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Shapiro DJ, Barak-Corren Y, Neuman MI, Mandl KD, Harper MB, Fine AM. Identifying Patients at Lowest Risk for Streptococcal Pharyngitis: A National Validation Study. J Pediatr 2020; 220:132-138.e2. [PMID: 32067779 DOI: 10.1016/j.jpeds.2020.01.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/08/2019] [Accepted: 01/13/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine the prevalence of features of viral illness in a national sample of visits involving children tested for group A Streptococcus pharyngitis. Additionally, we sought to derive a decision rule to identify patients with features of viral illness who were at low risk of having group A Streptococcus and for whom laboratory testing might be avoided. STUDY DESIGN Retrospective validation study using data from electronic health records of patients 3-21 years old evaluated for sore throat in a national network of retail health clinics (n = 67 127). We determined the prevalence of features of viral illness in patients tested for group A Streptococcus and developed a decision tree algorithm to identify patients with features of viral illness at low risk (<15%) of having group A Streptococcus. RESULTS Overall, 54% of patients had features of viral illness. Among patients with features of viral illness, those without tonsillar exudates who were 11 years or older and either lacked cervical adenopathy or had cervical adenopathy and lacked fever were identified as at low risk for group A Streptococcus according to the decision rule. This group comprised 34% of patients with features of viral illness, or 19% of all patients tested for group A Streptococcus infection. CONCLUSIONS Our findings provide an objective way to identify patients with features of viral illness who are at low risk of having group A Streptococcus. Improved identification such patients at low risk of group A Streptococcus could improve appropriate testing and antibiotic prescribing for pharyngitis.
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Affiliation(s)
- Daniel J Shapiro
- Department of Pediatrics, Boston Children's Hospital, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
| | - Yuval Barak-Corren
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Mark I Neuman
- Department of Pediatrics, Boston Children's Hospital, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Kenneth D Mandl
- Department of Pediatrics, Boston Children's Hospital, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Marvin B Harper
- Department of Pediatrics, Boston Children's Hospital, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Andrew M Fine
- Department of Pediatrics, Boston Children's Hospital, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Burrowes SAB, Rader A, Ni P, Drainoni ML, Barlam TF. Low Uptake of Rapid Diagnostic Tests for Respiratory Tract Infections in an Urban Safety Net Hospital. Open Forum Infect Dis 2020; 7:ofaa057. [PMID: 32166096 PMCID: PMC7060900 DOI: 10.1093/ofid/ofaa057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/13/2020] [Indexed: 01/21/2023] Open
Abstract
Background Rapid diagnostic tests (RDTs) have been developed with the aim of providing accurate results in a timely manner. Despite this, studies report that provider uptake remains low. Methods We conducted a retrospective analysis of ambulatory, urgent care, and emergency department (ED) encounters at an urban safety net hospital with a primary diagnosis of an upper or lower respiratory tract infection (eg, bronchitis, pharyngitis, acute sinusitis) from January 1, 2016, to December 31, 2018. We collected RDT type and results, antibiotics prescribed, demographic and clinical patient information, and provider demographics. Results RDT use was low; a test was performed at 29.5% of the 33 494 visits. The RDT most often ordered was the rapid Group A Streptococcus (GAS) test (n = 7352), predominantly for visits with a discharge diagnosis of pharyngitis (n = 5818). Though antibiotic prescription was more likely if the test was positive (relative risk [RR], 1.68; 95% confidence interval [CI], 1.58–1.8), 92.46% of streptococcal pharyngitis cases with a negative test were prescribed an antibiotic. The Comprehensive Respiratory Panel (CRP) was ordered in 2498 visits; influenza was the most commonly detected pathogen. Physicians in the ED were most likely to order a CRP. Antibiotic prescription was lower if the CRP was not ordered compared with a negative CRP result (RR, 0.77; 95% CI, 0.7–0.84). There was no difference in prescribing by CRP result (negative vs positive). Conclusions RDTs are used infrequently in the outpatient setting, and impact on prescribing was inconsistent. Further work is needed to determine barriers to RDT use and to address potential solutions.
