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Most Transfers from Urgent Care Centers to Emergency Departments Are Discharged and Many Are Unnecessary
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–7, 2018 Ó 2018 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
https://doi.org/10.1016/j.jemermed.2018.01.037
Administration of Emergency Medicine
MOST TRANSFERS FROM URGENT CARE CENTERS TO EMERGENCY DEPARTMENTS ARE DISCHARGED AND MANY ARE UNNECESSARY Tony Zitek, MD,*†‡ Ignasia Tanone, MD,* Alexzza Ramos,§ Karina Fama, BS,§ and Ahmed S. Ali, MD, MPH‡k *University of Nevada, Reno School of Medicine, Reno, Nevada, †University of Nevada, Las Vegas School of Medicine, Las Vegas, Nevada, ‡University Medical Center of Southern Nevada, Las Vegas, Nevada, §University of Nevada, Las Vegas, Las Vegas, Nevada, and kMountain View Hospital, Las Vegas, Las Vegas, Nevada Reprint Address: Tony Zitek, MD, Emergency Department, University of Nevada, Las Vegas School of Medicine, 901 Rancho Lane, Ste 135, Las Vegas, NV 89106
, Abstract—Background: Urgent care centers (UCCs) can offer a cheap alternative to emergency departments (EDs) for some patients with acute complaints. However, if patients who initially present to a UCC are unnecessarily transferred to an ED, those patients may suffer undue financial harm. The group of patients transferred from UCCs to EDs have never previously been studied. Objectives: The primary objective of this study was to determine the fraction of transfers from a UCC to an ED that were unnecessary. We also assessed the frequency with which these patients were discharged from the ED, and tried to determine which groups of patients were most likely to be unnecessarily transferred. Methods: This was a retrospective chart review performed on patients transferred from UCCs to our ED. If the transferred patient had no advanced imaging tests, advanced procedures, or specialty consultations in the ED, and was not admitted, we considered the transfer to be unnecessary. Patients were stratified by age (adult vs. pediatric) and type of insurance. Results: We identified 3232 patients who were transferred from UCCs to our ED over a 1-year period. Among those, 1159 (35.9%; 95% confidence interval [CI] 34.2–37.5%) met our criteria as unnecessary, and 2075 (64.2%; 95% CI 62.5–65.8%) were discharged from the ED. Notably, pediatric patients were more likely than adult patients to be unnecessarily transferred. Patients without medical insurance were not more likely to be transferred than those with private
insurance. Conclusion: Most patients transferred to our ED from a UCC were discharged, and many transfers were unnecessary, especially those involving pediatric patients. These transfers may represent an economic burden to our society. Ó 2018 Elsevier Inc. All rights reserved. , Keywords—urgent care; transfers to the emergency department; pediatric transfers
INTRODUCTION Background There are now over 9000 urgent care centers (UCCs) in the United States, and a substantial number of emergency department (ED) visits are for nonemergent conditions that could likely be managed at UCCs or retail clinics (1–3). As EDs become increasingly crowded, some have suggested that UCCs may be a means to lighten the load. Indeed, some data suggest that UCCs both reduce the number of nonemergent visits to the ED and can lead to cost savings (4–6). Moreover, some data suggest that the quality of care provided for certain conditions might be better in UCCs and retail clinics than in EDs (7).
Prior Presentations: Presented at American College of Emergency Physicians’ annual meeting in Washington DC on October 30, 2017.
RECEIVED: 8 August 2017; FINAL SUBMISSION RECEIVED: 24 December 2017; ACCEPTED: 25 January 2018 1
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Importance With the proliferation of UCCs, a large number of patients who present to an ED have first been seen at a UCC. Very little is known about the outcomes of this group of patients as, to our knowledge, no study has ever been published about this group of patients. In our experience, some patients are transferred to the ED only to be promptly discharged without any advanced diagnostic tests. Although UCCs have the potential to decrease health care costs, if there are a large number of unnecessary transfers from UCCs to the ED, UCCs may paradoxically increase health care expenditures. Goals of This Investigation The primary objective of this study was to determine the frequency of unnecessary transfers from UCCs to our ED. We also assessed the frequency of patients transferred from a UCC to our ED who were discharged, and we tried to determine which groups of patients were most likely to be unnecessarily transferred. MATERIALS AND METHODS Study Design and Setting This was a retrospective chart review of patients who were transferred from one of the local UCCs to our adult or pediatric ED (which are separated within our hospital). Our hospital is an academic, county, tertiary care facility in Las Vegas, Nevada. The annual census of our adult ED is approximately 77,000, and for the pediatric ED it is approximately 35,000. This study received approval from our hospital’s institutional review board, which waived full review. The chart review was performed by three trained research assistants who were blinded from the study hypothesis. A standardized data collection form was used with clearly defined variables. Periodic meetings were held with the chart abstractors to address any uncertainties. A sample of 40 charts was reviewed by all three abstractors to determine interrater reliability (k). To perform the chart review, we obtained a list of patients who were transferred from a UCC to one of our hospital’s EDs over a 1-year period from May 1, 2015 to April 30, 2016. This list was obtained using an electronic stamp in the chart that is supposed to be placed by the nurse triaging the patient whenever the patient has been transferred from a UCC. A patient was considered to have been ‘‘transferred from a UCC’’ only when the patient was instructed by the UCC provider to go directly to the ED, as indicated by transfer paperwork (in the possession of the patient or emergency medical services) filled out by the UCC provider. If a patient decided on
