Retail Health Clinics Research Articles

Women Accessing Care at a National Network of Retail Health Clinics.

Background: Retail health clinics offer easy access and lower costs in seeking nonemergent and usually focused care. The objective of this observational study was to describe the use of retail clinic services by women at MinuteClinic at CVS, the largest network of retail clinics in the United States. Methods: The retail clinic's large database included complete national data for every in-person encounter as recorded on the same electronic health record. Virtual care and pharmacist-delivered services like COVID-19 testing were excluded from the analysis. The primary reason for the visit and the patient's age group (<15, 15-44, 45-64, ≥65 years) and self-reported sex were recorded at each encounter from the most recent 5 years (January 1, 2018, to December 31, 2022). Results: There were 17,969,483 encounters by women seeking care, and women ≥15 years old were more likely than men to attend the clinics. Half of all encounters (50.6%) were for non-gynecologic acute care, whereas one-third (33.6%) dealt with either an infection or the need for a vaccination. Gynecologic reasons involved 5.6% of all encounters in women ≥15 years of age. No obstetrical care was provided except for pregnancy testing with referral, acute non-obstetric needs, or guideline-recommended vaccinations. Conclusion: Women, especially of reproductive age, are more inclined than men to seek care at retail clinics. Acute care is the most common need, although requests for immunizations, infection screening and treatment, and reproductive health issues occurred often.

Retail Health Clinic Growth as a Potential Primary Care Disruptor.

Retail health clinics (RHCs) have been described as a disruptive model of care delivery. We describe RHC market presence in the United States from 2008 to 2016 with a focus on the characteristics of counties where new clinics open. We merge national data on RHC openings and closings from Merchant Medicine with the Area Health Resources File. We examined county-level counts and ownership of RHCs over time. From 2008 to 2016, we found increasing ownership of RHCs by retail pharmacies, and, contrary to earlier predictions, RHCs continue to be located in affluent counties and did not open in underserved or provider shortage areas. Most new clinics opened in counties where RHCs already had a presence, and these counties also had greater primary care physician, nurse practitioner, and physician assistant density per capita (100,000). As RHCs expand and offer more services, they may place new competitive pressures on nearby primary care providers and practices.

Retrospective Analysis of a Nationwide Telelactation Program

BackgroundTelelactation is a modality for delivering remote clinical lactation care using telecommunications technology. Sonder Health, in partnership with Amwell, began offering synchronous video telelactation services to health plans and employer groups in 2016.MethodsWe completed a retrospective data analysis on a randomized selection of 1,087 telelactation visits covered by a health plan or employee-sponsored health plan conducted between 2016–2019. Our aim is to describe a telelactation model and review selected visits for technical modalities utilized, clinical workflow, top self-reported chief conditions, patient satisfaction, visit duration, acuity levels, alternative care options, peak visit time, visits conducted during or after business hours, and days visits took place, and discuss the potential for telelactation to bridge the gaps in timely access to IBCLC-level breastfeeding support.ResultsUsing a 5-star rating system, 95% of patients gave a 5-star rating; 52% of visits occurred outside normal business hours. Top three conditions identified: latching (31%), supply (24%), and nipple/breast pain (15%). Without access to the service, 59% reported they would have accessed an urgent care, emergency department, retail health clinic, or other office appointment; 41% reported they would have sought care “nowhere.”ConclusionsThis telelactation program provided access to skilled, comprehensive clinical lactation care and documents a strong use case for telelactation services.

Retail health clinics: What is their role in ObGyn care?

Retail health clinics: What is their role in ObGyn care?

