Advocates for Evidence-Based Health Policy Speakers
911 versus 7-11
Americans have increasingly been taking their medical ailments around the corner to the local urgent care or retail clinic. These alternatives to emergency departments may help offload some of the strain with ever-rising ED volumes.
The delivery of urgent health conditions ranges from the private physician offices to hospital emergency departments, with settings such as retail clinics and free-standing urgent care centers representing the middle road. However, as opposed to the traditional physician office, the last three sites of care focus on providing acute care services to walk-in patients and do not require appointments.
Emergency departments are legally bound to see and evaluate all comers, regardless of insurance type. Urgent care centers and retain clinics, while not mandated to the same extent, do see uninsured patients. In fact, over one-quarter of retail clinic patients lack insurance compared to 17 percent of emergency department patients.
Personnel staffing these different sites are care are often overlapping. Typically, retail clinics and urgent care centers are staffed by nurse practitioners and physician assistants. Within emergency departments, “fast tracks” are often staffed by these same providers. Within these “fast track” areas, the types of ailments evaluated typically overlap with what presents to urgent care centers and retail clinics.
Retail clinics seem to concentrate on the treatment of two major classes of conditions. Upper respiratory infections (ear, nose, and throat complaints) comprise 60.6 percent of all visits. Preventive care services account for another 21.6 percent.
Urgent care centers and emergency departments only experience 33.3 percent and 9.8 percent of their total volume with upper respiratory complaints, respectively. The proportion of preventive health services at these two sites is infinitesimally small.
More common conditions encountered in the emergency room and the urgent care center are musculoskeletal injuries and dermatologic conditions like lacerations and skin and soft tissue infections (nearly 20 percent and 10 percent, respectively, of each sites’ patient volume.
Over one-third of conditions encountered in the emergency department are things which urgent care centers and retail clinics are ill-equipped to handle. But, some conditions are amenable to care at a potentially lower cost clinical site. The researchers suggested that 13.7 percent of all emergency department visits could be successfully, and perhaps safely, diverted to retail clinics and another 13.4 percent to urgent care centers. If accounting for times when these sites are open, the estimate drops to 7.9 and 8.9 percent, respectively.
Patient demographics show that the extremely young (less than 2) and the elderly (65 or older tend to self triage toward hospital emergency departments versus urgent care centers and retail clinics ( 5.9 percent, 1.5 percent, 0.2 percent and 10.8 percent, 8.7 percent, and 7.2 percent, respectively). Other factors which predispose a patient to self triage to an emergency room versus a retail clinic or urgent care were not studied.
Commentary
Hospital emergency departments remain the only truly accessible, and universal, source of care to hundreds of millions of Americans 24/7/365.
Certain other sites of care such as retail clinics and urgent care centers are capable of evaluating certain minor conditions and could likely off-load some volume from emergency departments. If following the estimates given by the researchers, this could represent an additional 17 million visits to retail clinics and urgent care centers. While the subsequent cost savings seem promising ($4.4 billion annually), this amount only represents 0.2 percent of national health expenditures.
Instead of looking to retail clinics and urgent care centers as a cheaper mode of acute care, policy makers must look at how to best expand their capacity and promoting the continuity of care with community physicians.
Ultimately, the health care delivery system must seamlessly incorporate retail clinics and urgent care centers, uniting them with the outpatient setting. Emergency departments will continue to serve as the nexus between the inpatient and outpatient worlds.
An approach focusing on portability and sharing of medical information (with electronic records) would help ensure the smooth transition of the patient through these discrete medical silos.
by
Cedric K. Dark, MD, MPH
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