Urgent Care is a rapidly emerging health care delivery setting experiencing dramatic increases in patient volumes across the United States. Across the health care industry, consumers are driving growth in Urgent Care with a focus on accessibility, affordability, and digital expansion-key drivers in increased Urgent Care visitation.1 Patients are using Urgent Care clinics as a low-cost and time-saving alternative to the emergency department for low-acuity emergency services. In addition, Urgent Care clinics offer an alternative to primary care clinics when same-day walk-in appointments are not available. Urgent Care is a distinct clinical area that currently captures $18 billion of the health care market and is expected to grow annually by 5.8%.2 As this segment of the health care market continues to grow, connecting care delivery to evidence-based implementation practices is critical to improve operational efficiencies while providing consumers with the highest quality of care.
Urgent Care clinics provide convenient access to care for common acute conditions, many of which might have otherwise resulted in an emergency department or an urgent primary care visit. Fewer than 3% of Urgent Care encounters have a subsequent escalation of care, morbidity, or mortality.3 Respiratory conditions are the most common encounters and antibiotics are among the most frequently prescribed medications. In addition, inappropriate antibiotic prescribing occurs more often in Urgent Care settings than other ambulatory care settings according to work performed by the Centers for Disease Control and Prevention (CDC).4 In a retrospective analysis of Urgent Care encounters within the Intermountain Healthcare network, antibiotics were prescribed in 34% of all Urgent Care encounters and in 50% of respiratory encounters, with extreme variation among clinicians ranging from 3% to 94% of respiratory encounters receiving an antibiotic.5 These findings signal unique challenges faced by Urgent Care clinicians while suggesting that antibiotic stewardship is a priority requiring specific interventions targeting these settings.
Our objective is to explore unique barriers in the Urgent Care setting while highlighting a real-world example that is in progress at Intermountain Healthcare to reduce antibiotic prescribing for respiratory conditions in the Urgent Care setting.
ANTIBIOTIC PRESCRIBING: BARRIERS IDENTIFIED WITHIN URGENT CARE SETTINGS
Formative research was conducted among 5 high-volume Urgent Care clinics within Intermountain Healthcare's network of 38 clinics to inform future antibiotic stewardship interventions. Interview data were summarized using an established, implementation science framework-the Consolidated Framework for Implementation Research6- to classify reported barriers to appropriate antibiotic prescribing within these Urgent Care settings. These interviews were conducted prior to implementing antibiotic stewardship interventions in our organization and thus barriers associated with stewardship interventions were not assessed.
Individuals (ie, clinicians, clinical staff, patients)
Clinicians reported the presence of key barriers to optimal antibiotic prescribing: low self-efficacy to follow prescribing guidelines while routinely assuming patients expected antibiotics; lack of clarity about appropriate antibiotic prescribing goals; limited data and feedback regarding individual or group prescribing habits; and conflicting beliefs that antibiotic guidelines were too academic, yet necessary to deliver value to patients. Clinic staff described how antibiotic stewardship could be incorporated into the clinic workflow (eg, providing patient education while rooming a patient) but rarely received training according to clinical practice guidelines for antibiotic stewardship. Patients rarely reported expectations of receiving antibiotics but rather highly valued receiving education about symptom management during the encounter.
Inner setting (ie, Urgent Care clinic setting)
Urgent Care clinics utilize variable staffing models based on the established seasonality of the conditions that are treated-leading to limited resource availability at times. Many clinics are open long hours and most days of the week to provide on-demand and convenient access, which contributes to time constraints within encounters and makes training of all staff difficult. Clinicians within the Intermountain network often rotate among multiple, regionally based locations. Challenges exist in connecting Urgent Care clinicians with relevant consultative specialty services (eg, infectious disease) when questions arise during the encounter. Variability in affiliation and medical training among clinicians may also contribute to suboptimal awareness and adoption of locally developed evidence-based guidelines. How a team was organized contributed to how well the team communicated and trained all members, engaged in a team learning process, and participated in clear goal setting and improvement activities.
Outer setting (ie, Intermountain organization and national policy factors)
As with other health care settings, fee-for-service Urgent Care physician compensation (eg, Relative Value Units, or RVUs) potentially creates perverse incentives to code for higher acuity illnesses, perform more diagnostic tests, and/or prescribe more medications. Direct-to-consumer Urgent Care telehealth visits are also rising-countering rising labor costs and increasing patient convenience while providing equitable care to brick-and-mortar Urgent Care clinics.7,8 Rapidly changing market forces in the Urgent Care setting may make it difficult to balance the quality and access to services while staying competitive with rising costs and diminishing reimbursement.
ANTIBIOTIC STEWARDSHIP IN A LARGE NETWORK OF URGENT CARE CLINICS AT INTERMOUNTAIN HEALTHCARE
To address the need for better strategies to reduce antibiotic overuse, the CDC published the Core Elements of Outpatient Antibiotic Stewardship.9 Four interacting elements-action for policy and practice, education and expertise, tracking and reporting, and commitment-provide an evidence-based framework for the development, implementation, and sustainment of antibiotic stewardship interventions in outpatient settings.
In July 2019, Intermountain used the CDC Core Elements to deploy stewardship interventions in Urgent Care settings. Electronic medical record tools included prompts for using delayed prescriptions for selected respiratory conditions in place of immediate prescriptions, templated electronic notes for common respiratory conditions, and justification alerts for azithromycin (action).10 Patients receive education fact sheets and symptomatic therapy checklists (education). Urgent Care clinicians received education on Intermountain's updated care process model (education/expertise) and monthly, transparent antibiotic prescribing data (tracking and reporting). Prescribing data and educational material are reviewed at regional clinician meetings with Urgent Care leadership. Raising awareness and changing patient perceptions through media campaigns also include leadership commitment posters displayed visibly within clinics (commitment). Early implementation results suggest that clinicians are engaged, as delayed prescriptions have substantially increased across the network and the respiratory antibiotic prescribing rate has started to decline.
CONCLUSION
Health care settings have distinct contextual factors that need to be incorporated into the implementation design to maximize effectiveness, uptake, and sustainability of evidence-based practices. Urgent Care is an emerging health care delivery setting experiencing dramatic increases in patient volumes, which warrants tailored interventions including those focused on antibiotic stewardship. Formal study to understand the relationship between Urgent Care barriers, evidence-based interventions, and antibiotic use will inform future intervention iterations in this setting.
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