Cost and Quality of Care at Retail Clinics
Key point: Quality scores at retail clinics rivaled those at urgent care centers, physician offices, and EDs.
Citation: Mehrotra A, Liu H, Adams JL, et al. Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses. Ann Intern Med. 2009; 151(5): 321-328.
Professional organizations have raised concerns about the quality of care that is delivered at store-based retail clinics. Using claims data from a Minnesota health insurer, investigators searched for episodes of initial care for pharyngitis, otitis media, and urinary tract infections; they identified 2,100 episodes that occurred in retail clinics and matched them with 13,070 episodes that occurred in urgent care centers, physician offices, or emergency departments (EDs). In addition to location and aliment, cases were matched by age, sex, comorbidities, and income.
Aggregate quality scores (proportion that met indicators specific for each condition) were similar for retail clinics, physician offices, and urgent care centers (64%, 61%, and 63%, respectively) and lower at EDs (55%). Urine cultures for high-risk patients were ordered less often at retail clinics than in other settings (30% vs. 55% – 58%). Costs per episode (health plan reimbursements plus copayments) were lower for retail clinics ($110) than for physician office ($166), urgent care centers ($156), and EDs ($570).
Many physicians smirk when they hear about care that is delivered at a retail clinic or at a freestanding “doc-in-the-box.” This study won’t settle questions about quality of care in such settings, in part because all settings scored low and measures were obtained exclusively from claims data. But, clearly, these services have arisen in response to perceived needs.
[Published in J Watch Gen Med. September 17, 2009 – Richard Saitz, MD, MPH, FACP, FASAM.]
Do Corticosteroids and Antiviral Agents Have Benefits for Patients with Bell Palsy?
Key point: New evidence has emerged regarding the use of corticosteroids and antiviral agents in Bell palsy.
Citation: Almeida JR, Khabori MA, Guyatt GH, et al. Combined corticosteroid and antiviral treatment for bell palsy: A systemic review and meta-analysis. JAMA. 2009; 302(9): 985-993.
Eligible studies were randomized controlled trials comparing treatment with either corticosteroids or antiviral agents with a control and measuring at least one of the following outcomes: unsatisfactory facial recovery (four months), unsatisfactory short-term recovery (six week to less than four months), synkinesis and autonomic dysfunction, or adverse effects. Eighteen trials involving 2,786 patients were eligible.
Regression analysis identified a synergistic effect when corticosteroids and antiviral agents were administered in combination compared with alone.
Meta-analysis using a random-effects model showed corticosteroids alone were associated with:
- a reduced risk of unsatisfactory recover
- a reduced risk of synkinesis and autonomic dysfunction
- no increase in adverse effects
In addition:
- Antiviral agents alone were not associated with a reduced risk of unsatisfactory recovery.
- When combined with antiviral agents, corticosteroids were associated with greater benefit than antiviral agents alone.
- When combined with corticosteroids, antiviral agents were associated with greater risk reduction or borderline significance compared with corticosteroids alone.
Simple Abscesses – Can We Poke without the Pack?
Key point: Packing is not necessary.
Citation: Taira BR, Singer AJ, Thode HC Jr., et al. National epidemiology of cutaneous abscesses. J Emerge Med. 2009; 27: 289-292.
O’Mallet GF, Dominici P, Giraldo P, et al. Routine packing of simple cutaneous abscesses in painful and probably unnecessary. Acad Emerge Med. 2009; 16: 470-473.
Visits to the emergency department for cutaneous abscesses more than doubled between 1996 and 2005. Incision and drainage are the mainstay of treatment. The authors of these articles challenge the common wisdom that packing is critical to the care and healing of cutaneous abscesses.
Researchers conducted a prospective, randomized, single-blinded study of 48 adult subjects presenting to a single emergency department with simple cutaneous abscesses. All adult patients with cutaneous abscesses on the trunk or extremities that required I&D were eligible. Exclusion criteria included abscesses greater than 5 cm in diameter, pregnancy, comorbid medical conditions with possible immunosuppression including diabetes., HIV, malignancy, and chronic steroid use, as well as abscesses on other areas of the body and head, and a sulfa allergy.
Standard incision, drainage, and irrigation were performed on each abscess. Subjects were than randomized to packing with 1/4 inch plain gauze or no packing. Pain scores were measured in the ED using a standard 100-point visual analog scale (VAS); subjects were asked to record their VAS pain score twice daily until they were seen in a return visit in 48 hours. All subjects were prescribed trimethoprim-sulfamethoxazole (TMP-SMX), ibuprofen, and oxycodone/acetaminophen.
A physician blinded to the study examined each wound at the 48-hour visit and determined the need for further intervention and measured wound erythema, induration, and fluctuance. Measurements were repeated by a second, similarly blinded physician. All patients were contacted by phone 10-15 days after the initial visit to determine if their abscesses had required additional interventions.
Patients were randomized to the packing group (n=23) or the non-packed group (n=25). Only 34 subjects (66%) returned for the 48-hour follow-up visit. Thirteen were from the non-packed group and 21 were from the packed group. Four of the patients in the packed group and five of the patients in the non-packed group required intervention at follow-up.
Ten of the 11 patients in the non-packed group who did not return for follow-up and were contacted by phone reported that they did not think the abscess required re-evaluation and that they were pain free. Only one of the three patients in the packed group who did not follow up was reached and reported moderate pain but did not return to the ED.
There was no difference between the groups in pre-procedural pain scores. Subjects in the packed group reported higher pain scores in both the immediate post0procedural period and at the 48-hour follow up visit. There was no significant difference in the amount of ibuprofen taken, but patients in the packing group took a mean of 3.1 narcotic pain pills, compared with a mean of 0.91 pills in the non-packed group.
Given the prevalence of community acquired methicillin-resistant Staph aureus, it is unlikely that we will see a reduction in the prevalence of cutaneous abscesses. However, if the evidence bears out, elimination of packing of simple abscesses will save time and money and reduce patient discomfort.