1345. Impact of the COVID-19 Pandemic on Pediatric Ambulatory Antibiotic Use in an Academic Health System

BackgroundIt is unclear how the COVID-19 pandemic has impacted outpatient pediatric antibiotic prescribing.MethodsWe compared diagnoses and antibiotic prescription rates for children pre- vs post-COVID-19 in 5 ambulatory settings affiliated with Vanderbilt University Medical Center: emergency department (ED), urgent care clinics (including pediatric-only after-hours clinics [AHC]s and walk-in clinics [WIC] for all ages), primary care clinics (PCC), and retail health clinics (RHC). Time periods were pre-COVID-19 3/1/19 – 5/15/19 (P1); and post-COVID-19 3/1/20 – 5/15/20 (P2). Diagnoses and percent of encounters with an antibiotic prescription were analyzed by encounter (in-person vs telemedicine [TMed]), clinic and provider type. We also interviewed 16 providers about perceived COVID-19 impact on pediatric ambulatory antibiotic prescribing. Student’s T and χ 2 tests were used as appropriate.ResultsThe number of pediatric ambulatory visits was 16671 in P1 and 7010 in P2. There were no TMed visits in P1 vs 188 in P2 (2.7% of total P2 visits); 186 (99% of TMed visits) were in PCC (Table). In all settings, the number of encounters was lower in P2 vs P1 (p< 0.001). The percent of encounters with an antibiotic prescription was lower in P2 (32%) than in P1 (38.2%) (p< 0.001) (Table) overall and in all settings except RHCs. Only 14 (7.4%) TMed visits resulted in an antibiotic prescription. There were no differences in antibiotic prescribing rates by provider type. Diagnoses varied significantly between periods in all clinic types except the ED, with noninfectious diagnoses being higher in P2 vs P1 (Figure 1). Providers felt that COVID-19 led to fewer but sicker patients presenting for care, and variable impact on antibiotic prescribing (Figure 2).Table. Percent of Encounters with an Antibiotic by Clinic Type, Pre- and Post-COVID-19 Figure 1. Diagnosis Rates by Clinic Type, Pre- and Post-COVID-19 Figure 2. Themes from Provider Interviews about perceived Impact of COVID-19 on Clinician Practice ConclusionThe proportion of encounters with non-infectious diagnoses increased and antibiotic prescribing rates decreased significantly in all pediatric ambulatory settings post-COVID-19 except RHCs. Almost all TMed encounters occurred in the primary care setting, and few resulted in an antibiotic prescription. Providers felt they saw fewer patients and higher acuity of illness post COVID-19.DisclosuresHillary Spencer, MD, MPH, NIH (T32 grant support) (Grant/Research Support)

1334. A Qualitative Assessment of Drivers of Antimicrobial Prescribing for Pediatric Patients in Diverse Ambulatory Settings

BackgroundAntimicrobial prescribing rates vary across ambulatory settings and provider types. We sought to identify and compare non-clinical drivers of antimicrobial prescribing for children across diverse outpatient settings.MethodsWe recruited physicians and advanced practice providers (APPs) working in primary care, urgent care (walk-in and pediatric after-hours clinics), and retail health clinics affiliated with Vanderbilt University Medical Center (Table 1). We conducted in-person or telephone interviews using an interview guide created through an iterative process of literature review and sequential pilot testing with residents and administrators from included settings. All interviews were recorded and transcribed verbatim. Analysis is ongoing using inductive methods. The study was IRB approved with a waiver of consent.Table 1:Characteristics of interviewed providersResultsAmong the 38 providers interviewed to date, 22 (58%) were APPs. Twenty-eight (74%) interviews were conducted by telephone. In a closed-ended question, most providers (82%) identified “guideline recommended” as the primary factor informing their prescribing decisions. Providers perceived that guideline concordant care was determined by a complex interaction of patient, provider, and setting factors (Figure). A major theme identified by providers was that standardized antibiotic prescribing practices within each clinic setting and the larger community was perceived to inform parental expectations. Additionally, shaping parental expectations in a way that aligns with guidelines is a process that happens over time rather than being a one-time event. (Figure, Table 2)FigureDiagram of relationship between major categories and select themesTable 2:Select themes and sample quotesConclusionIn all outpatient settings, providers caring for children cited clinical guidelines as the most important factor influencing antibiotic prescribing. Providers felt that adherence to guidelines had downstream benefits including standardization of prescribing practices which may shape parental expectations in a way that aligns with guidelines, thus facilitating guideline-concordant care in future encounters. These findings can inform design of outpatient stewardship interventions. Additional provider recruitment and analysis by provider and setting type is ongoing.DisclosuresHillary Spencer, MD, MPH, NIH (T32 grant support) (Grant/Research Support)

Sexually Transmitted Infection Risk Assessments in Retail Health Clinics

Sexually transmitted infections (STIs) remain a costly, yet preventable public health problem in the United States. A complete sexual history and risk assessment should be included in each clinical encounter, when appropriate. This research aimed to increase the providers’ confidence level with sexual history taking and assessing for high-risk sexual behaviors using an STI risk assessment tool. Risk assessment tool training increased nurse practitioners’ confidence in screening patients at risk for STIs. Nurse practitioners in retail health clinics have the opportunity to address this preventable public health crisis by focusing on STI risk factors.

