Leaving emergency departments without completing treatment among First Nations and non–First Nations patients in Alberta: a mixed-methods study
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* Patrick McLane
* Lea Bill
* Bonnie Healy
* Cheryl Barnabe
* Tessy Big Plume
* Anne Bird
* Amy Colquhoun
* Brian R. Holroyd
* Kris Janvier
* Eunice Louis
* Katherine Rittenbach
* Kimberley D. Curtin
* Kayla M. Fitzpatrick
* Leslee Mackey
* Davis MacLean
* Rhonda J. Rosychuk

## Abstract

**Background:** Our previous research showed that, in Alberta, Canada, a higher proportion of visits to emergency departments and urgent care centres by First Nations patients ended in the patient leaving without being seen or against medical advice, compared with visits by non–First Nations patients. We sought to analyze whether these differences persisted after controlling for patient demographic and visit characteristics, and to explore reasons for leaving care.

**Methods:** We conducted a mixed-methods study, including a population-based retrospective cohort study for the period of April 2012 to March 2017 using provincial administrative data. We used multivariable logistic regression models to control for demographics, visit characteristics, and facility types. We evaluated models for subgroups of visits with pre-selected illnesses. We also conducted qualitative, in-person sharing circles, a focus group, and 1-on-1 telephone interviews with health directors, emergency care providers, and First Nations patients from 2019 to 2022, during which we reviewed the quantitative results of the cohort study and asked participants to comment on them. We descriptively categorized qualitative data related to reasons that First Nations patients leave care.

**Results:** Our quantitative analysis included 11 686 287 emergency department visits, of which 1 099 424 (9.4%) were by First Nations patients. Visits by First Nations patients were more likely to end with them leaving without being seen or against medical advice than those by non–First Nations patients (odds ratio 1.96, 95% confidence interval 1.94–1.98). Factors such as diagnosis, visit acuity, geography, or patient demographics other than First Nations status did not explain this finding. First Nations status was associated with greater odds of leaving without being seen or against medical advice in 9 of 10 disease categories or specific diagnoses. In our qualitative analysis, 64 participants discussed First Nations patients’ experiences of racism, stereotyping, communication issues, transportation barriers, long waits, and being made to wait longer than others as reasons for leaving.

**Interpretation:** Emergency department visits by First Nations patients were more likely to end with them leaving without being seen or against medical advice than those by non–First Nations patients. As leaving early may delay needed care or interfere with continuity of care, providers and departments should work with local First Nations to develop and adopt strategies to retain First Nations patients in care.

Patients come to emergency departments and urgent care centres because they judge it as their best option for urgent care, but some leave without being seen or against medical advice because of factors such as long wait times and crowding.1–14 Some studies report lower risk of return visits and death for patients leaving care.15,16 By contrast, other studies have found higher risks of death and return to hospital.4,17,18

Patient demographic factors, including race and ethnicity, are associated with the likelihood of patients leaving19–21 and Indigenous patients, specifically, have been reported to leave care more often, including in Canada.22–26

In a previous study, we found that 6.8% of emergency department visits by First Nations patients ended in the patient leaving without being seen or against medical advice, compared with 3.7% of visits by non–First Nations patients.22 Understanding whether and how anti-Indigenous racism in health care contributes to First Nations patients leaving without being seen or against medical advice is important to inform efforts to retain First Nations patients in care.27–31 This is especially pressing as crowding continues to worsen in emergency departments across Canada, and the proportion of patients leaving emergency department care has risen in several jurisdictions.32 We sought to determine whether the observed difference between First Nations and non–First Nations patients persisted when controlling for factors such as diagnosis, acuity, geography, or patient demographics other than First Nations status. We also sought to explore reasons for leaving without completing care described by both health care providers and First Nations patients. 2

## Methods

### Study design

Since 2018, First Nations and Western researchers based in Alberta have been evaluating the quality of emergency care for First Nations patients using an ongoing sequential, equal status, mixed-methods project (Appendix 1, Supplement 1, available at [www.cmaj.ca/lookup/doi/10.1503/cmaj.231019/tab-related-content](http://www.cmaj.ca/lookup/doi/10.1503/cmaj.231019/tab-related-content)).33 The current study involved a population-based retrospective cohort study of administrative health data (Apr. 1, 2012, to Mar. 31, 2017). The results were contextualized using focus groups, interviews, and sharing circles with First Nations patients, First Nations health directors, and emergency providers.

