Recruitment of parents from 19 pediatric offices.
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Garbutt JM, Mandrell KM, Allen M, et al. Parents’ Experiences With Pediatric Care at Retail Clinics. JAMA Pediatr. 2013;167(9):845–850. doi:10.1001/jamapediatrics.2013.352
Little is known about the use of retail clinics (RCs) for pediatric care.
To describe the rationale and experiences of families with a pediatrician who also use RCs for pediatric care.
Design and Setting
Cross-sectional study with 19 pediatric practices in a Midwestern practice-based research network.
Parents attending the pediatrician’s office.
Main Outcomes and Measures
Parents’ experience with RC care for their children.
In total, 1484 parents (91.9% response rate) completed the self-administered paper survey. Parents (23.2%) who used the RC for pediatric care were more likely to report RC care for themselves (odds ratio, 7.79; 95% CI, 5.13-11.84), have more than 1 child (2.16; 1.55-3.02), and be older (1.05; 1.03-1.08). Seventy-four percent first considered going to the pediatrician but reported choosing the RC because the RC had more convenient hours (36.6%), no office appointment was available (25.2%), they did not want to bother the pediatrician after hours (15.4%), or they thought the problem was not serious enough (13.0%). Forty-seven percent of RC visits occurred between 8 am and 4 pm on weekdays or 8 am and noon on the weekend. Most commonly, visits were reportedly for acute upper respiratory tract illnesses (sore throat, 34.3%; ear infection, 26.2%; and colds or flu, 19.2%) and for physicals (13.1%). While 7.3% recalled the RC indicating it would inform the pediatrician of the visit, only 41.8% informed the pediatrician themselves.
Conclusions and Relevance
Parents with established relationships with a pediatrician most often took their children to RCs for care because access was convenient. Almost half the visits occurred when the pediatricians’ offices were likely open.
Even parents whose children have a primary care pediatrician (PCP) who they know and trust may not always believe they have convenient and timely access to their care provider. Retail clinics (RCs), which have proliferated in response to patients’ demand for convenient health care access for minor illnesses, are predicted to number more than 6000 nationwide by 2013.1
Most RCs sit within high-traffic retail stores, such as Walgreens and CVS, and are staffed by nonpediatric nurse practitioners and physician assistants who provide care for patients aged 18 months and older.2 Treatment for common minor illnesses such as ear and throat infections is provided, and vaccinations and school or camp physicals are offered.1 Walk-in appointments are available 7 days a week, including evenings; wait time is short; and prices are fixed and transparent.3,4 Lower production costs have resulted in reduced prices for a visit compared with those of an emergency department, an urgent care center, or a physician’s office, and many health insurance plans, including Medicaid, will pay for RC visits in full or in part.5,6
While many patients and health insurance companies positively endorse RCs,4 professional organizations, including the American Academy of Pediatrics and the American Academy of Family Physicians, have raised concerns about the quality of care provided at RCs and the effect of fragmenting care on patients’ overall health.7,8 Recent evidence suggests that RCs may affect the continuity of care in the medical home9,10 and that use of RCs by families with children is increasing.11 However, the literature concerning RC use is scant, comprising mainly reviews of administrative databases, most commonly from Minnesota, the birthplace of RCs.1,5,12-16 Few studies have focused exclusively on pediatric care.17,18 The objectives of this study were to better understand when and why parents who have an established relationship with a PCP use RCs for pediatric care, describe parents’ perceptions of the care received, and discuss how information about RC visits is shared with the child’s PCP.
We conducted a survey in the waiting rooms of 19 pediatric offices in a Midwestern practice-based research network to assess parents’ attitudes toward and experiences with RC care. Most parents finished the survey before seeing their PCP. The study was approved by the Washington University Human Research Protection Office.
We developed and refined the survey after pilot testing with 6 parents. Each survey took approximately 5 minutes to complete and had a Flesch-Kincaid reading level of 4.5. The description of RCs provided to the parent was as follows: “In St. Louis, retail clinics sit within Walgreens as Take Care Clinics.”
All respondents provided demographic information and indicated if they had ever sought care at an RC for themselves or their children and whether their pediatrician had ever advised against taking their children to an RC to treat a minor illness. Those who had not used an RC for their children noted their reasons for not doing so by selecting options from a list. Those who had used an RC answered questions about the most recent RC visit for one of their children. These parents selected from a list of options to denote why they had not gone to the pediatrician on this occasion, the reason for the RC visit, and how they had learned about RCs in the St Louis metropolitan area. They provided details about the clinic visit process (day, time of day, wait time, and payment method) and if their child received a prescription for an antibiotic. Parents indicated if and where they were advised to get follow-up care, if they received any follow-up communication from the RC, whether they informed their pediatrician about the visit, if the RC had said it would inform the PCP directly about the child’s visit, and if they would use RCs in the future. Satisfaction with the RC visit was evaluated using a 4-point categorical scale (very satisfied to very dissatisfied).
