ICES | Emergency Department Services in Ontario 1993 - 2000 - page 7

How does ED use vary across the province?
Exhibit 10 illustrates ED use by DHC planning area. There was wide variation in
the rate of ED use among residents of different DHC areas. Northern Ontario
had high rates of use, as did Grey Bruce Huron Perth and Southeastern
Ontario. Lowest rates were found in DHC areas bordering Halton-Peel (see
Table T4 in the Technical Appendix).
Patients may visit EDs outside their DHC area boundaries. There is “net inflow”
when the number of ED visits taking place within a given DHC area is greater
than the number of ED visits made by residents of that area. Conversely, “net
outflow” exists when the number of visits made by DHC area residents is
greater than the number of visits made to EDs in that area. Certain DHC areas
in Southern Ontario had particularly high net inflows of over 4 per cent,
including Northern Shores, Grey Bruce Huron Perth and Southeastern Ontario
(see Table T4 in the Technical Appendix).
The ED Physician Workforce
How many physicians work in the ED? What type of training do they
have and how has this changed over time?
EDs may be staffed by general practitioners, family physicians or specialists
in emergency medicine who have completed a residency program and have
passed their fellowship exams (FRCP(C)). Some family physicians obtain a
special certification from the College of Family Physicians of Canada in
emergency medicine (CCFP(EM)), either by doing an extra year of residency
training in emergency medicine, or by passing an evaluation of their clinical
competence after accumulating several years of ED experience. A small
number of ED physicians belong to other specialties.
The total number of physicians who provide ED coverage has decreased over
time, from 2,525 in 1993 to 1,987 in 2000. (All figures in this section on
workforce exclude physicians working in non-fee-for-service, non-shadow
billing EDs). Almost all of this decline occurred among general practitioners
or family physicians without certification in emergency medicine (herein
referred to as GP/FPs). The number of CCFP(EM) physicians rose, as did the
number of emergency medicine specialists (Exhibit 11).
Most patient care in Ontario’s EDs is still provided by GP/FPs. However, the
proportion of the total ED visits provided by this group declined from 82 per
cent in 1993 to 71 per cent in 2000, while the proportion of visits provided by
CCFP(EM) physicians rose from 13 per cent to 25 per cent. The proportion
of ED visits provided by FRCP(C) specialists remained stable at four per cent
during the study period. Care provided by physicians of other specialties
accounted for less than one per cent of ED visits.
How hard do ED physicians work?
Physicians who worked in EDs in 2000 spent more days working in the ED,
saw about the same number of patients per day and saw more patients over
the course of the year, compared to their counterparts in 1993 (Exhibit 12).
These trends were observed for all specialties, except for FRCP(C) specialists.
What is the age and sex distribution of physicians who work in the ED?
The proportion of ED physicians who are women was relatively constant during
the study period (Exhibit 13). The proportion of ED physicians aged 40 years
and over, however, has risen significantly (Exhibit 13). The aging of the physi-
cian pool was noticeable for all ED physicians regardless of type of training.
Discussion and Recommendations
EDs are a common source of medical care for patients of all ages. One in five
Ontarians visit an ED at least once in a year, a rate comparable to previous
surveys of self-reported ED use in Ontario.
At younger ages, acute and
self-limited infections account for a large proportion of visits and most of these
individuals visit the ED no more than once a year. Not surprisingly, the elderly
are the most frequent users of ED services, often with conditions related to
their chronic diseases. During their child-bearing years, women use emergency
services more frequently than men. These trends are consistent with
utilization patterns for most other types of physician services.
Emergency Department Closures and Restructuring
During the study period, 9.5 per cent of Ontario’s EDs closed and 3.5 per cent
reduced their services. These numbers are similar to U.S. figures, where 8 per
cent of EDs closed between 1994 and 1999.
Reasons for U.S. closures are
unclear, but the desire of health maintenance organizations to rationalize
services may have been a contributing factor.
Some rural hospitals also
closed due to financial pressures.
In Ontario, most ED closures and reductions were implemented as part of the
overall restructuring of the hospital sector that took place over the past decade.
Emergency Department Services in Ontario
Institute for Clinical Evaluative Sciences
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