Sourial N MSc PhD(c)¹, Le Berre M MSc PT¹, Godard-Sebillotte C MD PhD(c)¹, Vedel I MD, PhD^1
1Department of Family Medicine, McGill University, 5858 Côte-des-Neiges St, 3^rd Floor, Montreal (Quebec)  H3S 1Z1

In June 2016, the former Quebec’s independent health watchdog, led by Commissioner Robert Salois, released a highly mediatized report on the state of wait times in emergency departments (EDs) in the province (1). The report concluded that Quebec has the worst wait times in the country and among the worst globally across Western countries. Results showed that 35% of Quebecers wait 5 or more hours in emergency compared to 19% in the rest of Canada (1). Moreover, almost half of emergency visits (45.5%) in 2015–2016 surpassed the maximum wait time norms set by the Ministry of Health. This percentage represents 1.5 million of the 3.2 million emergency visits in 2015–2016. In hours, this over-waiting was totalled at 13 million hours. The cost to society was estimated at $300 million in lost salary and work hours.

The Commissioner’s report outlined several reasons which could explain the poor performance of our EDs. These included the lack of availability of hospital beds, tests and consultations, the inefficient physical configuration of the emergency department, poor hospital organization, overuse of the emergency, lack of financial incentives, lack of performance measures, ineffective modes of remuneration and a lack of coordination with community services.

While many factors are arguably at play, we believe the inaccessibility to primary care is at the root of the failing report card on emergency wait times in Quebec. Although reactive solutions within the emergency setting may help to improve wait times, the problem can only truly be fixed by addressing it at the source: and that is by preventing inappropriate emergency visits through better patient management in primary care.

Why Are Wait Times So Long in Quebec?
The Commissioner’s report provided a breakdown of the level of severity of the emergency visits and showed that an astonishing 61% of visits were considered non-urgent and avoidable (1). These non-urgent cases were classified as triage level 4 or 5 based on the Canadian Triage and Acuity Scale and included presentations such as fever, vomiting, diarrhea, allergic reactions, mild to moderate pain and minor trauma (2).

The implication of this finding seems clear: no matter how well we streamline the organization of EDs, wait times will continue to be affected so long as overcrowding due to non-urgent cases persists.

Suboptimal Primary Care Management as the Differentiating Factor in Quebec
The next question becomes: “Why are so many non-urgent cases ending up in emergency?” Afilalo et al. and Northington et al. reported accessibility and lack of knowledge of primary care resources as the main reasons given by non-urgent patients for not seeking primary care prior to going to the emergency (3, 4).

If inaccessibility to primary care is to be a differentiating factor to explain why Quebec has the worst ED performance in the country, we would expect to see a higher degree of inaccessibility to primary care in Quebec compared to other provinces. In 2013, Statistics Canada reported the proportion of Canadians without a regular doctor in each province (5). Their data revealed that, excluding the Northern Territories, Quebec had the highest proportion at 25.1%. This is compared to the national average of 15.5% and only 8.8% in Ontario. If we compare Quebec and Ontario, which have similar population sizes and demographics, we see that, in Quebec, 1/4 of residents are without a family doctor and 35% of patients wait 5 or more hours in emergency; while in Ontario, less than 1/10 are without a family doctor and only 15% of patients experience long emergency wait times. Although the comparison between Quebec and Ontario is correlational, it stands to reason that more access to family doctors would result in fewer avoidable emergency cases which, in turn, would reduce the excessive wait times in emergency.

Recent findings also support the theory that the lack of primary care access is the root of the overuse of EDs. For example, the INSPQ (Institut national de santé publique du Québec) published a report in 2007 on factors influencing emergency use from a populational perspective (6). Their analysis showed that emergency use was 20% higher among patients without a regular source of primary healthcare and concluded that having a regular source of care is “protective” against ED use. A recent report by McCusker et al. in partnership with the Ministère de la santé et des services sociaux du Québec also supported these findings (7). The authors found the lack of a family doctor to be a strong predictor of ED visits. Roberge et al. wrote that inaccessibility to diagnostic services and family doctors have led to EDs becoming a substitute for primary care (8). The Commissioner’s report also cited the difficulty to access timely diagnostic services in the community as a reason for overcrowding in emergency (1). In his report, Salois said that family doctors often need to resort to referring their patients to emergency in order to obtain quicker test results than by waiting months in the community. This body of evidence clearly points to inaccessibility to primary care as a differentiating factor in Quebec compared to the other provinces.

