Methods of Inquiry Research
Literature Review Major Paper
School of Computer & Information Sciences
Patrick O McMahon PharmD MBA
Regis University
Literature Review Major Paper
The research problem this paper will identify is whether the addition of a primary care
clinic or urgent care center next to the Emergency Department (ED) will impact the wait time in
the ED. Imagine the following scenario: It is 9 o’clock on a Tuesday evening. There are no
seats; people are standing as patients line the walls in wheelchairs. A son is trying to get the
attention of the triage nurse about why his father has not been seen yet. The triage nurse is
managing the triage of a patient and attending to a screaming woman in labor. People are
complaining about their wait times, ranging from 4 to 5 hours. There are no open rooms, and the
number of patients waiting to be seen continues to increase. Unfortunately, this has become the
typical day in the emergency department waiting room. Overcrowding is a pandemic across the
United States that needs immediate intervention (Borkowski, 2012).
EDs are a routine site of care for patients with conditions that might otherwise be cared
for in an ambulatory setting (Parks, 2014). Hospitals throughout the developed world must meet
the health care needs of expanding and aging populations, which has led to notable increases in
non-urgent presentations at EDs (Crawford, 2017). Increasing hospital capacity may be out of
the control for the majority of front-line health care professionals, re-evaluating and altering the
process by which less urgent ED patients access the emergency department provide an
opportunity for front-line health care professionals to be innovative, improve patient satisfaction,
and decrease ED crowding for all ED patients in general (Finamore, 2015).
Retail clinics are located in retail shops (eg, pharmacies, grocery stores) and can be
staffed by nurse practitioners and physician assistants. They are open after normal business
hours on weekends and evenings plus appointments are not needed, wait times are short, and
they accept many private insurances, as well as Medicare. One third of the urban population in
the United States lives within a 10-minute drive of a retail clinic. Up to 13.7% of all ED visits
are for low-acuity conditions that in theory could be treated in retail clinics, which could lower
the wait times and the corresponding ED. Given their convenience, increasing popularity, and
lower cost, patients may prefer a retail clinic over an ED for some conditions (Martsolf, 2017).
A prevailing theory by groups that promote “convenience settings” is that they reduce ED visits.
Conceptually, the ill and injured with conditions potentially treatable in these settings would
choose them over the ED because of greater accessibility, shorter waiting times, and lower costs.
Unfortunately, theory and reality do not always align. The study by Martsolf et al challenges the
notion that convenience settings substitute ED visits. In actuality, the predominant effect is “new
use, “meaning that visits to convenience settings are mostly additive, rather than substitutive.
Many people who would not have otherwise received treatment seek care in convenience settings
because they’re accessible and available. A separate study found that 58% of retail clinic
encounters are new use as opposed to care by another outpatient provider, such as a primary care
physician (Pines, 2017).
Studies have also been published to determine the effect of enhancing the degree of
choice for non-urgent patients on duration of wait for ED visits and the effect of co-located
clinics on duration of wait times for emergency patients in EDs. The answers to these questions
help in understanding the effectiveness of demand management strategies, which are identified
as one of the solutions to ED crowding (Sharma, 2011).
In order to determine if the addition of a primary care clinic or urgent care center next to
the Emergency Department (ED) will impact the wait time in the ED a comprehensive literature
search was completed. The search parameters used were: Emergency Department, Primary Care
Clinic, Internal Medicine Clinic, and Wait Time. The databases searched were: PubMed,
CINAHL, Cochrane Library, and AHRQ. Only articles written in English and published in the
last 10 years were considered. Hundreds of articles were screened to make sure they actually
looked at the relationship between primary/urgent care clinics and EDs. It was determined that
seven articles met the criteria for inclusion in the literature review.
Urgent care centers have been increasing in popularity over the years, with a 50%
increase from 2000 – 2010. Urgent care centers evaluate and treat a broader scope of illness than
primary care offices and function similarly to emergency departments. They are open 7 days a
week with extended evening hours beyond normal business hours and do not require
appointments. The usual wait time to be seen at an urgent care center is less than 30 minutes,
compared with hours at an emergency department. They are run by physicians, nurse
practitioners, and nurses trained in primary or emergency care, and most can perform basic
laboratory tests, obtain radiographs, provide care for fractures, and offer intravenous fluids
(Borkowski, 2012).
Internationally, alternative models of care do appear to have an impact on ED
presentations reducing waiting times for more urgent cases. However, community members need
to be made aware of alternative options in order to make informed treatment options. An
understanding of patients’ reasons for choosing a care option will also inform healthcare plans
(Crawford, 2017). Domestically, no association between retail clinic penetration and ED
utilization for low-acuity conditions was found overall. There was an association among patients
with private insurance. However, the effect sizes were very small and would require a significant
increase in retail clinics to have even a modest influence on ED visits. These results do not
support the idea that patients will visit a retail clinic as an alternative to the ED (Martsolf, 2017).
Convenience settings create new use for three reasons: “they meet unmet demands for care,
motivations for seeking care differ in EDs and convenience settings, and groups of people who
are more likely to use EDs for low-acuity conditions do so because they have little access to
other types of care, including convenience settings” (Pines, 2017). The ED providing non-
emergent care has been hypothesized to result from a lack of primary care access, availability of
ambulatory care appointments, and general dissatisfaction with non-ED care. Given the current
rationale for accessing EDs for non-emergent conditions, it would seem reasonable that
ambulatory facilities in rural areas, not easily accessible to EDs would fill the role of providing
timely care for non-emergent conditions experienced by non-established visiting patients.
