Tag Archives: #antimicrobialstewardship #antibiotics #strep

Retail Urgent Care Clinics Do Not Decrease Emergency Department Visits

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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Limerick version of guideline on acute pharyngitis

This limerick is based on the Infectious Diseases Society of America’s Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis.

 

Whom do you test for Group A Strep?

To avoid treating strep carriers (a misstep!)

In kids under 3 don’t bother

Unless a sister or a brother

Has symptoms and a test that say yep.

 

In most children with acute pharyngitis

The cause is truly a virus

So if they have rhinorrhea,

Cough, ulcers or diarrhea,

Then don’t test for strep in situs.

 

For tho’ treating might make parents merrier

One in five kids is a strep carrier

So treating viral coxsackie

With penn or amoxi

Might cause resistant strep–that’s scarier!

 

If your history, exam and test

Confirm strep as the pharyngeal pest

Then amox or penn work magic

Or first-gen ceph if allergic

Then clinda or a macrolide are third-best.