Introduction: Frequent users to emergency departments (EDs) are a diverse group of patients with a disproportionate number of ED presentations. This study aimed to compare sociodemographic and clinical characteristics of adult high system users (HSUs) and control groups in two provinces. Methods: Cohorts of HSUs were created for Alberta and Ontario by identifying the patients with the top 10% of ED presentations in the National Ambulatory Care Reporting System during April 2015 to March 2016. Random samples of patients not in the HSU groups were selected in each province as controls (4:1 ratio). Sociodemographic and presentation data (e.g., Canadian Triage and Acuity Scale [CTAS], disposition) were extracted and compared using separate logistic regression models. Results: In Alberta, 101,250 HSU patients made 686,918 ED presentations (median [med] = 5 interquartile range [IQR] 4,7 presentations per patient), compared with 401,923 controls who made 560,765 ED presentations (med = 1 IQR 1,2 per patient). HSUs were more likely to be female (odds ratio (OR) = 1.20 95% confidence interval (CI) 1.18,1.22), older (OR = 1.03 per 5y 95%CI 1.03,1.03), live closer to hospital (OR = 1.02 per 100km 95%CI 1.00,1.03), and be from the lowest income quintile (OR = 1.39 95%CI 1.37,1.42) than controls. In Ontario, 478,424 HSUs made 2,222,487 ED presentations (med = 4 IQR 3,5 per patient) and 1,714,037 controls made 2,114,070 ED presentations (med = 1 IQR 1,1 per patient). Ontario HSUs were also more likely to be female (OR = 1.13 95%CI 1.12,1.14), older (OR = 1.03 per 5y 95%CI 1.03,1.03), and from the lowest income quintile (OR = 1.41 95%CI 1.40,1.42) than controls, but were less likely to live closer to hospital (OR = 0.93 per 100km 95%CI 0.92, 0.93). Higher acuity was seen in Ontario (CTAS 1/2 vs. others OR = 1.05 95%CI 1.04,1.06) but not for Alberta (CTAS 1/2 vs others OR = 0.75, 95%CI 0.74,0.76). Discharges were less likely in the HSUs compared to controls (Alberta OR = 0.89 95%CI 0.88,0,90; Ontario OR = 0.65 95%CI 0.65,0.66). HSUs were more likely to leave without being seen (Alberta OR = 1.10 95%CI 1.07,1.13; Ontario OR = 1.37 95%CI 1.35,1.40) and against medical advice (Alberta OR = 1.47 95%CI 1.41,1.53; Ontario OR = 1.67 95%CI 1.63,1.71). Conclusion: HSUs were more likely to be female, older, and poorer than controls. Ontario HSUs had higher acuity than the other groups. Disposition differed for HSUs and controls. Further study is required to identify ways to safely reduce ED utilization by HSUs.

Background: Since June 2017, the Primary Health Care Integrated Geriatric Services Initiative (PHC IGSI) has been implemented in Alberta, Canada to, among other aims. reduce costs of unplanned health service utilization while maximizing the utilization of available community resources to support people living with dementia living in communities. Aim of the Study: We performed an economic evaluation of this initiative to inform policy regarding sustainability, scale up and spread. Methods: We used a cohort design together with a difference-in-difference approach and a propensity score matching technique to calculate impacts of the intervention on patient's health service utilization, including inpatient, outpatient and physician services, as well as prescription drugs. We then used a decision tree to compare between benefits and costs of the intervention and reported net benefits (NB) and return on investment ratios (ROI). We used a health system perspective and a time horizon of 1 year. Both deterministic and probabilistic sensitivity analyses were performed for the uncertainty of parameters. We analyzed real-world data extracted from the Alberta Health Administrative Databases. All costs/savings were inflated to 2019 CAD (CAD 1 similar to= USD 0.75) using the Canadian Consumer Price Index. Results: The intervention reduced the use of hospital (inpatient, emergency, and outpatient) services by increasing the use of community services (physician and prescription drug). As hospital services are expensive, the PHC IGSI community intervention resulted in a NB from CAD 554 to 4,046 per patient-year for the health system, and a ROI from 1.3 to 3.1 meaning that every CAD invested in PHC IGSI would bring CAD 1.3 to 3.1 in return. The probability of PHC IGSI to be cost-saving was 56.4% to 69.3%. Implications for Health Care Provision and Use: The PHC IGSI is cost-effective in Alberta. Implications for Health Policy: The savings would be larger if the initiative is sustained, scaled up and spread because of not only a reduced cost of intervention in the sustainability phase, but also because of the increased number of patients that would be impacted. Implications for Further Research: Future studies taking a societal perspective to also include costs for families and health and social sectors at the community level, would be desirable. Additionally, future works to determine how wellbeing is impacted by the PHC IGSI as vertical and horizontal integration interventions are implemented at the community level, are essential to undertake. Finally, in addition to people living with dementia, the PHC IGSI also supports people living in the community with frailty and other geriatric syndromes, therefore, the cost-savings estimated in this study are likely underestimated.