their own volition to visit the ED after visiting a UCC, the patient was not considered to have been transferred. This group of transferred patients thus includes only those patients who were evaluated by a provider at a UCC. Our analysis does not include those patients who were turned away from a UCC and instructed to go directly to an ED. Once this list of patients was obtained, each chart was reviewed to abstract the following information: gender, age, type of medical insurance, Emergency Severity Index level, mode of transport to the ED, chief complaint, disposition, diagnostic tests performed, procedures performed, and specialty consultations in the ED. Prior to performing the chart review, we obtained background information about local UCCs. We attempted to identify all UCCs within the cities of Las Vegas or Henderson, Nevada. This was performed with a Yellow Pages search and a Google search for ‘‘urgent care in Las Vegas’’ or ‘‘urgent care in Henderson.’’ Research assistants reviewed the websites (if they existed) for the facilities, and they made phone calls to determine their hours, staffing, and diagnostic testing capabilities. The principal investigator audited 20% of these data to confirm their accuracy. The data gathered from this exercise helped us define an ‘‘unnecessary transfer’’ as described below. Outcomes As mentioned above, the primary goal of this study was to determine the fraction of transfers from a UCC to our ED that were unnecessary. We also sought to determine the fraction of patients transferred from a UCC to our ED that ended up getting discharged. We stratified our data by age (adult vs. pediatric) and type of medical insurance (public, private, or none) to determine if the frequency of unnecessary transfers or discharges differed between adult and pediatric patients or based upon type of medical insurance. Patients were considered to have ‘‘public’’ insurance if they had Medicare, Medicaid, or both without any supplementary private insurance. We also recorded some basic demographic data, the mode arrival, and the chief complaint for each transferred patient. As described in more detail in the Results section below, the background information for our study demonstrated that there is some variability in the capabilities of local UCCs, but we found that almost all UCCs are able to perform electrocardiograms (ECGs), onsite x-ray studies, and do some blood and urine tests. These findings are in line with what is expected from UCCs by the California Health Care Foundation (8). Therefore, for our study, we expected a UCC to be able to do ECGs, x-ray studies, and some blood and urine tests, and we defined a transfer as unnecessary if the patient was not admitted to the
Unnecessary Urgent Care Transfers
hospital, no advanced imaging tests were performed, no advanced procedures were performed, and no specialty consultations were obtained in the ED. An advanced imaging test was defined as an ultrasound, computed tomography (CT) scan, magnetic resonance imaging scan, or nuclear imaging test. An advanced procedure was defined as a procedural sedation, fracture/dislocation reduction, lumbar puncture, intubation, chest tube placement, thoracentesis, paracentesis, suprapubic catheter placement, central venous catheter placement, or arthrocentesis. If a specialist was contacted in the ED (by phone or otherwise), a specialty consultation was considered to have been obtained, regardless of whether or not the specialist ever saw the patient. If the patient was simply given the phone number for a specialist, this did not count as a specialty consultation. Analysis Data were tabulated in Microsoft Excel (Version 15; Microsoft Corporation, Redmond, WA). The data were uploaded into R for calculations. RESULTS As background for our chart review, we identified 56 medical facilities in the area surrounding our hospital that claimed to specialize in ‘‘urgent care.’’ However, two of these facilities actually did not have a physical space that treated patients. These two businesses were operated by having a provider go to the location of the patient, and seem to be primarily designed to treat tourists. These two businesses were unique, and were not grouped with the other facilities in the following statistics. With regard to diagnostic testing capabilities, all 54 had ECG machines and 53 of 54 (98.1%) had x-ray available. Forty of 54 (79.6%) had some laboratory studies available, but the exact number of laboratory studies available was highly variable. Just three (5.6%) had CT, and seven (13.0%) had ultrasound. One UCC had x-ray, extensive laboratory studies, CT scan, ultrasound, and even had the ability to admit patients to a 23-h observation area. With regard to staffing, 32 of 54 UCCs (59.3%) always had a physician in house when the UCC was open. Although we were unable to determine the exact percentage of providers in different specialties, only 3 of 54 UCCs (5.6%) had an emergency physician on staff. Through our chart review, we identified a sample of 3232 patients who were transferred from a UCC to our adult or pediatric ED from May 1, 2015 to April 30, 2016. Basic demographic data and Emergency Severity Index level are listed in Table 1.
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Overall, 1038 of the transferred patients (32.1%; 95% CI 30.5–33.8%) were admitted, 2075 (64.2%; 95% CI 62.5– 65.8%) were discharged, 101 (3.1%; 95% CI 2.6–3.8%) eloped or left against medical advice, and 17 (0.5%; 95% CI 0.3–0.9%) were transferred to another facility. In total, 1159 patient transfers (35.9%; 95% CI 34.2–37.5%) met our criteria as unnecessary. When separating the data into pediatric and adult patients, we found that pediatric patients transferred to our ED from UCCs were discharged and unnecessarily transferred at much higher rates than adult patients (Table 2A). When stratifying data based upon medical insurance type, we found that patients with private medical insurance and those without medical insurance had similar rates of unnecessary transfer and discharge from the ED. In comparison, patients with only public medical insurance (Medicare or Medicaid) were less likely to be discharged from the ED or meet criteria as an unnecessary transfer (Table 2B). By far the most common chief complaint of patients transferred from a UCC to our ED was abdominal pain/flank pain, accounting for 21.6% of all transferred patients. Table 3 lists the 10 most common chief complaints for patients transferred from a UCC to our ED with the associated percentages of patients of each chief complaint who were discharged and met criteria as an unnecessary transfer. Not listed in Table 3, but of note with regard to chief complaints was the fact that 1.2% of transfers from a UCC to the ED were for scrotal pain, and in none of those cases was the transfer unnecessary. The mode of arrival was not documented in 3.9% of reviewed cases, but among those patients in whom it was documented, 9.0% (95% CI 7.8–10.3%) of those patients who were ultimately discharged came by ambulance. Among those patients categorized as unnecessary transfers, 11.3% (95% CI 9.6–13.3%) came to the ED by ambulance from the UCC. Table 1. Basic Characteristics of Patients Transferred from an Urgent Care Center to Our ED Characteristic Male Female Adult Pediatric Age No insurance Private insurance ESI 1 ESI 2 ESI 3 ESI 4 ESI 5
Number of Patients
Percentage of Patients
1529 1703 2614 618 Median: 38 years 349 1842 1 696 2247 288 0
47.3% 52.7% 80.9% 19.1% IQR: 20–56 years 10.8% 57.0 0.03% 21.5% 69.5% 8.9% 0.0%
ED = emergency department; IQR = interquartile range; ESI = Emergency Severity Index.
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Table 2. The Percentage of Patients Transferred from an Urgent Care Center to Our ED Who Were Discharged and the Percentage Who Were Unnecessarily Transferred A. Stratified by Age: Pediatric vs. Adult
Pediatric Patients
% Discharged (95% CI) % Unnecessary (95% CI) B. Stratified by Type of Medical Insurance: Public, Private, or None % Discharged (95% CI) % Unnecessary (95% CI)
Adult Patients
Difference
86.1 (83.1–88.6) 59.2 (55.3–63.0)
59.1 (57.2–60.9) 30.3 (28.6–32.1)
27.0 (23.5–30.1) 28.9 (24.5–33.2)
No Insurance
Public Insurance Only
Private Insurance
78.7 (69.8–86.0) 41.7 (32.3–51.5)
47.1 (41.5–52.7) 28.8 (23.9–34.1)
74.4 (70.6–78.0) 40.8 (36.7–45.0)
CI = confidence interval; ED = emergency department.