The Alberta First Nations Information Governance Centre (AFNIGC) oversees our team’s adherence to First Nations principles of ownership, control, access, and possession (OCAP) of research data.34,35 First Nations partner organizations participated in the design and conduct of the project, and nominated members of an Elder Advisor group to guide the project. Results are co-interpreted with First Nations partners, university researchers, and Elders. Overall, the project is informed by Indigenous ways of knowing36,37 and complementary elements of critical Western paradigms.38 We recognize that research is not a matter of enumerating neutral facts but rather is a purposeful and ethically charged activity that challenges existing arrangements of who has power and where resources are invested. We orient to Elder Willie Ermine’s concept of ethical space, which argues that bringing different ways of knowing into dialogue opens the possibility of new ways of thinking and relating across differences.39

### Setting

First Nations are 1 of 3 broad, internally diverse Indigenous groups in Canada, alongside the Métis and Inuit.40,41 The provincial boundaries of Alberta cross the territories of the Anishnabé, Blackfoot, Cree, Dene suliné, Dené Tha’, Dunne-za, Nakoda, and Tsuu T’ina, and First Nations members from many other Peoples have made their homes in Alberta.42 Treaties form the contested basis for relations between Indigenous Peoples and settlers within much of Canada.43 Treaties are promises made between the Crown and Indigenous Peoples that the Crown must uphold, including a treaty right to health.44 Three treaty areas contain First Nations reserve lands in Alberta (Treaties 6, 7, and 8). A single health authority delivers emergency care in the province, which is provided in about 110 emergency and urgent care centres (depending on year).45

### Quantitative methods

We conducted a population-based retrospective cohort study by linking administrative health data to First Nations-identifying data. The descriptive results of this cohort have been published previously.22 Our main comparison was between First Nations and non–First Nations patients. The Alberta Health Care Insurance Plan Population Registry provided First Nations population identifiers,46 previously described for this project.22

#### Data sources

Alberta Health Services (AHS) and Alberta Health completed data linkage and transferred deidentified data to the research team. We used the National Ambulatory Care Reporting System for data on emergency department visits, including facility type. We used data on diagnoses to analyze specific health conditions and disease categories.47 In cases where patients leave before diagnosis by a physician, trained nosologists employed by AHS Health Information Management enter diagnoses using information from registration or triage and the most specific description provided in the available documentation. This is often the presenting problem (personal communication, AHS Health Information Management, Nov. 23, 2020).

We used the AHS Distance Tables to determine distance in kilometers from patient postal codes to the nearest emergency department.48 We used the approximate median distance (5 km) to create 2 categories of travel distance for modelling. The 2016 Canadian Census was our source for neighbourhood-level income data. Our models differentiated the lowest income quintile (< $42 000 average annual individual income) from all other income quintiles. Alberta Health Services used 2 years of inpatient and ambulatory care data for each patient to provide comorbidity information to the research team. Using Charlson comorbidities, plus hypertension, we categorized patients as having either no comorbidities or 1 or more comorbidities.49 Vital statistics data provided dates of patient death,50 where applicable.

#### Outcomes

Given our focus on reasons for leaving emergency care, we defined our primary outcome as visits ending in either leaving without being seen or leaving against medical advice, which we treated as a single outcome. Initial models showed leaving without being seen to be more common in urban sites, and leaving against medical advice to be more common in rural sites, while other patient and emergency department visit factors appeared to have similar associations to both outcomes. As such, geographic factors confounded interpretation when leaving without being seen and leaving against medical advice were analyzed separately. In addition, our research questions were aimed at understanding disparities in care for First Nations patients in Alberta rather than distinctions between leaving without being seen and leaving against medical advice.

We assessed the proportion of patients who left without being seen or against medical advice but returned to the emergency department within 72 hours, dispositions of return visits, and number of deaths within 3 days of leaving early descriptively as secondary outcomes.