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Affiliation(s)
- Shana A B Burrowes
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Alec Rader
- Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Pengsheng Ni
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, Massachusetts, USA
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Evans Center for Implementation and Improvement Sciences (CIIS), Boston University School of Medicine, Boston, Massachusetts, USA.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts, USA
| | - Tamar F Barlam
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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Hoff T, Prout K. Comparing Retail Clinics With Other Sites of Care: A Systematic Review of Cost, Quality, and Patient Satisfaction. Med Care 2020; 57:734-741. [PMID: 31274781 DOI: 10.1097/mlr.0000000000001164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Timothy Hoff
- D'Amore-McKim School of Business and School of Public Policy and Urban Affairs, Northeastern University
| | - Kathryn Prout
- School of Pharmacy, Bouvé College of Health Sciences, Northeastern University, Boston, MA
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Stuhr JK, Lykkegaard J, Kristensen JK, Kornum JB, Hansen MP. Danish GPs' and practice nurses' management of acute sore throat and adherence to guidelines. Fam Pract 2019; 36:192-198. [PMID: 29924311 DOI: 10.1093/fampra/cmy059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Sore throat is a frequent presentation of acute respiratory tract infections in general practice. Though these infections are often harmless and self-limiting, antibiotics are frequently prescribed. In Denmark, practice nurses manage an increasing part of patients with acute minor illnesses. OBJECTIVES We aimed (i) to investigate Danish practice nurses' and GPs' management of patients presenting with a sore throat and (ii) to explore to what extent management is according to current Danish guidelines. METHODS A cross-sectional study was conducted during winter 2017, involving GPs and practice nurses in Danish general practices. Patients with a sore throat were registered according to the Audit Project Odense method. RESULTS A total of 44 practices participated with the registration of 1503 patients presenting with a sore throat. Most patients had a strep A test performed, especially when managed by a practice nurse (84.6% versus 61.8%, χ2 = 90.1, P < 0.05). In total, 40.6% of performed strep A tests were not according to guideline recommendations. Antibiotics were prescribed for about one-third of patients, regardless whether managed by a practice nurse or a GP (χ2 = 0.33, P = 0.57). However, 32.4% of these prescriptions were not in line with Danish guidelines. CONCLUSION Patients with acute sore throat were managed similarly by GPs and practice nurses, apart from a higher use of strep A tests in patients seen by practice nurses. Importantly, this study demonstrated that there is still room for improvement of the management of these patients in Danish general practice.
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Affiliation(s)
- Janni Katharina Stuhr
- Research Unit for General Practice, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jesper Lykkegaard
- Audit Project Odense, Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jette Kolding Kristensen
- Research Unit for General Practice, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Malene Plejdrup Hansen
- Research Unit for General Practice, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Suda KJ, Roberts RM, Hunkler RJ, Taylor TH. Antibiotic prescriptions in the community by type of provider in the United States, 2005-2010. J Am Pharm Assoc (2003) 2016; 56:621-626.e1. [PMID: 27745794 DOI: 10.1016/j.japh.2016.08.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 06/28/2016] [Accepted: 08/22/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Although antibiotic prescriptions are decreasing in the United States, broad-spectrum prescribing is increasing. It is unknown if decreases observed in national antibiotic prescribing differ by provider group. Understanding prescribing trends over time by provider group can be helpful for customizing antimicrobial stewardship efforts. Therefore, the purposes of this study were to describe outpatient antibiotic prescribing by provider group overall and adjusted for population and number of providers. In addition, trends in prescribing by class and seasonal variation are described by provider group over 6 years. DESIGN Cross-sectional observation of outpatient antibiotic prescriptions. SETTING AND PARTICIPANTS A population-level analysis of U.S. prescribing from 2005 to 2010 with the use of the IMS Health Xponent dataset. MAIN OUTCOME MEASURES Number and rates of prescriptions dispensed overall and by provider group. RESULTS The majority (81.0%) of antibiotics were prescribed by physicians, followed by dentists (10.4%), nurse practitioners (NPs; 4.5%), and physician assistants (PAs; 4.2%). The percentage of antibiotic prescriptions decreased for physicians, but increased significantly for NPs and PAs. Provider-based and population-based prescribing rates decreased for physicians and dentists and increased for NPs and PAs. Penicillins were prescribed most frequently by all provider groups, decreasing for physicians and dentists. Increased prescribing of broad-spectrum agents was observed for NPs and PAs. With the exception of dentists, antibiotic prescriptions were higher in winter than in summer, with the largest seasonal increase by NPs. CONCLUSION Over 6 years, antibiotic prescriptions overall and for broad-spectrum agents decreased for physicians and increased for NPs and PAs. Thus, increasing trends in the US of broad-spectrum antibiotic prescriptions can be attributed to midlevel providers. Interventions should be designed to reverse increasing prescribing trends, especially of broad-spectrum agents prescribed by NPs and PAs. Stewardship efforts should also be targeted towards dentists, since this group prescribes a higher proportion of antibiotics compared with midlevel providers.
