Retail Clinic Visits For Low-Acuity Conditions Increase Utilization And Spending

Value-based comparison of ambulatory children with respiratory diseases in an emergency department and a walk-in clinic: a retrospective cohort study in Québec, Canada

OBJECTIVE

To compare health outcomes and costs given in the emergency department (ED) and walk-in clinics for ambulatory children presenting with acute respiratory diseases.

DESIGN

A retrospective cohort study.

SETTING

This study was conducted from April 2016 to March 2017 in one ED and one walk-in clinic. The ED is a paediatric tertiary care centre, and the clinic has access to lab tests and X-rays.

PARTICIPANTS

Inclusion criteria were children: (1) aged from 2 to 17 years old and (2) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia or acute asthma.

MAIN OUTCOME MEASURES

The primary outcome measure was the proportion of patients returning to any ED or clinic within 3 and 7 days of the index visit. The secondary outcome measures were the mean cost of care estimated using time-driven activity-based costing and the incidence of antibiotic prescription for URTI patients.

RESULTS

We included 532 children seen in the ED and 201 seen in the walk-in clinic. The incidence of return visits at 3 and 7 days was 20.7% and 27.3% in the ED vs 6.5% and 11.4% in the clinic (adjusted relative risk at 3 days (aRR) (95% CI) 3.17 (1.77 to 5.66) and aRR at 7 days 2.24 (1.46 to 3.44)). The mean cost (95% CI) of care (CAD) at the index visit was $C96.68 (92.62 to 100.74) in the ED vs $C48.82 (45.47 to 52.16) in the clinic (mean difference (95% CI): 46.15 (41.29 to 51.02)). Antibiotic prescription for URTI was less common in the ED than in the clinic (1.5% vs 16.4%; aRR 0.10 (95% CI 0.03 to 0.32)).

CONCLUSIONS

The incidence of return visits and cost of care were significantly higher in the ED, while antibiotic use for URTI was more frequent in the walk-in clinic. These data may help determine which setting offers the highest value to ambulatory children with acute respiratory conditions.

Proportion Of Preventive Primary Care Visits Nearly Doubled, Especially Among Medicare Beneficiaries, 2001-19

There is debate about the value of preventive visits in primary care, and multiple policy trends during the past fifteen years may have influenced the likelihood of US adults undergoing preventive primary care visits. Using nationally representative, serial cross-sectional data on adult visits to primary care physicians from the 2001-19 National Ambulatory Medical Care Survey, we characterized temporal trends in the proportion of primary care visits with a preventive focus and the differential characteristics of these visits. Based on a sample of 139,783 unweighted (5,902,144,258 weighted) US primary care visits, we found that the proportion of primary care visits with a preventive focus increased between 2001 and 2019 (12.8 percent of visits in 2001-02 versus 24.6 percent in 2018-19; [Formula: see text]), with the greatest rate of increase seen for people with Medicare. Primary care visits with a preventive focus involved more time spent with the physician and addressed fewer reasons for the visit compared with problem-based visits. At least one of the following was significantly more likely to occur during a preventive visit than a problem-based visit: counseling provision, ordering of preventive labs, or ordering of a preventive image or procedure. Our findings demonstrate a relative increase in preventive versus problem-based visits in primary care and suggest the importance of enhanced insurance coverage in influencing preventive care delivery trends.

A value-based comparison of the management of respiratory diseases in walk-in clinics and emergency departments

OBJECTIVES

Our aim was to compare some of the health outcomes and costs associated with value of care in emergency departments (ED) and walk-in clinics for ambulatory patients presenting with an acute respiratory disease.

METHODS

A health records review was conducted from April 2016 through March 2017 in one ED and one walk-in clinic. Inclusion criteria were: (i) ambulatory patients at least 18 years old, (ii) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. Primary outcome was the proportion of patients returning to any ED or walk-in clinic within three and seven days of the index visit. Secondary outcomes were the mean cost of care and the incidence of antibiotic prescription for URTI patients. The cost of care was estimated from the Ministry of Health's perspectives using time-driven activity-based costing.

RESULTS

The ED group included 170 patients and the walk-in clinic group 326 patients. The return visit incidences at three and seven days were, respectively, 25.9% and 38.2% in the ED vs. 4.9% and 14.7% in the walk-in clinic (adjusted relative risk (arr) of 4.7 (95% CI 2.6-8.6) and 2.7 (1.9-3.9)). The mean cost ($Cdn) of the index visit care was 116.0 (106.3-125.7) in the ED vs. 62.5 (57.7-67.3) in the walk-in clinic (mean difference of 56.4 (45.7-67.1)). Antibiotic prescription for URTI was 5.6% in the ED vs. 24.7% in the walk-in clinic (arr 0.2, 0.01-0.6).

CONCLUSIONS

This study is the first in a larger research program to compare the value of care between walk-in clinics and the ED. The potential advantages of walk-in clinics over EDs (lower costs, lower incidence of return visits) for ambulatory patients with respiratory diseases should be considered in healthcare planning.

Primary Care Visits in the USA and Australia 2000-2016

BACKGROUND

There are major concerns about the sustainability of the US primary care (PC) system.

OBJECTIVE

We use similar data from the USA and Australia on adult visits to primary care physicians to examine how primary care service delivery and content in the countries have changed since the year 2001.

DESIGN/SETTING/PARTICIPANTS

Longitudinal analyses of nationally representative data collected in a similar manner on outpatient visits to PC in the USA (National Ambulatory Medical Care Survey, NAMCS) and Australia (Bettering the Evaluation and Care of Health, BEACH), 2001-2016.

MAIN MEASURES

For each visit, we ascertained the problems/diagnoses managed; the length of the visit in minutes; what medications were recorded; whether counseling, advice, or education was provided; the rate of imaging and diagnostics tests; the laboratory tests ordered; and whether the visit resulted in a referral to another physician.

