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Your Child Is Sick and the Doctor’s Office Is Closed. What Do You Do?

as seen in The Washington Post

April 25
It was the middle of the night on a Saturday when Rob and Jessica Lott’s daughter, Shuli, awoke with deep, ragged coughs and trouble breathing. The Lotts were visiting Philadelphia for the weekend from D.C., and neither parent wanted to wait until Monday to see their pediatrician. But would this rise to the level of an emergency-room visit? And would an ER experience upset their sick toddler even more? The Lotts found a pediatric urgent-care center affiliated with the Children’s Hospital of Philadelphia that was open in the nearby town of King of Prussia. The experience was positive, the staff capable, friendly and efficient; 18-month-old Shuli was given a nebulizer treatment and a prescription for an antibiotic. Later in the day, many of her symptoms had improved. The $75 co-pay for the visit was a third of what an ER visit would have cost. “I’m not sure I would repeat the experience again if we could avoid it, but we’d definitely choose it over the ER or recommend it to others,” Rob Lott said.The original urgent-care centers, which began appearing in the 1980s, targeted adults, particularly those without insurance or a primary-care physician. Now, urgent-care centers — often operated by hospitals or doctors — are finding an appealing market in pediatrics. They’re occupying the ground between events that require an ER visit and less drastic ailments for which parents want immediate attention.And they’re offering not only evening hours, quick service and lower costs than emergency rooms but also staff trained in pediatrics.

So far, there has been little research into the quality of care at pediatric urgent-care centers, and the American Academy of Pediatrics has regarded them with caution.

But in a policy statement issued April 24, the AAP acknowledged their growth and urged pediatricians and the centers to develop lines of communication to prevent fragmented care. The AAP reiterated its position that parents should turn to their pediatrician first for nonemergency care.

“The updated statement represents an evolution in the pediatrician/urgent-care relationship,” said James Perrin, a professor of pediatrics at Boston’s MassGeneral Hospital for Children, co-author of the guidelines and a former AAP president. “Things have changed in these centers, and a lot of places provide good care. We’re seeing more pediatricians have relationships with urgent-care providers, and there are lot of opportunities there for collaboration that could be really productive.”

According to the Urgent Care Association of America, urgent-care centers totaled about 7,350 last year, an increase of 10 percent over the previous year. About 500 of them are aimed at children. (They differ from retail clinics, in drugstore and big-box stores, which usually are staffed by nurse practitioners who offer vaccinations, physicals and some tests.)

David Mathison, mid-Atlantic regional medical director of PM Pediatrics, a group of privately owned pediatric urgent-care centers in New York, New Jersey and Maryland, refers to research showing that the most common type of pediatric urgent-care diagnoses are similar to those at the ER, including respiratory infections, ear infections and fever.

Many childhood illnesses flare up at night, such as croup, where a young child awakes with a wheezy, barking cough and difficulty breathing. Or a child falls and needs stitches to repair a laceration or an X-ray and splint for a sprain or a broken bone. An off-duty pediatrician may recommend an ER, though a pediatric urgent care could also treat such cases effectively, Mathison says. “And for a fraction of the cost.”

The pediatric centers stay open late — often until midnight — and some open late, positioning themselves as a supplement to the pediatrician rather than an alternative.

PM Pediatrics developed its centers to capitalize on the shortcomings of the ER for nonemergency cases. The staff has pediatric training and patients are seen quickly. (The company estimates that it takes an average of 27 minutes from walking in the door to meeting with a provider, less time for repeat patients.)

Mathison spent nine years as an ER doctor at Children’s National Medical Center in D.C. before moving to pediatric urgent care.

For medical staff like Mathison, urgent care has its appeal: unlike an ER, there are no overnight shifts. For patients, the hours are convenient. A patient may come in with a diaper rash at 11:30 p.m. because both parents work late, Mathison says.

There has been an increased demand for all aspects of pediatric care, including well care and preventive services for children, says Julia Richerson, a pediatrician and chair of the AAP Committee on Practice and Ambulatory Medicine.

And children tend to have insurance (94.7 percent of those younger than 19 have private or public insurance, compared with 87.4 percent of working-age adults).

Emergency rooms are seeing a decrease in pediatric cases, says Alfred Sacchetti, chief of emergency services at Our Lady of Lourdes Medical Center in Camden, N.J., and a spokesman for the American College of Emergency Physicians.

“The ambulatory insured patients appear to be going to the urgent-care centers,” he said. “Insurance companies are marketing to parents that they should take their kids to an urgent care rather than an ER. Depending on what the child has, sometimes it works great. Sometimes — oops, wrong place, wrong child.”

It can be difficult for a parent to know when the ER is right and when urgent care is the best destination.

“You are asking the parent to make the decision ahead of time, and say, ‘I have made an assessment and I know this can be taken care of in this setting,’ ” Sachetti says. “Are parents good at that? Probably, but no one has good statistics on it.”

In any nonemergency medical situation, “the first call a parent should make is to the pediatrician,” Susan Kressly, a spokeswoman for the AAP and an author of its policy, said in an interview.

“As a pediatrician who personally sees patients, we hear that patients don’t want to bother us,” she says. “My answer to them: ‘You aren’t bothering us. This is our privilege. Please start with a phone call to us first. We can help you choose the right place to go.’ ”

Urgent cares, both general and pediatric, are regulated the same way a doctor’s office is: Physicians report to the state board of physicians, and the governing bodies that monitor lab testing, prescription drugs and X-rays, among others, have the same standards of oversight as they would in another health-care setting.

A study published in 2010 estimated that between 13.7 and 27.1 percent of all emergency room visits — for adults and children — could be handled in urgent-care settings.

Richerson says pediatricians have concerns that a child’s visit to an urgent care would take place outside what is known as the “medical home” with no subsequent communication with the pediatrician’s office. Particularly with chronic illnesses, one visit can disrupt an entire treatment plan, the AAP said in its updated policy statement.

“As pediatricians, we want children to have safe, high-quality care wherever they go,” said Richerson. “We feel that is best inside the medical home, but we know there are cases when that is not possible. We see [pediatric urgent cares] as potential partners in the medical neighborhood, and we all need to work together to put families in the center and do what is best for families.”

For many parents, the appeal of pediatric urgent care is straightforward: quick access at unpredictable times. As the Lotts found, it’s hard to expect a toddler’s Saturday night breathing problem to wait until Monday.

View the original Washington Post article here.