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The American Journal of Managed Care October 2014
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Quality of Care at Retail Clinics for 3 Common Conditions
William H. Shrank, MD, MSHS; Alexis A. Krumme, MS; Angela Y. Tong, MS; Claire M. Spettell, PhD; Olga S. Matlin, PhD; Andrew Sussman, MD; Troyen A. Brennan, MD, JD; and Niteesh K. Choudhry, MD, PhD
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Bruce E. Landon, MD, MBA; A. James O’Malley, PhD; M. Richard McKellar, BA; James D. Reschovsky, PhD; and Jack Hadley, PhD
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Delphine S. Tuot, MDCM, MAS; Justin L. Sewell, MD, MPH; Lukejohn Day, MD; Kiren Leeds, BA; and Alice Hm Chen, MD, MPH
Increasing Preventive Health Services via Tailored Health Communications
Kathleen T. Durant, PhD; Jack Newsom, ScD; Elizabeth Rubin, MPA; Jan Berger, MD, MJ; and Glenn Pomerantz, MD
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Meredith K. Shaw; Scott A. Davis, MA; Alan B. Fleischer, Jr, MD; and Steven R. Feldman, MD, PhD
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Harleen Singh, PharmD; Jessina C. McGregor, PhD; Sarah J. Nigro, PharmD; Amy Higginson, BS; and Greg C. Larsen, MD
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Eleftherios S. Xenos, MD, PhD; Jessica A. Lyden, BSc; Ryan L. Korosec, MBA, CPA; and Daniel L. Davenport, PhD
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Rebecca G. Mishuris, MD, MS; Jeffrey A. Linder, MD, MPH; David W. Bates, MD, MSc; and Asaf Bitton, MD, MPH
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Quality of Care at Retail Clinics for 3 Common Conditions

William H. Shrank, MD, MSHS; Alexis A. Krumme, MS; Angela Y. Tong, MS; Claire M. Spettell, PhD; Olga S. Matlin, PhD; Andrew Sussman, MD; Troyen A. Brennan, MD, JD; and Niteesh K. Choudhry, MD, PhD
Quality of care for 3 conditions, based on widely accepted objective measures, was superior in MinuteClinics compared with ambulatory care facilities or emergency departments.
Nearly 5% of income values were missing in the cohort prior to matching. After multiply imputing (N = 10) these values, results from the models adjusting for quality measure number were very similar ([OR 0.45; 95% CI, 0.42-0.48, comparing ACFs with MinuteClinics; OR 0.30; 95% CI, 0.29-0.32; comparing EDs with MinuteClinics]).

DISCUSSION

The results from this analysis suggest that overall quality of care for OM, pharyngitis, and UTI at MinuteClinics is superior to that delivered at ACFs or EDs13,14,24,25 based on widely accepted objective measures. Whereas ACFs and EDs performed better on several individual quality measures, overall performance at the index condition level and across all measures was consistently higher in MinuteClinics. These results did not differ after adjustment for baseline covariates.

This study is the largest to date evaluating the qualityof care for acute conditions at retail clinics compared with other care settings, and corroborates previous findings regarding quality of care.15 In particular, the success rates by quality measure and clinic type (Table 2) were similar to those of Mehrotra et al.15 However, Mehrotra et al did not observe statistically significant differences by site of care in regression analysis, which may in part be due to the fact that the sample from that prior analysis was less than 1/15 the size of ours. Moreover, we account for correlation within success rates by individuals who are eligible for more than 1 quality measure, as well as response trends within a quality measure (eg, 1 measure may have a higher success rate than another), providing more robust results. By matching on numerous demographic and clinical covariates, we also addressed concerns about residual confounding by baseline characteristics.

It is notable that MinuteClinics performed worse than other settings for UTI indicators that focused on high-risk patients and long-term antibiotic therapy to treat complicated UTIs (quality measures 12 and 14). MinuteClinic guidelines indicate that such patients should be referred to more acute settings; until 2014, MinuteClinics did not even offer urine cultures on the premises. The low prevalence of visits for these measures suggests that patients are selecting appropriate levels of care for this condition.

We did not include quality measure 11 in our multivariate analyses, consistent with the exclusion in the study conducted by Mehrotra et al. The indicator was not deemed clinically appropriate as designed, as it rewards antibiotic prescribing even in the absence of documented strep infection. In contrast, in the setting of an OM diagnosis, antibiotic treatment is clinically appropriate (measure 5).