Table 4 compares patients who met criteria as unnecessary transfers with those who did not for several variables. DISCUSSION To our knowledge, this is the first study to evaluate the growing group of patients who are transferred from UCCs to EDs, and it is the first study to attempt to estimate the frequency with which these transfers could have been avoided. Previous data have looked at interhospital transfers and found that transfers for certain issues, such as plastic surgery consultations and hand injuries, are often unnecessary (9,10). Whereas unnecessary interhospital transfers represent a facet of acute care medicine that requires further scrutiny, unnecessary transfers from UCCs to the ED represent a potentially even more wasteful use of resources because those patients initially presenting to UCCs are likely less complex than those involved in interhospital transfers. It is not entirely clear why there are so many unnecessary transfers from UCCs to the ED. Perhaps part of the issue is that UCCs are generally not bound by the Emergency Medical Treatment and Active Labor Act, which provides some guidance about interhospital
transfers and aims to reduce the transfer of patients with limited means of payment. Also, the ease with which a patient can be transferred from a UCC to an ED likely plays a role in the high percentage of patients transferred who may not have needed to be transferred. A UCC can always justify a transfer to an ED as a ‘‘higher level of care.’’ Another potential explanation for the large number of transfers from UCCs to EDs is that the providers staffing UCCs may not be adequately trained to assess and manage patients with acute complaints. In our area, the providers who staff UCCs are most commonly internal medicine and family medicine physicians. It is not certain that providers from these specialties receive enough training to be able to handle the spectrum of acute complaints that may show up in a UCC. Some evidence for this may be demonstrated by the fact that over 80% of patients transferred from a UCC to our ED with a laceration are transferred unnecessarily, and these are almost always discharged from the ED (Table 3). These patients are evidently being transferred because the UCC provider does not feel equipped to repair the laceration himself/herself, but in the ED the providers are generally repairing the lacerations without specialty consultation.
Table 3. The Top 10 Most Common Chief Complaints for Patients Transferred from a UCC to Our ED* ED Chief Complaint
Overall % of Transferred Patients (95% CI)
% Discharged from the ED (95% CI)
% Unnecessary Transfers (95% CI)
Abdominal/flank pain Chest pain Atraumatic extremity pain/swelling Skin abscess/cellulitis Extremity fracture/injury Dyspnea Headache Laceration Obstetric or gynecologic complaints Upper respiratory infection symptoms
21.6 (20.0–23.2) 7.6 (6.6–8.6) 6.9 (6.0–8.0) 4.9 (4.1–5.8) 3.6 (2.9–4.4) 3.5 (2.8–4.2) 3.4 (2.7–4.1) 3.0 (2.4–3.7) 2.8 (2.2–3.5) 2.4 (1.9–3.1)
75.8 (72.1–79.2) 43.4 (36.4–50.5) 89.8 (84.5–93.7) 81.8 (74.2–88.0) 91.8 (84.4–96.4) 34.4 (24.9–45.0) 85.6 (76.6–92.1) 97.5 (91.3–99.7) 93.4 (85.3–97.8) 93.8 (85.0–98.3)
24.9 (21.4–28.6) 43.8 (36.9–51.0) 40.3 (33.2–47.7) 53.8 (44.9–62.5) 44.3 (34.2–54.8) 32.3 (22.9–42.7) 44.4 (34.0–55.3) 81.3 (71.0–89.1) 22.4 (13.6–33.4) 83.1 (71.7–91.2)
UCC = urgent care center; ED = emergency department; CI = confidence interval. * For patients who presented with each of the listed chief complaints, the percentage of patients who were discharged from the ED and the percentage who fit our definition as an unnecessary transfer are listed.
Unnecessary Urgent Care Transfers
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Table 4. Shows a Comparison of Patients Who Fit Criteria for an Unnecessary Transfer vs. Those Who Did Not (Necessary Transfers)
Mean age (years) % Male Mean ESI % Arrived by ambulance
Difference (95% CI)
Necessary
Unnecessary
42.7
32.1
10.6 (8.9–12.2)
46.0 2.82 14.5
52.7 3.06 11.3
6.7 ( 1.3–14.7) 0.24 (0.16–0.32) 3.2 (0.2–5.5)
CI = confidence interval; ESI = Emergency Severity Index.
Similarly, the reason the rate of unnecessary pediatric transfers is so high is likely that providers at the UCCs are not comfortable evaluating pediatric patients. If this is the case, we wonder if these UCCs should be allowed to see pediatric patients. Previous data from interhospital transfers of pediatric patients found that patients transferred from EDs staffed by nonpediatric physicians were more likely to be discharged without needing additional studies or procedures, and patients transferred from EDs staffed by pediatricians were more likely to be admitted (11). Although UCCs specifically designed to treat pediatric patients might be a solution to this problem, our study was not designed to determine if the patients transferred from a pediatric UCC were less likely to be transferred unnecessarily than those transferred from other UCCs. A review of Table 3 identifies some groups of patients, in addition to pediatric patients, in whom we might be able to target interventions to reduce unnecessary transfers from UCCs to EDs and improve the efficiency of our health care system. For example, in noting that abdominal/flank pain was the most common chief complaint among patients transferred from a UCC to our ED, although less than a quarter of such transfers were deemed unnecessary, may suggest that patients with abdominal/flank pain should bypass the UCC and go directly to the ED, unless they go to a UCC that has the ability to do advanced imaging. Similar logic could be applied to patients with an obstetric chief complaint or scrotal pain. Because these issues also generally require advanced imaging, it makes more sense for these patients to go directly to a facility with the resources to adequately assess them. On the other hand, patients transferred from a UCC to the ED for skin abscess/cellulitis were discharged more than 80% of the time from our ED and met criteria as unnecessary transfers more than half the time. Patients with skin abscess/cellulitis generally do not require advanced imaging, but may require an incision and drainage (which could be done at a UCC). Perhaps education with regard to the management of patients with skin abscess/cellulitis for UCC providers would be beneficial.