#### Statistical analysis

We used multivariable logistic models to control for covariates of leaving without being seen or against medical advice, including First Nations status, patient demographics (i.e., sex, age, comorbidities, area of residence, average neighbourhood income), Canadian Triage Acuity Scale (CTAS) score, arrival by ambulance, time of day of presentation, and hospital type. We conducted statistical analyses in R software51 using the ClusterBootstrap52 and metaSEM packages.53

We included both geography (operationalized as AHS zone)54 and facility type55,56 through a composite variable created by the research team. Details are provided in Appendix 1, Supplement 2. Appendix 1, Supplement 3 shows the number of facilities of each type in each AHS zone. Including both geography and facility type as separate factors within our models was not parsimonious and we found the composite to be more interpretable.

We split the data set by year. For each year, we obtained estimates using the logistic model with cluster bootstrap to reflect the clustering of data at the patient level (500 bootstrap samples).52 We subsequently combined the yearly estimates through meta-analysis using a structural equation modelling approach. We calculated odds ratios (ORs) and 95% confidence intervals (CIs). Significance was set at *p* less than 0.05. We deleted cases with missing data for covariates because we believed that data were differently missing for First Nations and non–First Nations populations, and we were unable to make confident estimations of how they differed; thus, assumptions for multiple imputations would not be met.

We evaluated models for subsets of patients with 5 pre-selected episode disease categories57 and 5 specific diagnoses to assess effects of different reasons for visiting the emergency department on the likelihood of leaving without being seen or against medical advice among First Nations and non–First Nations patients. Elder Advisors and First Nations research partners selected the disease categories and diagnoses a priori. Pre-selecting conditions for analysis ensured that we focused on conditions of interest to First Nations partners, and mitigated against potential perceptions of reporting bias, which could occur if we examined all conditions and then focused only on significant or noteworthy findings when reporting.

We also ran a model for the overall data using First Nations status as an interaction term with all other variables to consider how covariates of leaving without being seen or against medical advice may be different for First Nations and non–First Nations populations.

### Qualitative methods

We employed interviews and a focus group to collect data from heath care providers and First Nations health directors. We recruited First Nations community members to participate in sharing circles. Through purposive sampling, we sought to recruit those with most knowledge of First Nations patients’ emergency care, namely First Nations patients, First Nations health directors, and emergency care providers of any background. We also aimed for geographic diversity and held sharing circles in each of the Treaty 6, 7, and 8 areas. We relied on our team’s professional and community networks via email and word of mouth to recruit for interviews and the focus group. First Nations partner organizations recruited participants for sharing circles. Two team members (L.M. and P.M.) conducted interviews with health care providers and health directors and a focus group with health directors by telephone from 2019 to 2020. After a training and observation period with both interviewers, 1 team member (L.M.) completed most of the interviews independently. Four team members (L.B., P.M., L.M., and K.C.) facilitated 3 in-person sharing circles from July 2020 to April 2022.

We presented descriptive quantitative results to participants as part of qualitative research and invited participants to comment on them. Audio recordings of qualitative data were transcribed by AFNIGC and transcripts were anonymized before analysis. Two team members (L.M. and K.M.F.) and 3 non-author research assistants coded the overall data set with guidance of 2 research leads (P.M. and L.B.). Further details on our team and qualitative methods are provided in Appendix 1, Supplement 4. An example of presentation slides used to guide sharing circles is available as Appendix 2, available at [www.cmaj.ca/lookup/doi/10.1503/cmaj.231019/tab-related-content](http://www.cmaj.ca/lookup/doi/10.1503/cmaj.231019/tab-related-content). We completed coding using NVivo software.58 For this paper, a research lead (P.M.) considered text coded as related to leaving care, and organized comments on reasons for leaving without being seen or against medical advice using descriptive categories. Each participant quote presenting a unique reason for leaving was the basis of a unique descriptive category. This qualitative descriptive approach is appropriate to this mixed-methods manuscript, where qualitative data were used to understand quantitative findings while remaining close to participants’ understandings of the phenomena being studied.59

### Ethics approval

This study was approved by the University of Alberta Health Research Ethics Board (no. Pro00082440).