Background Opioid use disorder is a major public health crisis, and evidence suggests ways of better serving patients who live with opioid use disorder in the emergency department (ED). A multi-disciplinary team developed a quality improvement project to implement this evidence. Methods The intervention was developed by an expert working group consisting of specialists and stakeholders. The group set goals of increasing prescribing of buprenorphine/naloxone and providing next day walk-in referrals to opioid use disorder treatment clinics. From May to September 2018, three Alberta ED sites and three opioid use disorder treatment clinics worked together to trial the intervention. We used administrative data to track the number of ED visits where patients were given buprenorphine/naloxone. Monthly ED prescribing rates before and after the intervention were considered and compared with eight nonintervention sites. We considered whether patients continued to fill opioid agonist treatment prescriptions at 30, 60, and 90 days after their index ED visit to measure continuity in treatment. Results The intervention sites increased their prescribing of buprenorphine/naloxone during the intervention period and prescribed more buprenorphine/naloxone than the controls. Thirty-five of 47 patients (74.4%) discharged from the ED with buprenorphine/naloxone continued to fill opioid agonist treatment prescriptions 30 days and 60 days after their index ED visit. Thirty-four patients (72.3%) filled prescriptions at 90 days. Conclusions Emergency clinicians can effectively initiate patients on buprenorphine/naloxone when supports for this standardized evidence-based care are in place within their practice setting and timely follow-up in community is available.

Background This paper describes and compares patient flow characteristics of adult high system users (HSUs) and control groups in Alberta and Ontario emergency departments (EDs), Canada. Methods Annual cohorts of HSUs were created by identifying patients who made up the top 10% of ED users (by count of ED presentations) in the National Ambulatory Care Reporting System during 2011–2016. Random samples of patients not in the HSU groups were selected as controls. Presentation (e.g., acuity) and ED times (e.g., time to physician initial assessment [PIA], length of stay) data were extracted and described. The length of stay for 2015/2016 data was decomposed into stages and Cox models compared time between stages. Results There were 20,343,230 and 18,222,969 ED presentations made by 7,032,655 and 1,923,462 individuals in the control and HSU groups, respectively. The Ontario groups had higher acuity than the Alberta groups: about 20% in the Ontario groups were from the emergent level whereas Alberta had 11–15%. Time to PIA was similar across provinces and groups (medians of 60 min to 67 min). Lengths of stay were longest for Ontario HSUs (median = 3 h) and shortest for Alberta HSUs (media n = 2.2 h). HSUs had shorter times to PIA (hazard ratio [HR] = 1.03; 95% confidence interval [CI] 1.02,1.03), longer times from PIA to decision (HR = 0.84; 95%CI 0.84,0.84), and longer times from decision to leaving the ED (HR = 0.91; 95%CI 0.91,0.91). Conclusions Ontario HSUs had higher acuity and longer ED lengths of stay than the other groups. In both provinces, HSU had shorter times to PIA and longer times after assessment.