All pediatricians in our practice-based research network, the Washington University Pediatric and Adolescent Ambulatory Research Consortium, were asked if they would allow a research assistant (M.A.) in their office for approximately 1 week to recruit study subjects. Eligible participants were the parents or legal guardians of children aged 18 months to 18 years. Parents were approached by the research assistant in the waiting room and invited to participate. They were not approached if they had been called immediately to see the physician, were preoccupied with an administrative task, or if the research assistant was busy with another parent. Unaccompanied minors and pregnant women with no children were ineligible, as were parents who could not speak English or had previously completed the survey.
Summary statistics are presented as mean and standard deviation or median and range or interquartile range for continuous variables and percentage for categorical variables. We used the Pearson χ2 or Fisher exact test to compare responses among those who did and did not use RCs for pediatric care. Race was dichotomized as white vs all other races, health insurance as Medicaid vs other insurance, respondents’ educational attainment as associate’s degree or higher vs less education, and family income as less than $60 000 per year vs $60 000 or more per year. Logistic regression was used to identify characteristics of families who used RCs for pediatric care, adjusting for clustering of parents within practices. The following factors that were significant (P < .05) in the univariate analyses were included in the regression model: parental RC care, more than 1 child, white race, parent age in years, income of $60 000 or more per year, and Medicaid insurance. The odds ratios with the 95% CI are reported. A probability of P < .05 (2-tailed) was used to establish statistical significance.
Participants were recruited from 19 primary care pediatric practices throughout the St Louis metropolitan area (16 in Missouri and 3 in Illinois; 3 solo practitioners and 16 group practices). These practices were typically open from 8:30 am to 5 pm and for 2 to 4 hours on Saturday mornings. The research assistant was at each practice for a median of 3.5 days (range, 2-5 days) from December 12, 2011, through April 20, 2012. Of the 2206 parents who were invited to participate, 136 declined the eligibility screen, leaving 2070 to be assessed for eligibility (Figure). Of these, 585 were ineligible, and 1 declined to participate after eligibility assessment. In total, 1484 participants completed the survey (median, 89 surveys per practice; range, 22-144); the minimal response rate was 91.9%. Overall, 84.8% of respondents were female, 29.5% did not work outside the home, 70.5% described their race as white, and 69.4% had an associate’s degree or higher education (Table 1).
Overall, 37.4% of respondents had used an RC for health care for themselves (range among practices, 21.3%-49.4%; median, 38.0%) and 23.2% had done so for pediatric care (range among practices, 10.5%-39.5%; median, 23.2%). Of those who used an RC for pediatric care, 47.8% had done so more than once in the prior year (13.9%, 1-2 times; 1.3%, 3-5 times; and 32.6%, >5 times).
Characteristics of respondents who reported they had or had not used an RC for their children are compared in Table 1. In the logistic regression model, parents who used an RC for pediatric care were more likely to report use of an RC for themselves (odds ratio, 7.79; 95% CI, 5.13-11.84), have more than 1 child (2.16; 1.55-3.02), and be older (1.05; 1.03-1.08) (Table 2).
Of the 344 parents who had used RCs for their children, 74.1% had considered going to their pediatrician first. The RC was selected because it offered more convenient hours (36.6%), no appointment was available at the pediatrician’s office (25.2%), or the parent did not want to bother the pediatrician after hours (15.4%) or did not think the problem was serious enough to bother the pediatrician (13.0%). If the RC had not been available at the time of the illness, parents indicated they would have gone to the pediatrician’s office (49.5%), urgent care center (30.0%), or the emergency department (14.0%) for care or not sought care at all (5.5%). Parents learned about RCs when they noticed the clinic in the store (52.0%), through in-store advertising (36.1%), from friends or family (23.6%), and through television advertising (20.9%). Few learned about RCs from their insurance company (1.7%).
The most common reason for not using an RC for pediatric care was the parents’ preference for care by the pediatrician (60.7%) (Table 3). Few parents (2%) indicated that their pediatrician had advised them not to take their children to RCs for care.