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Cohen JF, Bertille N, Cohen R, Chalumeau M. Rapid antigen detection test for group A streptococcus in children with pharyngitis. Cochrane Database Syst Rev 2016; 7:CD010502. [PMID: 27374000 PMCID: PMC6457926 DOI: 10.1002/14651858.cd010502.pub2] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Group A streptococcus (GAS) accounts for 20% to 40% of cases of pharyngitis in children; the remaining cases are caused by viruses. Compared with throat culture, rapid antigen detection tests (RADTs) offer diagnosis at the point of care (within five to 10 minutes). OBJECTIVES To determine the diagnostic accuracy of RADTs for diagnosing GAS in children with pharyngitis. To assess the relative diagnostic accuracy of the two major types of RADTs (enzyme immunoassays (EIA) and optical immunoassays (OIA)) by indirect and direct comparison. SEARCH METHODS We searched CENTRAL, MEDLINE, EMBASE, Web of Science, CDSR, DARE, MEDION and TRIP (January 1980 to July 2015). We also conducted related citations tracking via PubMed, handsearched reference lists of included studies and relevant review articles, and screened all articles citing included studies via Google Scholar. SELECTION CRITERIA We included studies that compared RADT for GAS pharyngitis with throat culture on a blood agar plate in a microbiology laboratory in children seen in ambulatory care. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for relevance, assessed full texts for inclusion, and carried out data extraction and quality assessment using the QUADAS-2 tool. We used bivariate meta-analysis to estimate summary sensitivity and specificity, and to investigate heterogeneity across studies. We compared the accuracy of EIA and OIA tests using indirect and direct evidence. MAIN RESULTS We included 98 unique studies in the review (116 test evaluations; 101,121 participants). The overall methodological quality of included studies was poor, mainly because many studies were at high risk of bias regarding patient selection and the reference standard used (in 73% and 43% of test evaluations, respectively). In studies in which all participants underwent both RADT and throat culture (105 test evaluations; 58,244 participants; median prevalence of participants with GAS was 29.5%), RADT had a summary sensitivity of 85.6%; 95% confidence interval (CI) 83.3 to 87.6 and a summary specificity of 95.4%; 95% CI 94.5 to 96.2. There was substantial heterogeneity in sensitivity across studies; specificity was more stable. There was no evidence of a trade-off between sensitivity and specificity. Heterogeneity in accuracy was not explained by study-level characteristics such as whether an enrichment broth was used before plating, mean age and clinical severity of participants, and GAS prevalence. The sensitivity of EIA and OIA tests was comparable (summary sensitivity 85.4% versus 86.2%). Sensitivity analyses showed that summary estimates of sensitivity and specificity were stable in low risk of bias studies. AUTHORS' CONCLUSIONS In a population of 1000 children with a GAS prevalence of 30%, 43 patients with GAS will be missed. Whether or not RADT can be used as a stand-alone test to rule out GAS will depend mainly on the epidemiological context. The sensitivity of EIA and OIA tests seems comparable. RADT specificity is sufficiently high to ensure against unnecessary use of antibiotics. Based on these results, we would expect that amongst 100 children with strep throat, 86 would be correctly detected with the rapid test while 14 would be missed and not receive antibiotic treatment.
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Affiliation(s)
- Jérémie F Cohen
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS), Inserm UMR1153, Paris Descartes UniversityObstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)ParisFrance
- Necker Hospital, AP‐HP and Paris Descartes UniversityDepartment of PediatricsParisFrance
| | - Nathalie Bertille
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS), Inserm UMR1153, Paris Descartes UniversityObstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)ParisFrance
| | - Robert Cohen
- Association Clinique et Thérapeutique Infantile du Val‐de‐Marne (ACTIV)27 Rue InkermannSaint‐Maur‐des‐FossésFrance
- Centre Hospitalier Intercommunal de Créteil (CHIC)Department of Microbiology40 avenue de VerdunCréteilFrance94010
| | - Martin Chalumeau
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS), Inserm UMR1153, Paris Descartes UniversityObstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)ParisFrance
- Necker Hospital, AP‐HP and Paris Descartes UniversityDepartment of PediatricsParisFrance
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Smith KL, Tran D, Westra BL. Sinusitis Treatment Guideline Adherence in the E-Visit Setting: A Performance Improvement Project. Appl Clin Inform 2016; 7:299-307. [PMID: 27437042 DOI: 10.4338/aci-2015-10-cr-0143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 02/15/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Studies demonstrate poor guideline adherence by health care providers for the treatment of upper respiratory infections, particularly acute bacterial rhinosinusitis (ABRS), in the appropriate prescribing of antibiotic medications. OBJECTIVE The purpose of this quality improvement project was to evaluate the effect of implementing interventions for improving adherence to a clinical practice guideline for the management of ABRS for patients treated in the e-visit setting. Interventions included: providing a report to providers of their adherence to the ABRS clinical guideline prior to the intervention, providing updated education on the ABRS guideline, and implementing a clinical decision support system reminder. METHODS A pre and post intervention evaluation design was used. Data were obtained from a retrospective electronic health record (EHR) data extract of all 316 diagnoses for ABRS in the pre-intervention 2-month time period and all 368 diagnoses of ABRS in the post-intervention 2-month time period. A review of the structured clinical data elements was performed to determine whether the provider adhered to the clinical guideline, meaning that only patients meeting the criteria for ABRS were to receive an antibiotic prescription. RESULTS AND CONCLUSION The interventions resulted in a 3.3% improvement in adherence to the ABRS clinical guideline from 95.25% adherence pre-intervention to 98.4% post-intervention. These results demonstrated that the use of an educational intervention and clinical decision support resulted in improved adherence to the ABRS clinical guideline in the e-visit setting. The implications for practice could be significant in that these quality improvement interventions improve guideline adherence and reduce unnecessary prescribing of antibiotics.