Antibiotic Stewardship for Treatment of Acute Bronchitis in Retail Health

The objective of this evidence-based project was to determine if a best practice alert (BPA) will decrease the number of oral antibiotic prescriptions for adults with acute bronchitis. The BPA is an electronic prompt that describes the guidelines for the treatment of acute bronchitis. The study sample included prescribing clinicians (N = 41) at 11 retail health clinics that are associated with 1 larger health care organization. A quantitative quasi-experimental pre-/post-study design was used. The chi-square test was used to compare antibiotic prescribing rates. Antibiotic prescribing rates decreased by 40%. The use of a targeted BPA significantly decreased antibiotic prescriptions for acute bronchitis.

Organizational Powers: Contested Innovation and Loss of Professional Jurisdiction in the Case of Retail Medicine

Innovative technology may reduce organizations’ reliance on professionals in the performance of expert tasks, weakening professions’ control over work. However, professions resist and challenge such innovation, framing it as unsafe and immoral. This paper theorizes a process by which innovative nonprofessional firms overcome the resistance, enter professionalized markets, and weaken professional control over work. It analyzes the rise of a new organizational form—retail health clinics—that deprofessionalized some medical tasks in U.S. primary healthcare. An analysis of newspaper articles, archival documents, and interviews with key industry participants suggests that retail clinic chains capitalized on long-standing jurisdictional tensions between the physician and nursing professions. The clinics operated by relying on nurses’ legal rights to perform physicians’ tasks and defended retail medicine as a safe and morally justified innovation by using the nursing profession’s established repertoire or frames and arguments. Sentiment analysis of over 1,600 newspaper articles suggests that the legitimacy of retail clinic chains in public discourse improved with the proliferation of the clinics, but the legitimacy of nurse practitioners did not. Nonprofessional firms thus introduced an innovation that weakened professional control over medical work by capitalizing on interprofessional tensions and repurposing professions’ own jurisdictional claims.

Organizational Powers: Capture of Professional Jurisdiction in the Case of U.S. Retail Clinics

Understanding inertia and change in professionalized organizational fields like health care is key to addressing inefficiencies like poor access to services, high costs, and inconsistent quality. New entrants are one source of change that may reduce the inefficiencies, but we lack a good understanding of how new entrant organizations overcome jurisdictional barriers of license and legitimacy that shelter professionalized fields. I analyze a case of emergence of retail health clinics in the U.S. primary care to theorize a strategy that allows external change agents to enter a professionalized field. Circumventing jurisdictional barriers and overcoming resistance of the incumbent profession requires jurisdictional work — cultural and market actions that effectively put forth a jurisdictional claim. Two aspects of jurisdictional work by retail clinics appear important: employing individual professionals as “front-men” who legitimize the new organizational form and finding allies among incumbent organizations that value efficiency. The problem of professional collective action allowed for the front-men strategy, in which organizations decoupled rights encoded in professional license and their use and thus turned license from a barrier into a vehicle for entry. The heterogeneity of logics and the competitive tensions among field incumbents allowed for the subsequent integration. The elaborated process model of entry generalizes the theory of professional jurisdictional competition by including organizations as actors in the division of expert labor.

Identifying Patients at Lowest Risk for Streptococcal Pharyngitis: A National Validation Study

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. Retrospective validation study using data from electronic health records of patients 3-21years 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. Overall, 54% of patients had features of viral illness. Among patients with features of viral illness, those without tonsillar exudates who were 11years 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. 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.

Lack of Diagnosis and Screening for Pediatric Obesity in the Retail Health Setting: Implications for Quality Improvement Measures.