The 3 conditions we examined, along with several upper respiratory conditions, swimmer’s ear, and pinkeye, comprise nearly 90% of all MinuteClinic acute care visits.16 When taken with evidence that retail clinics offer care at lower cost than other places of service and also lower the patient and payer’s total cost of care, the results of our study suggest that strategies for treatment of these conditions may be both economically advantageous and cost-effective.7,8

Our study did not examine MinuteClinic preventive care service visits, about half of which are for influenza vaccination.26 More research is needed to understand the quality of preventive care services offered at retail clinics as well as the integration of these services into a larger primary care medical home strategy. In particular, ACFs may provide better education or preventive services that reduce the rates of subsequent presentation.

Since 2010, retail clinics have begun to broaden their array of services, including care for chronic disease management. While early findings suggest that there is no detrimental effect of retail clinic care on preventive care and diabetes management,27,28 more research is needed to evaluate the quality of care in expanded domains and to examine the extent to which retail clinic care can be integrated into preventative care services offered in other settings.

Some research has shown that more affluent people have greater access to retail clinics,29 and that retail chain pharmacies tend to locate in wealthier neighborhoods. 30 Conversely, other studies have observed that retail clinics serve a large segment of people with weak or no ties to a primary care physician.31,32 In our analysis, members seen at MinuteClinics generally lived in more affluent areas than those seen at EDs and ACFs, but by matching on income we ensured that this potential confounder did not bias our results. Our analysis examined only MinuteClinic retail clinics, offered by a single pharmacy chain. While MinuteClinics represent more than half the nation’s retail clinics, the extent to which these findings can be generalized to other retail clinics is not known.

Performance measures are inherently limited in their ability to capture the full spectrum of clinically appropriate care. While the RAND QA Tools and other similar measure sets reflect the current standard of measurement for appropriate diagnosis, treatment, and follow-up for acute conditions,20,33 the use of any claims-based quality indicators is limited in its ability to fully account for illness severity and capture clinical reasoning that would justify diagnostic and treatment behavior outside clinical guidelines. Matching on Charlson Comorbidity Index score as well as other patient characteristics, such as age associated with illness severity, may account for many of the severity differences that exist across these care settings. If anything, we expect that patients with more severe illness would be more likely to receive guideline-adherent care, which would bias our results toward the null under the assumption that EDs and ACFs differentially treat patients with more severe illness. Additionally, the quality measures in this analysis focus on same-day care and so are not subject to any bias from follow-up care that may have been received differentially at another care setting. Mehrotra et al found that fewer than 20% of episodes in their analysis included any follow-up visits.15 Finally, to capture clinical reasoning that would justify treatment outside of these quality indicators, we would need data typically only available in electronic medical records, which were outside the scope of this analysis but may be an area of future research.

CONCLUSIONS

Overall, these findings are consistent with previous studies that demonstrate that quality of care is not compromised, and even appears superior, in retail clinics for specific acute conditions. When taken together with evidence suggesting that retail clinics are more cost-effective and even cost saving to patients, these results underscore the promise of retail clinics in offering care of higher quality and lower cost at a time of primary care shortages.7,8 In a healthcare system that sees 177 million ED and 577 million physician office visits annually, there is significant potential for retail clinics to play an increasingly important role in reducing the burden on our primary care channels.31 In light of a transforming healthcare system, more extensive studies exploring costs for chronic disease management and the role of retail clinics in improving care coordination and population health management are warranted.

Author Affiliations: CVS Caremark, Woonsocket, RI (WHS, OSM, AS, TAB); Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (AAK, AYT, NKC); Aetna Informatics, Blue Bell, PA (CMS).

Funding Source: This work was supported by a research grant from CVS Caremark to Brigham and Women’s Hospital.

Author Disclosure: Dr Shrank was on faculty at Brigham and Women’s Hospital when this work was completed. Drs Shrank, Matlin, Sussman, and Brennan are employees of CVS Caremark, the company that operates MinuteClinics. Dr Choudry and Mses Krumme and Tong from Brigham and Women’s Hospital have received research funding from CVS Caremark and Aetna.

Authorship Information: Concept and design (WHS, NKC); acquisition of data (WHS, NKC); analysis and interpretation of data (WHS, AAK, AYT, NKC); drafting of the manuscript (WHS, AAK); critical revision of the manuscript for important intellectual content (CMS, OSM, AS, TAB, NKC); statistical analysis (WHS, AAK, AYT); provision of study materials or patients (CMS); obtaining funding (WHS, NKC); administrative, technical, or logistic support, and supervision (CMS, OSM, AS, TAB).

Address correspondence to: William H. Shrank, MD, MSHS, CVS Caremark, 100 Scenic View Rd, Cumberland, RI 02864. E-mail: william.shrank@cvscaremark.com.
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