ICES | Emergency Department Services in Ontario 1993 - 2000 - page 4

For the purpose of this study,
an ED is defined as a facility that fulfills all
of the following criteria:
1. It serves unscheduled patients;
2. It is staffed by physicians;
3. Physicians’ services are remunerated on a fee-for-service basis using
OHIP emergency department fee codes, or through an emergency
department AFP under the auspices of the Ministry.
The following additional distinctions are made:
“full service” ED
accepts walk-in and ambulance patients 24 hours a
day, seven days a week;
“limited service” ED
limits walk-in or ambulance patients to certain
hours of the day or certain days of the week. Such a category includes
some EDs which are termed “urgent care centres” or “ambulatory care
“closed” ED
is a previously designated full or limited service ED which
ceases to offer ED services.
Counting Emergency Department Visits
This study counted only those visits where a patient with a valid Ontario
health insurance number came to an ED on an unscheduled basis and was
assessed by the emergency physician on-duty. This definition excludes all
of the following situations:
Patients who left without being seen;
Patients assessed by a nurse and not a physician;
Visitors from outside of Ontario;
Ontario residents eligible for a health card, but who do not have one (e.g.
homeless individuals or persons with severe mental health disorders who
lack the life skills necessary to apply for a health card);
Occupational accidents where the Workplace and Safety Inspection Board
pays for the assessment;
Scheduled appointments to see a physician in the ED;
Direct referrals to a specialist, where the patient does not see the ED
physician on duty;
Repeat patient assessments on the same day in the same ED by the same
physician (such claims are generally disallowed by OHIP);
Services provided in non-fee-for-service ED settings which do not submit
shadow billings.
Interpretive Cautions
Because this report relied on OHIP data, activity in the small number of
non-fee-for-service, non-shadow billing EDs could not be captured. Almost
all of these EDs for which data were unavailable were in university-affiliated
teaching hospitals. These EDs are estimated to account for 10% of all ED
visits in the province in 2000 (see Technical Appendix for calculations). The
omission of these EDs may lead to results being biased toward community
and small hospitals and data on regional variations in ED use must be
treated with caution.
Secondly, because of the stringent criteria used in defining ED visits, the
estimates of ED volumes are approximately 15% lower than figures reported
by individual hospitals. Hospital figures generally represent all patients regis-
tered in the ED, and hence include patients with the exclusions noted above.
It is expected that this discrepancy is greater in EDs close to an international
or provincial border, or in those that serve as tertiary referral centres and
accept large volumes of direct referrals to non-emergency specialists.
The advantage of this method is that standard definitions have been applied
to all hospitals to facilitate comparisons of service provided at different EDs
across Ontario. The disadvantage is that important components of ED activity
have not been captured. It is anticipated that the new National Ambulatory
Care Reporting System (NACRS) will fill in these data gaps. The Canadian
Institute for Health Information (CIHI), which developed this system, began
collecting data in the fall of 2000.
The diagnostic coding in OHIP billings may be imprecise. Coding is often
done by physicians, their administrative staff or commercial billing services
instead of health records personnel, and coding accuracy is not routinely
audited. Although the impact of imprecise coding has been minimized by
grouping diagnoses into broad system-based categories, these results
should be interpreted with caution.
In the analyses of the most recent fiscal year (2000), results were based on data
from all EDs that were reporting either fee-for-service or shadow billing data
Institute for Clinical Evaluative Sciences
Emergency Department Services in Ontario
Note that some EDs which describe themselves as “closed” would, by the definition used in this
report, be considered EDs with “limited service”. For example, a previously full service ED which converts
to an urgent care centre seeing unscheduled patients only 14 hours per day would be considered a
limited service ED in this analysis, if their physicians continued to bill OHIP emergency department fee
codes or were remunerated through an alternate funding plan under the auspices of the Ministry.
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