Early Return Visits by Primary Care Patients: A Retail Nurse Practitioner Clinic Versus Standard Medical Office Care

Introduction

R etail walk-in clinics staffed by nurse practitioners and physician assistants are becoming increasingly popular because they are more convenient and less expensive than scheduled appointments for low-acuity visits in the traditional medical practice. As these clinics have been established, some studies have reported about their effects on cost, quality, and access. However, relatively few studies have addressed this topic given the substantial growth in this care modality.

Walk-in care centers were first developed in the United States in the early 1970s as free-standing emergency care centers in an effort to offer a lower-cost alternative to emergency department visits. ^{1 –3} At least 1 study reported that patients in rural areas tend to use walk-in clinics as a supplement to, rather than a substitute for, having a regular physician. ⁴ The quality of medical care provided in walk-in clinics appears to be good. ⁵ Walk-in clinics are superior to emergency department visits when clinically appropriate because emergency department visits are more likely to result in return visits. ⁶

The advantages of walk-in care centers include greater convenience, ^7,8 good technical quality, ⁹ and lower cost than emergency department and routine office visits. Because of their superior accessibility, primary care walk-in clinics may be able to reduce disparities in access to medical care. ¹⁰ However, this last point (ie, that walk-in clinics improve access) has been disputed. ^11,12

Nontraditional care visits may increase the cost of medical care if they increase the risk of an early return visit to an emergency department or medical office. When the evidence was examined more than 10 years ago, Jones was able to report no evidence to support this concern. ¹ Subsequent studies explored the impact of walk-in primary care clinics on emergency department use or “reconsultations” by primary care physicians and reached similar conclusions. ^8,13,14 This issue warrants further investigation.

The purpose of the current study is to test the hypothesis that patients seen in standard medical offices are less likely to return within 2 weeks than patients who visit retail medicine clinics. Retail clinics, by definition of their menu of services, have a limited range of diagnoses. Therefore, in order to assure a fair comparison, this study focused on a single medical condition in adults—acute sinusitis—thus allowing a comparison of 2 groups with consistent patient complaints. If the theory is correct, then the operating procedures in retail clinic visits may require some adjustments to avoid increases in total medical care utilization. However, if no difference in the return visit rate is found between standard office care patients and retail medicine patients, then retail care may serve as a viable substitute for a low-acuity office visit.

Methods

Cases were limited to adult patients seen for sinusitis (International Classification of Diseases, Ninth Revision 461.x). The 2 cohorts were (1) patients seen in one of 2 retail medicine walk-in clinics in 2009, and (2) patients seen in one of 4 traditional, same-day medical office clinics during the same time period. The first listed visit for each patient was used as the index visit and the patient was the unit of analysis.

Results

Of the 1705 cases studied, 581 were seen in the retail medicine clinics and 1124 visited the same-day acute clinics. Office visits within 2 weeks were common, with 15.3% of retail medicine patients and 19.4% of standard clinic patients (P=0.04) returning for an early visit (for any reason).

Descriptive statistics are shown in Table 1. The typical patient was female, but the mix of sexes was different between clinic types (p=0.01), as was the age mix of patients. The percentage of patients who were married did not differ between clinic types. Patients seen in the retail medicine clinics tended to be lower utilizers of clinic visits in the previous 6 months.

Multiple logistic regression analysis (Table 2) was employed to investigate the possibility that case mix differences explained the significant difference in return visits within 2 weeks. Age, sex, and marital status were not significant after adjusting for the number of visits in the previous 6 months. Patients with more outpatient visits in the previous 6 months had higher odds of return visits within 2 weeks (2–6 prior visits: odds ratio [OR]=1.99, P=0.00; 6 or more prior visits: OR=6.80, P=0.00). The odds of a return visit within 2 weeks were not different by clinic type after adjusting for propensity to use services (OR=1.17, P=0.28).

