In this study we have documented many of the reasons that indigent patients rely on UCCs for their health care needs. The results confirm that patients tend to seek care in an urgent care setting due largely to convenience, affordability, and more timely care. Interestingly, the fact that there was no co-payment required at the time of the UCC visit was not reported as influential among a host of convenience factors. Our findings suggest that in order to shift a portion of the urgent care population to the primary care setting an attempt will not only need to be made to improve financial coverage for low income patients but also for the primary care setting to adopt many aspects of UCCs, which make them a preferred method to access care.
A perception of convenience was the most significant driving factor for patients in our study to seek care at the UCC. The lack of a need for an appointment was the most frequently cited reason (53.5%) for choosing urgent care. Since 40.6% of patients reported that they chose the UCC because it was open when they were off work we surmise that the long hours and 7 day schedule makes UCCs more accessible than primary care facilities which have more traditional hours. The degree to which the UCC's flexibility in scheduling attracted patients suggests that similar scheduling within conventional primary care systems may successfully attract a portion of these patients. The concept of "open access" appointment scheduling has been found to accommodate patients' urgent health care needs while providing continuous, routine care . A study examining the implementation of an open access scheduling system within a large multispecialty medical group found patients with chronic diseases (depression, heart disease, or diabetes) decreased utilization of UCCs by roughly one-third when open access scheduling was available at the primary care clinic . However, the study found no change in frequency of ED visits or hospitalizations.
In addition to suggesting convenience as a driving factor for patients choosing to obtain care at the UCC, our study also demonstrated that patients perceive the care in the urgent care setting to be timelier. Similar perceptions have previously been demonstrated as a driving factor for patients choosing urgent care . Young et al. found that twenty-one percent of ambulatory patients seeking care in an ED did so because they felt that they would receive better care and/or more prompt diagnosis and treatment . In our study, such perceptions were demonstrated by 43.9% of patients who recognized same-day test results as a primary reason for choosing our UCC and 46.4% who viewed the UCC as a means of obtaining care quickly. Notably, patient expectation of timely care has been shown to differ from that of physicians. In a recent study involving eleven written clinical scenarios, patients felt clinical evaluation should be performed significantly sooner than did physicians for eight of the eleven scenarios . Acknowledging this discrepancy in perceptions and educating patients may help mitigate this rationale for choosing the urgent care setting.
The evidence from our study that patient decision making is largely driven by convenience and a desire for timely care is particularly applicable to the recent national debate surrounding universal health care and the restructuring of primary care. The need for convenient access and timely care delivery is one of the seven cornerstones of the new "patient-centered medical home " as a model for primary care. Similarly, convenience and timely care have been emphasized in New England Journal of Medicine's recent perspective on "The Future of Primary Care" in which it is noted that "[p]atients needing urgent care must be able to get care on the day they request it ." The same article proposes that primary care should increasingly utilize "electronic or telephonic consultation" to serve as a convenient way of addressing patient issues while reducing demand for visits. Our data, which supports convenience as the largest driver in determining the means by which many patients seek care, strongly suggests that strategies such as these, which increase immediate healthcare accessibility, would be effective in attracting patients to the primary care setting.
The results of our study do raise some concern as to whether implementation of universal healthcare coverage without carefully addressing non-financial motivation for preferentially accessing urgent care may permit continued widespread miss-use of urgent care delivery systems. In particular, although lack of insurance was predictive of our patients delaying treatment and lacking primary care exposure, our data suggest non-economic causes to be equally strong predictors. Being male, white, or primarily Spanish speaking all had a higher odds ratio than did lack of insurance in predicting patient lack of a primary care source, and Spanish as a primary language had the highest odds ratio for predicting lack of a regular physician. Furthermore nearly three-quarters of our patients reported that not having to make a payment at the time of service was not perceived as an important reason for choosing the UCC. These findings suggest that increasing financial support, such as would be done through implementation of universal health coverage, may have only a limited effect on decreasing the number of non-urgent patients who present in the urgent care setting. This idea, in conjunction with a primary care shortage, can be seen in Massachusetts where the number of ED visits among low income newly insured patients remains 27% higher than the state average and concern exists as to whether overall urgent care visits may have actually increased since implementation of state-wide health insurance . Similar trends in increased urgent care utilization have been predicted in models assessing the impact of health insurance on medical care utilization . When viewed in the context of these examples our data strongly suggests a need for addressing the underlying social and cultural motivations highlighted in our study for choosing urgent care, in conjunction with offering wider financial support, to funnel non-urgent patients away from the urgent care setting.
Notably, our study also reinforced previous literature demonstrating that patients who preferentially seek care in the urgent care setting are at high risk of having many unmet preventive care needs. Our data demonstrated that patients with regular sources of primary care were significantly more likely to have had a flu shot, cholesterol test, or PAP smear within the generally accepted time frames. Access to primary care, even among those previously utilizing UCCs has been associated with decreased reliance on episodic care services and better quality of diabetes care .
An argument can be made that in light of the heavy reliance on UCCs by a large segment of the population that opportunities should be sought to provide preventive care interventions within the context of the UCC visit. Although follow-up remains problematic, we have previously shown it to be feasible with cervical cancer screening . There are also similar data in providing other interventions, such as immunizations [27, 28] without decreasing rates of subsequent use of primary care [29, 30]. Our study's findings highlight the possibility of enhancing the receipt of these preventive services during UCC visits. Despite the benefit of offering preventive care services in an opportunistic manner via the urgent care setting, the literature has clearly demonstrated the importance of developing a stable patient-provider relationship, which is associated with better preventive services than is having a regular site of care .
There are several limitations to this study. Perhaps most importantly, patients surveyed were those seeking care in our UCC at least once during the study period, rather than a population-based study in which a random sample of community residents were interviewed about their urgent care needs. In addition, there was no demographic information available on survey nonrespondents, although comparison of the study patient population to all users of the clinic during the study period demonstrated similarity in age, race/ethnicity, gender, and insurance status. Because of the methodology used, we were only able to verify patients' self-reported prior health care use if it had occurred at our institution. We were also unable to objectively determine the urgency of a patient's presenting complaint and/or their need as perceived by health care professionals to access urgent care services. This study was conducted during the summer months, so there may be unique seasonal variations in care-seeking behaviors that cannot be analyzed here. We intentionally avoided conducting the study during the busy flu season because we knew it would be a confounder for accessing urgent care. In our health care system there is a standard method of triage between patients seeking care in the ED and UCC so that during the study period all urgent care appropriate patients were seen in the urgent care and eligible for study inclusion. However, we made no attempt to assess where the patient first attempted to seek care (presenting directly to the urgent care or triaged there from the ED); there may be substantial differences between these two patient populations that influenced our results. Lastly, our findings may not be generalizable to other populations with different patient and delivery system characteristics.