marcel et al 2002). ED use is higher among the younger age groups, with a peak in the 20s and 30s (Schappert, 1998; Barer et al., 1994). People aged 45 and older have the lowest use of EDs as a percentage of all ambulatory care. This is likely because injuries account for a third or more of all visits to EDs, and injuries are more common in younger age groups (Burt and Fingerhut, 1998).  Distinction has often been made between people who use ED services, and those who become ‘high users’ of those services. High users of public EDs in the US tend to be males between the ages of 30-59 with Medicare-type insurance (Mandelberg, Khun, Kohn 2000). However in Canada very high users of EDs tend to be females between the ages of 25 and 64 with lower incomes than low ED users (Chan et al 2002). In New Zealand, children and the elderly were identified as the most frequent high users of ED services (Hider et al 2001) and that both sexes were equally represented (Helliwell et al 2001). In Canada, there appears to be some overlap between high use of EDs and frequency of visits to primary care physicians (Chan et al 2002; Hansagi et al 2001).  The average user (and ‘high user’) of ED services is different - at least in demographic terms - from the average user of physician services, which is, in turn, different from the demographic profile of the general population. The extent of these differences varies by jurisdiction. This inconsistency makes it difficult to guess what the experience of EDs in the province of British Columbia, and how the use of ED services fits in the context of health services utilization overall.  B.  GOALS and OBJECTIVES   This project was developed to address two broad objectives. First, we explored the extent to which the use of emergency departm nts is covered by fee-for-s rvice payments to physicians routinely collected at the individual (patient) level through existing administrative data systems. The purpose of this was to both develop a methodology for identifying services provided in EDs across the province and to answer questions about the validity of the available administrative data in describing ED use. The ability to create such a definition of ED services based on routinely collected (and linkable) administrative data would provide a rich s urc of information   3on an important aspect of health care service utilization even in the absence of a dedicated, province-wide emergency department information reporting system. Second, we used the ED data available to provide a broad-brush description of users of using EDs in BC, and how this use fits with their use of other ambulatory services. In summary, we: 1. Estimated the completeness of ED use captured in current administrative data sources, by combining information from FFS payments to physicians, ambulance data and hospital admission data, and comparing numbers of service encounters to a ‘gold standard’ provided by the Ministry of Health. 2. Described the use of EDs (as reflected in current data) by Local Health Area (LHA) of the province. 3. Described the current users of EDs in British Columbia by age, sex, and use of other ambulatory health care services.  C.  PROJECT ACTIVITIES and METHODOLOGY   In order to understand the use of EDs as a component of total health care use, rather than as a somehow separable or independent service component, it is necessary to have access to individual-level data. Such data are available through the BC Linked Health Data set. Over the past decade the Centre for Health Services and Policy Research, with funding from the British Columbia Ministry of Health, has developed a set of linked health data (Chamberlayne et al.; 1998). This data set (the BC Linked Health Data set, or BCLHD) includes mainly administrative data that have been collected for payment and other administrative purposes. The core is comprised of records of patient contact with hospitals, physicians, and the continuing care system, as well as vital statistics and pharmaceutical prescriptions for seniors and births and deaths. Ambulance Service data was recently added to the BCLHD, providing a record of all ambulance call-outs in BC. Because the health care system in the province is universal, these data represent a population-based picture of utilisation of these health care services. Most use of EDs is captured by fee-for-service payments made to physicians through the Medical Services Plan, but the process of identifying all services provided in that setting is not well understood. This is because there are several ways services provided in the ED might bebilled, and many physician specialties that might be billing for them. A small proportion of physicians who work in EDs are paid through alternative arrangements (i.e. salary or sessional   4payments), for which no individual-level data are available. The total number of visits to EDs covered by these alternative payment arrangements is only 9% of total provincial ED use. It is unfortunate that there are no patient-level data currently in the BCLHD for these encounters, but it is a small enough proportion to be manageable for research purposes.  Phase I –  validating records of ED service provision  The 1.6 million reported visits to EDs in British Columbia in 1998/99 were made to ninety hospitals across the province. Most, according to the Ministry of Health, we e paid for through the fee-for-service system. The exceptions are ED services provided at two tertiary care hospitals in Vancouver, which have special arrangements with the Alternative Payments Branch of the Ministry, and pay physicians a salary to provide ED coverage. As a result, visits to these two EDs are not captured in the administrative data that are part of the BCLHD.  