RAND: Shifting some patients, imaging out of ED could save $4.4B
About 17 percent of all visits to hospital emergency departments (EDs) across the U.S. could be treated at retail medical clinics or urgent care centers, potentially saving $4.4 billion annually in healthcare costs, according to a RAND Corporation study published in the September edition of Health Affairs.

Americans who use emergency departments for nonemergency care often face long waits and incur higher treatment charges than in other settings. “These higher charges may increase patients’ out-of-pocket spending and create added strain on national healthcare spending,” wrote Robin M. Weinick, senior social scientist at Arlington, Va.-based RAND, and colleagues.

Weinick and colleagues compared patient demographics, medical conditions treated and prescribed medications at retail clinics, urgent care centers and EDs to determine “the extent to which urgent care centers or retail clinics could substitute for EDs in providing nonemergent care.”

The researchers compiled data from 1.2 million visits to retail clinics through the summer of 2008, a random sample of 1,263 visits to urgent-care centers in 35 states between July 1, 2007 and Dec. 31, 2007 and 31,197 of the emergency department visits reported in the 2006 National Hospital Ambulatory Medical Care Survey (NHAMCS). They used ICD-9 codes to compare diagnoses and defined categories for drugs prescribed using the Multum classification system.

Weinick and colleagues determined the number of emergency visits that could be accommodated in the alternate settings by identifying conditions commonly treated in each setting and calculating conditions that accounted for more than 2 percent of all visits to each site. They applied an algorithm developed by John Billings and colleagues to determine the percentage of ED visits for a given diagnosis that could be managed at an alternate site.

The researchers reported that the most common conditions treated at retails clinics were: upper respiratory infections (60.6 percent), preventive care or exams (21.6 percent), minor conditions (9.5 percent) and urinary tract infections (3.7 percent).

The most common condition treated at urgent care centers were: upper respiratory infections (33.3 percent), musculoskeletal conditions (21.5 percent) and dermatological conditions (9.7 percent). The most common prescriptions at urgent care centers were antibiotics (41.5 percent) and pain medications (14 percent), the researchers reported.

“The majority of visits for these common conditions could be managed outside the ED,” wrote Weinick and colleagues.

After considering hours of operation and estimating the percentage of trauma-related conditions that could be managed at urgent care clinics, the research team concluded that 16.8 percent of emergency department visits could be treated in alternative settings. The shift translates into a potential savings of $4.4 billion annually, or 0.2 percent of healthcare spending.

The research team noted several imitations of its study, including:
  • The retail clinic and urgent care center data originated from a limited provider set;
  • No data addressed the percentage of trauma-related conditions that could be shifted from EDs to other settings;
  • Distance to alternate settings may deter some patients; and
  • Savings assume eligible patients would find alternate sites accessible, affordable and willing to provide care; retail clinics and urgent-care centers have sufficient capacity to meet demand and the study fully calculated all conditions treatable in alternate settings.

Other issues that need to be considered include patients’ ability to appropriately self-triage, a lack of research demonstrating comparable care across the three settings, the unknown impact of policy levers to encourage the use of alternate sites and limits to savings, noted Weinick.

“A continued increase in the number of emergency department visits for nonemergency causes is likely to be unsustainable,” according to Weinick, who cited “a continuing need for alternative sites for the provision of nonemergency care … retail clinics and urgent care centers could be reasonable, cost-saving alternatives for a sizable share of acute, nonemergency conditions.”