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Affiliation(s)
| | - Dang Tran
- Fairview Health System , Minneapolis, Minnesota, United States
| | - Bonnie L Westra
- University of Minnesota, School of Nursing , Minneapolis, Minnesota, United States
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Laughlin JJ, Simon GR, Baker C, Barden GA, Brown OW, Hardin A, Lessin HR, Meade K, Moore S, Rodgers CT. AAP principles concerning retail-based clinics. Pediatrics 2014; 133:e794-7. [PMID: 24567015 DOI: 10.1542/peds.2013-4080] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The American Academy of Pediatrics views retail-based clinics (RBCs) as an inappropriate source of primary care for pediatric patients, as they fragment medical care and are detrimental to the medical home concept of longitudinal and coordinated care. This statement updates the original 2006 American Academy of Pediatrics statement on RBCs, which flatly opposed these sites as appropriate for pediatric care, discussing the shift in RBC focus and comparing attributes of RBCs with those of the pediatric medical home.
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Fine AM, Nizet V, Mandl KD. Participatory medicine: A home score for streptococcal pharyngitis enabled by real-time biosurveillance: a cohort study. Ann Intern Med 2013; 159:577-83. [PMID: 24189592 PMCID: PMC3953456 DOI: 10.7326/0003-4819-159-9-201311050-00003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Consensus guidelines recommend against testing or treating adults at low risk for group A streptococcal (GAS) pharyngitis. OBJECTIVE To help patients decide when to visit a clinician for the evaluation of sore throat. DESIGN Retrospective cohort study. SETTING A national chain of retail health clinics. PATIENTS 71 776 patients aged 15 years or older with pharyngitis who visited a clinic from September 2006 to December 2008. MEASUREMENTS The authors created a score using information from patient-reported clinical variables plus the incidence of local disease and compared it with the Centor score and other traditional scores that require clinician-elicited signs. RESULTS If patients aged 15 years or older with sore throat did not visit a clinician when the new score estimated the likelihood of GAS pharyngitis to be less than 10% instead of having clinicians manage their symptoms following guidelines that use the Centor score, 230 000 visits would be avoided in the United States each year and 8500 patients with GAS pharyngitis who would have received antibiotics would not be treated with them. LIMITATION Real-time information about the local incidence of GAS pharyngitis, which is necessary to calculate the new score, is not currently available. CONCLUSION A patient-driven approach to pharyngitis diagnosis that uses this new score could save hundreds of thousands of visits annually by identifying patients at home who are unlikely to require testing or treatment. PRIMARY FUNDING SOURCE Centers for Disease Control and Prevention and the National Library of Medicine, National Institutes of Health.
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Michel-Lepage A, Ventelou B, Verger P, Pulcini C. Factors associated with the use of rapid antigen diagnostic tests in children presenting with acute pharyngitis among French general practitioners. Eur J Clin Microbiol Infect Dis 2013; 33:723-8. [PMID: 24173821 DOI: 10.1007/s10096-013-2003-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 10/16/2013] [Indexed: 11/26/2022]
Abstract
In this investigation, we wanted: (i) to describe the attitudes and declared practices of a representative sample of French general practitioners (GPs) regarding rapid antigen diagnostic tests (RADTs) for acute pharyngitis and (ii) to identify the GPs' characteristics associated with the use of an RADT in the last paediatric patient with pharyngitis. We performed a cross-sectional survey conducted in 2012 among a representative sample of 1,126 self-employed GPs in France. 60.1 % of GPs declared that they used an RADT in their last patient aged between 3 and 16 years presenting with acute pharyngitis; 29.6 % of these tests were positive. Among the GPs who did not use an RADT, 50.2 % prescribed an antibiotic, compared to 30.5 % of prescriptions among GPs who performed an RADT, whatever its result. In a multivariate analysis, GPs' age between 45 and 54 years and having attended Continuing Medical Education (CME) sessions on infectious diseases in the past year were significantly associated with an increased use of an RADT in the last patient with pharyngitis, whereas a low volume of activity, occasionally practising alternative medicine, receiving pharmaceutical representatives at the practice and declaring a consultation duration <15 min were factors associated with a decreased use of RADTs. The use of RADTs by GPs must be promoted; our findings could help define interventions to improve practice.