The purpose of the first phase of this project was to attempt to replicate the Ministry of Health numbers using routinely collected administrative data that are part of the BCLHD. The total number of ED visits reported to the Ministry of Health will serve as a ‘benchmark’ or ‘gold standard’ for this purpose. The concordance between these numbers and those derived from BCLHD service ncounters will give us a general idea of how much service provision is not available through current data resources. Table A outlines the data files used and provides a summary of the contents therein. Using 1998/99 and 1999/2000 data, we identified all ED-related services in the three administrative data files. These years were chosen because we had one full calendar year of Ambulance data for 1999.   5 Table A:  Data sources for ED services   Data source Description N Total number of ED visits Provides the ‘gold standard’ total number of visits to EDs reported to the Ministry of Health in 1998/99 and are reported by hospitals. 1,250,2631  Fee for service payments to physicians  Records of payments to physicians for ER services provided in BC. 1,046979 Hospital separations Records of separations from BC hospitals that came through the ED that linked to a physician payment for an ED visit ~126,4802 Ambulance data Records of ambulance transport to EDs across the province that linked to a physician payment for a  ED visit.  124,729  MSP Payment Information Master file (fee for service payments to physicians) The physician payment data were the most complicated in terms of creating a set of data applicable to emergency services, because there has been no work validating the coding system used to identify emergency services. We cannot be sure, then, that the process described below is sensitive in picking up all ED services, or specific in picking up only ED services. Nonetheless, it represents a first attempt at doing so. A combination of two-digit service codes, indicating a general category of service, and five-digit f e items, representing the specific service provided, were used to identify a relevant set of data. Extraction of the data began by:  1. Identifying all MSP PIM services that occur in a hospital using the ‘service location code’ = H for Hospital or E for Emergency (excluding diagnostic services and ‘no-charge referrals’)  2. Excluding all non-physician services with zero billings 3. Excluding all fee items3 except:  a. Service code ‘01’ identifying regional examinations, with a fee item code of 13200 or 13300 (out of office visits) if billed on the same day with 01200 (evening [1800 hrs –                                           1 We excluded visits from hospitals where ED physicians are paid through salary and sessional arrangements, because we could not identify visits to tho e hospitals in our data. This reduced the 1.6 million ED visits reported to the Ministry of Health to 1,250, 263 visits. Visits to the following hospitals were excluded: Vancouver General Hospital, St. Paul’s Hospital in Vancouver; Bella Coola General in B lla Coola, R.W Large Memorial Hospital in Waglisa, and, Wrinch Memorial Hospital in Hazelton. 2 The linkage rate between the ER visits identified in Hospital Separations and those identified in the physician data was low (only 68%). 3 Fee items are thunit of service billed by physicians in the fee-for-s rvice system. There are over 4,000 fee items, each of which indicates the type of service provided, and the specialty that ‘owns’ the fee item. Service codes group these fee items into about 40 broad service categories. We have validated that the same fee items is reliably assigned to the same service code, but there has not been any validation of the accuracy of that assignment in the first place.    62300 hrs]), 01201 (night [2300 hrs –  800 hrs]), or 01202 (Sat, Sun, or Stat Holiday) or if billed on same day with an emergency service code (06, 44, or 60) by the same physician;  b. Service code of ‘06’ identifying emergency visits, with fee item codes starting with 018* (emergency care), or 0012* (emergency visit), 0013* (on call, on site hospital visit), 00105 (on call, on site hospital visit), 00129 (WCB emergency call out);  c. Service code ‘09’ identifying visit premiums, with fee item codes 01200, 01201, 01202 (evening, night, weekend or holiday);  d. Service code ‘22’ identifying consultations with fee item code 01810 (emergency medicine consultation);  e. Service code ‘26’, identifying emergency care4, with f e service codes 00305, 04005, 00505, 08005, 07005, 02005, 02505, 06005, 00405, 03005, 00605, 07805, 00205, 01705, 31005 (emergency visits for specialists);  f. Service code ‘60’ identifying WCB services with fee item code 19921 (WCB hospital emergency per diem rate); and, g. Service code ‘44’ identifying minor surgery, minor therapy with fee service codes 13610, 13611, 13612 (minor and extensive lacerations). 4. Exclude if no billings for primary contact, the initial contact with the designated ED or on-all physician.  (i.e., service codes 01+06+44=0). Following this data extraction, a secondary validation step with the Hospital Separati ns data was carried out. The physician file service date was compared with the admission and separation dates in the Hospital Separations data. If the service date in the physician data occurred between the time of admission and separation it was not considered an ER visit. If the service date occurred on the admission date it was considered an ER visit. If there was no corresponding hospital admission date for a service date then it was considered an ER visit. This step was undertaken to exclude servic s that occurred in a hospital that were clearly part of an inpatient stay rather than emergency department outpatient services.  Hospital Separations data We extracted all separations that had either an entry code of ‘E’ indicating ‘emergency’, or a ‘transfer from level’ code of ‘X’ indicating the transfer was made from an emergency department. Using these criteria for extracting separation records resulted in a set of data that                                             7represent separations from acute care that were the result of initial contact with EDs. Only emergency room visits that result in a hospital admission are included in the Hospital Separations data, so the data extracted (approximately 186,000 visits) is a small proportion of ED visits in the Province (14.8%). These data were not us d to create the ER visit database but were used to validate the ED visits identified using the MSP PIM data. Ambulance data There were approximately 239,000 ambulance transports to a hospital in 1999. 124,729 of these linked to a physician payment for an ED visit while 113,000 transports did not. Of those 113,000 unlinked transports, 46,000 were between-hospital transports and probably not emergency transports. 16,000 were transports to Vancouver General and St. Paul’s Hospitals where we would not expect to find physician records because of salary and sessional payment arrangements for staff in those EDs. 27,000 had payment records but were not counted as emergency billings (using the cohort definition from the physician data described above). 24,000 did not have any payment records (10,461 of which were transports for lab or x-ray services). Since only approximately 10% of all visits to an ED arrive by ambulance these data were not used to create the ED visit database. Like hospital separations, these d ta were u d to validate the ED data set derived from physician payment data.               Ambulance Transports N=239,000 Ambulance transports linked to an ED visit N=124,729 Ambulance transports not linked to an ED visit N~113,000 Between hospital transports N=46,000 Transports to VGH & St. Paul’s N=16,000 Other transports N=27,000 Transports without payment records N=24,000 Lab & x-ray transports N=10461   8Validation of the ED visit database The 1,046,979 ER visits identified using the physician payment data were validated using the 124,729 Ambulance transports provided a link between a physician payment and the admitting hospital. Patients in this group of 124,729 services were assigned to a hospital according to the hospital they were admitted to in the Hospital Separations data. The assigned hospital was compared with the ‘hospital carried to’ field in the Ambulance Data. The results in table below show there was 87.73% agreement between the assigned hospital and the carried to hospital. The proportion of disagreements could be reduced by combining hospitals that amalgamate their services (e.g., Victoria General Hospital).  Validation of ED Visit Database  Frequency Percent Disagreement 15,305 12.27 Agreement 109,424 87.73 Agreement between Hospital Carried to and Hospital Admitted to Total 124,729 100.00  The resulting set of data, the Emergency Department database, is an estimate of the number of emergency services provided in the province during fiscal year 1998/99, excluding the services provided by hospitals with salary and sessional physicians staffing the ED, as described above. The total number of ED visits derived from physician payment data was 1,046,979. This compares to the ‘gold standard’ from the Ministry of Health of 1,250,263 –  implying that we were able to find 83% of ED visits in BC, again excluding those provided in EDs staffed by physicians paid through salary and sessional arrangements. Table 1 (see page 13) provides information on rates of comparison on a hospital-specific basis.  We learned the following in the process of idntifying ED services using physician payment information: 1. Not all Emergency Services take place in the ED 2. Emergency Services can be billed by ED physicians or on-c ll physicians   93. Emergency services can be divided into primary and secondary contacts a. The primary emergency contact is the initial contact with the designated ED or on-all physician. The primary emergency contact is with a GP, an ED physician or in some cases a paediatrician. b. The secondary emergency contact is usually billed as a consult or a specialist emergency visit. The consult can be with a GP but usually with a Specialist. (We were not interested in these secondary contacts.) 4. Emergency services billed by ED physicians are easy to identify because they take place in the ED and ED physicians only bill fee items that begin with ‘018’. These account for about 60% of emergency department billings.5. Emergency services billed by on-call physicians are more difficult to identify. Out-of-office visits may indicate emergency visits if billed with an on-call fee item or a visit premium. Visit premiums may indicate an ED service if billed with an out-of-office visit, but not always.  