KEY RESULTS

Between 2001 and 2016, there were 128,770 encounters with adult patients in NAMCS and 1,338,963 in BEACH. In the USA, the proportion of encounters with 3 or more problems managed increased from 28.7 to 54.8% whereas Australia started at a lower proportion (10.6%) and increased to just 14.1%. Visit times in the USA increased from 17.2 min in 2001 to 22.9 min in 2016 as compared to 14.4 min increasing to 15.2 in Australia. There were significantly more medications recorded over time in NAMCS than BEACH (2.02 in 2001 to 3.32 in 2016, USA, and 1.10 and 1.04, Australia), and US encounters resulted in imaging studies, lab tests, or referrals with relatively increasing frequency.

CONCLUSION

Relative to Australia, PC visits in the USA increasingly entail more complexity with visits that have grown comparatively longer over time, with more problems addressed, and with more content.

Applying embedded program evaluation for care delivery transformation: An analysis of a home-based urgent care program

Background

In 2014, Mass General Brigham, formerly Partners HealthCare, launched a novel urgent home-based medical care program to provide rapid medical evaluation and treatment to homebound patients and older adults with frailty or limited mobility named the partners mobile observation unit (PMOU) program.

Methods

We conducted a pragmatic, embedded evaluation assessing the impact of PMOU on postreferral utilization and total medical expenditure (TME). We used propensity weighting and logistic regression to estimate the 30-day adjusted odds ratios (ORs) of emergency department (ED) utilization and inpatient medical hospitalization for patients enrolled in PMOU (891 episodes of care) relative to those who were referred but not enrolled in the program (57 episodes of care) during the period of April 2017 to June 2018. We additionally conducted a difference-in-differences analysis assessing program impact on TME, comparing claims data 30 days pre/post referral.

Results

Despite positive trends, there were no statistically significant differences between the two groups with regard to postreferral ED visits or hospitalizations, with an OR of 0.83 (p = 0.56) and OR of 0.64 (p = 0.21), respectively. There was no statistically significant difference in pre/post referral TME for intervention relative to control episodes (p = 0.64). In post hoc analysis of control episodes, 75% received care elsewhere within 14 days of referral.

Conclusion

Although the results suggested positive trends, this analysis of this relatively mature program was unable to identify statistically significant reductions in ED visits, hospitalizations, or TME associated with the PMOU program. Future efforts to build home-based urgent care programs or related programs targeting older adults with frailty or limited mobility should aim to improve patient targeting and identify opportunities to improve program operations and generate meaningful reductions in healthcare utilization and spending.

Provider-Referred Versus Self-Referred Emergency Department Visit After Urgent Care Center Visit

BACKGROUND

Urgent care centers (UCCs) provide an alternative to emergency departments (EDs) for low-acuity acute care, as they are convenient with shorter wait time, but little is known about the quality of care at UCCs.

OBJECTIVE

We described and determined the differences in characteristics of patients who were sent to the ED by UCC physicians (provider-referred) with those of patients who went to the ED on their own (self-referred) within 72 h of discharge after a UCC visit. Our primary objective was to investigate whether observation unit use or hospital admission rates were different between the two groups. Our secondary objective was to identify whether their follow-up ED visits were avoidable.

METHODS

We conducted this prospective cohort study between March 22, 2017 and September 30, 2018 in a closed health system. A total of 53,178 UCC visits resulted in 582 provider-referred and 263 self-referred ED visits. We compared the characteristics of the two groups and measured the outcomes of observation unit or hospital admissions.

RESULTS

Patients with self-referred ED visits were younger; mean (standard deviation) age was 47.9 (24.5) years. Provider-referred patients appeared to be significantly associated with observation unit or hospital admission (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.24-2.46). Among the predictors for observation unit or hospital admission, consultation with a specialist in the ED was the strongest (adjusted OR 9.09; 95% CI 6.24-13.24); other significant predictors were Medicaid or no insurance.

CONCLUSIONS

We found that after an urgent care visit, patients who were sent to the ED by a UCC provider were not more likely than self-referred patients to be admitted to an observation unit or hospital from the ED. Significant predictors for observation unit or hospital admission after UCC discharge were specialist consultation and type of insurance.

Predicting Unplanned Health Care Utilization and Cost: Comparing Patient-reported Outcomes Measurement Information System and Claims

OBJECTIVES

There is little literature describing if and how payers are utilizing patient-reported outcomes to predict future costs. This study assessed if Patient-reported Outcomes Measurement Information System (PROMIS) domain scores, collected in routine practice at neurology clinics, improved payer predictive models for unplanned care utilization and cost.

STUDY DESIGN

Retrospective cohort analysis of private Health Plan-insured patients with visits at 18 Health Plan-affiliated neurology clinics.

METHODS

PROMIS domains (Anxiety v1.0, Cognitive Function Abilities v2.0, Depression v1.0, Fatigue v1.0, Pain Interference v1.0, Physical Function v2.0, Sleep Disturbance v1.0, and Ability to Participate in Social Roles and Activities v2.0) are collected as part of routine care. Data from patients' first PROMIS measures between June 27, 2018 and April 16, 2019 were extracted and combined with claims data. Using (1) claims data alone and (2) PROMIS and claims data, we examined the association of covariates to utilization (using a logit model) and cost (using a generalized linear model). We evaluated model fit using area under the receiver operating characteristic curve (for unplanned care utilization), akaike information criterion (for unplanned care costs), and sensitivity and specificity in predicting top 15% of unplanned care costs.

RESULTS

Area under the receiver operating curve values were slightly higher, and akaike information criterion values were similar, for PROMIS plus claims covariates compared with claims alone. The PROMIS plus claims model had slightly higher sensitivity and equivalent specificity compared with claims-only models.

CONCLUSION

One-time PROMIS measure data combined with claims data slightly improved predictive model performance compared with claims alone, but likely not to an extent that indicates improved practical utility for payers.

The impact of urgent care centers on nonemergent emergency department visits

OBJECTIVE

To estimate the impact of urgent care centers on emergency department (ED) use.

DATA SOURCES

Secondary data from a novel urgent care center database, linked to the Healthcare Cost and Utilization Project State Emergency Department Databases (SEDD) from six states.

