Author Archives: Marion Sills

About Marion Sills

I am a Professor of Pediatrics and Emergency Medicine at the University of Colorado. I work as a physician in the emergency departments of the Children's Hospital of Colorado and as a health services researcher at the University's Adult and Child Consortium for Health Outcomes (ACCORD).

Retail Urgent Care Clinics Do Not Decrease Emergency Department Visits

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A study published online today in Annals of Emergency Medicine (“Association Between the Opening of Retail Clinics and Low-Acuity Emergency Department Visits”) demonstrated that, contrary to expectations, retail clinics had little effect on rates of low-acuity visits to nearby emergency departments (EDs). This contradicts the popular theory that retail clinics would reduce ED visits.  A 2015 report “Building a Culture of Health: The Value Proposition of Retail Clinics“, found that consumer use of retail clinics was rising, with consumers citing convenient hours/location and perceived lower cost as the main reasons for choosing retail clinics for care. Another study projected that 13% to 27% of US ED visits could be treated in retail clinic settings, with an estimated cost savings of $4.4 billion.

However, this theory did not align with the new study’s findings. During the study period (2007-2012), the number of retail clinics grew from 130 to nearly 1,400 in the 23 states studied. During the same period, the rate of retail clinic penetration – in other words, the proportion of each ED’s catchment area that overlaps with a 10-minute drive radius of a retail clinic – more than doubled (8.1 to 16.4).

In the 2,053 emergency departments in these states, more retail clinics did not correlate with fewer low-acuity ED visits; however, increased retail clinic density did correlate with a slight reduction in the subset of low-acuity visits, albeit only among the privately insured. As an example, for an ED with 40,000 annual visits and 50% private insurance, there would be approximately 8 fewer visits per year for each 10% increase in retail clinic density.

 

The accompanying editorial offers three theories as to why retail clinics increase health care use:

  1. They meet unmet demands for care. The demand for episodic acute care often exceeds the supply of physicians or facilities in many communities, and retail clinics attempt to meet this need.
  2. Motivations for seeking care differ in EDs and retail clinics. A patient who might otherwise not seek care for a cough would stop by the neighborhood retail clinic but would not invest the time and travel to schedule an appointment with their medical home or risk a long ED wait.
  3. Groups of people who are more likely to use EDs for low-acuity conditions–particularly patients withMedicaid and ED super-users–do so because they have little access to other types of care, including retail clinics. Retail clinics follow the money–they locate in affluent areas in which few Medicaid patients live. Also, Medicaid plans often do not cover retail clinic use.  ED superusers commonly have Medicaid insurance and infrequently live in affluent neighborhoods, and often have complex medical/mental health conditions that cannot be cared for in retail clinics.

As an ED physician, my primary concern is that these clinics introduce added fragmentation into an already fragmented health care system. I treat many patients who have sought care for an illness from 1-2 different retail clinics in the past week, without seeing their regular doctor, and then end up in my ED with no record (other than the patient’s recollection) of what happened at those clinics and why. I do my best to reconstruct the story–the antibiotics given for the sore throat on Monday at one retail clinic where they did not check a strep test, followed by a visit to a second retail clinic on Wednesday for the ongoing sore throat where they sold them different antibiotics from the co-located pharmacy and where they did check a strep test and some type of blood test that were both negative–and make a coherent decision based on guessing why each retail clinic did what it did and how the patient is today.

A second concern is illustrated by my patient anecdote. Retail clinics tend to compete with primary care providers for patient business, and, in so doing, they prescribe more antibiotics to meet patients’ expectations.

If patients continue to vote with their feet, using convenient retail clinics in lieu of their primary care providers, my hope is that we find a way to better integrate them into the healthcare system so that we are all working collaboratively to best serve the patient.

 

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2016 Presidential Candidates’ Positions on Child Health Issues

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In September, the Pediatric Policy Council (PPC)—a nonpartisan collaboration of the Academic Pediatric Association, the American Pediatric Society, the Association of Medical School Pediatric Department Chairs, and the Society for Pediatric Research dedicated to promoting public policies to advance child health and well-being—developed four general questions related to child health to be sent to the campaigns of the two major party candidates for President of the United States, Donald J. Trump and Hillary Clinton, with the goal of better understanding where both candidates stand for children.

In early October, the campaigns of both presidential candidates submitted their responses, which are as follows.

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Paid Sick Leave Lowers Costs

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An Upshot column “The High Costs of Not Offering Paid Sick Leave” argues that employees and their co-workers may be better off with an incentive to take time off when sick. About 45 percent of the American work force does not have paid sick leave; that’s about 50 million workers. Families with less ability to afford unpaid time off are more likely to lack paid sick leave. According to a study in Health Affairs, 65 percent of families with incomes below $35,000 had no paid sick leave, while the same was true of only 25 percent of families with annual incomes above $100,000. Those without sick leave were farm ore likely to go to work sick (“presenteeism”), as well as to forgo seeking medical care for themselves or for an ill family member. Although expanding health insurance helps people pay for health care, it does nothing to help them afford to take time off to get it.