Pediatric obesity has reached an epidemic status. The purpose of this study was to examine the prevalence of overweight and obesity in patients and how often and how accurately a diagnosis was coded. The population for this study included children aged 3-18 years. This cohort presented to retail health clinics in a large urban health system for school or sports physicals from June 1, 2017, to November 30, 2017. A retrospective chart review was conducted. Statistical analysis was performed to determine if there was a relationship between obesity and age, ethnicity, race, and sex. The study identified that 15.9% of patients were overweight and 16.5% were obese. In practice, 99% of patients lacked a formal diagnosis of overweight or obesity; in addition, appropriate screening measures reflecting nutrition and physical activity were found to be lacking in 99% of cases. Strategies are needed to improve efforts to diagnose and manage overweight and obesity in pediatric population in the retail health setting. Organizational recommendations for change are suggested based on guidelines for childhood obesity.

969. Antibiotic Prescribing in a Large Retail Health Clinic Chain: Opportunities for Stewardship

BackgroundRetail health is a growing outpatient setting. Research using claims data found that antibiotics were linked with 46% of urgent care, 17% of medical office, and 14% of retail health visits for acute respiratory infections (ARIs) for which antibiotics are not needed. We aimed to quantify antibiotic prescribing rates to adult patients in a large retail health clinic chain using electronic health records and to identify future stewardship targets.MethodsWe included visits by adults ≥18 years to network retail health clinics from 2012 to 2016. We classified diagnoses by ICD codes. We calculated the percent of visits with systemic antibiotics prescribed among all visits, by individual diagnosis, and for ARIs as a group (e.g., pneumonia, sinusitis, pharyngitis, acute otitis media [AOM], bronchitis, and viral upper respiratory infections [URI]). We also assessed the percent of visits for sinusitis and pharyngitis with first-line antibiotics prescribed.ResultsOf 2,893,413 visits by adults during 2012–2016, 1,866,145 (66%) resulted in antibiotic prescriptions. ARIs accounted for 2,039,423 (72%) of visits and 1,475,069 (79%) of antibiotic prescriptions. The most common diagnoses regardless of antibiotic prescription were sinusitis (31% of visits), pharyngitis (15%, of which 81% were coded as streptococcal pharyngitis), urinary tract infection (9%), viral URI (8%), AOM (7%), and bronchitis (5%). Antibiotics were frequently prescribed for sinusitis, urinary tract infection, pharyngitis, and AOM but not for viral URI and bronchitis (Figure 1). First-line antibiotics were prescribed in the majority of sinusitis and pharyngitis visits (Figure 2).ConclusionARIs are major drivers of visits by adult patients and of antibiotic prescribing to adults in this retail clinic network. Inappropriate antibiotic use was low in this setting for viral URI and bronchitis and first-line antibiotic selection was high for sinusitis and pharyngitis, although additional opportunities for improvement exist. Future antibiotic stewardship efforts may target examining adherence to guideline-recommended diagnostic criteria for sinusitis, AOM, and pharyngitis and increasing use of watchful waiting for sinusitis and AOM. Disclosures All Authors: No reported Disclosures.

The role of chain pharmacies to promote healthy food retail: Current trends, legal limits, and policy opportunities

Chain drug stores have increased their health care role through expanded pharmacy services and retail health clinics. They also are major food retailers. This creates a tension between health promotion and sales of unhealthy foods and beverages to pharmacy customers. This article explores opportunities to improve the nutritional quality of foods sold at chain drug stores that differ from general healthy food retail approaches. It considers the legal limits on marketing to pharmacy customers; the potential roles of health insurers, pharmacy benefit managers and retail health clinics to voluntarily improve food offerings; and formal policymaking legal considerations and approaches.

Variation in Outpatient Antibiotic Dispensing for Respiratory Infections in Children by Clinician Specialty and Treatment Setting.