## Results

### Quantitative results

Overall, 11 686 287 emergency department visits occurred during the study period (Table 1). Compared with visits of non–First Nations patients, visits of First Nations patients involved a higher proportion of visits by females or patients of other genders, younger patients, patients who travelled farther, patients from lower-income areas, and patients who arrived by ambulance (including air ambulance). Furthermore, visits among First Nations patients were determined to be less urgent in terms of CTAS, occurred more often in the evening, were more often in community hospitals, were less often in urgent care centres, and were largely in the North Zone. Visits by First Nations status and by visit completion status (completed, patient left before being seen, or patient left against medical advice) are presented in Appendix 1, Supplements 6–8.

View this table:
[Table 1:](http://www.cmaj.ca/content/196/15/E510/T1)

Table 1: 
Characteristics of emergency department visits in Alberta from Apr. 1, 2012, to Mar. 31, 2017

Adjusted model results for the overall data set are presented in Table 2. First Nations status was associated with greater odds of leaving without being seen or against medical advice, compared with non–First Nations status (OR 1.96, 95% CI 1.94–1.98).

View this table:
[Table 2:](http://www.cmaj.ca/content/196/15/E510/T2)

Table 2: 
Adjusted association of variables with odds of leaving without being seen or against medical advice*

Table 3 presents the OR for leaving without being seen or against medical advice for First Nations status for each of the models of the 5 episode disease categories and 5 diagnoses. First Nations status was associated with greater odds of leaving without being seen or against medical advice in subset models for all 5 disease categories and 4 of 5 diagnoses. First Nations status was not significantly associated with leaving without being seen or against medical advice in the model of opioid-related visits (OR 1.15, 95% CI 0.95–1.36). Descriptive statistics related to leaving without being seen or against medical advice for each model are provided in Appendix 1, Supplement 9, and show a high proportion of visits ending with patients leaving without being seen or against medical advice among both First Nations and non–First Nations patients with opioid-related diagnoses.

View this table:
[Table 3:](http://www.cmaj.ca/content/196/15/E510/T3)

Table 3: 
Adjusted association between First Nations status and leaving without being seen or against medical advice for different subgroup models*

Table 4 presents the interaction of First Nations status with each covariate. First Nations patients who arrived in the evening or at night (both compared with daytime arrival) had lower odds of leaving without being seen or against medical advice relative to non–First Nations patients. A CTAS score of 1 of 2 (resuscitation or “emergency), compared with a score of 3 (urgent), was associated with lower odds of leaving without being seen or against medical advice for both patient groups. Visits among First Nations patients with CTAS scores of 4 or 5 (less urgent or non-urgent) were more likely to end with patients leaving without being seen or against medical advice (OR 1.28, 95% CI 1.26–1.31) than those among non–First Nations patients of the same acuity (OR 1.12, 95% CI 1.11–1.13). Where triage score was missing, First Nations patients were more likely to leave without being seen or against medical advice. First Nations patients had lower odds of leaving without being seen or against medical advice at smaller care sites and regional hospitals outside metropolitan centres but higher odds of leaving at large metropolitan sites and small metropolitan sites, relative to large community hospitals. Patient sex, age, distance travelled to care, and average neighbourhood income all made statistically significant but small differences (≤ 0.1 difference in OR) for First Nations versus non–First Nations patients.

View this table:
[Table 4:](http://www.cmaj.ca/content/196/15/E510/T4)

Table 4: 
Association of variables with odds of leaving without being seen or against medical advice, from modelling interaction of First Nations status with all other independent variables

After leaving without being seen or against medical advice, 22.7% of visits among First Nations patients were followed by a return to the emergency department within 72 hours (v. 19.9% among non–First Nations patients, *p* < 0.001). Table 5 presents dispositions of return visits within fewer than 3 days of discharge among First Nations and non–First Nations patients. A smaller proportion of return visits among First Nations patients led to hospitalization (5.5% v. 6.1%); however, a larger proportion of return visits among First Nations patients again ended in patients leaving without being seen or against medical advice (14.9% v. 8.8%).