It is reassuring that patients without medical insurance and those with private insurance have similar rates of unnecessary transfer and discharge from the ED after transfer from a UCC. The fact that patients with only public insurance who are transferred to our ED from a UCC are less likely to be discharged from the ED or meet criteria for an unnecessary transfer compared with those with private insurance or no insurance probably suggests that this group of patients is sicker than those with private insurance or those without insurance, a factor not accounted for in our univariate analysis. We hope that UCCs may be able to decrease health care expenditures and ED wait times, but to this point, the data do not demonstrate that they have done either. Indeed, a prior publication found that low-complexity patients that can be treated in UCCs do not add significantly to ED wait times, so UCCs do not decrease ED wait times (12). Although retail clinics are a little different from UCCs, there are many similarities between the two types of facilities, and the literature regarding the utility of retail clinics may also be applicable to UCCs. Recent data about retail clinics found that they do not result in a reduction in low-acuity ED visits, and that they may actually increase health care spending (13,14). Unnecessary transfers from UCCs to EDs represent a previously unpublished means by which UCCs may lead to increased health care spending. Limitations This study was a retrospective chart review, and therefore, was limited by the usual disadvantages of retrospective studies, including the potential for confounding. This study was also limited in that it was an evaluation of UCCs in one area of the United States. The UCCs in other areas may be staffed differently or may transfer patients less often. However, many of the UCCs in our area are affiliated with national companies, so it is likely that our findings would be true in other areas as well. Next, our definition of ‘‘unnecessary’’ is not validated and can be debated. Prior studies have shown that internists and emergency physicians disagree about what constitutes an appropriate ED visit (15). That being said, because transfers from UCCs to EDs have never been studied before, we think our definition of ‘‘unnecessary’’ is reasonable. Although there was some variability in the capabilities of UCCs, we did our best to determine the capabilities of local UCCs to help define an ‘‘unnecessary’’ transfer. (As a side note, the fact that there was some variability in the capabilities of UCCs is problematic in and of itself, as physicians and patients alike may not know what to expect from a given UCC). Some transfers that were counted as unnecessary may have been necessary for reasons not accounted for in our
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definition of ‘‘unnecessary.’’ For example, in some cases, the patient may have had improvement in his or her clinical status in between the time the patient was evaluated at the UCC and when he or she was evaluated at the ED. However, it is also highly likely that some transfers from the UCC to the ED did not meet our definition of unnecessary even though they were. When a patient is sent from another facility because the provider at that facility felt the patient needed a certain test or procedure, we believe the patient is more likely to get that test or procedure even if the provider at the receiving facility did not necessarily think the patient needed it. We call this ‘‘clinical momentum.’’ The clinical momentum involved in certain transfers could have resulted in patients not being counted as unnecessary transfers because the provider who saw that patient ordered a test they would not have ordered had the provider seen that patient prior to the urgent care provider. Finally, the rules regarding interfacility patient transfers in our hospital may have increased the rate of unnecessary transfers. At our hospital, only pediatric (and not adult) transfers require physician approval. Therefore, the ease with which UCCs can transfer patients to our ED may have played a role in the high rate of unnecessary transfers found. However, data from another study found that even when a surgeon screened transfers for hand trauma, 75% of interhospital transfers still did not require the resources of a Level I trauma center (16). CONCLUSIONS In summary, we found that patients who were transferred from UCCs to our EDs were usually discharged and frequently did not need to be transferred. This was particularly true for pediatric patients. Additional oversight of UCCs may be in order. Future studies are needed to assess the financial impact of unnecessary transfers from UCC to ED care and identify particular groups of patients in whom these unnecessary transfers are most likely to occur. Acknowledgments—University Medical Center Emergency Department Research Assistants.
REFERENCES 1. Yee T, Lechner AE, Boukus ER. The surge in urgent care centers: emergency department alternative or costly convenience? Cent Stud Health Sys Change 2013;26:1–6. 2. Young GP, Wagner MB, Kellermann AL, Ellis J, Bouley D. Ambulatory visits to hospital emergency departments, patterns and reasons for use. JAMA 1996;276:460–5. 3. Weinick RM, Burns RM, Mehrotra A. How many emergency department visits could be managed at urgent care centers and retail clinics? Health Aff (Millwood) 2010;29:1630–6. 4. Merritt B, Naamon E, Morris SA. The influence of an Urgent Care Center on the frequency of ED visits in an urban hospital setting. Am J Emerg Med 2000;18:123–5. 5. Montalbano A, Rodean J, Kangas J, Lee B, Hall M. Urgent care and emergency department visits in the pediatric Medicaid population. Pediatrics 2016;137:e20153100. 6. Warren BH, Isikoff SJ. Comparative costs of urgent care services in university-based clinical sites. Arch Fam Med 1993;2:523–8. 7. Mehrotra A, Liu H, Adams JL, et al. The costs and quality of care for three common illnesses at retail clinics as compared to other medical settings. Ann Intern Med 2009;15:321–8. 8. Weinick RM, Betancourt RM. No appointment needed: the resurgence of urgent care centers in the United States. Oakland, CA: California HealthCare Foundation; 2007. Available at: http://www.chcf. org//media/MEDIA%20LIBRARY%20Files/PDF/PDF%20N/PDF %20NoAppointmentNecessaryUrgentCareCenters.pdf. Accessed April 15, 2017. 9. Martsolf G, Fingar KR, Coffey R, et al. Association between the opening of retail clinics and low-acuity emergency department visits. Ann Emerg Med 2017;69:397–403. 10. Ashwood JS, Gaynor M, Setodji CM, Reid RO, Weber E, Mehrotra A. Retail clinic visits for low-acuity conditions increase utilization. Health Aff (Millwood) 2016;35:449–55. 11. Drolet BC, Tandon VJ, Ha AY, et al. Unnecessary emergency transfers for evaluation by a plastic surgeon: a burden to patients and the health care system. Plast Reconstr Surg 2016; 137:1927–33. 12. Weinick RM, Bristol SJ, DesRoches CM. Urgent care centers in the U.S.: findings from a national survey. BMC Health Serv Res 2009;9: 79. 13. Shaw G. Insured patients flock to freestanding EDs while hospital EDs feel the financial pressure. Emerg Med News 2016;11: 20–1. 14. Schull MJ, Kiss A, Szalai J-P. The effect of low-complexity patients on emergency department waiting times. Ann Emerg Med 2007;49: 257–64. 15. Hartzell TZ, Kuo P, Eberlin KR, Winograd JM, Day CS. The overutilization of resources in patients with acute upper extremity trauma and infection. J Hand Surg 2013;38A:766–73. 16. Gattu RJ, Teshome G, Cai L, Wright C, Lichenstein R. Interhospital pediatric patient transfers—factors influencing rapid disposition after transfer. Pediatr Emerg Care 2014;30:26–30.
Unnecessary Urgent Care Transfers
ARTICLE SUMMARY 1. Why is this topic important? Whereas urgent care centers (UCCs) may offer a cheap alternative to emergency departments (EDs) for certain patients with acute complaints, some patients who initially present to a UCC are transferred to an ED, only to be promptly discharged without any advanced diagnostic testing. These transfers may represent a previously unstudied means of increased health care expenditures. 2. What does this study attempt to show? This study attempts to determine the frequency of unnecessary patient transfers from UCCs to EDs. It also attempts to show if the rate of unnecessary transfers differs between adult and pediatric patients. 3. What are the key findings? Patients who are transferred from UCCs to EDs are usually discharged, and many of those transfers are unnecessary. These findings are particularly true for pediatric patients. 4. How is patient care impacted? This study identifies a previously unrecognized group of patients who are at risk for serious financial harm by being transferred to the ED for issues that should have been able to be cared for at a UCC. Future studies should identify means to reduce these unnecessary transfers.