6. Minor surgery billed by an ED or on-call physicians are considered emergency services. 7. The Workers’ Compensation Board ‘owns’ the fee items 19921 (WCB hospital emergency per diem rate) and 00129 (WCB emergency call out). 19921 is problematic because almost 9000 visits are billed to the WCB program, probably duplication information recorded elsewhere. 8. Some hospitals have ED physician  paid by salary and therefore ED services cannot be identified at these hospitals. These include: Vancouver General Hospital and St. Paul’s Hospital in Vancouver; Bell Coola General in Bella Coola; R.W Large Memorial Hospital in Waglisa; and, Wrinch Memorial Hospital in Hazelton. 9. ‘Service location’ for ED services is usually coded as H-hospital or E-emergency department but can also be coded as O-office or “ “- blank  Phase II –  a description of ED users The first part of this descriptive component produced a regional breakdown of ED use in British Columbia. This was done by attributing each ED visit to one of the Local Health Areas in the province using postal codes available on each of the data sets. After allocating ED visits, we produced crude and ge- and sex- adjusted rates (indirect) of use per 1,000 population, based on population numbers provided by BC Stats (see Table 2 on page 15). There is a more than ten-  10fold variation in rates of ED use by LHA, though some of the extremes are seen in smaller local health areas, and thus may be the result of small numbers. Even after adjustment and accounting for areas where we know we are missing information on ED use, there remains substantial variation in the use of ED services. In order to describe ED use as one component of health services utilisation, we needed to expand the data set extracted for Phase I and the descriptive analysis outlined above. Each individual who appeared in the ED visit database for Phase I was identified. All encounters with physicians and alternative providers (also paid for through the fee-for-service system), all hospital separations, and all encounters with the Ambulance Service were then extracted for these individuals. Instead of just ED services, all service encounters in these data sets for the subset of individuals who use the ED at least once during fiscal year 1998/99 were accumulated. Individual identifiers were converted to study ids prior to release of data to the research team, which allowed individual-specific but non-identifying analyses of data.This descriptive analysis fills a gap in ED research, because users of EDs are not often described in the research literature. The availability of linked data enabled us to answer several questions of interest:  1) Are users of EDs also significant users of health care services, such as physician office visits and hospital days? Defining ‘high use’ based on total physician expenditures over the course of a year, high users of EDs also tend to be high users of other physician services (see Table 3 on page 17). When use of EDs is categorized by number of visits during the year, the proportion of high users increases in lock step with the increase in ED use. Looking at it a slightly different way, ED expenditures make up (on average) onlya small proportion of all physician expenditures –  about $14 out of $466, or 3%. If we limit consideration to only individuals whose ED expenditures are 75% or more of their total health expenditures, we find that this group includes only 41,041 pe ple (1.2% of all those who use physician services during 1999), and their total use of physician services is a little under $2.5 million, which is far less than 1% of the total (see Table 4 on page 17). To take this one step further we can consider high users of ED services who are also high users of physician services (see also Table 4 on page 17). Of the more than 130,000 adults who are classified as ‘high users’ based on overall physician service use, only 3 generate more than 75% of their physician use through the ED. Taken together,   11these findings suggest that sick people tend to use ED services, but that relatively few people appear to be making the ED their location of primary care. 2) Do High Users of EDs use EDs because of an apparent increase in medical n ed? Previous research in British Columbia has shown that ‘high use’ of physician services tends to be associated with increased morbidity (Reid et al., 2003). In other words, high users are such because of medical complaints and conditions, and not because of frivolous demands on the health care system. A similar relationship appears to hold for high users of ED services, since we see that ten times as many high ED users than non-ED users died during the study period (see Table 5 on page 18).3) Are users of EDs in British Columbia similar to users in other jurisdictions with respect to average age and sex?Users of EDs in British Columbia are similar to ED users in other jurisdictions according to age (see Table 6 on page 18) with the greatest proportionate use c m ng from those under age 30 and over age 75.  In terms of sex, ED users in BC differ from other jurisdictions in that females are higher users of EDs than males (see Table 7 on page 19). In others jurisdictions (Schappert 1998), females are more fr quent users of all health services than males exc pt ED services. We also looked at socioeconomic status and found that those in the lowest SES quintile made up the highest proportion of high ED users, at almost 29% (see Table 8 on page 19).  