Choosing Between Urgent Care Center, In-Store Clinic, and ER

 

When you're sick with no doc -- or face too long a wait -- determining where to go isn't always clear

Feeling sick -- or you have a kid who does -- but you find out that your doctor's office cannot fit you in for another week?

Primary-care physicians are not the only game in town.

In fact, depending on where you live, you may have several places to turn, including an urgent care clinic and an in-store "retail clinic" set up in a grocery store or pharmacy along with the local hospital emergency department.

The inevitable question then becomes: Which level of care should you seek -- and for what ailments?

Here's the rub: Based on conversations with an emergency department doctor, a primary-care physician who runs and co-owns an urgent care clinic, and a nurse practitioner who cares for patients at clinics inside pharmacies, it turns out there are no black-and-white answers. You can do your own triage, however, and potentially avoid hours in a waiting room.

Consider these points:

Severity.

You've undoubtedly heard the message on a physician's voice mail: "If this is an emergency, call 911, or go to the nearest emergency room." But how you define emergency might be entirely different from how a clinician working the ER does. Research has found that 82 percent of patients who were deemed "nonurgent" by triage nurses disagreed and thought their case was, in fact, urgent. That's not to deter you from getting care at the local emergency department, however. According to the Centers for Disease Control and Prevention, only 12 percent of patients who come to the emergency department could safely wait between two and 24 hours to be seen (suggesting that they didn't actually need the high level of service given in an ER and could possibly have gone elsewhere for treatment).

A general guideline:

Crushing chest pain, severe bleeding, trouble breathing, or signs of stroke should have you calling 911 immediately, says Angela F. Gardner, president-elect of the American College of Emergency Physicians and associate professor of emergency medicine at the University of Texas Southwestern in Dallas.

Otherwise, "if you're having serious symptoms and you think you need hospitalization or surgery, go to the emergency department," she says; for example, an intense pain, which could indicate appendicitis or a kidney stone. And if you don't believe it's life threatening, the primary-care physician is always the first call you should make, says Gardner. That is, if you have one. Some 20 percent of Americans don't have a "medical home" to address primary-care needs like headaches, colds, or high blood sugar, says the American Academy of Family Physicians.

Services provided.

The emergency department can handle everything, but the wait time and cost can be factors, depending on the patient's complaint. In-store clinics, like Minute Clinics, which have a partnership with CVS pharmacies, offer a specific menu of services that would typically be addressed in the office of a primary-care physician. Care is typically given by nurse practitioners who can write prescriptions. Each service has an out-of-pocket cost, though insurance companies may cover care received (a copay is usually required). Minute Clinic's website, for example, lists treatable ailments under several categories--from minor illness including coughs, body aches, and itchy eyes ($62) to wellness and prevention services ($20 to $66) like college and camp physicals and screening for hypertension and diabetes. And the menu of services is growing as such in-store clinics expand. Take Care Clinic, affiliated with Walgreens stores, for example, recently announced it will offer nebulizer treatments, which involve patients breathing medication from a small machine to treat respiratory distress, like an asthma attack.

Urgent care clinics, on the other hand, are staffed by doctors trained in primary care or emergency medicine, often along with nurses. Patients can pay out of pocket, but insurance regularly covers a visit (with a copay). But services offered can really differ by clinic, says Lou Ellen Horwitz, executive director of the Urgent Care Association of America; some may have the ability to perform blood work, a chest X-ray, an EKG of the electrical pulses of a patient's heart, or even a CAT scan, while others don't. Patients would be wise to call ahead to be sure their concern can be handled. The menu of offerings at urgent care centers, too, may be influenced by the type of clinicians who staff them. Those run by doctors trained in emergency medicine might cater more to one-time issues, like a cut or ankle sprain, while those run by doctors trained in family medicine might serve as a regular source of primary care--offering well-baby exams, pap smears, and prescriptions for chronic conditions, like high cholesterol or hypertension. "I have patients I've seen 50 times," explains Phillip Disraeli, who co-owns Metro Urgent Care in Frisco, Texas, and is director of clinical programs for the Urgent Care Association of America.

Quality.

Since the first in-store clinics began to show up in 2000, concern has arisen among physicians (as well as the American Medical Association and the American Academy of Pediatrics) over the quality of care a person could expect to get at these centers, which are staffed by nurse practitioners. The hope, says Gardener, is that if you go to an in-store clinic you have a clinician astute enough to recognize when something that appears to be simple is actually more serious. "How do patients really know how sick they are?" asks Disraeli. Getting a comprehensive assessment, he argues, may depend on where they seek care. Disraeli and Gardner both note that years of training and the technology make identifying the rare though serious anomaly more likely, say, when a headache is really an indicator of high blood pressure or a urinary tract infection is actually pelvic inflammatory disease. Of course, doctors are not beyond reproach and misdiagnose patients, too. Disraeli's urgent care clinic has relationships with specialists in the community as well as hospitals. If a person goes to an in-store clinic, he says, he'd want the clinic to have a safety net for patients, including relationships with a nearby urgent care clinic, primary-care physicians, and hospitals.

But research published in an August issue of the Annals of Internal Medicine suggests that for three common ailments--earache, sore throat, and urinary tract infection--patients get care as good as that delivered by physicians in other settings. "We are acutely aware of what's safe in our setting and what's not," explains Anne Pohnert, a nurse practitioner at Minute Clinics in Northern Virginia. She points out that many of the basic tests available in ERs and urgent care clinics--urinalysis, rapid strep throat testing, rapid flu testing--are also offered in the in-store clinic setting.

It's not just about training. Pohnert notes that Minute Clinic's use of an electronic medical system for each patient visit has prompts, for example, that alert her to a potentially bad drug interaction if she prescribes, say, Zithromax (an antibiotic) to someone who also takes Lipitor. The combination can damage muscle tissue. Having the system is an advantage that not even every doctor's office has, she says. Each Minute Clinic, she explains, has a list of local primary-care physicians taking new patients as well as nearby urgent care centers and hospitals for patient referrals. According to data from Take Care Clinics, which are found inside Walgreens stores, clinicians refer patients on to a higher level of care about 10 percent of the time (90 percent of which is to a primary-care physician and 1.5 percent of which is to an ER).

Timing.

You'll need to check hours of operation. Both urgent care centers and in-store clinics have extended hours beyond those of a typical doctor's office--often before or after work during the week plus hours on the weekends. The emergency department, of course, never closes and is federally mandated to take all comers, regardless of their ability to pay. A little-known truth about the ER, says Gardner, is that it's busiest not on weekend nights when drunk revelers start getting in accidents (though that's a hectic time, too). "The busiest day is Monday afternoon," she says. The reasons: People couldn't get in to their doctors because the wait was too long, say a week or more, or they got injured over the weekend and waited. "What isn't obvious is that [Monday] is the busiest operating room day in the hospital, and lots of beds are reserved for people coming out of the ORs or doctors' clinics," she explains. So folks who come in through the emergency department and need to be admitted must often wait in the ER.

Cost.

If bargain shopping is a motivation in your decision-making process, it seems in-store clinics may have the best deals. In the Annals of Internal Medicine study, the total cost per episode was found to vary by location: with a visit to a retail (or in-store) clinic averaging $110, a visit to a physician's office averaging $166, a visit to an urgent care clinic averaging $156, and a visit to an emergency department averaging $570.

 

 

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