Antibiotics are commonly prescribed for children with acute respiratory infections (ARIs). This study describes the distribution of ARI diagnoses and specifically quantifies antibiotic dispensing for bronchitis and upper respiratory infection (URI) by treatment setting and specialty. This retrospective, observational cross-sectional study used data from the HealthCore Integrated Research Environment containing claims from 14 commercial health plans for 2012 to 2014. Children (2-17 years) with first-episode ARI were identified by diagnosis of acute otitis media (AOM), sinusitis, pharyngitis, bronchitis or URI with no competing infections or chronic illnesses. Treatment setting was where diagnoses were made: primary care offices, urgent care centers (UCC), retail health clinics (RHCs) or emergency departments. Primary outcome measure was antibiotic prescription fills from pharmacies within 2 days of start of ARI episode. For URI, the highest proportions in antibiotic dispensing were ordered by office-based or UCC family physicians (28% and 30%, respectively) and office-based or UCC nurse practitioners/physician assistants (30% and 29%, respectively). Across all settings and specialties, there was high proportion of antibiotic dispensing for bronchitis (75%). Overall, 48% of 544,531 children diagnosed with ARI filled antibiotics. Nurse practitioners/physician assistants in RHC made the most diagnoses of AOM (24%) and streptococcal pharyngitis (22%). Outreach efforts to decrease antibiotic dispensing for URI can be focused on office-based and UCC family physicians and nurse practitioners/physician assistants. All specialties need widespread interventions to reduce antibiotic dispensing for bronchitis. RHC nurse practitioners/physician assistants can be targeted to reduce high proportion of AOM and streptococcal pharyngitis diagnoses.

Political, Institutional, and Economic Conditions for New Industry Emergence: Retail Clinics

What conditions predict new organizational entry and growth in an emergent industry? We investigate regulatory and economic market conditions associated with new entry and integration of retail health clinics–a radically new organizational form–into the organizational field of primary care in the U.S. While prior literature examines, separately, economic, institutional, and political predictors of new industry emergence, we use fuzzy set qualitative comparative analysis (fsQCA) to identify configurations of field conditions on the three dimensions simultaneously that are associated with clinics presence and growth. We find all three dimensions played a role in the initial growth of the new organizational form across U.S. states up to 2008, the industry’ subsequent growth from 2008 to 2013. Most important, we find that regulatory barriers of professional license, which research on professions and occupational licensure would predict to be a key hurdle for new entrants, did not matter for retail clinics proliferation, when political and economic was favorable for entry.

THE BENEFITS OF RETAIL HEALTH CLINICS FOR AGING POPULATIONS

Retail health clinics (RHC) offer a scope of services pertaining to minor acute conditions and preventive screenings. This emerging phenomenon advertises quick, convenient, and affordable care; therefore, the retail clinic industry has garnered considerable interest among stakeholders in the healthcare industry. This study presents a framework for understanding the RHC industry, its impact on the care continuum and emergency department (ED) overcrowding, and its value for elderly populations. A systematic literature review was conducted using the online databases ProQuest and PubMed. Articles (n = 38) were retrieved that examined varying facets of the RHC industry. Our study revealed that there is a rising affinity for RHC services among elderly populations. According to our findings, convenience and proximity to RHCs have been identified as leading factors of clinic use. Additionally, RHCs have received relatively high consumer satisfaction scores, and the quality of care in RHCs is comparable to alternative care settings. The use of RHCs is increasing among elderly individuals, and this care model has the potential to act as a safety net for aging populations through their transitions of care. Moreover, RHCs may prevent unnecessary ED overcrowding by providing timely care for minor health conditions at low costs. Our findings identify the importance of RHC use and its potential to increase access to care for elderly individuals at lower costs, without compromising quality. RHC use is particularly important among community dwelling elders, family care providers, and healthier aging individuals who are seeking preventive care or treatment for minor illnesses.

Virtual Visits for Acute, Nonurgent Care: A Claims Analysis of Episode-Level Utilization.

