First Nations Patients Often Leave ED Before Completing Care

First Nations patients in Alberta have higher rates of incomplete emergency department (ED) care than do non–First Nations patients, often leaving early because of concerns about racism and anti-Indigenous sentiment, according to a new study.

The difference was observed throughout the province and persisted even in cases of emergent conditions such as long bone fractures. In a previous study, the researchers found that 6.8% of First Nations patient visits to the ED ended without completing care, compared with 3.7% of non–First Nations patient visits.

photo of Patrick McLane
Patrick McLane, PhD

“Prior research shows First Nations members rely heavily on emergency care due to lack of alternatives such as accessible and culturally safe primary care,” lead author Patrick McLane, PhD, adjunct associate professor of emergency medicine at the University of Alberta in Edmonton and assistant scientific director of the Emergency Strategic Clinical Network of Alberta Health Services, told Medscape Medical News. “Prior research also shows First Nations members commonly report negative experiences in emergency care.” 

Leaving before completion of care can interrupt continuity of care, McLane added. “Racism and stereotyping are a cause of First Nations patients leaving care, which members from Alberta’s White majority do not face.”

The study was published online on April 22, 2024, in CMAJ.

Analyzing ED Visits

McLane and colleagues conducted a mixed-methods study, including a population-based retrospective cohort study of provincial administrative health data from April 2012 through March 2017 to analyze differences in ED visits for First Nations and non–First Nations patients. They controlled the analysis for demographics, visit characteristics, facility types, and subgroups with preselected illnesses.

Between 2019 and 2022, the research team also held sharing circles with First Nations patients, focus groups, and phone interviews with healthcare providers, including health directors and Alberta emergency care physicians. During this time, they asked participants to comment on the quantitative results of the cohort study and reasons that First Nations patients leave care.

Among nearly 11.7 million ED visits, about 1 million (9.4%) were by First Nations patients. Overall, First Nations patients were more likely to end visits by leaving without being seen or against medical advice (odds ratio, 1.96). The difference could not be explained by factors such as diagnosis, acuity, geography, or patient demographics (other than First Nations status).

First Nations status was associated with greater odds of leaving without being seen or against medical advice for all five disease categories and four of five diagnoses. In addition, First Nations patients had lower odds of leaving when they arrived in the evening, had an emergency, or visited smaller care sites and regional hospitals.

After leaving without being seen or against medical advice, 22.7% of First Nations patients had a return ED visit within 72 hours, compared with 19.9% of non–First Nations patients. A larger proportion of return visits among First Nations patients once again ended in leaving early (14.9%) compared with non–First Nations patients (8.8%). Even more First Nations patients probably miss needed care because they don’t return to the ED, the study authors wrote.

During the qualitative analysis, 64 participants listed several reasons why First Nations patients may leave early, including stereotyping in diagnostic questions or case management; anti-Indigenous discrimination in providers’ attitudes and quality of care; overhearing anti-Indigenous racism expressed by providers; other communication issues, transportation barriers, and longer wait times than other patients.

“We are working with First Nations organizations and EDs to conduct intervention research on advancing antiracism and equity in emergency care,” said McLane.

As crowding continues to worsen in EDs across Canada, the proportion of patients leaving early has risen in several jurisdictions, the study authors wrote. To reduce the disproportionate effects among First Nations patients, ED directors and physicians should work with First Nations to find ways to reduce early departures, they added.

Addressing Care Gaps

Commenting on the findings for Medscape Medical News, Rachit Batta, MD, a resident in emergency medicine at the University of Saskatchewan in Saskatoon, said, “After reading this new study, I am saddened to see all the quotes of discrimination, racism, and stereotyping.” 

photo of Rachit Batta
Rachit Batta, MD

Batta, who wasn’t involved with this study, has researched the equality of care between First Nations and non–First Nations patients in Saskatoon EDs. He and his colleagues did not find significant differences in parameters such as time to doctor or length of stay but highlighted the need to examine other important factors, including patients’ perspectives.

“As someone who works in the ED, I aim to provide culturally sensitive care, while also providing a haven for people in need,” said Batta. “This study highlights how much work we still must do and the need to collaborate with local Indigenous communities to move healthcare forward.” 

Future studies should explore additional factors that may influence decisions to remain in care, the study authors wrote. First Nations patients may be more willing to receive Indigenous-led services or stay at Indigenous-owned and -operated facilities that employ Indigenous ways on Indigenous lands. Spaces that use Indigenous design, languages, and architecture may also be perceived as safer and more welcoming, the authors wrote.

photo of Lea Bill
Lea Bill, RN

“There are multiple factors that influence the decision to leave the ED without being seen,” said Lea Bill, RN, executive director of the Alberta First Nations Information Governance Centre, which participated in the study, along with seven other First Nations organizations.

“Some of these [factors] include how First Nations patients are treated while waiting to be seen, such as minimizing and dismissing the urgency of presenting symptoms, feeling unsafe, and having inappropriate language directed at them while in the ED,” she said.

The study was funded by a Canadian Institutes for Health Research grant. McLane reported research funding from the Canadian Institutes for Health Research, travel support from Alberta Health Services, and payment for expert witness testimony from Weir Bowen. Batta reported no relevant disclosures.

Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape, MDedge, and WebMD.


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