Urgent care centers are seen as the epitome of efficiency in the US healthcare model. And for good reason - urgent cares were born out of the needs-based gap between hospital care and outpatient primary care clinics. They have a history of leveraging the latest innovations in treatment practices, payment models, and patient workflows. In the context of a complex, compartmentalized, and slow-to-change healthcare system, this legacy of adaptability has allowed urgent cares to be the most prepared to adopt the efficiencies afforded by emerging technologies like PCR testing.
For all that the urgent care/retail health model has contributed to the modern landscape of medical care, operating one is not without its difficulties. Experts have weighed in on what these are and what might be done about them.
If tackling the complex issue of diagnostic error in practice seems daunting, it’s because it is. Paul Epner, the CEO of and Co-Founder of the Society to Improve Diagnosis in Medicine, weighs in that these errors may constitute a larger safety issue “than every other safety issue (e.g. medication errors, wrong-side surgery, hospital-acquired infections) combined” and that this “impacts not just the patient, but also the health system – there are estimates that it costs the US economy in excess of US $100 billion per year.”
While research to evaluate the prevalence of diagnostic errors specifically in urgent cares is sparse, the reasons why wrong diagnoses happen are just as present in urgent cares as other settings. The two worlds that urgent cares straddle - Primary Care clinics and Emergency Departments - have alarmingly high rates of errors. Johns Hopkins researchers discovered that 71% of these diagnostic errors occur in these settings, with infections constituting one of the “big three” categories of missed illnesses, alongside cancers and vascular events.
Operating costs are typically higher for urgent cares than primary care clinics, which means a lot of effort is spent in capturing as much reimbursement as possible. And this presents its own unique challenges - despite sharply elevated patient volumes throughout the pandemic, many urgent care practices’ overall revenue remained stagnant. Practolytics finds this comes down to a few issues including limited time for pre-authorization, proportionally lower reimbursements for urgent cares than other types of practices, and lack of expertise on the most effective billing/coding techniques.
One of the unfortunate casualties in the COVID-19 pandemic has been a loss of focus on other pressing health issues. One of the greatest of these with a high potential for latent effects is antibiotic stewardship. Unfortunately, it also constitutes more of a difficulty in urgent cares than in other settings. In a 2018 CDC study published in JAMA, urgent cares were shown to be the largest contributors (45.7%) to inappropriately-prescribed antibiotics for respiratory conditions. What makes this a particular difficulty in retail health likely has to do with its point-of-care nature and a heavy reliance on empiric prescribing.
Prior to the COVID-19 pandemic, PCR wasn’t getting the utilization it warranted. Based on the idea that you could multiply fragments of DNA in order to find a causative pathogen, the healthcare industry had not begun to use it in earnest until it became the gold standard of testing for the SARS-CoV-2 virus. So much so that in 2020, the average urgent care saw a 58% increase in daily patient volume, with much of this dedicated to assessment, testing, and vaccination for COVID-19.
And where PCR has shined in COVID-19, research has also shown its effectiveness in a broad array of other diagnostics, like urinary, respiratory, and skin infections, among others. It surprises many to learn that there are other infections outside of SARS-CoV-2 that can be detected with PCR, but the truth is that multi pathogen panels are being used for a wide array of infections, including:
But how does PCR help with the aforementioned urgent care challenges? It offers opportunities in a few ways:
There are many moving parts to the complex issue of errors in diagnosis, but the specific way PCR might be useful is in its broad ability to catch infections. Paul Epner goes on to say that while the overuse of testing is in fact a challenge in our health system, research actually shows that under-testing is a more prevalent issue and one that has a palpable impact on missing what’s causing a patient’s symptoms. With testing that comes back rapidly (often in as little as 2 hours), PCR offers the chance to tailor antibiotic therapy rapidly with fewer opportunities for patient miscommunication or delays in treatment.
Since PCR testing can result at the point-of-care, many practices are opting to develop Physician-Office-Labs (POLs) in-house to capitalize on the benefits of PCR. Doing this can reduce the costly inefficiencies of outside lab testing and allow a fair and direct financial relationship with the patient.
One of the cornerstones of antibiotic stewardship is administering the right antibiotic for a specific pathogen. A strong handling of empiric prescribing (where the physician knows the most common pathogens for any given disease and what antibiotics typically work for them) helps, but research is showing that the infective landscape is changing and an empiric approach is not as effective at killing infections as it used to be. In the past, lengthy cultures and sensitivities would be required to provide targeted antibiotics, but PCR allows this to be done in as little as 2 hours. This can help your patient walk out the door knowing they are on the right drug for their infection.