STUDY DESIGN

We used a difference-in-differences design to examine ZIP code-level changes in the acuity mix of emergency department visits when local urgent care centers were open versus closed. ZIP codes with no urgent care centers served as a control group. We tested for differential impacts of urgent care centers according to ED wait time and patient insurance status.

DATA COLLECTION/EXTRACTION METHODS

Urgent care center daily operating times were determined via the urgent care center database. Emergency department visit acuity was assessed by applying the NYU ED algorithm to the SEDD data. Urgent care locations and nearby emergency department encounters were linked via zip code.

PRINCIPAL FINDINGS

We found that having an open urgent care center in a ZIP code reduced the total number of ED visits by residents in that ZIP code by 17.2% (P < 0.05), due largely to decreases in visits for less emergent conditions. This effect was concentrated among visits to EDs with the longest wait times. We found that urgent care centers reduced the total number of uninsured and Medicaid visits to the ED by 21% (P < 0.05) and 29.1% (P < 0.05), respectively.

CONCLUSIONS

During the hours they are open, urgent care centers appear to be treating patients who otherwise would have visited the ED. This suggests that urgent care centers have the potential to reduce health care expenditures, though questions remain about their net cost impact. Future work should assess whether urgent care centers can improve health care access among populations that often experience barriers to receiving timely care.

Urgent Care Centers Deter Some Emergency Department Visits But, On Net, Increase Spending

There is substantial interest in using urgent care centers to decrease lower-acuity emergency department (ED) visits. Using 2008-19 insurance claims and enrollment data from a national managed care plan, we examined the association within ZIP codes between changes in rates of urgent care center visits and rates of lower-acuity ED visits. We found that although the entry of urgent care deterred lower-acuity ED visits, the impact was small. We estimate that thirty-seven additional urgent care center visits were associated with a reduction of a single lower-acuity ED visit. In addition, each $1,646 lower-acuity ED visit prevented was offset by a $6,327 increase in urgent care center costs. Therefore, despite a tenfold higher price per visit for EDs compared with urgent care centers, use of the centers increased net overall spending on lower-acuity care at EDs and urgent care centers.

A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study

BACKGROUND

In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal.

OBJECTIVE

The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease.

METHODS

A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness.

RESULTS

Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025.

CONCLUSIONS

The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/25619.

Distance From Freestanding Emergency Departments to Nearby Emergency Care

STUDY OBJECTIVE

The number of freestanding emergency departments (EDs) has increased rapidly in the United States, and there is concern that such entities are located near existing EDs rather than in areas lacking emergency care. In 2018, the Medicare Payment Advisory Commission recommended a reduction in Medicare reimbursement rates to freestanding EDs located within 6 miles of the nearest hospital-based ED. We aim to assess the potential effect of this proposal.

METHODS

Using the 2016 National Emergency Department Inventory-USA database, we identified the locations and visit volumes of all US freestanding EDs. Using QGIS, we mapped the distances from all freestanding EDs to both the nearest hospital-based ED and to the nearest ED (either hospital-based or freestanding ED).

RESULTS

We collected location information for all 5,375 EDs open in 2016. Of these EDs, 609 (11%) were freestanding. Few freestanding EDs (1.4%) were located in rural areas and only 11% were located in areas with a median household income of less than $43,000. Overall, 460 freestanding EDs (76%) were within 6 miles of the nearest hospital-based ED, and these had 5.3 million total patient visits, whereas those greater than 6 miles away had 2.6 million visits.

CONCLUSION

We found that most freestanding EDs (76%) are within 6 miles of the nearest hospital-based ED, and most visits (67%) to freestanding EDs are to those within that proximity, indicating that many freestanding EDs would be affected by this Medicare Payment Advisory Commission proposal, if implemented.

Primary Care Office Visits For Acute Care Dropped Sharply In 2002-15, While ED Visits Increased Modestly

The traditional model of primary care practices as the main provider of care for acute illnesses is rapidly changing. Over the past two decades the growth in emergency department (ED) visits has spurred efforts to reduce "inappropriate" ED use. We examined a nationally representative sample of office and ED visits in the period 2002-15. We found a 12 percent increase in ED use (from 385 to 430 visits per 1,000 population), which was dwarfed by a decrease of nearly one-third in the rate of acute care visits to primary care practices (from 938 to 637 visits per 1,000 population). The decrease in primary care acute visits was also present among two vulnerable populations: Medicaid beneficiaries and adults ages sixty-five and older, either in Medicare or privately insured. As acute care delivery shifts away from primary care practices, there is a growing need for integration and coordination across an increasingly diverse spectrum of venues where patients seek care for acute illnesses.

Study protocol: effects, costs and distributional impact of digital primary care for infectious diseases-an observational, registry-based study in Sweden

INTRODUCTION

The ability to provide primary care with the help of a digital platform raises both opportunities and risks. While access to primary care improves, overuse of services and medication may occur. The use of digital care technologies is likely to continue to increase and evidence of its effects, costs and distributional impacts is needed to support policy-making. Since 2016, the number of digital primary care consultations for a range of conditions has increased rapidly in Sweden. This research project aims to investigate health system effects of this development. The overall research question is to what extent such care is a cost-effective and equitable alternative to traditional, in-office primary care in the context of a publicly funded health system with universal access. Three specific areas of investigation are identified: clinical effect; cost and distributional impact. This protocol describes the investigative approach of the project in terms of aims, design, materials, methods and expected results.

METHODS AND ANALYSIS

The research project adopts a retrospective study design and aims to apply statistical analyses of patient-level register data on key variables from seven regions of Sweden over the years 2017-2018. In addition to data on three common infectious conditions (upper respiratory tract infection; lower urinary tract infection; and skin and soft-tissue infection), information on other healthcare use, socioeconomic status and demography will be collected.

ETHICS AND DISSEMINATION

This registry-based study has received ethical approval by the Swedish Ethical Review Authority. Use of data will follow the Swedish legislation and practice with regards to consent. The results will be disseminated both to the research community, healthcare decision makers and to the general public.

Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008-2016

BACKGROUND

Primary care is known to improve outcomes and lower health care costs, prompting recent U.S. policy efforts to expand its role. Nonetheless, there is early evidence of a decline in per capita primary care visit rates, and little is understood about what is contributing to the decline.

OBJECTIVE

To describe primary care provider (PCP) visit trends among adults enrolled with a large, national, commercial insurer and assess factors underlying a potential decline in PCP visits.

DESIGN

Descriptive repeated cross-sectional study using 100% deidentified claims data from the insurer, 2008-2016. A 5% claims sample was used for Poisson regression models to quantify visit trends.

SETTING

National, population-based.

PARTICIPANTS

Adult health plan members aged 18 to 64 years.

MEASUREMENTS

PCP visit rates per 100 member-years.

RESULTS

In total, 142 million primary care visits among 94 million member-years were examined. Visits to PCPs declined by 24.2%, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. Rates of visits addressing low-acuity conditions decreased by 47.7% (95% CI, -48.1% to -47.3%). The decline was largest among the youngest adults (-27.6% [CI, -28.2% to -27.1%]), those without chronic conditions (-26.4% [CI, -26.7% to -26.1%]), and those living in the lowest-income areas (-31.4% [CI, -31.8% to -30.9%]). Out-of-pocket cost per problem-based visit rose by $9.4 (31.5%). Visit rates to specialists remained stable (-0.08% [CI, -0.56% to 0.40%]), and visits to alternative venues, such as urgent care clinics, increased by 46.9% (CI, 45.8% to 48.1%).

LIMITATION

Data were limited to a single commercial insurer and did not capture nonbilled clinician-patient interactions.

CONCLUSION

Commercially insured adults have been visiting PCPs less often, and nearly one half had no PCP visits in a given year by 2016. Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care.

PRIMARY FUNDING SOURCE

None.

Comparing Retail Clinics With Other Sites of Care: A Systematic Review of Cost, Quality, and Patient Satisfaction

BACKGROUND

Retail clinics, also referred to as walk-in or convenient care clinics, share common features such as a limited menu of primary care services, on-demand patient appointments, greater use of nonphysician providers such as nurse practitioners, and more convenient hours and access points for patients.

OBJECTIVES

Given their rising popularity as an alternative primary care delivery site, it is important to examine retail clinics' impact on patient outcomes. This study's aim was to systematically review the extant literature on retail clinics in the United States with respect to 3 outcomes of interest: quality, cost, and patient satisfaction.

RESEARCH DESIGN

A systematic search of 4 databases was done using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies needed to be empirical, measure care in retail, walk-in, or convenient care clinic, and present quality, cost, and/or satisfaction findings.

MEASURES

The majority of studies used commercial, administrative claims databases to procure patient outcome data (n=9). Nine of the 15 studies examined costs, 6 examined quality, and only 1 examined patient satisfaction.

RESULTS

Overall, retail clinic care compares favorably with similar care in other settings in terms of lower costs, although the evidence on quality and patient satisfaction is minimal and less conclusive.

CONCLUSIONS

Future research on retail clinic care requires more rigorous study designs, richer quality measures, inclusion of the patient experience in outcomes, less reliance on administrative claims data, and greater independence from industry stakeholders with interest in seeing the retail clinic model grow.

Essential Attributes for the Community Pharmacist as Care Provider

Objective. To identify skills and attributes that pharmacy students need upon graduation if planning to pursue a career path as a community pharmacy practice care provider. Methods. In-depth interviews with community pharmacy stakeholders were conducted, audio-recorded, and transcribed. Interview transcripts were thematically analyzed to identify the skills and attributes pharmacy students need upon graduation to be prepared to practice as a community pharmacy-based care provider. Results. Forty-two participants were interviewed. Identified attributes that were deemed transformative for community pharmacy practice included three behaviors, five skills, and two knowledge areas. Behavioral attributes needed by future community pharmacists were an approach to practice that is forward thinking and patient-centric, and having a provider mentality. The most commonly mentioned skill was the ability to provide direct patient care, with other skills being organizational competence, communication, building relationships, and management and leadership. Critical knowledge areas were treatment guidelines and drug knowledge, and regulatory and payer requirements. Additional skills needed by community pharmacy-based providers included identification and treatment of acute self-limiting illnesses and monitoring activities for chronic health conditions. Conclusion. Essential attributes of community pharmacists that will allow practice transformation to take place include behaving in a forward-thinking, patient-centric manner; displaying a provider mentality through use of effective communication to build relationships with patients and other providers, and learning how to meet regulatory and payer requirements for prescribers. These attributes should be fostered during the student's experiential curriculum.

The academic-industry divide in health communication: A call for increased partnership

OBJECTIVE

Healthcare communication research, teaching, and practice is in a period of innovation and disruption from new technologies, consumerization, and emerging models of care delivery. The goal of this commentary is to discuss perceived barriers and provide baseline metrics of academic-industry partnership in health communication.

METHODS

We coded industry affiliations of authors published in Patient Education and Counseling (PEC) in 2018, and attendees and authors of accepted submissions at the 2018 International Conference on Communication in Healthcare (ICCH). We examined perceived barriers to collaboration by summarizing a roundtable discussion between industry and academic participants at the 2018 ICCH conference.

RESULTS

In 2018, less than 5% of contributions to PEC, 16 abstracts (3.1%) and only 7 attendees (1.4%) at ICCH had industry affiliations. Roundtable participants identified actual or perceived motivational differences, publication challenges, and distinct metrics/outcomes as key barriers to collaboration.

CONCLUSION

These rough estimates provide a benchmark for current industry collaboration in our professional society. We discuss potential benefits of increased partnerships, suggest approaches to reduce barriers, and highlight recent progress.

PRACTICE IMPLICATIONS

As individuals and professional organizations, we should promote ethical, multidisciplinary, and high impact research, teaching, and practice in partnership with our colleagues in industry.