The Way Forward
Several recommendations have been proposed in the Commissioner’s report to improve emergency wait times in Quebec through enhanced primary care access (1). These included priority access to patients with an immediate need to make an appointment quickly, offering more evening and weekend hours, increased support and resources for family physicians and more accessible diagnostic services. These recommendations are also echoed by researchers. In the report by McCusker et al., the authors concluded that “the strong link between primary care and ED visits suggests that investments to improve primary care […] will help to limit the use of EDs” (7).

Recent primary care health reforms in Quebec may increase access to primary care. First, Bill 20 proposes to open approximately 50 “superclinics” with extended hours offering walk-in non-urgent medical care and may, in the short term, relieve overcrowding of the Quebec EDs (9). Walk-in clinics, however, cannot provide some of the crucial features primary care should offer to be efficient, such as handling complex patients or taking care of chronic diseases. Other recent reforms might prove to be more beneficial. For instance, a modification to the Specific Medical Activities (“activités médicales particulières” or AMPs) obligation will increase the time family physicians can spend in primary care. The abolition of annual exams and the introduction of Advanced Access, a modification of the appointments scheduling in primary care, both promise to free up time for family physicians and increase availability for same-day visits for acute episodes (10). If these reforms deliver on their promise, Quebec’s next report care on emergency wait times will hopefully become a passing grade.

Conclusion
The health and welfare Commissioner’s report has renewed the alarm bell on the poor performance of our healthcare system in regards to emergency wait times. The evidence presented paints a clear picture pointing to inaccessibility to primary care in Quebec as a critical factor to explain these long wait times. Indeed, the evidence shows that suboptimal access to primary care 1) leads to over and inappropriate use of the emergency department and 2) is a key differentiating factor in Quebec compared to elsewhere in the country. If we want to reduce wait times in Quebec’s emergency departments, we need to first and foremost tackle the large number of patients going to the emergency unnecessarily. While there is no one simple solution, increasing access to family doctors and greater continuity of care would play a dramatic role in curbing the problem at its source by reducing inappropriate emergency use.

Nadia Sourial
2^nd Year PhD Student
McGill University — Downtown Campus

Nadia is a Vanier Scholar who is currently completing a PhD in Family Medicine and Primary Care Research at McGill University. Her research interests include the application of causal inference methods for the evaluation of primary care reforms and policies. As part of a national team on Research on Organization of Healthcare Services for Alzheimer’s, Nadia’s doctoral thesis will focus on the evaluation of the Alzheimer Plan in Quebec, a reform aimed at empowering and enabling primary care to lead the management of the growing Alzheimer’s population. Prior to her doctoral work, Nadia worked as a biostatistician in research as well for the federal government and the pharmaceutical industry. She looks forward to cross-fertilizing her knowledge of Statistics and Health Services Research to improve the healthcare system through a strong primary care based on sound policy!

References

1. Commissaire à la santé et au bien-être du Québec. Apprendre des meilleurs : Étude comparative des urgences du Québec. Jun 2, 2016.
2. Beveridge R, Clarke B, Janes L, et al. Implementation guidelines for the Canadian ED Triage & Acuity Scale (CTAS). Available at: http://www.caep.ca/002.policies/002-02.CTAS/CTAS-guidelines.htm. Accessed Oct 1, 2004.
3. Afilalo J, Marinovich A, Afilalo M, et al. Non-urgent emergency department patient characteristics and barriers to primary care. Acad Emerg Med. 2004; 11 (12):1302–1310.
4. Northington WE, Brice JH, Zou B. Use of an emergency department by non-urgent patients. Am J Emerg Med. 2005; 23 (2):131–137.
5. Statistics Canada. Table 105-0501 — Health indicator profile, annual estimates, by age group and sex, Canada, provinces, territories, health regions (2013 boundaries) and peer groups, occasional, CANSIM (database). (accessed: June 9, 2016)
6. Roberge D, Larouche D, Pineault R, et al. Hospital Emergency Departments: Substitutes for Primary Care? Results of a Survey of the Population of Montreal and Montérégie.
7. McCusker J, Roberge D, Tousignant P, et al. Closer Than You Think: Linking Primary Care to Emergency Department Use in Quebec.
8. Roberge D, Pineault R, Larouche D et al. The Continuing Saga of Emergency Room Overcrowding: Are We Aiming at the Right Target? Healthcare Policy, 5 (3) March 2010: 27–39.
9. Assemblée nationale. Loi édictant la Loi favorisant l’accès aux services de médecine de famille et de médecine spécialisée et modifiant diverses dispositions législatives en matière de procréation assistée. Éditeur officiel du Québec. November 2015.
10. Godard-Sebillotte C, Le Berre M, Sourial N, Vedel I. Poor primary care access in Quebec: barriers and solutions to access during an acute episode. McGill Journal of Medicine, 15 (4) March 2017.