D.  CONCLUSIONS:  This preliminary work suggests that it is possible to identify most ED services in British Columbia using physician payment information. The algorithm to identify these services is complex, but yields a set of data that appears to represent actual ED services, hough it does not capture all of those services. This is an important finding, as there is no province-wide tracking system available for ED services, so up to this point it has not been feasible to think about studying the population of ED users. An initial description of these users indicates that the profile of ED use in BC is somewhat different than in other jurisdictions, that ED users tend to be sicker than the general population, and that for the most part ED use remains a relatively small proportion of total physician service use. A more thorough understanding of the dynamics of ED service use will assist planners and policy-makers with the rational allocation of health services budgets. An   12ability to define this use through readily available administrative data will go a long way to making this understanding possible.    13Table 1: EDVisits by Hospital A Comparison of 1999/2000 Data from the Ministry of Health  and 1999 Data Derived from Physician Payment Information              continued… 418ER HOSP Hospital N Ratio003 The Arthritis Society050 1051 5101 101 Vancouver Hospital & HSC 73,413 3,439 + 123 17,978 21,417 0.29102 102 St. Paul's 50,446 1,965 0.04103 103 CHARA (St. Vincent's) 22,406 11,182 + 106 10,110 21,292 0.95104 B.C. Women's Hospital 1,631105 105 B.C. Children's 33,463 26,263 0.78106 106 Mt. Saint Joseph 10,110107 B.C. Cancer Agency 13109 109 Simon Fraser Health Board 125,609 82,413 + 136 1,492 + 604 21,182 105,087 0.84110 Saint Mary's (New Westminster) 170111 111 Powell River 20,548 15,507 0.75112 112 Lion's Gate 43,271 39,839 0.92113 113 St. Mary's (Sechelt) 12,291 9,021 0.73114 Sunny Hill Health Centre For Children115 115 Langley Memorial 39,036 33,408 0.86116 116 Surrey Memorial 73,470 68,934 0.94118 Holy Family119 B.C. Rehab Society121 121 Richmond 39,309 34,535 0.88122 Louis Brier123 123 U.B.C.  Health Sciences Centre 17,978128 128 Squamish General 11,303 8,829 0.78130 130 Burnaby 57,230 53,884 0.94131 131 Peace Arch District 31,552 23,093 0.73134 134 Delta 21,562 16,708 0.77136 136 Eagle Ridge Hospital 1,492137 St. Michael's Centre201 17650VRHB CB PROVIDENCE 28,900202 202 Victoria General 78,436 41,235 + 201 28,900 + 211 108 70,243 0.90203 203 Cowichan District 23,382 24,198 1.03204 Queen Alexandra Centre 9206 206 The Lady Minto Gulf Islands 5,667 1,804 0.32211 Gorge Road Extended Care 108212 Mount St. Mary217 217 Saanich Peninsula 17,295 11,898 0.69220 Juan de Fuca301 301 Vernon Jubilee 21,461302 302 Kelowna General 48,138 39,225 0.81303 303 Penticton Regional 26,482 12,529 0.47305 305 Princeton General 7,499 1,820 0.24306 306 Enderby and District Memorial 1,796307 307 Pleasant Valley Health Centre 14308 308 Summerland General 5,104 2,354 0.46309 309 South Okanagan General 11,871 5,122 0.43310 Keremeos D & T Centre401 401 Royal Inland 35,598 34,031 0.96402 402 Queen Victoria 2,626403 403 Nicola Valley General 7,636 4,226 0.55404 404 Shuswap Lake General 9,449405 405 St. Bartholomew's 1,093 19 0.02406 406 Cariboo Memorial 15,542408 408 Ashcroft and District General 2,721 675 0.25409 409 Golden and District General 3,208412 Blue River Red Cross Outpost 1416 Alexis Creek Red Cross Outpost 6417 417 Lillooet District 3,364 1,210 0.36419 419 Dr. Helmcken Memorial 3,615 1,668 0.46421 Overlander422 Pemberton D & T Centre 4,479423 Logan Lake Health Centre 469424 Barriere and District Health Centre 660425 Whistler D & T Centre 21,749426 Chase and District Health Centre 3,206501 501 Nanaimo Regional General 39,477 33,603 0.85502 502 St. Joseph's General 21,804 18,702 0.86AMALGAMATED HOSPITALSER VISITS USING PHYSICIAN PAYMENT INFORMATIONER VISITS - GOLD STANDARD1999/2000Non-Scheduled Visits  14Table 1 (continued): ED Visits by Hospital A Comparison of 1999/2000 Data from the Ministry of Health  and 1999 Data Derived from Physician Payment Information   418ER HOSP Hospital N Ratio504 Cumberland Health Care Facility 8505 Chemainus Health Care Centre 2,974506 506 Ladysmith and District General 3,635507 507 Mount Waddington Health Council 733508 508 Campbell River and District General 23,184 17,368 0.75510 510 Port Hardy 6,424 3,246 0.51511 511 Port McNeill 3,575 1,911 0.53601 601 Chilliwack General 34,487 25,121 0.73602 602 Mission Memorial 21,852 14,096 0.65603 603 Matsqui-Sumas-Abbotsford General 41,780 38,839 0.93604 604 Maple Ridge 21,182606 606 Fraser Canyon 6,329 3,683 0.58607 Menno651 651 Kootenay Lake District 12,735 6,618 0.52652 652 Slocan Community Hospital 88 365 4.15653 Victorian Hospital of Kaslo 66654 654 Creston Valley 7,865 3,791 0.48655 655 Arrow Lakes 965656 Edgewood Red Cross Outpost 1657 Mount St. Francis701 701 Fort St. John General 25,896 13,719 0.53702 702 St. John 153 1,980 12.94703 703 Prince George Regional 45,224 41,222 0.91704 704 Dawson Creek and District 17,340 9,382 0.54705 705 G.R. Baker Memorial 12,540 7,824 0.62706 Pouce Coupe Care Home707 707 Lakes District Hospital 6,515 2,180 0.33708 708 100 Mile District General 4,447713 713 McBride and District 79714 714 Fort Nelson General 5,019 1,468 0.29715 715 Mackenzie and District 942716 716 