Urgent care centers and retail clinics top the list when it comes to the inappropriate use of antibiotics, according to a new study in JAMA Internal Medicine. The overuse of antibiotics for self-limiting viral infections is imposing a hefty price on society, including but not limited to the rise of antibiotic resistance and the escalating cost from the negative chain reactions the practice creates. When business models drive medical systems, low value care ensues.
The concern is compounded by the tremendous growth in urgent cares and retail clinics. These facilities are now contributing to 40% of outpatient antibiotic prescriptions and due to their surge that number is rising. When compared to traditional hospital-based emergency departments and medical offices, researchers found:
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Antibiotic prescriptions were linked to 39.0% of 2.7 million urgent care center visits, 36.4% of 58, 206 retail clinic visits, 13.8% of 4.8 million ED visits, and 7.1% of 148.5 million medical office visits.
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Visits for antibiotic-inappropriate respiratory diagnoses accounted for 17% of retail clinic visits, 16% of urgent care center visits, 6% of medical office visits, and 5% of ED visits.
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For antibiotic-inappropriate respiratory diagnoses, antibiotic prescribing was highest in urgent care centers (45.7%), then EDs (24.6%), medical offices (17.0%), and retail clinics (14.4%).
Antibiotics treat bacterial infections, not viral ones (eg. the common cold or flu). The danger of their continued use for conditions outside of their therapeutic capacity (eg. asthma, viral pneumonia, viral upper respiratory or ear infections) is the increased threat of antibiotic resistance - as well as allergy risk. These infections are quite smart and develop ways to combat our treatments, unnecessarily exposing them contributes to this problem. Reforming provider overprescribing and educating the public about the hazards of misuse of antibiotics have been targets of many public health campaigns.
Shifting public perception not to pressure a provider for a prescription and to educate about the harms of misuse is a constant challenge. This is such an issue it prompted JAMA Internal Medicine to launch a Patient Page section, free-of-charge, intended to “to distill high-quality evidence and make it more accessible for patient education and help guide patient decisions.” The first installment advises on this topic:
“...a large portion of visits to urgent care and retail clinics are for self-limited upper respiratory infections (URIs). People who attended in-person visits at these locations for URI symptoms often receive low-value care in the form of unnecessary antibiotics. Why would this finding prompt us to create our inaugural Patient Page, when there are ample existing resources on the natural history of URIs? In this instance, while the biology of the common cold has not changed, the health care landscape has--the rapid proliferation of urgent care centers and retail clinics has lowered the bar for access for an in-person visit for common cold symptoms…” Such visits “are more likely to result in unnecessary care, such as antibiotics for a viral infection, in which case antibiotics are more likely to cause harm than good.”
The journal tripled down on the subject by including an accompanying editorial to the research findings that touched on reasons why these centers spur low-value care:
“The urgent care sector is growing at an astronomical rate, representing a $15 billion industry with more than 10 000 high-volume clinics nationwide. This rapid proliferation is fueled by the convenience of same-day access, proximity, and lower out-of-pocket costs than a visit to the emergency department; however, lowering barriers for an office visit to such a degree may prompt frequent visits for mild self-resolving illnesses that would be better treated with rest and symptom management at home. Indeed, the authors found that a shocking percentage (54%) of visits to these sites were for upper respiratory tract conditions. Antibiotic prescriptions for this group were 2 to 3 times higher at urgent care centers than at other outpatient sites.”
The author touches upon the lack of continuity of care these markets promote as a contributing factor. It is known, through innumerable studies (and a sprinkling of common sense), that continuity of care improves outcomes and ultimately costs. Staffing is another consideration given the use of “mid-level providers” or “advanced practitioners” (eg nurse practitioners, physician assistants) in these facilities and the rise in their ability to prescribe independent of a supervising physician along with clinicians treating patients outside of their expertise and the scope of their training (eg. non-pediatrician treating a child).
According to physician search and consulting firm Merritt Hawkins' 2015 research on "Convenient Care: Growth and Staffing Trends in Urgent Care and Retail Medicine"
"The urgent care staffing model also includes the regular use of advanced practitioners, including nurse practitioners and physician assistants. According to VMG Research, 59% of urgent care clinics use either nurse practitioners or physician assistants. In retail medicine, nurse practitioners and physician assistants provide the great majority of care."
In medicine, doing things the right way from the outset prevents a whole trajectory of negative outcomes - no matter the clinical environment. Convenience and business models are routinely out of line with this concept, often creating perverse incentives. Whether it is about antibiotic resistance or another subject, the highest quality of care requires consistency and continuity. Informing the public on this as well as the risks of overprescribing antibiotics is essential to ensuring truly patient-centered medical care.
