Relationship between racial disparities in ED wait times and illness severity.

BACKGROUND: Prolonged emergency department (ED) wait times could potentially lead to increased mortality. Studies have demonstrated that black patients waited significantly longer for ED care than nonblack patients. However, the disparity in wait times need not necessarily manifest across all illness severities. We hypothesize that, on average, black patients wait longer than nonblack patients and that the disparity is more pronounced as illness severity decreases. METHODS: We studied 34143 patient visits in 353 hospital EDs in the National Hospital Ambulatory Medical Care Survey in 2008. In a 2-model approach, we regressed natural logarithmically transformed wait time on the race variable, other patient-level variables, and hospital-level variables for 5 individually stratified illness severity categories. We reported results as percent difference in wait times, with 95% confidence intervals. We used P < .05 for significance level. RESULTS: On average, black patients experienced significantly longer mean ED wait times than white patients (69.2 vs 53.3 minutes; P < .001). In the multivariate model, black patients did not experience significant different wait times for the 2 most urgent severity categories; black patients experienced increasingly longer waits vs nonblack patients for the 3 least urgent severity categories (14.7%, P < .05; 15.9%, P < .05; 29.9%, P < .001, respectively). CONCLUSION: Racial disparity in ED wait times between black and nonblack patients exists, and the size of the disparity is more pronounced as illness severity decreases. We do not find a racial disparity in wait times for critically ill patients.

The increasing number of clinical items addressed during the time of adult primary care visits.

BACKGROUND: Primary care physicians report that there is insufficient time to meet patients' needs during clinical visits, but visit time has increased over the past decade. OBJECTIVE: To determine whether the number of clinical items addressed during the primary care visit has increased, and if so, whether this has been associated with changes in visit length and the pace of clinical work. DESIGN: Analysis of non-hospital-based adult primary care visits from 1997 to 2005, as reported in the National Ambulatory Medical Care Survey. PARTICIPANTS: A total of 46,431 adult primary care visits. MEASUREMENTS: We assessed changes over time for the total number of clinical items addressed per visit (including diagnoses, medications, tests ordered, and counseling), visit duration, and average available time per clinical item. In adjusted analyses we controlled for patient and physician characteristics. RESULTS: The number of clinical items addressed per visit increased from 5.4 to 7.1 from 1997 to 2005 (p < 0.001). Visit duration concurrently increased from 18.0 to 20.9 min (p < 0.001). The increase in the number of clinical items outpaced the increase in duration, resulting in a decrease in time per clinical item from 4.4 to 3.8 (p = 0.04). These changes occurred across patient age and payer status and were confirmed in adjusted analyses. CONCLUSIONS: The volume of work associated with primary care visits has increased to a greater extent than has visit duration, resulting in less available time to address individual items. These findings have important implications for reimbursing physician time and improving the quality of care.

Making health spending work.

Medical Savings Accounts (MSAs) are usually promoted as a demand-management tool that gives consumers incentives to economize on medical expenses. "Making Health Spending Work" takes the concept one step further and shows how MSAs can be used to design a publicly funded system that incorporates market dynamics. MSAs can bring efficiency-enhancing incentives to the supply side, creating consumer choice and empowerment with a public system that meets Medicare's key principles. Over the last few months, Canada's political leaders have begun to break away from the reform-stalling tactics of special interest groups - which profit mightily from the the current system - and to examine sensible reforms that could benefit all Canadians. By breaking free of old dogmas, Canada can turn myth into reality: we can have the best medicare system in the world, one that expands choice and creates efficiency-enhancing dynamics.

Public and private pharmaceutical spending as determinants of health outcomes in Canada.

Canadian per capita drug expenditures increased markedly in recent years and have become center stage in the debate on health care cost containment. To inform public policy, these costs must be compared with the benefits provided by these drugs. This paper measures the statistical relationship between drug spending in Canadian provinces and overall health outcomes. The analysis relies on more homogenous data and includes a more complete set of controls for confounding factors than previous studies. Results show a strong statistical relationship between drug spending and health outcomes, especially for infant mortality and life expectancy at 65. This relationship is almost always stronger for private drug spending than for public drug spending. The analysis further indicates that substantially better health outcomes are observed in provinces where higher drug spending occurs. Simulations show that if all provinces increased per capita drug spending to the levels observed in the two provinces with the highest spending level, an average of 584 fewer infant deaths per year and over 6 months of increased life expectancy at birth would result.