Chetwynd General 5,368 1,009 0.19717 717 Stuart Lake 4,016 1,561 0.39718 Valemount Health Centre720 Tumbler Ridge Health Care Centre 2,191752 752 Kimberley and District 2,357753 753 Fernie District 3,152 2,168 0.69754 754 Sparwood General 2,382 1,329 0.56755 755 Invermere and District 0 1,821756 756 Cranbrook Regional 10,496757 Elkford Health Care Centre 1,771758 Fraser Lake D & T Centre 3,177759 Hudson's Hope Gething D & T Centre 944770 Stikine Regional Health Centre801 801 Trail Regional 10,754 5,899 0.55802 802 Mater Misericordiae 2803 803 Boundary 10,408 3,237 0.31804 804 Castlegar and District 9,768 2,506 0.26851 851 West Coast General 21,589 9,108 0.42854 854 Tofino General 3,228 1,387 0.43855 Bamfield Red Cross Outpost 8857 Kyuquot Red Cross Outpost 1859 859 Port Alice 446860 Gold River Health Clinic 3,350861 Tahsis Health Centre 787901 901 Wrinch Memorial 4,037 6 0.00902 902 Prince Rupert Regional 13,939 7,984 0.57903 903 Bulkley Valley District 5,819904 904 R.W. Large Memorial 2,047 1906 906 Bella Coola General 2907 907 Queen Charlotte Islands General 9909 Houston Health Centre910 910 Stewart General 458 2912 912 Mills Memorial 18,243 8,912 0.49914 Atlin Red Cross Outpost916 Cassiar917 917 Kitimat General 5,720 3,474 0.61AMALGAMATED HOSPITALSER VISITS USING PHYSICIAN PAYMENT INFORMATIONER VISITS - GOLD STANDARD1999/2000Non-Scheduled Visits  15Table 2: Crude and Age/Sex Adjusted ER Visit Rates for BC Population by LHA               continued…  OBSERVED OBSERVED EXPECTED EXPECTED RATIOLHA LHA Name POPULATION ER VISITS RATES/1000 ER VISITS RATES/1000 OBS/EXP1999 1999 1999 1999 1999 1999001 Fernie 15,157 3,926 259.0 3,750 247.4 1.05002 Cranbrook 25,836 9,598 371.5 6,770 262.0 1.42003 Kimberley 8,697 2,536 291.6 2,286 262.8 1.11004 Windermere 8,734 2,101 240.6 2,200 251.9 0.96005 Creston 12,917 3,525 272.9 3,454 267.4 1.02006 Kootenay Lake 3,651 380 104.1 926 253.7 0.41007 Nelson 24,712 5,934 240.1 6,462 261.5 0.92009 Castlegar 13,652 2,792 204.5 3,577 262.0 0.78010 Arrow Lakes 5,244 1,635 311.8 1,335 254.5 1.23011 Trail 20,938 5,677 271.1 5,689 271.7 1.00012 Grand Forks 9,270 3,195 344.7 2,372 255.9 1.35013 Kettle Valley 3,675 564 153.5 880 239.5 0.64014 Southern Okanagan 18,544 6,065 327.1 5,029 271.2 1.21015 Penticton 40,281 9,956 247.2 11,388 282.7 0.87016 Keremeos 4,763 1,393 292.5 1,223 256.7 1.14017 Princeton 5,011 1,762 351.6 1,251 249.7 1.41018 Golden 7,440 2,973 399.6 1,864 250.6 1.59019 Revelstoke 8,565 2,619 305.8 2,190 255.7 1.20020 Salmon Arm 31,911 9,454 296.3 8,301 260.1 1.14021 Armstrong - Spallumcheen 9,785 2,052 209.7 2,580 263.7 0.80022 Vernon 58,491 17,390 297.3 15,687 268.2 1.11023 Central Okanagan 150,686 36,929 245.1 40,942 271.7 0.90024 Kamloops 102,727 31,190 303.6 26,772 260.6 1.17025 100 Mile House 15,277 4,213 275.8 3,792 248.2 1.11026 North Thompson 5,057 1,751 346.3 1,256 248.3 1.39027 Cariboo - Chilcotin 28,802 16,020 556.2 7,248 251.6 2.21028 Quesnel 26,264 7,835 298.3 6,704 255.2 1.17029 Lillooet 4,736 1,350 285.1 1,180 249.1 1.14030 South Cariboo 7,624 1,467 192.4 1,912 250.8 0.77031 Merritt 11,672 4,211 360.8 3,009 257.8 1.40032 Hope 8,545 3,526 412.6 2,227 260.6 1.58033 Chilliwack 72,161 24,517 339.8 19,445 269.5 1.26034 Abbotsford 117,481 35,579 302.8 31,768 270.4 1.12035 Langley 113,967 29,934 262.7 30,217 265.1 0.99036 Surrey 366,754 95,980 261.7 97,760 266.6 0.98037 Delta 101,524 26,816 264.1 26,534 261.4 1.01038 Richmond 167,158 31,651 189.3 44,463 266.0 0.71040 New Westminster 55,736 16,659 298.9 15,447 277.2 1.08041 Burnaby 196,083 47,288 241.2 52,989 270.2 0.89042 Maple Ridge 78,298 21,528 274.9 20,407 260.6 1.05043 Coquitlam 192,928 49,289 255.5 50,099 259.7 0.98044 North Vancouver 132,068 27,325 206.9 35,259 267.0 0.77045 West Vancouver - Bowen Island 49,897 8,340 167.1 13,981 280.2 0.60046 Sunshine Coast 26,732 8,053 301.2 7,064 264.2 1.14047 Powell River 20,482 14,735 719.4 5,309 259.2 2.78048 Howe Sound 29,699 11,255 379.0 7,427 250.1 1.52049 Bella Coola Valley 3,421 396 115.8 836 244.2 0.47050 Queen Charlotte 5,349 391 73.1 1,265 236.5 0.31051 Snow Country 787 79 100.4 194 246.3 0.41052 Prince Rupert 17,822 8,028 450.5 4,558 255.8 1.76053 Upper Skeena 5,782 499 86.3 1,428 246.9 0.35054 Smithers 18,173 5,626 309.6 4,555 250.6 1.24055 Burns Lake 7,733 3,001 388.1 1,965 254.1 1.53056 Nechako 17,643 4,625 262.1 4,450 252.2 1.04057 Prince George 102,525 39,228 382.6 25,935 253.0 1.51059 Peace River South 28,483 10,257 360.1 7,232 253.9 1.42060 Peace River North 29,844 12,980 434.9 7,617 255.2 1.70061 Greater Victoria 208,440 52,042 249.7 60,798 291.7 0.86062 Sooke 53,755 10,526 195.8 13,722 255.3 0.77063 Saanich 60,805 15,284 251.4 16,490 271.2 0.93064 Gulf Islands 14,156 2,347 165.8 3,777 266.8 0.62065 Cowichan 52,399 19,763 377.2 13,825 263.8 1.43066 Lake Cowichan 6,349 1,806 284.5 1,594 251.0 1.13Crude Age/Sex Adj  16Table 2 (continued): Crude and Age/Sex Adjusted ER Visit Rates for BC Population by LHA   OBSERVED OBSERVED EXPECTED EXPECTED RATIOLHA LHA Name POPULATION ER VISITS RATES/1000 ER VISITS RATES/1000 OBS/EXP1999 1999 1999 1999 1999 1999067 Ladysmith 16,405 6,771 412.7 4,362 265.9 1.55068 Nanaimo 92,556 26,461 285.9 24,727 267.2 1.07069 Qualicum 38,965 5,772 148.1 10,367 266.0 0.56070 Alberni 32,214 10,486 325.5 8,327 258.5 1.26071 Courtenay 58,293 18,381 315.3 15,208 260.9 1.21072 Campbell River 40,621 16,394 403.6 10,275 253.0 1.60075 Mission 37,153 13,619 366.6 9,427 253.7 1.44076 Agassiz - Harrison 7,812 1,908 244.2 