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Affiliation(s)
- A Michel-Lepage
- Aix Marseille Université (Aix Marseille School of Economics-SESSTIM UMR 912, Inserm IRD), Marseille, France
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11
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Garbutt JM, Mandrell KM, Allen M, Sterkel R, Epstein J, Kreusser K, O’Neil J, Sayre B, Sitrin H, Stahl K, Strunk RC. Parents' experiences with pediatric care at retail clinics. JAMA Pediatr 2013; 167:845-50. [PMID: 23877236 PMCID: PMC4019395 DOI: 10.1001/jamapediatrics.2013.352] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Little is known about the use of retail clinics (RCs) for pediatric care. OBJECTIVE To describe the rationale and experiences of families with a pediatrician who also use RCs for pediatric care. DESIGN AND SETTING Cross-sectional study with 19 pediatric practices in a Midwestern practice-based research network. PARTICIPANTS Parents attending the pediatrician’s office. MAIN OUTCOMES AND MEASURES Parents’ experience with RC care for their children. RESULTS In total, 1484 parents (91.9% response rate) completed the self-administered paper survey. Parents (23.2%) who used the RC for pediatric care were more likely to report RC care for themselves (odds ratio, 7.79; 95% CI, 5.13-11.84), have more than 1 child (2.16; 1.55-3.02), and be older (1.05; 1.03-1.08). Seventy-four percent first considered going to the pediatrician but reported choosing the RC because the RC had more convenient hours (36.6%), no office appointment was available (25.2%), they did not want to bother the pediatrician after hours (15.4%), or they thought the problem was not serious enough (13.0%). Forty-seven percent of RC visits occurred between 8 am and 4 pm on weekdays or 8 am and noon on the weekend. Most commonly, visits were reportedly for acute upper respiratory tract illnesses (sore throat, 34.3%; ear infection, 26.2%; and colds or flu, 19.2%) and for physicals (13.1%). While 7.3% recalled the RC indicating it would inform the pediatrician of the visit, only 41.8% informed the pediatrician themselves. CONCLUSIONS AND RELEVANCE Parents with established relationships with a pediatrician most often took their children to RCs for care because access was convenient. Almost half the visits occurred when the pediatricians’ offices were likely open.
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Affiliation(s)
- Jane M. Garbutt
- Department of Pediatrics, Washington University St Louis, St. Louis, MO,Department of Medicine, Washington University St Louis, St. Louis, MO
| | - Kathy M. Mandrell
- Department of Pediatrics, Washington University St Louis, St. Louis, MO
| | - Melissa Allen
- Department of Pediatrics, Washington University St Louis, St. Louis, MO
| | - Randall Sterkel
- Department of Pediatrics, Washington University St Louis, St. Louis, MO,St. Louis Children’s Hospital, St. Louis, MO
| | - Jay Epstein
- Department of Pediatrics, Washington University St Louis, St. Louis, MO
| | | | - Jerome O’Neil
- Department of Pediatrics, Washington University St Louis, St. Louis, MO
| | - Blaine Sayre
- Department of Pediatrics, Washington University St Louis, St. Louis, MO
| | - Harold Sitrin
- Department of Pediatrics, Washington University St Louis, St. Louis, MO
| | - Kristin Stahl
- Department of Pediatrics, Washington University St Louis, St. Louis, MO
| | - Robert C. Strunk
- Department of Pediatrics, Washington University St Louis, St. Louis, MO
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Pollack CE, Gidengil C, Mehrotra A. The growth of retail clinics and the medical home: two trends in concert or in conflict? Health Aff (Millwood) 2013; 29:998-1003. [PMID: 20439897 DOI: 10.1377/hlthaff.2010.0089] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There has been growing interest in the patient-centered medical home as a way to provide coordinated, high-quality primary care. At the same time, the number of retail clinics has increased dramatically. Many are concerned that retail clinics undermine the medical home by fragmenting care. In this article we explore the juxtaposition of these trends, highlighting shared characteristics and sources of tension. We describe three types of relationships between retail clinics and primary care providers. We argue that for some relationships there is no conflict, and we describe areas of potential concern for others.
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Affiliation(s)
- Craig E Pollack
- George Washington University School of Medicine, Washington, DC, USA.
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13
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Fine AM, Nizet V, Mandl KD. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. ACTA ACUST UNITED AC 2012; 172:847-52. [PMID: 22566485 DOI: 10.1001/archinternmed.2012.950] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The Centor and McIsaac scores guide testing and treatment for group A streptococcal (GAS) pharyngitis in patients presenting with a sore throat, but they were derived on relatively small samples. We perform a national-scale validation of the prediction models on a large, geographically diverse population. METHODS We analyzed data collected from 206,870 patients 3 years or older who presented with a painful throat to a United States national retail health chain from September 1, 2006, to December 1, 2008. Main outcome measures were the proportions of patients testing positive for GAS pharyngitis according to the Centor and McIsaac scores (both scales, 0-4). RESULTS For patients 15 years or older, 23% (95% CI, 22%-23%) tested positive for GAS, including 7% (95% CI, 7%-8%) of those with a Centor score of 0; 12% (95% CI, 11%-12%) of those with a Centor score of 1; 21% (95% CI, 21%-22%) of those with a Centor score of 2; 38% (95% CI, 38%-39%) of those with a Centor score of 3; and 57% (95% CI, 56%-58%) of those with a Centor score of 4. For patients 3 years or older, 27% (95% CI, 27%-27%) tested positive for GAS, including 8% (95% CI, 8%-9%) of those testing positive with aMcIsaac score of 0; 14% (95% CI, 13%-14%) of those with a McIsaac score of 1; 23% (95% CI, 23%-23%) of those with a McIsaac score of 2; 37% (95% CI, 37%-37%) of those with a McIsaac score of 3; and 55% (95% CI, 55%-56%) of those with a McIsaac score of 4. The 95% CIs overlapped between our retail health chain–derived probabilities and the prior reports. CONCLUSION Our study validates the Centor and McIsaac scores and more precisely classifies risk of GAS infection among patients presenting with a painful throat to a retail health chain.