Background: Since January 1, 2016 2358 people have died from opioid poisoning in Alberta. Buprenorphine/naloxone (bup/nal) is the recommended first line treatment for opioid use disorder (OUD) and this treatment can be initiated in emergency departments and urgent care centres (EDs). Aim Statement: This project aims to spread a quality improvement intervention to all 107 adult EDs in Alberta by March 31, 2020. The intervention supports clinicians to initiate bup/nal for eligible individuals and provide rapid referrals to OUD treatment clinics. Measures & Design: Local ED teams were identified (administrators, clinical nurse educators, physicians and, where available, pharmacists and social workers). Local teams were supported by a provincial project team (project manager, consultant, and five physician leads) through a multi-faceted implementation process using provincial order sets, clinician education products, and patient-facing information. We used administrative ED and pharmacy data to track the number of visits where bup/nal was given in ED, and whether discharged patients continued to fill any opioid agonist treatment (OAT) prescription 30 days after their index ED visit. OUD clinics reported the number of referrals received from EDs and the number attending their first appointment. Patient safety event reports were tracked to identify any unintended negative impacts. Evaluation/Results: We report data from May 15, 2018 (program start) to September 31, 2019. Forty-nine EDs (46% of 107) implemented the program and 22 (45% of 49) reported evaluation data. There were 5385 opioid-related visits to reporting ED sites after program adoption. Bup/nal was given during 832 ED visits (663 unique patients): 7 visits in the 1st quarter the program operated, 55 in the 2nd, 74 in the 3rd, 143 in the 4th, 294 in the 5th, and 255 in the 6th. Among 505 unique discharged patients with 30 day follow up data available 319 (63%) continued to fill any OAT prescription after receiving bup/nal in ED. 16 (70%) of 23 community clinics provided data. EDs referred patients to these clinics 440 times, and 236 referrals (54%) attended their first follow-up appointment. Available data may under-report program impact. 5 patient safety events have been reported, with no harm or minimal harm to the patient. Discussion/Impact: Results demonstrate effective spread and uptake of a standardized provincial ED based early medical intervention program for patients who live with OUD.

Background: Buprenorphine/naloxone (bup/nal) is a partial opioid agonist/antagonist and recommended first line treatment for opioid use disorder (OUD). Emergency departments (EDs) are a key point of contact with the healthcare system for patients living with OUD. Aim Statement: We implemented a multi-disciplinary quality improvement project to screen patients for OUD, initiate bup/nal for eligible individuals, and provide rapid next business day walk-in referrals to addiction clinics in the community. Measures & Design: From May to September 2018, our team worked with three ED sites and three addiction clinics to pilot the program. Implementation involved alignment with regulatory requirements, physician education, coordination with pharmacy to ensure in-ED medication access, and nurse education. The project is supported by a full-time project manager, data analyst, operations leaders, physician champions, provincial pharmacy, and the Emergency Strategic Clinical Network leadership team. For our pilot, our evaluation objective was to determine the degree to which our initiation and referral pathway was being utilized. We used administrative data to track the number of patients given bup/nal in ED, their demographics and whether they continued to fill bup/nal prescriptions 30 days after their ED visit. Addiction clinics reported both the number of patients referred to them and the number of patients attending their referral. Evaluation/Results: Administrative data shows 568 opioid-related visits to ED pilot sites during the pilot phase. Bup/nal was given to 60 unique patients in the ED during 66 unique visits. There were 32 (53%) male patients and 28 (47%) female patients. Median patient age was 34 (range: 21 to 79). ED visits where bup/nal was given had a median length of stay of 6 hours 57 minutes (IQR: 6 hours 20 minutes) and Canadian Triage Acuity Scores as follows: Level 1 – 1 (2%), Level 2 – 21 (32%), Level 3 – 32 (48%), Level 4 – 11 (17%), Level 5 – 1 (2%). 51 (77%) of these visits led to discharge. 24 (47%) discharged patients given bup/nal in ED continued to fill bup/nal prescriptions 30 days after their index ED visit. EDs also referred 37 patients with OUD to the 3 community clinics, and 16 of those individuals (43%) attended their first follow-up appointment. Discussion/Impact: Our pilot project demonstrates that with dedicated resources and broad institutional support, ED patients with OUD can be appropriately initiated on bup/nal and referred to community care.