Relationship based care - how general practice developed and why it is undermined within contemporary healthcare systems

Objective: Investigating the state of generalism in medicine from the outlook of general practice. Line of argument: General practice developed when its pioneers, in continuing relationships, learnt to know their patients through the variety of medical situations. From the 50s, there is an increasing literature on the virtues and challenges of relationship based general practice, and register-based research indicate its benefits. Generalist perspectives and person-centeredness are implemented in specialised care and medical education but need to be complemented by an input from relationship based general practice. The politically defined aim of primary care is not to balance the draw-backs of specialisation, but to provide medicine at the primary care level. In Sweden, and increasingly even in traditional strongholds of general practice, team-based primary care is thought to respond to increasing demands, filtering out non- and minor disease through triage, practicing task distribution, and moving the GP to a secondary level working with the 'really sick', in all a decline in direct contact between patient and GP. Conclusions: When this happens, clinical medicine as a whole becomes drained of the practice of its human dimension. The lack of absolute proof of medical benefits cannot justify a disregard of the value of mutual knowledge and trust in the relationship, but still, in several countries, relationshipbased general practice will be hard to achieve for GPs planning their career. If the political winds should change, a sustaining profession of GPs preserving their relational ethos inside the team model, may be prepared to reform primary care. KEY POINTS Proclaiming both biomedical breadth and the trustful relationship between doctor and patient, as a specialty, general practice embodies medical generalism. A direct input from the patient's personal GP is necessary to make specialised care become more comprehensive and individualised. In reality, the team, practicing triage and task distribution, is increasingly replacing the doctor-patient relationship as working mode in primary care When the disease rather than the doctor-patient relationship, becomes the organising principle of primary care, medicine as a whole will be drained of the practice of its human dimension.

Transformation Support Provided Remotely to a National Cohort of Optometry Practices

PURPOSE

We describe the results of a practice transformation project conducted within a national cohort of optometry practices participating in the Southern New England Practice Transformation Network.

METHODS

Participants were 2,997 optometrists in 1,706 practices in 50 states. The multicomponent intervention entailed curriculum dissemination through a preexisting network of optometrists supported by specialized staff and resources, and data collection through a web portal providing real-time feedback. Outcomes included practices reporting data, urgent optometry visits for target conditions, and projected cost savings achieved by reducing emergency department (ED) use through increased provision of urgent care for conditions amenable to management in optometry practices.

RESULTS

Over 13 months, 69.9% of practices reported data for a mean of 6.7 months. Beginning with the fourth month, the number of urgent optometry visits increased steadily. Among reporting practices, the total cost savings were estimated at $152 million (176,703 ED visits avoided at an average cost differential of $860 per visit). Monthly projected cost savings per optometrist were substantially greater in rural vs urban practices ($10,800 vs $7,870; P <.001).

CONCLUSIONS

Technical assistance to promote practice transformation can be provided remotely and at scale at low per-practice cost. Through the provision of timely, easily accessed ambulatory care, optometrists can improve the patient experience and reduce ED use, thereby reducing costs. The cost savings opportunities are immense because of the large volume and high expense of ED visits for ocular conditions that might otherwise be managed in ambulatory optometry practices.

Comparison of eVisit Management of Urinary Symptoms and Urinary Tract Infections with Standard Care

Background: Urinary symptoms and urinary tract infections (UTIs) are common complaints for which women seek health care. Evolving modalities of care delivery have shifted management of these complaints from in-person face-to-face (F2F) visits, to nurse phone protocol management, and recently to online assessment via eVisit. While research has vetted the use of nurse phone protocol management, eVisit management outcomes have not been thoroughly studied. Purpose: To compare antibiotic prescribing, follow-up rates, and clinical outcomes between F2F visits at a retail clinic, nurse phone protocol encounters, and eVisits for the assessment and management of urinary symptoms and UTIs. Methods: A retrospective chart review of primary care empaneled patients at Mayo Clinic Rochester was conducted of females, 18 to 65 years old, who sought care for urinary symptoms via phone, eVisit, or F2F visit from August 1, 2016, through May 1, 2017. A total of 450 encounters, 150 from each of the 3 encounter types, were manually reviewed and compared for antibiotic prescribing rates, clinical outcomes, and 30-day follow-up rates. Results: Antibiotic prescribing rates for all three encounter types were similar. Referral for follow-up at initial encounter was more likely to be recommended from phone and eVisit encounters than F2F. No significant differences in follow-up rates or clinical outcomes were noted between the three encounter types. Conclusions: eVisits for urinary symptoms and UTI offer patients a convenient option for care without an increased use of antimicrobials, follow-up, or adverse clinical outcomes when compared with F2F visits or nurse-administered phone protocols.

Retail clinics colocated with pharmacies: A Delphi study of pharmacist impacts and recommendations for optimization

OBJECTIVES

To identify workforce issues likely to affect pharmacists working in retail clinics (RCs) colocated with community pharmacies and to generate recommendations for optimizing health, cost, and operations outcomes.

DESIGN AND PARTICIPANTS

A Delphi expert panel process using researchers with pharmacist workforce research experience was used. Panelists responded to 2 surveys of 3 rounds each. In survey 1, panelists used a 4-point linear numeric scale to rate the importance of 15 impact factors on pharmacists working in the RC/pharmacy setting. In survey 2, panelists used a 3-point linear numeric scale to rate the importance of recommendations for optimal outcomes. Recommendations were structured around elements from collaboration theory, a framework for evaluating critical areas for success in merged operations.

MAIN OUTCOME MEASURES

Consensus was defined as ≥ 80% rating an impact "very" or "moderately" important (survey 1) and "very" important (survey 2). Impact factors were rank-ordered by ratings and numeric scoring. Selected comments about consensus items were reported.

RESULTS

The 8-person panel had 100% response rates for both surveys. 12 of the 15 impact variables achieved consensus (survey 1). The highest ranking impacts were ability to establish collaborative relationships, relationships with coworkers, including nurse practitioners, and location of the RC relative to the pharmacy. Of 15 recommendations (survey 2), 5 achieved consensus and focused heavily on information sharing and early and ongoing collaboration among all stakeholders.

