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Urgent Care Could Replace ED For Some Patients, Report Says

 |  By cclark@healthleadersmedia.com  
   September 08, 2010

A trip to a retail clinic or urgent care center can substitute for a trip to the emergency department for between 13.7% and 27.1% of patients who don't require hospital level of care, "with a potential cost-saving of $4.4 billion annually."

That's the conclusion of a new report by Robin Weinick and colleagues from the RAND Corp. in a report published in this month's edition of the journal Health Affairs.

Use of an urgent care or a retail clinic might be a good solution for the growing shortage of office-based primary care doctors, a deficit that will only get worse as an aging physician workforce retires and as the country's population ages, requiring more acute care and pushing more patients into already crowded emergency rooms, the authors wrote.

This shortage is expected to further crowd emergency rooms with patients who can't make a timely appointment with their primary care doctor.

"A continued increase in the number of emergency department visits for nonemergency causes is likely to be unsustainable in our current healthcare system," the researchers wrote, especially as more people have health coverage under the Affordable Care Act.

But Angela Gardner, MD, president of the American College of Emergency Physicians, said in an interview Tuesday that her organization strongly disagrees with the RAND report's suggestions.

"My worry and nightmare is that patients would go to a retail clinic for a truly emergent condition, and waste valuable time. You know that emergency departments all have the equipment to treat real acute emergencies.  But all retail clinics are not created equally.

Gardner added, "They don't say at what cost all those patients could be seen in retail or urgent care clinics, the clinics aren't open in the deep of night."

Additionally, she said, the authors are relying on an assumption that these patients would know whether they needed emergency care in a hospital or not. She recounted a story of a man who appeared in an emergency room complaining of simple shoulder pain but who turned out to be having the earliest symptoms of a myocardial infarction. "A few minutes later he was in the cath lab," a life that was saved as a result, she said.

"I don't have any problems with urgent care as a concept. But the trouble is there is variability in that kind of care, and a lay person doesn't know what that variability is."

She added that for a hospital, "you can know if it passed its Joint Commission certification and if it's Medicare-qualified. You can ask about credentials of the doctors.  But in a retail clinic, I don't know that you can."

The RAND report suggests that patients with less acute conditions, such as strains, fractures and lacerations, could direct themselves to retail clinics or urgent care centers just as effectively as if they had gone to a hospital emergency room and endured the long wait, saving .2% of the nation's healthcare costs and avoiding long emergency room waits at the same time.

"Although many policy makers may prefer that patients seek care for nonemergency conditions from a primary care provider, acute care is increasingly provided outside of the primary care setting," the authors conclude.

"New initiatives such as medical home demonstrations and accountable care organizations encourage the use of primary care and seek to improve access to it. However, these initiatives are unlikely to provide a widespread solution in the near term," the authors wrote.

While the healthcare reform bill will provide health coverage to as many as 32 million people. But when they have an urgent care issue, they may not be able to see a doctor. Instead, they will further crowd emergency rooms.

The Massachusetts experience is a case in point, the RAND researchers noted, because even as the numbers of insured increased, there was not a corresponding drop in low-acuity emergency department visits.

The RAND researchers based their evaluation of 354 million annual visits for acute care in three types of settings between 2001 and 2004—retail clinics, urgent care centers and emergency departments.

But Gardner took issue with that as well because the data is at least five years old, and fails to consider that the number of patients who go to the emergency room for non-urgent reasons has been declining.

In recent years, according to the Centers for Disease Control and Prevention, the percentage of patients who sought care in an emergency room who were considered non-urgent—defined as whether they could wait 24 hours to be seen by a physician—has been dropping. In 2006 and 2007, it was 12% but last year, it was 8.9%.

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