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IN RESPONSE: Comparing costs and quality of care at retail clinics
Submit responseDr. Kochar is correct that the follow-up care of an episode at a retail clinic could occur at another care site. But we feel it is unlikely this impacted our quality scores. Less than 20% of episodes included any follow-up visits. Also our quality measures generally focused on care around the first visit. For example, we looked at antibiotic prescriptions for otitis media that were filled on the day of the first visit or subsequent two days.
We shared the concern with Dr. Kochar that patients who presented to a physician's office could be more ill and this might drive some of the cost differences we observed. Yet our sensitivity analyses that directly addressed this issue did not support this concern. The major driver of cost differences is reimbursement for the first visit. Costs which are likely to be related to severity of illness (e.g. laboratory costs, follow -up visits) were less important. Nonetheless, as we note in the manuscript, there could be residual differences between the patient populations at the care sites, though we feel that matching on income, level of illness, and insurance plan minimize these differences.
While we agree with Dr. Young that most cases of otitis media and pharyngitis are self-limited, it is notable that 11.4% all pediatric primary care visits are for just these two problems.(1) Seeking care for these problems is the established norm in our society and it is unclear whether this is a fair criticism of retail clinics. We agree with Dr. Young that retail clinics are not a magic bullet for health care costs. In our own models, we estimate there would be $2 billion in cost savings if retail clinics become widespread. But this constitutes less than 0.1% of health care spending.
We disagree with Dr. Young that the more important quality issue is how undifferentiated symptoms like lower abdominal pain are managed. Proper management of uncomplicated urinary tract infections is an important issue and the subject of much research and several guidelines.(2) Also, the goal in the study was to compare the care at retail clinics to other care sites and retail clinics do not manage undifferentiated abdominal pain
Consistent with our previous work,(3) the present study does find problems with quality across all the care sites. We agree with Dr. Johnson that efforts to improve quality of care across the health care system are critical.
References
1. Mehrotra A, Wang MC, Lave JR, Adams JL, McGlynn EA. Retail clinics, primary care physicians, and emergency departments: a comparison of patients' visits. Health Aff (Millwood). 2008;27(5):1272-82.
2. Fihn SD. Clinical practice. Acute uncomplicated urinary tract infection in women. N Engl J Med. 2003;349(3):259-66.
3. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635- 45.
Conflict of Interest:
None declared
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Quality (?) of care for UTI
Submit responseTo the editor:
Although intended primarily as a comparison of retail clinics with other medical settings, the study by Mehrotra et al. incidentally documents disturbing lapses in urinary tract infection (UTI) management in the comparison standard (1). Thus, the observed non-inferiority of retail clinics says less about the adequacy of these clinics' performance than about the inadequate performance of the traditional care settings studied. Specifically, in the physician office, urgent care, and emergency department groups, > 40% of high-risk patients had no urine culture done (despite the known greater diversity of pathogens and higher likelihood of antimicrobial-resistance among such patients); antibiotics were prescribed for longer than 7d for > 40% of patients with uncomplicated cystitis (whereas high-quality evidence supports 3-day therapy here) (2); and > 40% of patients with complicated UTI received less than 7d therapy (whereas expert opinion and some clinical trial evidence supports longer treatment durations). Little comfort is provided by knowing that retail clinics are not doing any worse than traditional care settings for UTI management, when the traditional settings are doing so poorly. On the contrary, the latter finding is quite concerning.
References
1. Mehrotra A, Liu H, Adams JL, et al. Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses. Ann Intern Med. 2009;151:321-8.
2. Warren JW, Abrutyn E, Hebel JR, Johnson JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Clin Infect Dis. 1999;29:745-8.
Conflict of Interest:
Research grants and/or consultancies from Bayer, Wyeth-Ayerst, Procter and Gamble, Merck, and Ortho-McNeil.
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Outcomes of retail clinics
Submit responseThe outcomes measured in the article by Mehrotra, et al demonstrate the fundamental weaknesses of retail clinics. Otitis media and pharyngitis are ultimately self-limited conditions whose clinical course are not significantly altered by medical interventions in most cases (1). Many physicians in other developed countries do not commonly prescribe antibiotics for otitis media (2) or pharyngitis (3).
Many retail clinics display a menu of diagnoses with prices. If a patient truly has one of these conditions, Mehrotra, et al successfully demonstrated that the quality of care provided by retail clinics for these conditions is probably reasonable. I have heard stories from people who have visited these clinics who tell me that no matter what the presenting set of circumstances, the patient will usually be diagnosed with one of the conditions on the menu.
Drawing conclusions based on ICD-9 diagnosis codes misses the point. The quality issue is how an undifferentiated symptom like lower abdominal pain is managed, not how a UTI is treated. If primary care clinics in the U.S. used the International Classification of Primary Care codes, such research could probably occur without having to look through thousands of charts (4).
Ultimately, retail clinics will likely neither help or hurt American healthcare in any measureable way. With 75% of healthcare expenditures attributable to chronic diseases, (5) how a self-limited sore throat is treated is of little consequence.