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Affiliation(s)
- Andrew M Fine
- Department of Medicine, Division of Emergency Medicine, Children's Hospital Boston, Massachusetts, USA.
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Abstract
Pharyngitis is a common clinical complaint for children and accounts for 3.1% of all visits to selected ambulatory care settings. Most children with pharyngitis have benign, self-limited disease with infrequent complications such as peritonsillar abscess, mastoiditis, or lymphadenitis. Recent studies have touted the benefits of steroids in the treatment of children with pharyngitis for pain control. These studies do not address the potential life-threatening complication of steroids in patients with pharyngitis or lymphadenopathy in the setting of undiagnosed acute lymphocytic leukemia (ALL) or lymphoma. We report 4 cases of children treated with steroids for pharyngitis or adenitis that subsequently were diagnosed with ALL or lymphoma. If steroids are to be used in children with pharyngitis or adenitis, the following recommendations should be strongly considered: Careful history and physical examination should be obtained. Presence of hepatosplenomegaly or lymphadenopathy outside the cervical region should raise suspicions regarding an underlying malignancy. Normal results of complete blood cell count in the setting of clear cut pharyngitis with exudates and a lack of significant adenopathy essentially rules out the diagnosis of ALL. Because traditional analgesics are available, which do not affect the curability of ALL or lymphoma, the routine use of steroids in pharyngitis in children should be considered only in rare circumstances.
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Pulcini C, Pauvif L, Paraponaris A, Verger P, Ventelou B. Perceptions and attitudes of French general practitioners towards rapid antigen diagnostic tests in acute pharyngitis using a randomized case vignette study. J Antimicrob Chemother 2012; 67:1540-6. [PMID: 22398648 DOI: 10.1093/jac/dks073] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVES This study had three objectives: (i) to assess the use of rapid antigen diagnostic tests (RADTs) and their impact on the antibiotic prescribing behaviour of general practitioners (GPs) for acute pharyngitis; (ii) to study the barriers to the use of RADTs; and (iii) to identify GPs' characteristics associated with non-compliance with French guidelines. METHODS We conducted a cross-sectional survey of a representative sample of 369 self-employed GPs in south-eastern France using a randomized case vignette study. RESULTS The availability of an RADT allowed a 44% relative reduction in the rate of antibiotic prescriptions. Of GPs for whom the test was available, 34% did not use an RADT in our acute pharyngitis vignette and 13% of those who used the test prescribed an antibiotic despite a negative RADT result. Non-compliance with French guidelines (i.e. not using an RADT and/or prescribing an antibiotic despite a negative RADT result) was independently associated with the following factors: less reading of medical journals, less benefits/risks discussion with patients about vaccinations and higher perception that clinical examination was sufficient to prescribe antibiotics. The three main declared barriers to RADT use were: time to perform the test, patient expectations regarding antibiotics and the perception that clinical examination was sufficient to decide to prescribe an antibiotic. CONCLUSIONS RADTs are a useful but not sufficient tool to reduce antibiotic prescribing in general practice. The results of this study increase understanding of the factors underlying clinical decision making for acute pharyngitis and may contribute to the development of interventions to improve practice.
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Affiliation(s)
- Céline Pulcini
- Centre Hospitalier Universitaire de Nice, Service d'Infectiologie, Nice, France.
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Fine AM, Nizet V, Mandl KD. Improved diagnostic accuracy of group A streptococcal pharyngitis with use of real-time biosurveillance. Ann Intern Med 2011; 155:345-52. [PMID: 21930851 PMCID: PMC3651845 DOI: 10.7326/0003-4819-155-6-201109200-00002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Clinical prediction rules do not incorporate real-time incidence data to adjust estimates of disease risk in symptomatic patients. OBJECTIVE To measure the value of integrating local incidence data into a clinical decision rule for diagnosing group A streptococcal (GAS) pharyngitis in patients aged 15 years or older. DESIGN Retrospective analysis of clinical and biosurveillance predictors of GAS pharyngitis. SETTING Large U.S.-based retail health chain. PATIENTS 82 062 patient visits for pharyngitis. MEASUREMENTS Accuracy of the Centor score was compared with that of a biosurveillance-responsive score, which was essentially an adjusted Centor score based on real-time GAS pharyngitis information from the 14 days before a patient's visit: the recent local proportion positive (RLPP). RESULTS Increased RLPP correlated with the likelihood of GAS pharyngitis (r(2) = 0.79; P < 0.001). Local incidence data enhanced diagnostic models. For example, when the RLPP was greater than 0.30, managing patients with Centor scores of 1 as if the scores were 2 would identify 62, 537 previously missed patients annually while misclassifying 18, 446 patients without GAS pharyngitis. Decreasing the score of patients with Centor values of 3 by 1 point for an RLPP less than 0.20 would spare unnecessary antibiotics for 166, 616 patients while missing 18, 812 true-positive cases. LIMITATIONS Analyses were conducted retrospectively. Real-time regional data on GAS pharyngitis are generally not yet available to clinicians. CONCLUSION Incorporating live biosurveillance data into clinical guidelines for GAS pharyngitis and other communicable diseases should be considered for reducing missed cases when the contemporaneous incidence is elevated and for sparing unnecessary antibiotics when the contemporaneous incidence is low. Delivering epidemiologic data to the point of care will enable the use of real-time pretest probabilities in medical decision making.