1,805 231.0 1.06077 Summerland 11,524 2,523 218.9 3,215 279.0 0.78078 Enderby 7,405 2,121 286.4 1,921 259.4 1.10080 Kitimat 12,475 3,627 290.7 3,063 245.5 1.18081 Fort Nelson 6,292 1,816 288.6 1,574 250.1 1.15083 Central Coast 1,817 111 61.1 441 242.6 0.25084 Vancouver Island West 2,858 1,070 374.4 666 233.0 1.61085 Vancouver Island North 14,664 6,220 424.2 3,584 244.4 1.74087 Stikine 1,271 101 79.5 314 246.8 0.32088 Terrace 22,799 8,918 391.2 5,787 253.8 1.54092 Nisga'a 1,970 398 202.0 481 244.1 0.83094 Telegraph Creek 622 116 186.5 152 243.6 0.77161 Vancouver - City Centre 89,420 8,897 99.5 24,454 273.5 0.36162 Vancouver - Downtown Eastside 51,594 8,152 158.0 12,664 245.5 0.64163 Vancouver - North East 96,167 18,927 196.8 25,712 267.4 0.74164 Vancouver - Westside 121,391 19,147 157.7 34,670 285.6 0.55165 Vancouver - Midtown 86,134 14,687 170.5 23,173 269.0 0.63166 Vancouver - South 122,552 20,005 163.2 33,834 276.1 0.59Total British Columbia 4,028,072 1,056,474 262.3 1,072,863 266.3 0.98Crude Age/Sex Adj  17Table 3: High Users by Number of ER Visits - Adult Pop (18+) 95th Percentile - Total Expenditures ($1,880) Data Source:  PIM - Calendar Year 1999      Table 4: Expenditures by Ratio  (Ed Exp/Total Exp) Data Source:  PIM - Calendar Year 1999   N % N % N % N % N %0-Low 2,072,740 97.1% 412,106 89.0% 29,489 69.3% 6,754 46.9% 2,521,089 95.0%1-High 60,850 2.9% 51,145 11.0% 13,036 30.7% 7,651 53.1% 132,682 5.0%Total 2,133,590 100.0% 463,251 100.0% 42,525 100.0% 14,405 100.0% 2,653,771 100.0%Notes: Table includes BC population with health care expenditures in calendar year 1999.Population with no expenditures are excluded.Total0-No ER Visits 1-2 ER Visits 3-4 ER Visits 5+ ER VisitsALL USERS (ADULT + PAED) ADULT USERS 18+ HI USERS (ADULT 18+)RATIOER Exp / Total Exp Total Expenditures ER Expenditures Total Expenditures ER Expenditures Total Expenditures ER Expenditures1  No ER Exp N 2,681,315 2,681,315 2,133,590 2,133,590 60,850 60,850Mean $375.51 $0.00 $427.20 $0.00 $2,978.20 $0.00Median $197.39 $0.00 $237.38 $0.00 $2,462.39 $0.00Sum $1,006,852,175.27 $0.00 $911,460,043.64 $0.00 $181,223,177.19 $0.00Range $25,061.16 $0.00 $25,061.16 $0.00 $23,182.60 $0.00Std. Deviation $575.90 $0.00 $621.07 $0.00 $1,538.62 $0.002  <= 25% N 506,292 506,292 404,109 404,109 71,307 71,307Mean $1,059.50 $65.66 $1,187.02 $68.56 $3,288.51 $117.92Median 658.235 47.19 776.21 47.47 $2,693.40 $82.25Sum $536,418,042.20 $33,243,480.07 $479,685,931.84 $27,705,174.81 $234,493,558.28 $8,408,458.36Range $41,701.66 $3,163.94 $41,685.50 $3,163.94 $39,865.40 $3,158.43Std. Deviation $1,232.17 $61.52 $1,302.85 $65.02 $1,807.65 $115.573  25 - 50 % N 119,687 119,687 68,379 68,379 492 492Mean $233.05 $79.45 $256.38 $86.56 $3,190.37 $1,054.65Median $166.01 $63.33 $175.38 $63.33 $2,646.69 $878.32Sum $27,893,498.55 $9,509,490.46 $17,530,918.80 $5,918,843.75 $1,569,664.22 $518,888.57Range $12,486.49 $5,491.29 $12,486.49 $5,491.29 $10,643.54 $5,001.17Std. Deviation $286.54 $95.52 $349.65 $116.95 $1,511.48 $562.924  50 - 75% N 41,006 41,006 22,403 22,403 30 30Mean $136.12 $82.11 $141.13 $85.06 $3,230.09 $1,889.82Median 103.62 66.44 103.93 66.44 $2,537.12 $1,569.56Sum $5,581,722.53 $3,367,156.48 $3,161,842.53 $1,905,626.40 $96,902.58 $56,694.49Range $9,493.60 $4,964.70 $9,493.60 $4,964.70 $7,639.73 $4,042.70Std. Deviation $142.85 $83.02 $174.14 $101.17 $1,626.36 $887.455  > 75% N 41,041 41,041 25,290 25,290 3 3Mean $60.75 $57.88 $61.11 $58.56 $3,380.67 $3,053.89Median $42.17 $42.17 $42.17 $42.17 $3,365.21 $3,135.41Sum $2,493,133.82 $2,375,624.96 $1,545,447.53 $1,480,932.86 $10,142.00 $9,161.67Range $4,716.14 $4,326.26 $4,716.14 $4,326.26 $2,681.85 $2,652.62Std. Deviation $60.46 $52.32 $65.99 $57.66 $1,340.99 $1,328.19Total N 3,389,341 3,389,341 2,653,771 2,653,771 132,682 132,682Mean $465.94 $14.31 $532.59 $13.95 $3,145.82 $67.78Median $230.50 $0.00 $276.46 $0.00 $2,577.43 $33.75Sum $1,579,238,572.37 $48,495,751.97 $1,413,384,184.34 $37,010,577.82 $417,393,444.27 $8,993,203.09Range $41,743.99 $5,501.71 $41,743.99 $5,501.71 $39,865.43 $5,501.71Std. Deviation $746.11 $42.29 $807.20 $43.84 $1,695.49 $128.73Notes: Table includes BC population with health care expenditures in calendar year 1999.Population with no expenditures are excluded.ER expenditures are for primary ER physician contact only.  18Table 5: Death In Year by Number of ER Visits - Adult Pop (18+) Data Source:  PIM - Calendar Year 1999      Table 6: Age Category by Number of ED Visits - Adult+Paed Data Source:  PIM - Calendar Year 1999    Row %AGE N % N % N % N % N % 0 - 17 547,725 20.4% 170,687 26.9% 14,328 25.2% 2,830 16.4% 735,570 21.7% 25.5%18 - 29 380,734 14.2% 116,192 18.3% 11,118 19.6% 3,364 19.5% 511,408 15.1% 25.6%30 - 44 661,458 24.7% 138,571 21.9% 11,401 20.1% 4,265 24.7% 815,695 24.1% 18.9%45 - 59 567,625 21.2% 93,406 14.7% 7,082 12.5% 2,618 15.2% 670,731 19.8% 15.4%60 - 74 346,004 12.9% 60,439 9.5% 5,733 10.1% 1,912 11.1% 414,088 12.2% 16.4%75 + 177,254 6.6% 54,559 8.6% 7,188 12.6% 2,246 13.0% 241,247 7.1% 26.5%Unknown 515 0.0% 84 0.0% 3 0.0% 0.0% 602 0.0%Total 2,681,315 100.0% 633,938 100.0% 56,853 100.0% 17,235 100.0% 3,389,341 100.0%Notes: Table includes BC population with health care expenditures in calendar year 1999.Population with no expenditures are excluded.Total0-No ER Visits 1-2 ER Visits 3-4 ER Visits 5+ ER VisitsN % N % N % N % N %DIED 0-No 2,122,073 99.5% 451,505 97.5% 40,539 95.3% 13,686 95.0% 2,627,803 99.0%1-Yes 11,517 0.5% 11,746 2.5% 1,986 4.7% 