BackgroundExpansion of virtual health care—real-time video consultation with a physician via the Internet—will continue as use of mobile devices and patient demand for immediate, convenient access to care grow.ObjectiveThe objective of the study is to analyze the care provided and the cost of virtual visits over a 3-week episode compared with in-person visits to retail health clinics (RHC), urgent care centers (UCC), emergency departments (ED), or primary care physicians (PCP) for acute, nonurgent conditions.MethodsA cross-sectional, retrospective analysis of claims from a large commercial health insurer was performed to compare care and cost of patients receiving care via virtual visits for a condition of interest (sinusitis, upper respiratory infection, urinary tract infection, conjunctivitis, bronchitis, pharyngitis, influenza, cough, dermatitis, digestive symptom, or ear pain) matched to those receiving care for similar conditions in other settings. An episode was defined as the index visit plus 3 weeks following. Patients were children and adults younger than 65 years of age without serious chronic conditions. Visits were classified according to the setting where the visit occurred. Care provided was assessed by follow-up outpatient visits, ED visits, or hospitalizations; laboratory tests or imaging performed; and antibiotic use after the initial visit. Episode costs included the cost of the initial visit, subsequent medical care, and pharmacy.ResultsA total of 59,945 visits were included in the analysis (4635 virtual visits and 55,310 nonvirtual visits). Virtual visit episodes had similar follow-up outpatient visit rates (28.09%) as PCP (28.10%, P=.99) and RHC visits (28.59%, P=.51). During the episode, lab rates for virtual visits (12.56%) were lower than in-person locations (RHC: 36.79%, P<.001; UCC: 39.01%, P<.001; ED: 53.15%, P<.001; PCP: 37.40%, P<.001), and imaging rates for virtual visits (6.62%) were typically lower than in-person locations (RHC: 5.97%, P=.11; UCC: 8.77%, P<.001; ED: 43.06%, P<.001; PCP: 11.26%, P<.001). RHC, UCC, ED, and PCP were estimated to be $36, $153, $1735, and $162 more expensive than virtual visit episodes, respectively, including medical and pharmacy costs.ConclusionsVirtual care appears to be a low-cost alternative to care administered in other settings with lower testing rates. The similar follow-up rate suggests adequate clinical resolution and that patients are not using virtual visits as a first step before seeking in-person care.

Variation in Antibiotic Prescribing among Emergency Departments, Urgent Care Centers, and Retail Health Clinics in the United States, 2014

BackgroundAt least 30% of antibiotic courses prescribed in physician offices’ and emergency departments (EDs) are unnecessary, but little is known about other ambulatory settings. The study aimed to assess antibiotic prescribing for acute respiratory conditions across U.S. EDs, urgent care centers (UCs), and retail health clinics (RHs).MethodsWe included visits to EDs, UCs and RHs based on claims from individuals < 65 years old with medical and pharmacy benefits captured in the 2014 Truven MarketScan Commercial Claims and Encounters Database, a convenience sample of employer-based health insurance. Claims for dispensed systemic antibiotics were linked to the most recent ED, UC and RH visit within 3 days for oral antibiotics and on the same day for parenteral antibiotics. Diagnoses were assigned to each visit based on a previously-described tiered system to assign the most likely indication for antibiotics. Antibiotic-inappropriate respiratory conditions (i.e., viral respiratory infections, asthma, and allergy) were identified, and the percent of visits leading to antibiotics were calculated with 95% confidence intervals (CI) by setting.ResultsIn 2014, antibiotics were prescribed in 13.8% (95% CI 13.7–13.8) of 4,954,084 included ED visits, 38.8% (38.8–38.9) of 2,831,950 UC visits, and 36.3% (35.9–36.6) of 59,599 RH visits. Antibiotic-inappropriate respiratory conditions accounted for 5.4% of ED visits, 16.4% of UC visits, and 17.2% of RH visits. UCs had the highest percent of antibiotic prescriptions for all antibiotic-inappropriate respiratory conditions (45.3%, 95% CI 45.2–45.5), followed by EDs (24.5%, 24.3–24.6) and then RHs (14.4%, 13.8–15.1). This pattern persisted when examined by diagnosis (figure).ConclusionAntibiotic prescribing for antibiotic-inappropriate respiratory infections was common in these settings. UCs are a particularly important target for antibiotic stewardship.Figure.Percent of visits for antibiotic-inappropriate respiratory conditions leading to antibiotic prescriptions according to diagnosis by setting — United States, 2014.Disclosures All authors: No reported disclosures.

Navigating Primary Care

Navigating Primary Care