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Administration of Emergency Medicine
MOST TRANSFERS FROM URGENT CARE CENTERS TO EMERGENCY DEPARTMENTS ARE DISCHARGED AND MANY ARE UNNECESSARY Tony Zitek, MD,*†‡ Ignasia Tanone, MD,* Alexzza Ramos,§ Karina Fama, BS,§ and Ahmed S. Ali, MD, MPH‡k *University of Nevada, Reno School of Medicine, Reno, Nevada, †University of Nevada, Las Vegas School of Medicine, Las Vegas, Nevada, ‡University Medical Center of Southern Nevada, Las Vegas, Nevada, §University of Nevada, Las Vegas, Las Vegas, Nevada, and kMountain View Hospital, Las Vegas, Las Vegas, Nevada Reprint Address: Tony Zitek, MD, Emergency Department, University of Nevada, Las Vegas School of Medicine, 901 Rancho Lane, Ste 135, Las Vegas, NV 89106
, Abstract—Background: Urgent care centers (UCCs) can offer a cheap alternative to emergency departments (EDs) for some patients with acute complaints. However, if patients who initially present to a UCC are unnecessarily transferred to an ED, those patients may suffer undue financial harm. The group of patients transferred from UCCs to EDs have never previously been studied. Objectives: The primary objective of this study was to determine the fraction of transfers from a UCC to an ED that were unnecessary. We also assessed the frequency with which these patients were discharged from the ED, and tried to determine which groups of patients were most likely to be unnecessarily transferred. Methods: This was a retrospective chart review performed on patients transferred from UCCs to our ED. If the transferred patient had no advanced imaging tests, advanced procedures, or specialty consultations in the ED, and was not admitted, we considered the transfer to be unnecessary. Patients were stratified by age (adult vs. pediatric) and type of insurance. Results: We identified 3232 patients who were transferred from UCCs to our ED over a 1-year period. Among those, 1159 (35.9%; 95% confidence interval [CI] 34.2–37.5%) met our criteria as unnecessary, and 2075 (64.2%; 95% CI 62.5–65.8%) were discharged from the ED. Notably, pediatric patients were more likely than adult patients to be unnecessarily transferred. Patients without medical insurance were not more likely to be transferred than those with private
insurance. Conclusion: Most patients transferred to our ED from a UCC were discharged, and many transfers were unnecessary, especially those involving pediatric patients. These transfers may represent an economic burden to our society. Ó 2018 Elsevier Inc. All rights reserved. , Keywords—urgent care; transfers to the emergency department; pediatric transfers
INTRODUCTION Background There are now over 9000 urgent care centers (UCCs) in the United States, and a substantial number of emergency department (ED) visits are for nonemergent conditions that could likely be managed at UCCs or retail clinics (1–3). As EDs become increasingly crowded, some have suggested that UCCs may be a means to lighten the load. Indeed, some data suggest that UCCs both reduce the number of nonemergent visits to the ED and can lead to cost savings (4–6). Moreover, some data suggest that the quality of care provided for certain conditions might be better in UCCs and retail clinics than in EDs (7).
Prior Presentations: Presented at American College of Emergency Physicians’ annual meeting in Washington DC on October 30, 2017.
RECEIVED: 8 August 2017; FINAL SUBMISSION RECEIVED: 24 December 2017; ACCEPTED: 25 January 2018 1
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T. Zitek et al.
Importance With the proliferation of UCCs, a large number of patients who present to an ED have first been seen at a UCC. Very little is known about the outcomes of this group of patients as, to our knowledge, no study has ever been published about this group of patients. In our experience, some patients are transferred to the ED only to be promptly discharged without any advanced diagnostic tests. Although UCCs have the potential to decrease health care costs, if there are a large number of unnecessary transfers from UCCs to the ED, UCCs may paradoxically increase health care expenditures. Goals of This Investigation The primary objective of this study was to determine the frequency of unnecessary transfers from UCCs to our ED. We also assessed the frequency of patients transferred from a UCC to our ED who were discharged, and we tried to determine which groups of patients were most likely to be unnecessarily transferred. MATERIALS AND METHODS Study Design and Setting This was a retrospective chart review of patients who were transferred from one of the local UCCs to our adult or pediatric ED (which are separated within our hospital). Our hospital is an academic, county, tertiary care facility in Las Vegas, Nevada. The annual census of our adult ED is approximately 77,000, and for the pediatric ED it is approximately 35,000. This study received approval from our hospital’s institutional review board, which waived full review. The chart review was performed by three trained research assistants who were blinded from the study hypothesis. A standardized data collection form was used with clearly defined variables. Periodic meetings were held with the chart abstractors to address any uncertainties. A sample of 40 charts was reviewed by all three abstractors to determine interrater reliability (k). To perform the chart review, we obtained a list of patients who were transferred from a UCC to one of our hospital’s EDs over a 1-year period from May 1, 2015 to April 30, 2016. This list was obtained using an electronic stamp in the chart that is supposed to be placed by the nurse triaging the patient whenever the patient has been transferred from a UCC. A patient was considered to have been ‘‘transferred from a UCC’’ only when the patient was instructed by the UCC provider to go directly to the ED, as indicated by transfer paperwork (in the possession of the patient or emergency medical services) filled out by the UCC provider. If a patient decided on
their own volition to visit the ED after visiting a UCC, the patient was not considered to have been transferred. This group of transferred patients thus includes only those patients who were evaluated by a provider at a UCC. Our analysis does not include those patients who were turned away from a UCC and instructed to go directly to an ED. Once this list of patients was obtained, each chart was reviewed to abstract the following information: gender, age, type of medical insurance, Emergency Severity Index level, mode of transport to the ED, chief complaint, disposition, diagnostic tests performed, procedures performed, and specialty consultations in the ED. Prior to performing the chart review, we obtained background information about local UCCs. We attempted to identify all UCCs within the cities of Las Vegas or Henderson, Nevada. This was performed with a Yellow Pages search and a Google search for ‘‘urgent care in Las Vegas’’ or ‘‘urgent care in Henderson.’’ Research assistants reviewed the websites (if they existed) for the facilities, and they made phone calls to determine their hours, staffing, and diagnostic testing capabilities. The principal investigator audited 20% of these data to confirm their accuracy. The data gathered from this exercise helped us define an ‘‘unnecessary transfer’’ as described below. Outcomes As mentioned above, the primary goal of this study was to determine the fraction of transfers from a UCC to our ED that were unnecessary. We also sought to determine the fraction of patients transferred from a UCC to our ED that ended up getting discharged. We stratified our data by age (adult vs. pediatric) and type of medical insurance (public, private, or none) to determine if the frequency of unnecessary transfers or discharges differed between adult and pediatric patients or based upon type of medical insurance. Patients were considered to have ‘‘public’’ insurance if they had Medicare, Medicaid, or both without any supplementary private insurance. We also recorded some basic demographic data, the mode arrival, and the chief complaint for each transferred patient. As described in more detail in the Results section below, the background information for our study demonstrated that there is some variability in the capabilities of local UCCs, but we found that almost all UCCs are able to perform electrocardiograms (ECGs), onsite x-ray studies, and do some blood and urine tests. These findings are in line with what is expected from UCCs by the California Health Care Foundation (8). Therefore, for our study, we expected a UCC to be able to do ECGs, x-ray studies, and some blood and urine tests, and we defined a transfer as unnecessary if the patient was not admitted to the
Unnecessary Urgent Care Transfers
hospital, no advanced imaging tests were performed, no advanced procedures were performed, and no specialty consultations were obtained in the ED. An advanced imaging test was defined as an ultrasound, computed tomography (CT) scan, magnetic resonance imaging scan, or nuclear imaging test. An advanced procedure was defined as a procedural sedation, fracture/dislocation reduction, lumbar puncture, intubation, chest tube placement, thoracentesis, paracentesis, suprapubic catheter placement, central venous catheter placement, or arthrocentesis. If a specialist was contacted in the ED (by phone or otherwise), a specialty consultation was considered to have been obtained, regardless of whether or not the specialist ever saw the patient. If the patient was simply given the phone number for a specialist, this did not count as a specialty consultation. Analysis Data were tabulated in Microsoft Excel (Version 15; Microsoft Corporation, Redmond, WA). The data were uploaded into R for calculations. RESULTS As background for our chart review, we identified 56 medical facilities in the area surrounding our hospital that claimed to specialize in ‘‘urgent care.’’ However, two of these facilities actually did not have a physical space that treated patients. These two businesses were operated by having a provider go to the location of the patient, and seem to be primarily designed to treat tourists. These two businesses were unique, and were not grouped with the other facilities in the following statistics. With regard to diagnostic testing capabilities, all 54 had ECG machines and 53 of 54 (98.1%) had x-ray available. Forty of 54 (79.6%) had some laboratory studies available, but the exact number of laboratory studies available was highly variable. Just three (5.6%) had CT, and seven (13.0%) had ultrasound. One UCC had x-ray, extensive laboratory studies, CT scan, ultrasound, and even had the ability to admit patients to a 23-h observation area. With regard to staffing, 32 of 54 UCCs (59.3%) always had a physician in house when the UCC was open. Although we were unable to determine the exact percentage of providers in different specialties, only 3 of 54 UCCs (5.6%) had an emergency physician on staff. Through our chart review, we identified a sample of 3232 patients who were transferred from a UCC to our adult or pediatric ED from May 1, 2015 to April 30, 2016. Basic demographic data and Emergency Severity Index level are listed in Table 1.
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Overall, 1038 of the transferred patients (32.1%; 95% CI 30.5–33.8%) were admitted, 2075 (64.2%; 95% CI 62.5– 65.8%) were discharged, 101 (3.1%; 95% CI 2.6–3.8%) eloped or left against medical advice, and 17 (0.5%; 95% CI 0.3–0.9%) were transferred to another facility. In total, 1159 patient transfers (35.9%; 95% CI 34.2–37.5%) met our criteria as unnecessary. When separating the data into pediatric and adult patients, we found that pediatric patients transferred to our ED from UCCs were discharged and unnecessarily transferred at much higher rates than adult patients (Table 2A). When stratifying data based upon medical insurance type, we found that patients with private medical insurance and those without medical insurance had similar rates of unnecessary transfer and discharge from the ED. In comparison, patients with only public medical insurance (Medicare or Medicaid) were less likely to be discharged from the ED or meet criteria as an unnecessary transfer (Table 2B). By far the most common chief complaint of patients transferred from a UCC to our ED was abdominal pain/flank pain, accounting for 21.6% of all transferred patients. Table 3 lists the 10 most common chief complaints for patients transferred from a UCC to our ED with the associated percentages of patients of each chief complaint who were discharged and met criteria as an unnecessary transfer. Not listed in Table 3, but of note with regard to chief complaints was the fact that 1.2% of transfers from a UCC to the ED were for scrotal pain, and in none of those cases was the transfer unnecessary. The mode of arrival was not documented in 3.9% of reviewed cases, but among those patients in whom it was documented, 9.0% (95% CI 7.8–10.3%) of those patients who were ultimately discharged came by ambulance. Among those patients categorized as unnecessary transfers, 11.3% (95% CI 9.6–13.3%) came to the ED by ambulance from the UCC. Table 1. Basic Characteristics of Patients Transferred from an Urgent Care Center to Our ED Characteristic Male Female Adult Pediatric Age No insurance Private insurance ESI 1 ESI 2 ESI 3 ESI 4 ESI 5
Number of Patients
Percentage of Patients
1529 1703 2614 618 Median: 38 years 349 1842 1 696 2247 288 0
47.3% 52.7% 80.9% 19.1% IQR: 20–56 years 10.8% 57.0 0.03% 21.5% 69.5% 8.9% 0.0%
ED = emergency department; IQR = interquartile range; ESI = Emergency Severity Index.
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Table 2. The Percentage of Patients Transferred from an Urgent Care Center to Our ED Who Were Discharged and the Percentage Who Were Unnecessarily Transferred A. Stratified by Age: Pediatric vs. Adult
Pediatric Patients
% Discharged (95% CI) % Unnecessary (95% CI) B. Stratified by Type of Medical Insurance: Public, Private, or None % Discharged (95% CI) % Unnecessary (95% CI)
Adult Patients
Difference
86.1 (83.1–88.6) 59.2 (55.3–63.0)
59.1 (57.2–60.9) 30.3 (28.6–32.1)
27.0 (23.5–30.1) 28.9 (24.5–33.2)
No Insurance
Public Insurance Only
Private Insurance
78.7 (69.8–86.0) 41.7 (32.3–51.5)
47.1 (41.5–52.7) 28.8 (23.9–34.1)
74.4 (70.6–78.0) 40.8 (36.7–45.0)
CI = confidence interval; ED = emergency department.