The median age for a child most recently seen at the RC was 8 years (range, 1.5-18 years). Clinic visits occurred on weekdays (49.8%) and weekends or holidays (50.2%). During the week, 55.1% of RC visits occurred between 8 am and 4 pm, 28.2% between 4 pm and 6 pm, and 16.7% between 6 pm and 8 pm (Table 4). Parents reported wait times of less than 30 minutes (57.5%), 30 to 60 minutes (31.5%), or more than 60 minutes (11.0%). Health insurance covered all (36.5%) or part (47.1%) of the cost of the visit, while 17.4% paid out of pocket in full. Of those with Medicaid insurance, 74.6% reported that the cost of the RC visit was covered in full (13.6% in part and 11.9% paid out of pocket in full). Five percent of parents received a voucher or coupon for purchases in the retail store (median value, $5; range, $2-$10).
Most commonly, visits were for acute upper respiratory tract illnesses, including sore throat (34.3%), ear infection (26.2%), and colds or flu (19.2%) (Table 5). By parent report, antibiotics were prescribed to 85.2% of children with an ear infection, 78.6% of those with a sore throat, and 67.7% of those with a cold or flu. Of the 118 children being treated for a sore throat, 96 (81.4%) had a throat swab taken (reported by the parent as 70.8% positive, 21.9% negative, and 7.3% did not know). Antibiotics were prescribed to 6 of 21 patients (28.6%) who had a negative throat swab result. Of the 8 children who needed asthma care, reported treatment included albuterol sulfate (n = 5), a prescription for an antibiotic (n = 4), an oral corticosteroid (n = 3), and a controller medication (n = 1). Of the 8 children being treated for allergies, 6 parents reported receipt of an antibiotic prescription.
Thirty-two children were taken to the RC because their parent thought their health-related problem was not serious enough to bother the PCP. Among these children, the reason for the visit included sore throat (n = 12), ear infection (n = 9), cold (n = 4), flu shot (n = 3), physical (n = 3), and allergies (n = 1). Among the children seen for an upper respiratory tract infection, 18 of 26 (69.2%) parents reported receipt of an antibiotic prescription.
Forty percent of parents reported follow-up communication from the RC (34.9% via a telephone call, 2.5% via email, and 2.2% other). The RC recommended follow-up care with the pediatrician (43.2%), the RC (1.3%), or the emergency department (0.6%). Most parents (61.8%) did not recall the RC indicating that it would notify their PCP about the clinic visit (30.9% were unsure and 7.8% thought the RC would notify the PCP), and 33.3% were advised to tell their PCP about the clinic visit (23.2% were unsure and 43.4% were not advised). Only 41.8% of parents who had sought care at the RC informed their pediatrician about the visit (11.6% were unsure and 46.7% did not inform their PCP). Parents were more likely to inform the PCP if advised to do so by the RC (66.7% vs 26.1%, P < .001). Parents selected the following reasons for not informing the PCP about the RC visit: they did not think the visit was important (37.5%), had not seen the PCP since the RC visit (34.0%), had forgotten to tell the PCP (18.8%), or thought the clinic would do so (3.5%). No one selected the response option “I thought the doctor might not approve.”
Most parents were satisfied (61.7%) or very satisfied (32.8%) with the care their child received at the RC, and 53.4% indicated they would use RCs in the future for pediatric care (38.9% responded maybe and 7.7% would not).
In our study population with an established relationship with a PCP, about 1 in 4 families had used an RC for pediatric care at least once, and many reported multiple visits, double that of prior estimates (10% for children and 19% for adults),1,17 likely reflecting increasing use of RCs by families with children.11 Most visits were reportedly for care of acute upper respiratory tract illnesses, and satisfaction with the care was high, similar to findings in other studies.1,9,18,19 Visits to the RC most often occurred when the pediatrician’s office was open, with parents choosing to go to the RC for reasons of convenience.3,11 Many parents first considered going to the pediatrician for care but were unable to or believed they would be unable to get a convenient, timely appointment for an office visit; or thought the illness was not severe enough to warrant an office visit or bother their PCP after hours. Use of an RC was more likely if the parent had received RC care himself or herself, suggesting familiarity and satisfaction with this mode of care delivery. Similar to previous studies,5,15,20 RC users were more likely than nonusers to be older, white, and more educated and have a higher income, possibly representing a group more likely to seek convenient access to care for minor illnesses.
