title: An ED paradox: patients who arrive by ambulance and then leave without consulting an ED provider.
abstract: BACKGROUND
  Scientists have called for strategies to identify ED patients with unmet needs. We identify the unique profile of ED patients who arrive by ambulance and subsequently leave without consulting a provider (ie, a paradoxical visit, PV).
  
  
  METHODS
  Using a retrospective cohort design, administrative data from Winnipeg, Manitoba were interrogated to identify all ED patients 17+ years old as having zero, single or multiple PVs in 2012/2013. Analyses compare the sociodemographic, physical (eg, arthritis), mental (eg, substance abuse) and concurrent healthcare use profile of non-PV, single and multiple PV patients.
  
  
  RESULTS
  The study cohort consisted of 122 639 patients with 250 754 ED visits. Across all ED sites, 2.3% of patients (N=2815) made 3387 PVs, comprising 1.4% of all ED visits. Descriptively, more single versus non-PV patients lived in urban core and lowest-income areas, were frequent ED users generally, were substance abusers and had seven plus primary care physician visits. Multiple PV patients had a similar but more extreme profile versus their single PV counterparts (eg, 54.7% of multiple vs 27.4% of single PV patients had substance abuse challenges). From multivariate statistics, single versus non-PV patients are defined uniquely by their frequent ED use, by their substance abuse, as living in a core and low income area, and as having multiple visits with primary care physicians.
  
  
  CONCLUSIONS
  PV patients have needs that do not align with the acute model of ED care. These patients may benefit from a more integrated care approach likely involving allied health professionals.
authors.affiliation: Faculty of Health Sciences, College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.|Manitoba Centre for Health Policy, Winnipeg, Manitoba, Canada.|College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Malcolm B
authors.initials: MB
authors.lastname: Doupe
authors.affiliation: Women's Xchange, Women's College Hospital, Toronto, Ontario, Canada.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Day
authors.affiliation: Faculty of Medicine, Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Wes
authors.initials: W
authors.lastname: Palatnick
authors.affiliation: Faculty of Medicine, Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Alecs
authors.initials: A
authors.lastname: Chochinov
authors.affiliation: Faculty of Medicine, Department of Community Health Sciences, Manitoba Centre for Health Policy (MCHP), University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Dan
authors.initials: D
authors.lastname: Chateau
authors.affiliation: Faculty of Medicine, Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Snider
authors.affiliation: Winnipeg Regional Health Authority, Seven Oaks Hospital, Winnipeg, Manitoba, Canada.
authors.forename: Ricardo
authors.initials: R
authors.lastname: Lobato de Faria
authors.affiliation: Faculty of Medicine, Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Erin
authors.initials: E
authors.lastname: Weldon
authors.affiliation: Faculty of Medicine, Manitoba Centre for Health Policy (MCHP), University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Shelley
authors.initials: S
authors.lastname: Derksen
mesh_terms: D000293:Adolescent; D000328:Adult; D000552:Ambulances / Q000706:statistics & numerical data*; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008350:Manitoba; D008875:Middle Aged; D015999:Multivariate Analysis; D012189:Retrospective Studies
keywords: emergency department utilisation; mental health; research, epidemiology