Table 4 compares patients who met criteria as unnecessary transfers with those who did not for several variables. DISCUSSION To our knowledge, this is the first study to evaluate the growing group of patients who are transferred from UCCs to EDs, and it is the first study to attempt to estimate the frequency with which these transfers could have been avoided. Previous data have looked at interhospital transfers and found that transfers for certain issues, such as plastic surgery consultations and hand injuries, are often unnecessary (9,10). Whereas unnecessary interhospital transfers represent a facet of acute care medicine that requires further scrutiny, unnecessary transfers from UCCs to the ED represent a potentially even more wasteful use of resources because those patients initially presenting to UCCs are likely less complex than those involved in interhospital transfers. It is not entirely clear why there are so many unnecessary transfers from UCCs to the ED. Perhaps part of the issue is that UCCs are generally not bound by the Emergency Medical Treatment and Active Labor Act, which provides some guidance about interhospital
transfers and aims to reduce the transfer of patients with limited means of payment. Also, the ease with which a patient can be transferred from a UCC to an ED likely plays a role in the high percentage of patients transferred who may not have needed to be transferred. A UCC can always justify a transfer to an ED as a ‘‘higher level of care.’’ Another potential explanation for the large number of transfers from UCCs to EDs is that the providers staffing UCCs may not be adequately trained to assess and manage patients with acute complaints. In our area, the providers who staff UCCs are most commonly internal medicine and family medicine physicians. It is not certain that providers from these specialties receive enough training to be able to handle the spectrum of acute complaints that may show up in a UCC. Some evidence for this may be demonstrated by the fact that over 80% of patients transferred from a UCC to our ED with a laceration are transferred unnecessarily, and these are almost always discharged from the ED (Table 3). These patients are evidently being transferred because the UCC provider does not feel equipped to repair the laceration himself/herself, but in the ED the providers are generally repairing the lacerations without specialty consultation.
Table 3. The Top 10 Most Common Chief Complaints for Patients Transferred from a UCC to Our ED* ED Chief Complaint
Overall % of Transferred Patients (95% CI)
% Discharged from the ED (95% CI)
% Unnecessary Transfers (95% CI)
Abdominal/flank pain Chest pain Atraumatic extremity pain/swelling Skin abscess/cellulitis Extremity fracture/injury Dyspnea Headache Laceration Obstetric or gynecologic complaints Upper respiratory infection symptoms
21.6 (20.0–23.2) 7.6 (6.6–8.6) 6.9 (6.0–8.0) 4.9 (4.1–5.8) 3.6 (2.9–4.4) 3.5 (2.8–4.2) 3.4 (2.7–4.1) 3.0 (2.4–3.7) 2.8 (2.2–3.5) 2.4 (1.9–3.1)
75.8 (72.1–79.2) 43.4 (36.4–50.5) 89.8 (84.5–93.7) 81.8 (74.2–88.0) 91.8 (84.4–96.4) 34.4 (24.9–45.0) 85.6 (76.6–92.1) 97.5 (91.3–99.7) 93.4 (85.3–97.8) 93.8 (85.0–98.3)
24.9 (21.4–28.6) 43.8 (36.9–51.0) 40.3 (33.2–47.7) 53.8 (44.9–62.5) 44.3 (34.2–54.8) 32.3 (22.9–42.7) 44.4 (34.0–55.3) 81.3 (71.0–89.1) 22.4 (13.6–33.4) 83.1 (71.7–91.2)
UCC = urgent care center; ED = emergency department; CI = confidence interval. * For patients who presented with each of the listed chief complaints, the percentage of patients who were discharged from the ED and the percentage who fit our definition as an unnecessary transfer are listed.
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Table 4. Shows a Comparison of Patients Who Fit Criteria for an Unnecessary Transfer vs. Those Who Did Not (Necessary Transfers)
Mean age (years) % Male Mean ESI % Arrived by ambulance
Difference (95% CI)
Necessary
Unnecessary
42.7
32.1
10.6 (8.9–12.2)
46.0 2.82 14.5
52.7 3.06 11.3
6.7 ( 1.3–14.7) 0.24 (0.16–0.32) 3.2 (0.2–5.5)
CI = confidence interval; ESI = Emergency Severity Index.
Similarly, the reason the rate of unnecessary pediatric transfers is so high is likely that providers at the UCCs are not comfortable evaluating pediatric patients. If this is the case, we wonder if these UCCs should be allowed to see pediatric patients. Previous data from interhospital transfers of pediatric patients found that patients transferred from EDs staffed by nonpediatric physicians were more likely to be discharged without needing additional studies or procedures, and patients transferred from EDs staffed by pediatricians were more likely to be admitted (11). Although UCCs specifically designed to treat pediatric patients might be a solution to this problem, our study was not designed to determine if the patients transferred from a pediatric UCC were less likely to be transferred unnecessarily than those transferred from other UCCs. A review of Table 3 identifies some groups of patients, in addition to pediatric patients, in whom we might be able to target interventions to reduce unnecessary transfers from UCCs to EDs and improve the efficiency of our health care system. For example, in noting that abdominal/flank pain was the most common chief complaint among patients transferred from a UCC to our ED, although less than a quarter of such transfers were deemed unnecessary, may suggest that patients with abdominal/flank pain should bypass the UCC and go directly to the ED, unless they go to a UCC that has the ability to do advanced imaging. Similar logic could be applied to patients with an obstetric chief complaint or scrotal pain. Because these issues also generally require advanced imaging, it makes more sense for these patients to go directly to a facility with the resources to adequately assess them. On the other hand, patients transferred from a UCC to the ED for skin abscess/cellulitis were discharged more than 80% of the time from our ED and met criteria as unnecessary transfers more than half the time. Patients with skin abscess/cellulitis generally do not require advanced imaging, but may require an incision and drainage (which could be done at a UCC). Perhaps education with regard to the management of patients with skin abscess/cellulitis for UCC providers would be beneficial.