Discussion

Patient demand for convenient, affordable care has driven the establishment of retail primary care clinics throughout the United States and in other countries. Young people, especially, may place a high value on speed for all types of services, including medical care. The body of systematic evidence supporting retail care models has been growing slowly. In a Canadian study of walk-in clinics, Campbell et al ⁶ measured re-utilization with 2 variables: follow-up visits within 3 days, and follow-up visits in 3 days to 2 weeks. Return of pediatric patients ^16,17 and adult patients ^{18 –20} to emergency departments has been studied. The cost differences between retail clinics and other forms of care have been examined. ²¹ The impact of retail clinics on early return visits among pediatric patients was reported in 2008. ¹⁵ A 2009 study used 2 different comparison groups to “triangulate” the assessment of return primary care visits by adults. ²² This previous study was an evaluation of a new retail medicine clinic in the same medical care system assessed by the current study. However, the previous study was not limited to a single condition and did not analyze a full year of data from a mature clinic. Revisit rates were not shown to be higher in retail medicine than in standard care in any of the previously reported studies.

Practice innovations, such as retail primary care clinics, should be evaluated early and periodically. Methods for conducting evaluative studies using quasi-experimental designs and retrospective data are within the reach of most medical providers. ^{23 –25} The importance of conducting such studies shortly after start-up should be clear. However, we note that the findings of this study support our previous findings as described in the previous paragraph. The current study benefited from a larger archive of completed visits that allowed focus on a single condition and a longer time window.

There are clear differences between the patients who seek care in retail clinics and those who visit standard medical offices for common conditions. Patients who seek care in standard medical offices are older and have a higher propensity to utilize medical services. These differences account for the higher percentage of 2-week return visits among standard medical office patients. After adjusting for these underlying differences, there is no difference in the rate of 2-week return visits between retail clinics and standard medical clinics. Because no difference between groups is found, it follows that retail care may serve as a viable substitute for a low-acuity office visit, especially when comparing adult patients with a similar diagnosis (in this instance, acute sinusitis).

Consequently, we can say with greater confidence that retail clinics have return visit rates that are comparable to standard office care. Several studies of nurse practitioners working in primary care indicate that the quality of care usually is comparable and patient satisfaction may be higher. ^9,26 We acknowledge that follow-up visits are sometimes desirable, especially for chronic medical conditions. For chronic illness care, the follow-up visit is deemed more cost-effective than allowing the patient to deteriorate clinically and utilize more costly resources such as the emergency department or hospitalization. However, follow-up visits for patients with low-acuity illness may not be cost-effective. In this study, focusing on 1 low-acuity illness—sinusitis—allowed us to determine if the retail care model generated more follow-up utilization than standard office care.

Additional research is needed to verify that the findings reported here apply to other common conditions and to pediatric age groups. Our findings may not be generalizable to other medical care systems. Also, the reasons behind the differences between retail clinic patients and standard medical clinic patients warrant further study. We intend to repeat our studies periodically so as to monitor the performance of this relatively new care modality.

Conclusion

The results of this retrospective analysis of electronic medical records suggest that our retail primary care clinics do not increase the risk of early return visits, disconfirming our hypothesis. This effect is masked when making unadjusted comparisons because the patients seen in standard care tend to be older and have a higher propensity to use medical care. Our findings suggest that if those patients had been equally distributed across care modalities, the return visit rate in retail clinics would have been comparable to that found in standard clinics.

Our findings, along with the general thrust of this line of research, suggest that retail clinics should be encouraged. We note, however, that our retail clinics are managed within the same large group practice as the standard care clinics, thus facilitating information sharing and coordination to assure continuity of care. We suspect that comparisons between our retail clinic model and more independent retail clinics might be instructive. Additional research is needed before definitive recommendations can be made regarding the optimal structure of retail medicine. However, organizations that provide medical care can be encouraged to experiment with different structures and to carefully evaluate the impact on quality and efficiency.