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Affiliation(s)
- Andrew M. Fine
- Division of Emergency Medicine, Department of Medicine, Children’s Hospital Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston MA
| | - Victor Nizet
- Department of Pediatrics and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California
| | - Kenneth D. Mandl
- Division of Emergency Medicine, Department of Medicine, Children’s Hospital Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston MA
- Children’s Hospital Informatics Program, Harvard-MIT Health Sciences and Technology, Boston, MA
- Center for Biomedical Informatics, Harvard Medical School, Boston, MA
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Burns LR, David G, Helmchen LA. Strategic Response by Providers to Specialty Hospitals, Ambulatory Surgery Centers, and Retail Clinics. Popul Health Manag 2011; 14:69-77. [DOI: 10.1089/pop.2010.0021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lawton R. Burns
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Guy David
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lorens A. Helmchen
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois
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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) 2011; 27:1272-82. [PMID: 18780911 DOI: 10.1377/hlthaff.27.5.1272] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this study we compared the demographics of and reasons for visits in national samples of visits to retail clinics, primary care physicians (PCPs), and emergency departments (EDs). We found that retail clinics appear to be serving a patient population that is underserved by PCPs. Ten clinical problems such as sinusitis and immunizations encompass more than 90 percent of retail clinic visits. These same ten clinical problems make up 13 percent of adult PCP visits, 30 percent of pediatric PCP visits, and 12 percent of ED visits. Whether there will be a future shift of care from EDs or PCPs to retail clinics is unknown.
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Ahmed A, Fincham JE. Patients’ view of retail clinics as a source of primary care: Boon for nurse practitioners? ACTA ACUST UNITED AC 2011; 23:193-9. [DOI: 10.1111/j.1745-7599.2010.00577.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Jacoby R, Crawford AG, Chaudhari P, Goldfarb NI. Quality of care for 2 common pediatric conditions treated by convenient care providers. Am J Med Qual 2010; 26:53-8. [PMID: 20861514 DOI: 10.1177/1062860610375106] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rates of adherence to 2 quality measures, modeled after Heathcare Effectiveness Data and Information Set (HEDIS) measures, were evaluated in a pediatric population in a convenient care (retail medicine) clinic setting. The measures were appropriate testing for children with pharyngitis and appropriate treatment for children with upper-respiratory infection (URI). The convenient care clinic (CCC) achieved a ranking above the HEDIS 90th percentile for the pharyngitis measure and approximately midway between the 50th and 90th percentiles for the URI measure for the 2007 reporting period. This represents the third major study reporting quality of care for pharyngitis in a CCC setting and the first study for URIs. Other aspects of quality--namely access, follow-up, and equity--are also reported on for the population in question.
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Affiliation(s)
- Richard Jacoby
- Jefferson School of Population Health, Philadelphia, PA 19107, USA.
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Ahmed A, Fincham JE. Physician office vs retail clinic: patient preferences in care seeking for minor illnesses. Ann Fam Med 2010; 8:117-23. [PMID: 20212298 PMCID: PMC2834718 DOI: 10.1370/afm.1052] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Revised: 06/02/2009] [Accepted: 07/27/2009] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Retail clinics are a relatively new phenomenon in the United States, offering cheaper and convenient alternatives to physician offices for minor illness and wellness care. The objective of this study was to investigate the effects of cost of care and appointment wait time on care-seeking decisions at retail clinics or physician offices. METHODS As part of a statewide random-digit-dial survey of households, adult residents of Georgia were interviewed to conduct a discrete choice experiment with 2 levels each of 4 attributes: price ($59; $75), appointment wait time (same day; 1 day or longer), care setting-clinician combination (nurse practitioner in retail clinic; physician in private office), and acute illness (urinary tract infection [UTI]; influenza). The respondents indicated whether they would seek care under each of the 16 resulting choice scenarios. A cooperation rate of 33.1% yielded 493 completed telephone interviews. RESULTS The respondents preferred to seek care for both conditions; were less likely to seek care for UTI (beta = -0.149; P = .008); preferred to seek care from a physician (beta = 1.067; P < .001) and receive same day care (beta = -2.789; P < .001). All else equal, cost savings of $31.42 would be required for them to seek care at a retail clinic and $82.12 to wait 1 day or more. CONCLUSIONS Time and cost savings offered by retail clinics are attractive to patients, and they are likely to seek care there given sufficient cost savings. Appointment wait time is the most important factor in care-seeking decisions and should be considered carefully in setting appointment policies in primary care practices.