It is reassuring that patients without medical insurance and those with private insurance have similar rates of unnecessary transfer and discharge from the ED after transfer from a UCC. The fact that patients with only public insurance who are transferred to our ED from a UCC are less likely to be discharged from the ED or meet criteria for an unnecessary transfer compared with those with private insurance or no insurance probably suggests that this group of patients is sicker than those with private insurance or those without insurance, a factor not accounted for in our univariate analysis. We hope that UCCs may be able to decrease health care expenditures and ED wait times, but to this point, the data do not demonstrate that they have done either. Indeed, a prior publication found that low-complexity patients that can be treated in UCCs do not add significantly to ED wait times, so UCCs do not decrease ED wait times (12). Although retail clinics are a little different from UCCs, there are many similarities between the two types of facilities, and the literature regarding the utility of retail clinics may also be applicable to UCCs. Recent data about retail clinics found that they do not result in a reduction in low-acuity ED visits, and that they may actually increase health care spending (13,14). Unnecessary transfers from UCCs to EDs represent a previously unpublished means by which UCCs may lead to increased health care spending. Limitations This study was a retrospective chart review, and therefore, was limited by the usual disadvantages of retrospective studies, including the potential for confounding. This study was also limited in that it was an evaluation of UCCs in one area of the United States. The UCCs in other areas may be staffed differently or may transfer patients less often. However, many of the UCCs in our area are affiliated with national companies, so it is likely that our findings would be true in other areas as well. Next, our definition of ‘‘unnecessary’’ is not validated and can be debated. Prior studies have shown that internists and emergency physicians disagree about what constitutes an appropriate ED visit (15). That being said, because transfers from UCCs to EDs have never been studied before, we think our definition of ‘‘unnecessary’’ is reasonable. Although there was some variability in the capabilities of UCCs, we did our best to determine the capabilities of local UCCs to help define an ‘‘unnecessary’’ transfer. (As a side note, the fact that there was some variability in the capabilities of UCCs is problematic in and of itself, as physicians and patients alike may not know what to expect from a given UCC). Some transfers that were counted as unnecessary may have been necessary for reasons not accounted for in our
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definition of ‘‘unnecessary.’’ For example, in some cases, the patient may have had improvement in his or her clinical status in between the time the patient was evaluated at the UCC and when he or she was evaluated at the ED. However, it is also highly likely that some transfers from the UCC to the ED did not meet our definition of unnecessary even though they were. When a patient is sent from another facility because the provider at that facility felt the patient needed a certain test or procedure, we believe the patient is more likely to get that test or procedure even if the provider at the receiving facility did not necessarily think the patient needed it. We call this ‘‘clinical momentum.’’ The clinical momentum involved in certain transfers could have resulted in patients not being counted as unnecessary transfers because the provider who saw that patient ordered a test they would not have ordered had the provider seen that patient prior to the urgent care provider. Finally, the rules regarding interfacility patient transfers in our hospital may have increased the rate of unnecessary transfers. At our hospital, only pediatric (and not adult) transfers require physician approval. Therefore, the ease with which UCCs can transfer patients to our ED may have played a role in the high rate of unnecessary transfers found. However, data from another study found that even when a surgeon screened transfers for hand trauma, 75% of interhospital transfers still did not require the resources of a Level I trauma center (16). CONCLUSIONS In summary, we found that patients who were transferred from UCCs to our EDs were usually discharged and frequently did not need to be transferred. This was particularly true for pediatric patients. Additional oversight of UCCs may be in order. Future studies are needed to assess the financial impact of unnecessary transfers from UCC to ED care and identify particular groups of patients in whom these unnecessary transfers are most likely to occur. Acknowledgments—University Medical Center Emergency Department Research Assistants.
REFERENCES 1. Yee T, Lechner AE, Boukus ER. The surge in urgent care centers: emergency department alternative or costly convenience? Cent Stud Health Sys Change 2013;26:1–6. 2. Young GP, Wagner MB, Kellermann AL, Ellis J, Bouley D. Ambulatory visits to hospital emergency departments, patterns and reasons for use. JAMA 1996;276:460–5. 3. Weinick RM, Burns RM, Mehrotra A. How many emergency department visits could be managed at urgent care centers and retail clinics? Health Aff (Millwood) 2010;29:1630–6. 4. Merritt B, Naamon E, Morris SA. The influence of an Urgent Care Center on the frequency of ED visits in an urban hospital setting. Am J Emerg Med 2000;18:123–5. 5. Montalbano A, Rodean J, Kangas J, Lee B, Hall M. Urgent care and emergency department visits in the pediatric Medicaid population. Pediatrics 2016;137:e20153100. 6. Warren BH, Isikoff SJ. Comparative costs of urgent care services in university-based clinical sites. Arch Fam Med 1993;2:523–8. 7. Mehrotra A, Liu H, Adams JL, et al. The costs and quality of care for three common illnesses at retail clinics as compared to other medical settings. Ann Intern Med 2009;15:321–8. 8. Weinick RM, Betancourt RM. No appointment needed: the resurgence of urgent care centers in the United States. Oakland, CA: California HealthCare Foundation; 2007. Available at: http://www.chcf. org//media/MEDIA%20LIBRARY%20Files/PDF/PDF%20N/PDF %20NoAppointmentNecessaryUrgentCareCenters.pdf. Accessed April 15, 2017. 9. Martsolf G, Fingar KR, Coffey R, et al. Association between the opening of retail clinics and low-acuity emergency department visits. Ann Emerg Med 2017;69:397–403. 10. Ashwood JS, Gaynor M, Setodji CM, Reid RO, Weber E, Mehrotra A. Retail clinic visits for low-acuity conditions increase utilization. Health Aff (Millwood) 2016;35:449–55. 11. Drolet BC, Tandon VJ, Ha AY, et al. Unnecessary emergency transfers for evaluation by a plastic surgeon: a burden to patients and the health care system. Plast Reconstr Surg 2016; 137:1927–33. 12. Weinick RM, Bristol SJ, DesRoches CM. Urgent care centers in the U.S.: findings from a national survey. BMC Health Serv Res 2009;9: 79. 13. Shaw G. Insured patients flock to freestanding EDs while hospital EDs feel the financial pressure. Emerg Med News 2016;11: 20–1. 14. Schull MJ, Kiss A, Szalai J-P. The effect of low-complexity patients on emergency department waiting times. Ann Emerg Med 2007;49: 257–64. 15. Hartzell TZ, Kuo P, Eberlin KR, Winograd JM, Day CS. The overutilization of resources in patients with acute upper extremity trauma and infection. J Hand Surg 2013;38A:766–73. 16. Gattu RJ, Teshome G, Cai L, Wright C, Lichenstein R. Interhospital pediatric patient transfers—factors influencing rapid disposition after transfer. Pediatr Emerg Care 2014;30:26–30.
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ARTICLE SUMMARY 1. Why is this topic important? Whereas urgent care centers (UCCs) may offer a cheap alternative to emergency departments (EDs) for certain patients with acute complaints, some patients who initially present to a UCC are transferred to an ED, only to be promptly discharged without any advanced diagnostic testing. These transfers may represent a previously unstudied means of increased health care expenditures. 2. What does this study attempt to show? This study attempts to determine the frequency of unnecessary patient transfers from UCCs to EDs. It also attempts to show if the rate of unnecessary transfers differs between adult and pediatric patients. 3. What are the key findings? Patients who are transferred from UCCs to EDs are usually discharged, and many of those transfers are unnecessary. These findings are particularly true for pediatric patients. 4. How is patient care impacted? This study identifies a previously unrecognized group of patients who are at risk for serious financial harm by being transferred to the ED for issues that should have been able to be cared for at a UCC. Future studies should identify means to reduce these unnecessary transfers.
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