View this table:
[Table 5:](http://www.cmaj.ca/content/196/15/E510/T5)

Table 5: 
Emergency department visits that ended with patients leaving without being seen or against medical advice and that resulted in return visits within 3 days of discharge, by disposition of return visit*

We did not observe a statistical difference in the proportion of visits among First Nations patients where the patient died within 3 days of leaving without being seen, compared with visits among non–First Nations patients (*n* = 13 visits among First Nations patients v. *n* = 47 visits among non–First Nations patients, *p* = 0.12) or in the proportion of patients who died within 3 days of leaving against medical advice (*n* = 10 visits among First Nations patients v. *n* = 34 visits among non–First Nations patients, *p* = 0.87).

### Qualitative results

Sixty-four participants contributed qualitative data in sharing circles, a health directors’ focus group or interviews. Sharing circles included 9–17 participants (*n* = 43 total). The health directors’ focus group included 4 participants. We conducted 17 individual interviews with health care providers. Table 6 provides participant demographics and Table 7 provides participants’ explanations for why First Nations patients may leave care. In some cases, First Nations participants described their own reasons for leaving without completing care in specific past instances. Some reasons given could affect any patient, such as long wait times, transportation considerations, poor communication between patients and providers, the need to attend to other responsibilities, and perceptions that the emergency department could not or would not address patient needs. Negative aspects of the emergency department’s environment (e.g., urgency of interactions, the environment not being conducive to rest) could also affect any patient. Other reasons were unique to Indigenous patients. Participants described providers relying on anti-Indigenous stereotypes in diagnostic questions or case management, anti-Indigenous discrimination in providers’ attitudes and quality of care, and patients overhearing anti-Indigenous racism expressed by providers. First Nations participants also expressed perceptions of being made to wait longer than White patients who appeared to be in less urgent need of care.

View this table:
[Table 6:](http://www.cmaj.ca/content/196/15/E510/T6)

Table 6: 
Demographics of interview, focus group, and sharing circle participants

View this table:
[Table 7:](http://www.cmaj.ca/content/196/15/E510/T7)

Table 7: 
Reasons for leaving the emergency department without being seen or against medical advice, with example quotes

## Interpretation

First Nations status was associated with greater odds of leaving without being seen or against medical advice and this was not explained by other factors such as diagnosis, acuity, geography, or patient demographics. Subgroup results showed that First Nations patients were more likely to leave without being seen or against medical advice, even when they receive the same diagnosis as non–First Nations patients, including for such emergent conditions as long bone fractures. Few First Nations and non–First Nations patients who left without being seen or against medical advice died within 3 days of an emergency department visit; however, a greater proportion of First Nations patients returned to the emergency department within 72 hours of leaving than non–First Nations patients. About 1 in 20 patients in both groups required hospitalization upon returning to the emergency department, suggesting that leaving without being seen or against medical advice is disrupting continuity of care and delaying needed care in at least some cases.

We believe these findings indicate that leaving without being seen or against medical advice is disproportionately disrupting and delaying care for First Nations patients. Qualitative results suggested discrimination and stereotyping as reasons why more First Nations patients leave without being seen or against medical advice. Transportation availability may also disproportionately affect First Nations populations. Travel distance, availability of drivers for First Nations’ medical transportation services, and complicated policies around transport coverage provided by the Non-Insured Health Benefits program are factors that may affect transit to and from emergency care for First Nations patients.

In addition to Canadian literature,22–24 our results align with Australian findings of greater rates of leaving emergency care among Aboriginal and Torres Straight Islander people.26 In Australian inpatient settings, both racism and discrimination have been reported as reasons Aboriginal patients leave care.61 Askew and colleagues61 highlighted how overhearing staff saying derogatory things about them led patients to leave care, which was also reported by participants in our study.

Participants’ descriptions of stereotyping often related to provider assumptions of substance use, echoing societal racist stereotypes of Indigenous people as being prone to substance use.62 Stigmatization of substance use has been reported as a reason patients leave care in general.63 Indeed, in a previous publication, a physician participant noted how substance-using patients can be led to leave care by ignoring them.60 This reflects a long-reported tendency for emergency departments to see patients who present with substance use as problems for their department’s operations, rather than presenting with medical issues pertinent to the emergency department.64 Several of our qualitative examples of patients leaving related to mental health and substance use, while our quantitative data showed higher proportions of leaving without being seen or against medical advice among patients presenting for substance use and mental health problems (compared with injuries, infections, and women’s health issues) among both First Nations and non–First Nations patients, but with higher proportions among First Nations patients.