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Affiliation(s)
- Arif Ahmed
- Henry W. Bloch School of Business and Public Administration, University of Missouri-Kansas City, Kansas City, Missouri 64110, USA.
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Hansen–Turton T, Ridgway C, Ryan SF, Nash DB. Convenient Care Clinics: The Future of Accessible Health Care—The Formation Years 2006–2008. Popul Health Manag 2009; 12:231-40. [DOI: 10.1089/pop.2009.0041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Caroline Ridgway
- Public Health Management Corporation, Philadelphia, Pennsylvania
| | | | - David B. Nash
- Jefferson School of Population Health, Philadelphia, Pennsylvania
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Rudavsky R, Pollack CE, Mehrotra A. The geographic distribution, ownership, prices, and scope of practice at retail clinics. Ann Intern Med 2009; 151:315-20. [PMID: 19721019 PMCID: PMC2746672 DOI: 10.7326/0003-4819-151-5-200909010-00005] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Retail clinics are clinics within a retail store that provide simple acute and preventive care services for a fixed price without an appointment. OBJECTIVE To describe characteristics of retail clinics, including their location, scope of practice, prices, acceptance of insurance, and ownership, and to estimate the proportion of the U.S. population that lives within a short driving distance of such a clinic. DESIGN Cross-sectional descriptive study. SETTING United States. PARTICIPANTS All 982 retail clinics operating as of August 2008. MEASUREMENTS Population living within a 5- and 10-minute driving distance of a retail clinic. RESULTS In August 2008, 42 operators ran 982 clinics in 33 states; 88.4% were located in urban areas. Nearly half (44%) of all clinics were located in 5 states (Florida, California, Texas, Minnesota, and Illinois). All offered sore throat treatment (average price, $78) and more than 95% offered treatment of skin conditions, immunizations, pregnancy testing, and lipid or diabetes screening. Almost all (97%) accepted private insurance and Medicare fee-for-service (93%). Among 42 clinic operators, 25 are existing health care companies that operate 11% of the clinics, and 3 are for-profit retail chains that operate 73% of the clinics. An estimated 10.6% of the total U.S. and 13.4% of the urban U.S. population lives within a 5-minute driving distance of a retail clinic, whereas 28.7% (total) and 35.8% (urban) live within a 10-minute driving distance. LIMITATION Our inventory of clinics stopped in August 2008 and estimates of proximity are based on 2000 census data. CONCLUSION Retail clinics are positioned to provide immunizations and care for simple acute conditions for a substantial segment of the urban U.S. population. PRIMARY FUNDING SOURCE California Healthcare Foundation.
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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; 151:321-8. [PMID: 19721020 PMCID: PMC2805258 DOI: 10.7326/0003-4819-151-5-200909010-00006] [Citation(s) in RCA: 176] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Retail clinics are an increasingly popular source for medical care. Concerns have been raised about the effect of these clinics on the cost, quality, and delivery of preventive care. OBJECTIVE To compare the care received at retail clinics for 3 acute conditions with that received at other care settings. DESIGN Claims data from 2005 and 2006 from the health plan were aggregated into care episodes (units that included initial and follow-up visits, pharmaceuticals, and ancillary tests). After 2100 episodes (700 each) were identified in which otitis media, pharyngitis, and urinary tract infection (UTI) were treated first in retail clinics, these episodes were matched with other episodes in which these illnesses were treated first in physician offices, urgent care centers, or emergency departments. SETTING Enrollees of a large Minnesota health plan. PATIENTS Enrollees who received care for otitis media, pharyngitis, or UTI. MEASUREMENTS Costs per episode, performance on 14 quality indicators, and receipt of 7 preventive care services at the initial appointment or subsequent 3 months. RESULTS Overall costs of care for episodes initiated at retail clinics were substantially lower than those of matched episodes initiated at physician offices, urgent care centers, and emergency departments ($110 vs. $166, $156, and $570, respectively; P < 0.001 for each comparison). Prescription costs were similar in retail clinics, physician offices, and urgent care centers ($21, $21, and $22), as were aggregate quality scores (63.6%, 61.0%, and 62.6%) and patient's receipt of preventive care (14.5%, 14.2%, and 13.7%) (P > 0.05 vs. retail clinics). In emergency departments, average prescription costs were higher and aggregate quality scores were significantly lower than in other settings. LIMITATIONS A limited number of quality measures and preventive care services were studied. Despite matching, patients at different care sites might differ in their severity of illness. CONCLUSION Retail clinics provide less costly treatment than physician offices or urgent care centers for 3 common illnesses, with no apparent adverse effect on quality of care or delivery of preventive care. PRIMARY FUNDING SOURCE California HealthCare Foundation.
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Laws M, Scott MK. The Emergence Of Retail-Based Clinics In The United States: Early Observations. Health Aff (Millwood) 2008; 27:1293-8. [PMID: 18780913 DOI: 10.1377/hlthaff.27.5.1293] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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