A checkup for retail medicine

Comparison of UK’s Minor Ailments Scheme and US’s retail clinic model: a narrative review

There is a raising demand for unscheduled care in the United Kingdom. Minor Ailments Schemes (MAS) were introduced to reduce the burden of minor ailments on higher cost settings such as general practices and emergency departments. The number of visits for minor ailments at GPs often declined following the implementation of MAS. Retail clinics in America employ nurse practitioners (NPs) and physician assistants (PAs) who can diagnose and treat minor illness, and minor injuries. Similar to the retail clinics, MAS can merge with walk-in centres. PAs and NPs can take over some primary care workload from pharmacists to prevent the pharmacists from being overwhelmed with all their current duties. MAS can also initiate the development of telehealth service to accommodate the home-bound patients. MAS must continue to change and evolve to meet the current and future demands of health care.

Participatory medicine: A home score for streptococcal pharyngitis enabled by real-time biosurveillance: a cohort study

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.

Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis

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.

Improved diagnostic accuracy of group A streptococcal pharyngitis with use of real-time biosurveillance

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.

Comércio internacional de serviços e complexo industrial da saúde: implicações para os sistemas nacionais de saúde

Os serviços de saúde evidenciam um padrão de inovação - na forma de expansão para mercados públicos e do comércio internacional - que os credencia a assumir um papel preponderante no complexo industrial da saúde. O comércio internacional e suas bases regulatórias, definidas no General Agreement on Trade in Services (GATS), têm o potencial de gerar desenvolvimento econômico, mas também de reordenar os recursos disponíveis para a saúde em âmbito nacional e global, em direções favoráveis ou não. Onde houver uma combinação de prestadores públicos e privados atuando na saúde pública, como no caso brasileiro, os termos do GATS admitem a interpretação de que a prestação pública recai no âmbito do GATS, criando-se restrições às opções políticas dos países para a saúde. São necessárias informações sistematizadas e específicas para cada país sobre serviços eletrônicos, movimento de pacientes e profissionais, e investimento direto estrangeiro em serviços de saúde para compor evidências que permitam decisões mais informadas sobre adesão ao GATS.

The geographic distribution, ownership, prices, and scope of practice at retail clinics

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.