CONCLUSION

Clinical, economic, health care quality, and patient preference data suggest that RCs colocated with pharmacies are likely to play a permanent role in U.S. health care. RCs can affect pharmacists and pharmacies positively or negatively. Positive impacts are most likely where establishing collaborative partnerships with all stakeholders, including patients, throughout planning, implementation, and operation are emphasized. With only about 3% of pharmacy operations colocated with RCs now, attention and resources should be devoted to developing and testing models based on collaboration principles.

Patients' preferences over care settings for minor illnesses and injuries

OBJECTIVES

To identify consumers' preferences over care settings, such as physicians' offices, emergency rooms (ERs), urgent care centers, retail clinics, and virtual physicians on smartphones, for minor illnesses.

DATA SOURCES

A survey conducted between 9/27/16 and 12/7/16 emailed to all University of California, Irvine employees.

STUDY DESIGN

Participants were presented with 10 clinical scenarios and asked to choose the setting in which they wanted to receive care. We estimated multinomial conditional logit regression models, conditioning the choice on out-of-pocket costs, wait time, travel time, and chooser characteristics.

DATA COLLECTION

5451 out of 21 037 employees responded.

PRINCIPAL FINDINGS

Out-of-pocket costs and wait time had minimal impact on patient's preference for site of care. Choices were driven primarily by the clinical scenario and patient characteristics. For chronic conditions and children's well-visits, the doctor's office was the preferred choice by a strong majority, but for most acute conditions, either the ER (for high severity) or urgent care clinics (for lower severity) were preferred to the office setting, particularly among younger patients and those with less education.

CONCLUSIONS

Patients have several alternatives to traditional physicians' offices and ERs. The low impact of out-of-pocket costs suggests that insurers interested in encouraging increased utilization of alternatives would need to consider substantial changes to benefit structure.

Consensus Statement on Urgent Care Centers and Retail Clinics in Acute Care of Children

This article provides recommendations for pediatric readiness, scope of services, competencies, staffing, emergency preparedness, and transfer of care coordination for urgent care centers (UCCs) and retail clinics that provide pediatric care. It also provides general recommendations for the use of telemedicine in these establishments. With continuing increases in wait times and overcrowding in the nation's emergency departments and the mounting challenges in obtaining timely access to primary care providers, a new trend is gaining momentum for the treatment of minor illness and injuries in the form of UCCs and retail clinics. As pediatric visits to these establishments increase, considerations should be made for the type of injury or illnesses that can be safely treated, the required level training and credentials of personnel needed, the proper equipment and resources to specifically care for children, and procedures for safe transfer to a higher level of care, when needed. When used appropriately, UCCs and retail clinics can be valuable and convenient patient care resources.

Evolution of Care and Nursing: Moving With the Patients

Health care costs are growing exponentially. They will continue to erode disposable income, especially among those most in need of health care-the poor and elderly. As the baby boomer generation ages, we will see dramatic growth in health care spending, which will influence the health care market in new ways. Increased government intervention and technological advancements will only further this shift. Factors driving the need for health care transformation include fragmentation, access problems, unsustainable costs, suboptimal outcomes, and disparities of care. Nurses now have more tools (ie, mHealth, telemedicine, and electronic health records) that they can use to provide assistance to their practices outside of acute care settings. These realities are all contributors to an evolving trend: retail health.

Pediatric Urgent Care-New and Evolving Paradigms of Acute Care

Parents of pediatric patients seek appropriate high-quality care in a timely, cost-effective, and convenient manner. Pediatric urgent care offers a new and evolving delivery model that serves a growing demand by complementing services provided by the medical home and by pediatric emergency departments. Pediatric urgent care services are used by both nonprofit and for-profit sectors and include hospital and satellite clinics, free-standing clinics, retail-based clinics, and telemedicine services. The clinical scope is variable and there are distinct and unique operational considerations. Training models are evolving and further research is warranted.

Patterns of Use and Correlates of Patient Satisfaction with a Large Nationwide Direct to Consumer Telemedicine Service

BACKGROUND

Despite its rapid expansion, little is known about use of direct to consumer (DTC) telemedicine.

OBJECTIVE

To characterize telemedicine patients and physicians and correlates of patient satisfaction DESIGN: Cross-sectional study PARTICIPANTS: Patients and physicians of a large nationwide DTC telemedicine service MAIN MEASURES: Patient characteristics included demographics and whether or not they reported insurance information. Physician characteristics included specialty, board certification, and domestic versus international medical training. Encounter characteristics included time of day, wait time, length, coupon use for free or reduced-cost care, diagnostic outcome, prescription receipt, and patient/physician geographic concordance. Patients rated satisfaction with physicians on scales of 0 to 5 stars and reported where they would have sought care had they not used telemedicine. Logistic regression was used to assess factors associated with 5-star physician ratings.

KEY RESULTS

The analysis included 28,222 encounters between 24,040 patients and 277 physicians completed between January 2013 and August 2016. Sixty-five percent of patients were under 40 years and 32% did not report insurance information. Family medicine was the most common physician specialty (47%) and 16% trained at a non-US medical school. Coupons were used in 24% of encounters. Respiratory infections were diagnosed in 35% of encounters and 69% resulted in a prescription. Had they not used telemedicine, 43% of patients reported they would have used urgent care/retail clinic, 29% would have gone to the doctor's office, 15% would have done nothing, and 6% would have gone to the emergency department. Eighty-five percent of patients rated their physician 5 stars. High satisfaction was positively correlated with prescription receipt (OR 2.98; 95%CI 2.74-3.23) and coupon use (OR 1.47; 95%CI 1.33-1.62).

CONCLUSIONS

Patients were largely satisfied with DTC telemedicine, yet satisfaction varied by coupon use and prescription receipt. The impact of telemedicine on primary care and emergency department use is likely to be small under present usage patterns.

Trends in Visits to Acute Care Venues for Treatment of Low-Acuity Conditions in the United States From 2008 to 2015

IMPORTANCE

Over the past 2 decades, a variety of new care options have emerged for acute care, including urgent care centers, retail clinics, and telemedicine. Trends in the utilization of these newer care venues and the emergency department (ED) have not been characterized.