References
1. Del Mar C, Glasziou P, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. BMJ. May 24 1997;314(7093):1526-1529.
2. Froom J, Culpepper L, Grob P, et al. Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network. BMJ. Mar 3 1990;300(6724):582-586.
3. Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Ann Fam Med. Sep-Oct 2007;5(5):436-443.
4. Hofmans-Okkes IM, Lamberts H. The International Classification of Primary Care (ICPC): new applications in research and computer-based patient records in family practice. Fam Pract. Jun 1996;13(3):294-302.
5. Tynan A, Draper D. Getting what we pay for: innovations lacking in provider payment reform for chronic disease care.June 2008. http://www.hschange.com/CONTENT/996/. Accessed May 2, 2009.
Conflict of Interest:
None declared
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Retail Clinics-buy a tomato and get a vaccine?
Submit responseThe article “Comparing Costs and Quality of Care at Retail Clinics with That of Other Medical Settings” is an important start to understanding appropriate, high quality delivery of care that is timely in view of our current healthcare reform debate(1). Simple diseases should be easy and cheap to treat, wherever the delivery stetting is. Uncomplicated urinary tract infections are treated over the phone without charge, as I just did a few minutes ago while on-call. Preferably, I would have rather been paid for this, but our current system in most cases does not support that.Although the authors attempted to determine if other preventative services were also delivered within 3 to 6 months after the visit, this may have been flawed due to inadequate preventative reminders in the comparator group. If the physician offices were using electronic medical records (EMR) with reminders this would have increased preventative care. Some preventative care is only needed every 1, 5, or 10 years and a 3 to 6 month observational period would be inadequate. Although it is ideal to be able to integrate care by a common EMR, current legal constraints make this difficult to achieve.
Low acuity illness may have simple algorithms to prevent errors, over-treatment and excessive costs. As retail clinics expand to treat other financially lucrative services to help their stock prices (dermatologic procedures, hypertension, asthma, Gardasil, HPV vaccine, and motion sickness), errors may increase due to lack of proper follow-up and continuity (2,3). Dizziness is often due to vestibulitis, however cardiac arrhythmia, medication side-effects and other serious illness maybe misdiagnosed without the availability of accurate past history and current medication lists. Physician-patient continuity and review of prior records greatly assist with the accuracy of diagnosis. Expansion will increase the real costs to primary care offices and further add to the fragmented care we already have in the United States.
Pneumovax and Influenza vaccines are often administered before discharge from a hospital, although many patients have already received them. How will these retail clinics assure that the vaccine is not erroneously given an extra time, since there are no integrated electronic records? If the vaccinations are given at these clinics or at a grocery store, what happens when the patient has a reaction? Should we tell them to go to the store that they received the vaccine at and purchase a tomato and rub it on the site?
References
1. Mehrotra, A, Liu H, Adams JL, Wang MC, Lave JR, Thygeson M, Soberg LI, McGlynn EA. Comparing Costs and Quality of Care at Retail Clinics with That of Other Medical Settings, Ann Intern Med. 2009;151:321-8.
2. Merrick A. Retail Health Clinics Move to Treat Complex Illnesses, Rankling Doctors, Wall Street Journal, September 10, 2009
3 Retail Clinics Expand Services. Medical Economics, August 21, 2009,10
Conflict of Interest:
None declared
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Comparing costs and quality of care at retail clinics with that of other medical settings
Submit responseI read the paper by Mehrotra et al with great interest(1). However, I do have some concerns. Firstly, the study compares patient ‘episodes’ that were ‘first’ seen in different clinical settings of retail clinic, physician's office, urgent care clinic and emergency department. Patients may not have received care in the same clinical setting throughout the episode. Although the authors mention that the percentages of episodes with any follow up visits was similar for retail clinics, urgent care centers and physician offices and higher for emergency departments, we do not have any information regarding the number of follow up visits or the clinical settings in which they were conducted. It is possible that several patients that were first seen in retail clinics followed up in urgent care clinics or physician offices. Therefore, the quality of care measures and preventive services attributed to retail clinics could have been due to follow up in other clinical settings.
Secondly, the study subjects were matched by diagnosis codes but not by severity of symptoms leading to a high likelihood of selection bias. It is possible that patients with initial visit to retail clinics had less severe illness and the majority may not have required lab testing and prescription medications. The overall cost for these patients may have been even lower if they were first seen in an urgent care clinic or a physician’s office since the higher cost of evaluation in these settings would be balanced by reduced or no cost of unnecessary lab testing and medications.
Finally, the authors matched the study subjects by income category but not by race or geographic location. Retail clinics are more likely to be present in areas with higher median income and lower black population percentage, and are less likely to present in medically underserved areas(2). Therefore, the population served by the retail clinics may be significantly different from that served by urgent care clinics and physician’s offices even though all patients had the same health plan.
REFERENCES
1. Mehrotra A, Liu H, Adams JL, Wang MC, Lave JR, Thygeson NM, Solberg LI, McGlynn EA. Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses. Ann Intern Med. 2009 Sep 1;151(5):321-8.
2. Pollack CE, Armstrong K. The geographic accessibility of retail clinics for underserved populations. Arch Intern Med. 2009 May 25;169(10):945-9.
Conflict of Interest:
None declared