However, increased distance from the nearest ED had no impact on the likelihood of booking an
appointment. In actuality, clinics located near a UC were more likely to grant an appointment
than clinics without close alternative outpatient healthcare options (OR 2.45, 95% CI [1.19-
5.80]). This paradox suggests proximity to UCs creates more competition for patients,
increasing PCP offices’ willingness to accommodate non-established visiting patients.
Alternatively these facilities may be appropriately decreasing the volume burden experienced by
PCPs allowing them time to see patients with urgent concerns in a timely manner (Parks, 2014).
The use of an ED satellite clinic that sees returning patients for follow-up diagnostics or
treatment to bypass the main emergency department is consistent with the concept of using
urgent care centers and primary care clinics to funnel non-urgent visits away from the main ED.
Capacity can be increased by removing returning patients from the pool of patients requiring care
in the ED. The process can be streamlined by creating a separate registration area and a
separately staffed treatment area (Finamore, 2015).
The major gap in knowledge regarding the research question is that there has not been a
major study looking at individual EDs for a time period before and after the opening of a retail
clinic and measuring low-acuity visits. The quality of the available research does not
definitively tell the audience if there is a correlation between retail clinics in the vicinity of EDs
and low-acuity visits. The power and sample size implications are that this would be a more
labor-intensive approach and would either require more resources or a longer time period of data
collection. The crisis of ED overcrowding has a dismal future because primary care is expected
to worsen over the next decade. The emergency department is working at maximum capacity
and cannot absorb more patients who are unable to find other sources of care. Urgent care
centers are a piece of the solution. Urgent care centers have the capability to manage patients
who have non–life-threatening emergencies. However, a serious effort needs to be made to
provide more urgent care centers in urban areas and educate communities about their resources.
If solutions are not taken seriously, the national crisis of ED overcrowding is going to result in
catastrophic outcomes (Borkowski, 2012).
Retail clinics have the potential to impact on ED workloads but there is little recent
research and more work is required to substantiate this pathway. Primary care cooperatives with
nurse-led triage of medical emergency care (as in The Netherlands) do receive and reduce a
proportion of ED presentations in less urgent patient categories. More evidence is required to be
confident of the efficacy of these care pathways as an alternative to ED treatment, particularly
regarding patients’ medical outcomes (Crawford, 2017). Important barriers to rural ambulatory
care for non-emergent medical conditions exist, resulting in use of EDs for non-emergent care by
non-established visiting patients. There appears to be a disparity for financially vulnerable
populations, leaving those uninsured and unable to pay large upfront fees less likely to be able to
acquire timely access to outpatient care for semi-urgent ambulatory concerns. Barriers to care do
not seem to be limited to financially vulnerable populations; it was found that insured patients
were also unable to schedule ambulatory care appointments. Primary care centers located greater
distances from continuously staffed EDs are not surrogates for ED care. Timely access to
outpatient care for urgent ambulatory concerns is necessary to prevent unnecessary ED visits.
Barriers to this form of care have the potential to create challenges for both EDs and patients
seeking care in facilities other than their established doctor office. Patients with concerns that
could not be treated in the outpatient setting will experience increased wait times due to ED
crowding. Patients with concerns that could be treated in the outpatient setting will accrue
considerable costs that could otherwise be avoided if barriers to this care did not exist. These
barriers do in fact exist and UC facilities might have a major impact on timely ambulatory
healthcare access in rural and suburban areas. Further research evaluating the impact of these
sites of care would provide a better understanding if their specific impact on ED utilization in
rural and suburban environments (Parks, 2014).
The degree of choice for non-urgent patients has a non-linear effect: more choice for
non-urgent patients is associated with longer waits for emergency patients at lower values and shorter
waits at higher values of degree of choice. Thus more choice of EDs for non-urgent patients is related to a
longer wait for emergency (category 2) patients in EDs. The waiting time for emergency patients in
hospital campuses with co-located urgent care clinics was 19% lower (1.5 min less) on average than for
those waiting in campuses without co-located GP clinics. These findings suggest that diverting non-
urgent patients to an alternative model of care (co-located GP clinics) is a more effective demand
management strategy and will reduce ED crowding (Sharma, 2011).
There are several distinct reasons explaining why patients choose to access emergency
and urgent care services: limited access to or confidence in primary care; patient perceived
urgency; convenience; views of family, friends, or other health professionals; and a belief that
their condition required the resources and facilities offered by a particular healthcare provider.
There is a need to examine demand from a whole system perspective to gain better
understanding of demand for different parts of the emergency and urgent care system and the
characteristics of patients within each sector. Many people do not know what an urgent care
center is or what services it has to offer. If people cannot be seen at their primary care
physician’s practice, they either are referred to the emergency department by their primary
clinician or believe that the emergency department is their only option for care. In addition to
increasing the number of urgent care centers, funding must be allocated to educating the public
and advertising the resources of urgent care centers. The literature examined in this review did
not examine the qualitative nature of these reasons and further research would serve the
academic community, hospital administrators, third party payer, and patients well to explore
further.