OBJECTIVE

To describe trends in visits to different acute care venues, including urgent care centers, retail clinics, telemedicine, and EDs, with a focus on visits for treatment of low-acuity conditions.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used deidentified health plan claims data from Aetna, a large, national, commercial health plan, from January 1, 2008, to December 31, 2015, with approximately 20 million insured members per study year. Descriptive analysis was performed for health plan members younger than 65 years. Data analysis was performed from December 28, 2016, to February 20, 2018.

MAIN OUTCOMES AND MEASURES

Utilization, inflation-adjusted price, and spending associated with visits for treatment of low-acuity conditions. Low-acuity conditions were identified using diagnosis codes and included acute respiratory infections, urinary tract infections, rashes, and musculoskeletal strains.

RESULTS

This study included 20.6 million acute care visits for treatment of low-acuity conditions over the 8-year period. Visits to the ED for the treatment of low-acuity conditions decreased by 36% (from 89 visits per 1000 members in 2008 to 57 visits per 1000 members in 2015), whereas use of non-ED venues increased by 140% (from 54 visits per 1000 members in 2008 to 131 visits per 1000 members in 2015). There was an increase in visits to all non-ED venues: urgent care centers (119% increase, from 47 visits per 1000 members in 2008 to 103 visits per 1000 members in 2015), retail clinics (214% increase, from 7 visits per 1000 members in 2008 to 22 visits per 1000 members in 2015), and telemedicine (from 0 visits in 2008 to 6 visits per 1000 members in 2015). Utilization and spending per person per year for low-acuity conditions had net increases of 31% (from 143 visits per 1000 members in 2008 to 188 visits per 1000 members in 2015) and 14% ($70 per member in 2008 to $80 per member in 2015), respectively. The increase in spending was primarily driven by a 79% increase in price per ED visit for treatment of low-acuity conditions (from $914 per visit in 2008 to $1637 per visit in 2015).

CONCLUSIONS AND RELEVANCE

From 2008 to 2015, total acute care utilization for the treatment of low-acuity conditions and associated spending per member increased, and utilization of non-ED acute care venues increased rapidly. These findings suggest that patients are more likely to visit urgent care centers than EDs for the treatment of low-acuity conditions.

To Keep Patients, Some Physicians Get Creative

In the face of growing competition, traditional practices have begun trying to guarantee same-day appointments.

Direct-To-Consumer Telehealth May Increase Access To Care But Does Not Decrease Spending

The use of direct-to-consumer telehealth, in which a patient has access to a physician via telephone or videoconferencing, is growing rapidly. A key attraction of this type of telehealth for health plans and employers is the potential savings involved in replacing physician office and emergency department visits with less expensive virtual visits. However, increased convenience may tap into unmet demand for health care, and new utilization may increase overall health care spending. We used commercial claims data on over 300,000 patients from three years (2011-13) to explore patterns of utilization and spending for acute respiratory illnesses. We estimated that 12 percent of direct-to-consumer telehealth visits replaced visits to other providers, and 88 percent represented new utilization. Net annual spending on acute respiratory illness increased $45 per telehealth user. Direct-to-consumer telehealth may increase access by making care more convenient for certain patients, but it may also increase utilization and health care spending.

Patients' demographics of a convenient clinic located in a large railway station in metropolitan Tokyo area

Hidden barriers to visit a medical facility especially for young busy workers have been neglected in the aging society. The aim of this cross-sectional study is to analyze demographics of patients who had visited the first known convenient clinic located inside a railway station, which is adjusted to the lifestyle of working generations.We analyzed de-identified data of patients who had visited the department of internal medicine of a clinic, which is located inside a railway station building and offers primary care with after-hours accessibility in Tokyo, between August 2013 and June 2016. Data were collected on patients' sex, age, time of visit, waiting time, presence or absence of an appointment, diagnosis, and patients' addresses using the electronic health and billing records.Overall, 28,001 patients visited 87,126 times. Number of visits increased in winter season compared with the other seasons. Sixty-one percent were women and the median age of all patients was 38 years (range, 0-102). The number of visits on Mondays was the highest in a week and the most frequent visiting time was between 6 and 7 p.m. The number of visits of working generations (from 15 to 65 years old) and men increased after 6 p.m. and on weekends. The 3 most common diagnoses were upper respiratory tract infection (22,457), allergic rhinitis (20,916), and hypertension (4869). The number of individuals who were referred to other medical institutions was 1022 (1.2%). The median waiting time was 748 seconds (range, 2-5344). The number of visits from within 2-, 5-, and 10-mile radius from our clinic was 41,696 (50.6%), 63,190 (76.7%), and 75,015 (91.1%), respectively, and patients' addresses were mainly located along the railway network.The locational and temporal convenience of our clinic has attracted the unmet medical demands especially for young workers who have difficulty in visiting conventional medical institutions.

Virtual Visits and Patient-Centered Care: Results of a Patient Survey and Observational Study

BACKGROUND

Virtual visits are clinical interactions in health care that do not involve the patient and provider being in the same room at the same time. The use of virtual visits is growing rapidly in health care. Some health systems are integrating virtual visits into primary care as a complement to existing modes of care, in part reflecting a growing focus on patient-centered care. There is, however, limited empirical evidence about how patients view this new form of care and how it affects overall health system use.

OBJECTIVE

Descriptive objectives were to assess users and providers of virtual visits, including the reasons patients give for use. The analytic objective was to assess empirically the influence of virtual visits on overall primary care use and costs, including whether virtual care is with a known or a new primary care physician.

METHODS

The study took place in British Columbia, Canada, where virtual visits have been publicly funded since October 2012. A survey of patients who used virtual visits and an observational study of users and nonusers of virtual visits were conducted. Comparison groups included two groups: (1) all other BC residents, and (2) a group matched (3:1) to the cohort. The first virtual visit was used as the intervention and the main outcome measures were total primary care visits and costs.