Virtually no parents reported that their pediatrician had raised the topic of RC care with them, and fewer than half volunteered information about their RC visit to the PCP. Effective communication about care is essential to avoid duplication of services and ensure safety and effective care coordination.21 This will become even more important if RCs assume a more active role in management of chronic diseases.22 In settings where RCs are affiliated with a hospital system, an integrated electronic medical record can facilitate communication between the RC and the child’s medical home within 24 hours of a clinic visit,6,21 as recommended by the American Academy of Pediatrics.8 However, most RCs are independently owned,23 and in this setting, PCPs rely more on parents to inform them about RC visits. Our data suggest that parents would be more likely to report an RC visit when recommended to do so by the RC. The pediatrician could improve communication about RC use by routinely asking about RC visits and educating families about why the child’s medical home should be aware of any health care received by the child.
Physicians have voiced concerns about the quality of care at RCs.7,8 Our data raise concern about the frequency of unnecessary antibiotic prescriptions in local RCs, although a prior study of claims data from a large health plan found no difference in antibiotic prescriptions for pharyngitis for 2- to 64-year-old patients seen at RCs, physician offices, urgent care clinics, and emergency departments.5 In our study population, contrary to national recommendations,24,25 receipt of an antibiotic prescription was reported by two-thirds of those who sought care for nonspecific upper respiratory tract infections and a quarter of those with a negative throat swab result. It is important to note that these data are self-reported and cannot be confirmed by a review of medical or pharmacy records. We do not have data to determine antibiotic prescribing rates for local PCPs for these diagnoses, but the reported RC antibiotic prescribing rates were much higher than in other primary care settings26 and need further investigation. Upper respiratory tract infections and pharyngitis account for up to half of pediatric RC visits,1 and the potential harm from widespread overuse of antibiotics for these common illnesses could be considerable.
Our study provides data about RC use for pediatric care by families attending the office of their PCP, but several study limitations should be noted. The data are self-reported and may not accurately represent care provided in RCs. Several factors may have influenced parents’ responses, including recall bias and confusion between RCs and urgent care centers. It is also possible that parents’ responses were influenced by the survey being conducted in the office of their PCP, even though the survey was anonymous and distributed by study staff rather than by office personnel. Although the study sample was large and the participation rate was high, participants were from the St Louis metropolitan area, and RCs are more common in urban areas.6 Thus, study findings may not be generalizable to other communities. Future studies should confirm our findings using objective data from different communities.
In summary, many parents with established relationships with a pediatrician use RCs for themselves and for their children, with some repeatedly choosing the RC instead of an office visit. These parents believe RCs provide better access to timely care at hours convenient to the family’s schedule. Pediatricians can address concerns about quality of care, duplication of services, and disrupted care coordination by working to optimize communication with the RCs themselves, as well as with their patients regarding appropriate management of acute minor illnesses and the role of RCs. They also will need to directly address parents’ need for convenient access to care.
Accepted for Publication: January 17, 2013.
Corresponding Author: Jane M. Garbutt, MB, ChB, Department of Pediatrics, Washington University School of Medicine, Campus Box 8116, 660 S Euclid Ave, St Louis, MO 63110 (firstname.lastname@example.org)
Published Online: July 22, 2013. doi:10.1001/jamapediatrics.2013.352.
Author Contributions: Drs Garbutt, Sterkel, Epstein, Sayre, Sitrin, and Strunk and Mss Mandrell and Allen had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Garbutt, Sterkel, O’Neil, Sayre, Sitrin, Stahl, Strunk.
Acquisition of data: Garbutt, Mandrell, Allen.
Analysis and interpretation of data: Garbutt, Mandrell, Sterkel, Epstein, Kreusser, Sitrin.
Drafting of the manuscript: Garbutt.
Critical revision of the manuscript for important intellectual content: Mandrell, Allen, Sterkel, Epstein, Kreusser, O’Neil, Sayre, Sitrin, Stahl, Strunk.
Statistical analysis: Garbutt, Mandrell.
Obtained funding: Garbutt.
Administrative, technical, and material support: Mandrell, Allen.
Study supervision: Garbutt, Sterkel, Strunk.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by grant UL1 RR024992 from the National Center for Research Resources, a component of the National Institutes of Health, and a National Institutes of Health Roadmap for Medical Research. Study data were collected and managed using REDCap (Research Electronic Data Capture) tools hosted at Washington University School of Medicine. REDCap is a secure, web-based application designed to support data capture for research studies, providing (1) an intuitive interface for validated data entry, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for importing data from external sources.27
Role of Sponsors: The sponsors had no involvement in study design, collection, analysis, or interpretation of the data; the writing of the report; or the decision to submit the article for publication.
Additional Contributions: We thank all pediatricians who volunteered use of their offices for recruitment and all parents who completed the survey.