Lack of clear communication of treatment plans is also a reason patients leave care, observed both in our data and in the literature.63 First Nations patients whose first language is not English may have language barriers, and communication issues can arise when providers and paperwork use unfamiliar, English-language medical terminology. In our previous study, some emergency providers in Alberta reported frustration with the communication style they perceived First Nations patients to use and made judgments about patients because of their First Nations “accent.”60 Such factors put First Nations patients at a greater risk of poor communication and interactions with providers.

Wait times also affect leaving without being seen. Our previous research showed that First Nations patients received less-acute triage scores than comparable non–First Nations patients,65 and that providers made judgments about whether a patient deserved emergency care based on their perceptions of the patient’s place in society.60 Racial stereotyping, discrimination, and biased provider judgments may lead to under-triage, longer wait times, and abbreviated care for First Nations patients, and therefore increased motivation to leave the care environment. Furthermore, First Nations members have described how they cannot generally know whether a negative experience in the emergency department (such as a long wait) is related to racism or not, but that racism is always a stress-inducing possibility.66

Child care concerns have been reported as a reason for leaving emergency department.67,68 Given the age distribution of the First Nations population in Alberta, with higher numbers of children among First Nations people than non–First Nations people,69 First Nations patients may be more affected by the need to leave care for childrearing responsibilities. Moreover, given disproportionate apprehension of Indigenous children by Child and Family Services,70 First Nations parents and guardians may be especially reluctant to leave their children in care of friends and relatives for the duration of a long emergency department visit or hospital admission.

A strength of our research is that it was conducted through Western and Indigenous lenses. Co-leadership by First Nations researchers and close collaboration with Elders improved the cultural safety of the research and its relevance to Indigenous people. Results from this work may inform quality-improvement efforts to retain First Nations patients in care. Such efforts should be co-developed with and overseen by First Nations organizations representing the population that uses each particular emergency department. An example of an intervention trialed in Australia involved a specialized care team seeing Aboriginal patients and efforts to ensure continuity of care between their emergency department visits.71 Efforts to promote equity-oriented care in British Columbia have resulted in a reduction in rates of leaving care at 1 of 3 pilot sites.72 Interventions involving communicating with patients about their next steps and offering comfort items and reassurance to waiting patients may be avenues to explore.

The form and operation of emergency care facilities may also be important elements influencing decisions to remain in care. First Nations patients may be more willing to remain in care in Indigenous–owned and operated facilities employing Indigenous ways on Indigenous lands (i.e., Indigenous-led services). Spaces using Indigenous design, languages, and architecture may also be perceived as more welcoming and safer by First Nations patients.

Efforts to retain patients in emergency care have usually focused on changes to processes in the emergency department (e.g., at triage, creating diagnosis and treatment tracks for different categories of patients) to improve efficiency and reduce wait times.73–75 However, solutions may not lie primarily within emergency departments. Admitted patients waiting for hospital beds in the emergency department are a primary driver of wait times,32 and this issue requires system-level solutions. Any efforts to address leaving the emergency department without being seen or against medical advice must be rigorously evaluated. In a study conducted in the United States, efforts to fast-track patients with less urgent conditions to treatment in chairs, as opposed to regular treatment spaces with beds, was associated with Black patients being disproportionately treated in chairs compared with White patients with similar conditions.76