RESULTS

During 2013-2014, there were 7286 virtual visit encounters, involving 5441 patients and 144 physicians. Younger patients and physicians were more likely to use and provide virtual visits (P<.001), with no differences by sex. Older and sicker patients were more likely to see a known provider, whereas the lowest socioeconomic groups were the least likely (P<.001). The survey of 399 virtual visit patients indicated that virtual visits were liked by patients, with 372 (93.2%) of respondents saying their virtual visit was of high quality and 364 (91.2%) reporting their virtual visit was "very" or "somewhat" helpful to resolve their health issue. Segmented regression analysis and the corresponding regression parameter estimates suggested virtual visits appear to have the potential to decrease primary care costs by approximately Can $4 per quarter (Can -$3.79, P=.12), but that benefit is most associated with seeing a known provider (Can -$8.68, P<.001).

CONCLUSIONS

Virtual visits may be one means of making the health system more patient-centered, but careful attention needs to be paid to how these services are integrated into existing health care delivery systems.

Nonemergency Acute Care: When It's Not the Medical Home

The American Academy of Pediatrics (AAP) affirms that the optimal location for children to receive care for acute, nonemergency health concerns is the medical home. The medical home is characterized by the AAP as a care model that "must be accessible, family centered, continuous, comprehensive, coordinated, compassionate, and culturally effective." However, some children and families use acute care services outside the medical home because there is a perceived or real benefit related to accessibility, convenience, or cost of care. Examples of such acute care entities include urgent care facilities, retail-based clinics, and commercial telemedicine services. Children deserve high-quality, appropriate, and safe acute care services wherever they access the health care system, with timely and complete communication with the medical home, to ensure coordinated and continuous care. Treatment of children under established, new, and evolving practice arrangements in acute care entities should adhere to the core principles of continuity of care and communication, best practices within a defined scope of services, pediatric-trained staff, safe transitions of care, and continuous improvement. In support of the medical home, the AAP urges stakeholders, including payers, to avoid any incentives (eg, reduced copays) that encourage visits to external entities for acute issues as a preference over the medical home.

Virtual Visits for Acute, Nonurgent Care: A Claims Analysis of Episode-Level Utilization

Background

Expansion of virtual health care—real-time video consultation with a physician via the Internet—will continue as use of mobile devices and patient demand for immediate, convenient access to care grow.

Objective

The objective of the study is to analyze the care provided and the cost of virtual visits over a 3-week episode compared with in-person visits to retail health clinics (RHC), urgent care centers (UCC), emergency departments (ED), or primary care physicians (PCP) for acute, nonurgent conditions.

Methods

A cross-sectional, retrospective analysis of claims from a large commercial health insurer was performed to compare care and cost of patients receiving care via virtual visits for a condition of interest (sinusitis, upper respiratory infection, urinary tract infection, conjunctivitis, bronchitis, pharyngitis, influenza, cough, dermatitis, digestive symptom, or ear pain) matched to those receiving care for similar conditions in other settings. An episode was defined as the index visit plus 3 weeks following. Patients were children and adults younger than 65 years of age without serious chronic conditions. Visits were classified according to the setting where the visit occurred. Care provided was assessed by follow-up outpatient visits, ED visits, or hospitalizations; laboratory tests or imaging performed; and antibiotic use after the initial visit. Episode costs included the cost of the initial visit, subsequent medical care, and pharmacy.

Results

A total of 59,945 visits were included in the analysis (4635 virtual visits and 55,310 nonvirtual visits). Virtual visit episodes had similar follow-up outpatient visit rates (28.09%) as PCP (28.10%, P=.99) and RHC visits (28.59%, P=.51). During the episode, lab rates for virtual visits (12.56%) were lower than in-person locations (RHC: 36.79%, P<.001; UCC: 39.01%, P<.001; ED: 53.15%, P<.001; PCP: 37.40%, P<.001), and imaging rates for virtual visits (6.62%) were typically lower than in-person locations (RHC: 5.97%, P=.11; UCC: 8.77%, P<.001; ED: 43.06%, P<.001; PCP: 11.26%, P<.001). RHC, UCC, ED, and PCP were estimated to be $36, $153, $1735, and $162 more expensive than virtual visit episodes, respectively, including medical and pharmacy costs.

Conclusions

Virtual care appears to be a low-cost alternative to care administered in other settings with lower testing rates. The similar follow-up rate suggests adequate clinical resolution and that patients are not using virtual visits as a first step before seeking in-person care.

Association Between the Opening of Retail Clinics and Low-Acuity Emergency Department Visits

STUDY OBJECTIVE

We assess whether the opening of retail clinics near emergency departments (ED) is associated with decreased ED utilization for low-acuity conditions.

METHODS

We used data from the Healthcare Cost and Utilization Project State Emergency Department Databases for 2,053 EDs in 23 states from 2007 to 2012. We used Poisson regression models to examine the association between retail clinic penetration and the rate of ED visits for 11 low-acuity conditions. Retail clinic "penetration" was measured as the percentage of the ED catchment area that overlapped with the 10-minute drive radius of a retail clinic. Rate ratios were calculated for a 10-percentage-point increase in retail clinic penetration per quarter. During the course of a year, this represents the effect of an increase in retail clinic penetration rate from 0% to 40%, which was approximately the average penetration rate observed in 2012.

RESULTS

Among all patients, retail clinic penetration was not associated with a reduced rate of low-acuity ED visits (rate ratio=0.999; 95% confidence interval=0.997 to 1.000). Among patients with private insurance, there was a slight decrease in low-acuity ED visits (rate ratio=0.997; 95% confidence interval=0.994 to 0.999). For the average ED in a given quarter, this would equal a 0.3% reduction (95% confidence interval 0.1% to 0.6%) in low-acuity ED visits among the privately insured if retail clinic penetration rate increased by 10 percentage points per quarter.

CONCLUSION

With increased patient demand resulting from the expansion of health insurance coverage, retail clinics may emerge as an important care location, but to date, they have not been associated with a meaningful reduction in low-acuity ED visits.