Another study in Health Services Research by a Cornell economist supports the theory that paid sick leave could reduce the spread of contagion. This study found that each week, up to 3 million U.S. employees go to work sick. Females, low-income earners, and those aged 25 to 34 years have a significantly elevated risk of presenteeism behavior.

The Upshot column presents the benefits of paid sick leave for one illness, flu, although morbidity and mortality from other contagious conditions would also be reduced:

Paid sick leave slows the spread of disease. Cities and states that require employers to offer paid sick leave — Washington, D.C.; Seattle; New York City; and Philadelphia, as well as Connecticut, California, Massachusetts and Oregon — have fewer cases of seasonal flu than other comparable cities and states. Flu rates would fall 5 percent if paid sick leave were universal. According to one estimate, an additional seven million people contracted the H1N1 flu virus in 2009 because employees came to work while infected. The illnesses led to 1,500 additional deaths.

Beyond reducing flu deaths, paid sick leave is associated with

Though a few cities and states mentioned above mandate employers provide paid sick leave, the Family and Medical Leave Act requires only unpaid sick leave be provided by employers with more than 50 workers. A new Obama administration rule is extending paid sick leave to ~300,000 private-sector employees working on government contracts starting on Jan. 1.  Policy makers should consider the potential public health implications of their decisions when contemplating guaranteed sick leave benefits.

Obamacare Succeeds in Expanding Insurance Coverage

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Amidst news of the increasing premiums and decreasing choice of plans in some healthcare markets, the New York Times‘ Upshot column brings us this visual display of the impressive and varied impact of Obamacare on insurance coverage rates from 2013-2016. States that decided to expand their Medicaid programs saw much larger declines in their uninsured rates compared with those that didn’t. The proposed mechanisms for this effect were that Medicaid expansion

  • provided a new coverage option for childless adults below or near the poverty line
  • helped spur many people who were already eligible for the program to sign up
  • boosted enrollment in Obamacare’s marketplace plans.

The column analyzed the difference in insurance coverage expansion between states that did and did not take the Medicaid expansion:

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Two most common pediatric migraine medications no more effective than placebo

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Neither of the two drugs used most frequently to prevent migraines in children–amitriptyline and topiramate–is more effective than a placebo, according to results of the Childhood and Adolescent Migraine Prevention (CHAMP) trial published this week in The New England Journal of Medicine. The investigators found no significant differences in reduction in headache frequency or headache-related disability in childhood and adolescent migraine with amitriptyline, topiramate, or placebo over a period of 24 weeks.

The active drugs were associated with higher rates of adverse events. One child on topiramate attempted suicide. Three taking amitriptyline had mood changes; one told his mother he wanted to hurt himself, while another wrote suicide notes at school and was hospitalized.screen-shot-2016-10-28-at-4-01-47-pm

Migraine headaches are common in children. Up to 11 percent of 7- to 11-year-olds and 23 percent of 15-year-olds have migraines.

A Medical Degree in Paperwork

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A recent study in Annals of Internal Medicine found that physicians in four office-based specialties spent the majority of their time on documentation and paperwork:

  • Overall, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on documentation (paper and electronic).
  • While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on documentation.
  • Physicians reported 1 to 2 hours of after-hours work each night, devoted mostly to electronic health record tasks.

A Forbes commentary noted there was a steady increase in the proportion of physician time taken up by paperwork. Reasons for this trend include

  • The multitude of diverse stakeholders requiring increasing amounts of documentation in the paperwork, including administration, lawyers and insurance companies. For example, for a patient with a broken arm, insurance companies require that we ask about at least ten organ systems (a “review of systems“) and document our findings completely. So at least part of that clinical face time is spent asking the patient with the broken arm about things like pain with urination and visual change.
  • The stakeholders, and not the physicians, design the forms, and so they are not designed in a way that fits a medical way of thinking about a patient encounter and are often redundant. For example, when I transfer a patient from one hospital to another, I fill out a form for the lawyers (the EMTALA form, explaining the medical necessity of the transfer) and a form for the insurers explaining the medical necessity of the transfer. These contain a lot of the same information.
  • Hospitals and clinics do not seem to be investing in clerical and administrative support for doctors, sometimes because of regulations requiring a physician complete the forms. For example, 90% of the information on the two transfer rationale forms I mentioned above both could be completed by clerical personnel, or could be copied by a non-MD from one form onto the other.

The Forbes piece notes that the trend pushing ever increasing paperwork burdens onto physicians is a recipe for low career satisfaction and burnout.

On Informing Families a Child has Died

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I am sharing a moving piece by Naomi Rosenberg, an emergency room doctor at Temple University Hospital in Philadelphia, about telling a mother her child has died. It is hauntingly familiar; over the past 20 years as a pediatric emergency medicine physician, I have followed a sequence similar to the steps she describes in her piece. It is the hardest part of the job, as it should be. It never gets easier–this, too, is as it should be. I am thankful that few others among my friends and family have outlived their own child.