719 5.0% 25,968 1.0%Total 2,133,590 100.0% 463,251 100.0% 42,525 100.0% 14,405 100.0% 2,653,771 100.0%Notes: Table includes BC population with health care expenditures in calendar year 1999.Population with no expenditures are excluded.Total0-No ER Visits 1-2 ER Visits 3-4 ER Visits 5+ ER Visits  19Table 7:  Sex by Number of ER Visits - Adult Pop (18+) Data Source:  PIM - Calendar Year 1999    Sex by Number of ER Visits - Adult+Paed Data Source:  PIM - Calendar Year 1999       Table 8: SES Quintile by Number of ER Visits - Adult Pop (18+) Data Source:  PIM - Calendar Year 1999    N % N % N % N % N %SES QUINTILE 0 23,224 1.09% 6,310 1.36% 675 1.59% 238 1.65% 30,447 1.15%1 421,548 19.76% 97,036 20.95% 10,290 24.20% 4,162 28.89% 533,036 20.09%2 405,421 19.00% 88,583 19.12% 8,465 19.91% 2,863 19.88% 505,332 19.04%3 408,372 19.14% 89,224 19.26% 7,995 18.80% 2,480 17.22% 508,071 19.15%4 421,696 19.76% 91,300 19.71% 7,847 18.45% 2,488 17.27% 523,331 19.72%5 418,478 19.61% 82,682 17.85% 6,536 15.37% 1,986 13.79% 509,682 19.21%99 34,851 1.63% 8,116 1.75% 717 1.69% 188 1.31% 43,872 1.65%Total 2,133,590 100.00% 463,251 100.00% 42,525 100.00% 14,405 100.00% 2,653,771 100.00%Notes: Table includes BC population with health care expenditures in calendar year 1999.Population with no expenditures are excluded.Total0-No ER Visits 1-2 ER Visits 3-4 ER Visits 5+ ER VisitsN % N % N % N % N %SEX F 1,173,782 55.0% 235,391 50.8% 22,776 53.6% 7,986 55.4% 1,439,935 54.3%M 955,068 44.8% 226,845 49.0% 19,649 46.2% 6,398 44.4% 1,207,960 45.5%U 4,740 0.2% 1,015 0.2% 100 0.2% 21 0.1% 5,876 0.2%Total 2,133,590 100.0% 463,251 100.0% 42,525 100.0% 14,405 100.0% 2,653,771 100.0%Total0-No ER Visits 1-2 ER Visits 3-4 ER Visits 5+ ER VisitsN % N % N % N % N %SEX F 1,448,152 54.0% 312,664 49.3% 29,059 51.1% 9,284 53.9% 1,799,159 53.1%M 1,228,274 45.8% 320,207 50.5% 27,691 48.7% 7,930 46.0% 1,584,102 46.7%U 4,889 0.2% 1,067 0.2% 103 0.2% 21 0.1% 6,080 0.2%Total 2,681,315 100.0% 633,938 100.0% 56,853 100.0% 17,235 100.0% 3,389,341 100.0%Notes: Table includes BC population with health care expenditures in calendar year 1999.Population with no expenditures are excluded.Total0-No ER Visits 1-2 ER Visits 3-4 ER Visits 5+ ER Visits  20REFERENCES   Barer ML, Sheps SB, Mustard C, Kasian P (1994), Emergency Room Use in Winnipeg Hospitals, 1991-1992, Final report presented to Manitoba Health, November.  BC Ministry of Health, Emergency department visits by hospital, available on request.  Burt CW, Fingerhut LA (1998), “Injury visits to hospital emergency departments: United States, 1992-1995”, Vital & Health Statistics - series 13, data from the National Health Survey; 131:1-76.  Chan B and Ovens J (2002), “Frquent users of emergency departments”, Canadian FamilyPhysician, 48:1654-1660  Chamberlayne R, Green B, Barer ML, Hertzman C, Lawrence WJ, Sheps SB (1998) “Creating a Population-based Linked Health Database: A New Resource for Health Services Research”, Canadian Journal of Public Health July/Aug 89(4):270- 3.  Franco SM, Mitchell CK and Buzon RM (1997), “Primary care physician access and gatekeeping: A key to reducing emergency department use”, Clinical Pediatrics, February, 36(2):63-8.  Green J and Dale J (1992), “Primary care in accident and emergency and g neral practice: A comparison”, Social Science and Medicine, 35(8):987-995.  Hansagi H, Olsson M, Sjöberg S, Tomson Y, Göransson S (2001), “Frequent use of the hospital emergency department is indicative of high use of other health care services”, Annals of Emergency Medicine, 37(6):561-567  Helliwell P, Hider P, Ardagh M (2001), “Frequent attenders at Christchurch Hospital’s emergency department”, New Zealand Medical Journal, 114(1129):160-1.  Hider P, Helliwell P, Ardagh M, Kirk R (2001), “The epidemiology of emergency department attendances in Christchurch”, New Zealand Medical Journal, 114(1129):157-9.  Leydon GM, Lawrenson R, Meakin R, Roberts JA (1998), “The cost of alternative models of care for primary care patients attending accident and emergency departments: a systematic review”, Journal of Accident & Emergency Medicine, March, 15(2):77-83.  Mandelberg J, Kuhn R, Kohn M (2000), “Epidemiologic analysis of an urban, public emergency department’s frequent users”, Academic Emergency Medicine, 7:637-646  McGrail KM, Evans RG, Barer ML, Sheps SB, Hertzman C, Kazanjian A (1998), “The Quick and the Dead: The Utilisation of Hospital Services in British Columbia, 1969 to 1995/96”, Centre for Health Services and Policy Research, February, HPRU 98:3D.    21Mustard CA, Koryrskyj AL, Barer ML and Sheps SB (1998), “Emergency department use as a component of total ambulatory care: a population perspective”, Canadian Medical Association Journal, 13 January, 158(1):49-55.  Reid RJ, Evans RG, Barer ML, Sheps SB, Kerluke KJ, McGrail KM, Hertzman C and Pagliccia N (2003), “Conspicuous consumption: Characterizing high users of physcian services in one Canadian province”, Journal of Health Services Research and Policy, forth oming.  Schappert SM (1998), “Ambulatory care visits to phy ician offices, hospital outpatient departments, and emergency departments: United States, 1996”, Vital & Health Statistics - series 13, data from the National Health Survey; 134:1-37. Wright CJ, Cardiff K, Kilshaw M (1997), “Acute Medical Beds: How Are They Used in British Columbia?”, Centre for Health Services and Policy Research, April, HPRU 97:07D.  

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