### Limitations

Identifiers of First Nations status used in our analysis undercount First Nations members; therefore, a large number of First Nations people in Alberta are counted as non–First Nations in our data. We may have thus underestimated differences in proportions of visits that ended in patients leaving without being seen or against medical advice between First Nations and non–First Nations patients. Diagnoses for patients who left without being seen were based on presenting problems and may not reflect the final diagnoses that physicians would have reached if the patient had remained in care. Our analysis is also limited in that we did not have data on patient housing status, which may be related to leaving without being seen or against medical advice. Our economic variable relied on neighbourhood-level income measures rather than individual economic circumstances. Missing income and travel distance data (both derived from census data) were associated with higher proportions of visits that ended in patients leaving without being seen or against medical advice, but we excluded visits with missing data for income and travel distance from our models on the grounds they may be systemically missing for different reasons for First Nations and non–First Nations populations. As a result, our models excluded groups with high proportions of visits that ended in patients leaving without being seen or against medical advice. However, only 4% were missing overall for this data set. Our administrative data sets did not include all the possible factors a person considers when seeking emergency care, such as perceived or actual wait times, or perceptions of specific hospitals. We also chose to examine the composite outcome of leaving without being seen or against medical advice. Separate analyses of leaving without being seen and leaving against medical advice by First Nations status could be conducted as quality-improvement analyses for individual emergency departments. Finally, we dichotomized a number of variables to produce interpretable models, and this may have concealed nonlinear relationships between independent and dependent variables.

### Conclusion

In this retrospective cohort study, First Nations status was associated with greater odds of leaving the emergency department without being seen or against medical advice. We consider that systemic racism and inequity in health care contribute to this outcome, which is supported by our qualitative data. As leaving without being seen or against medical advice may delay needed care or interfere with continuity of care, providers and departments should work with local First Nations to develop and adopt strategies to retain First Nations patients in care.

## Acknowledgements

Alireza Jalaeian Bashirzadeh and Anqi Chen assisted in statistical analysis. Deanna Neri and Chyloe Healy contributed to qualitative coding. Deanna Neri also contributed to data transcription for tables and supplements. The authors are very grateful to Elder Advisors Leonard Bastien (Alberta First Nations Information Governance Centre), Helen Bull (Maskwacis Health Services), and Patsy Tina Jacobs (Stoney Nakoda Tsuut’ina Tribal Council), who contributed to interpretation of the data. The Indigenous Wellness Core at Alberta Health Services has been a supportive knowledge user partner for the wider project of which this manuscript forms a part.

## Footnotes

*   Competing interests: Patrick McLane reports research funding from the Canadian Institutes for Health Research, travel support from Alberta Health Services, and payment for expert witness testimony from Weir Bowen LLP. Katherine Rittenbach reports funding from the Calgary Health Foundation. No other competing interests were declared.

*   This article has been peer reviewed.

*   Contributors: Patrick McLane, Lea Bill, Bonnie Healy, Cheryl Barnabe, Amy Colquhoun, Brian Holroyd, Katherine Rittenbach, and Rhonda Rosychuk conceptualized and designed the work. Patrick McLane, Lea Bill, Bonnie Healy, Tessy Big Plume, Amy Colquhoun, Eunice Louis, Kimberley Curtin, and Leslee Mackey contributed to data acquisition. Patrick McLane, Lea Bill, Kayla Fitzpatrick, Leslee Mackey, and Rhonda Rosychuk contributed to data analysis. All authors contributed to data interpretation. Patrick McLane wrote the manuscript, relying on initial draft paragraphs written by Leslee Mackey. All of the authors revised it critically for important intellectual content, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.

*   Funding: Funding was provided by the Canadian Institutes for Health Research (no. 156176). The funder had no role in directing research methods, data collection, analysis, or interpreting and reporting results.

*   Data sharing: Data for this project are subject to research agreements reflecting First Nations data sovereignty and so cannot be shared by the research team. Original quantitative data sources are held by Alberta Health and Alberta Health Services and may be accessed through appropriate processes by First Nations organizations. Qualitative data are held by the Alberta First Nations Information Governance Centre as custodian for Alberta First Nations.

*   Disclaimer: Parts of this publication are based on data and information from the Understanding and Defining Quality of Care in the Emergency Department with First Nations Members in Alberta project. The analyses, conclusions, opinions, and statements expressed herein, however, do not necessarily reflect the views of the Alberta First Nations Information Governance Centre and are solely those of the authors. Statistics reproduced from this document must be accompanied by a citation of this document, including a reference to the page on which the statistic in question appears. Patrick McLane is an employee at Alberta Health Services and Brian Holyroyd was a contractor for Alberta Health Services. The views expressed in this document are solely those of the authors and do not represent those of their employers.

*   Accepted March 6, 2024.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

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