ER alternatives: Urgent-care clinic or in-store clinic might work instead

Feeling sick - or you have a kid who does - but you find out that your doctor's office can't fit you in for another week?

Primary-care physicians aren't the only game in town. In fact, you have several places to turn, including urgent care clinics, in-store "retail clinics" set up in a grocery store or pharmacy, and the hospital emergency department.

The inevitable question then becomes: Which level of care should you seek - and for what ailments?

Here's the rub: Based on conversations with an emergency department doctor, a primary-care physician who runs and co-owns an urgent care clinic, and a nurse practitioner who cares for patients at clinics inside pharmacies, it turns out there are no black-and-white answers.

You can do your own triage, however, and potentially avoid hours in a waiting room. Consider these points:

Severity: A general guideline: Crushing chest pain, severe bleeding, trouble breathing or signs of stroke should have you calling 911 immediately, says Angela F. Gardner, president-elect of the American College of Emergency Physicians and associate professor of emergency medicine at the University of Texas Southwestern, Dallas.

Otherwise, "if you're having serious symptoms and you think you need hospitalization or surgery, go to the emergency department," she says; for example, an intense pain, which could indicate appendicitis or a kidney stone.

If you don't believe it's life threatening, the primary-care physician is always the first call you should make, says Gardner. That is, if you have one. Some 20 percent of Americans don't have a "medical home" to address primary-care needs like headaches, colds, or high blood sugar, says the American Academy of Family Physicians.

Services provided: The emergency department can handle everything, but the wait time and cost can be factors, depending on the patient's complaint.

In-store clinics, like Minute Clinics at CVS pharmacies and Take Care Clinics at Walgreens, offer a specific menu of services that would typically be addressed in the office of a primary-care physician. Care is typically given by nurse practitioners who can write prescriptions. Each service has an out-of-pocket cost, though insurance companies may cover care received (a copay is usually required).

Minute Clinic's Web site, for example, lists treatable ailments under several categories - from minor illness including coughs, body aches and itchy eyes ($62) to wellness and prevention services ($20 to $66) like college and camp physicals and screening for hypertension and diabetes.

And the menu of services is growing as such in-store clinics expand. Take Care Clinic, for example, recently announced it will offer nebulizer treatments, which involve patients breathing medication from a small machine to treat respiratory distress like an asthma attack.

Urgent-care clinics, on the other hand, are staffed by doctors trained in primary care or emergency medicine, often along with nurses. Patients can pay out of pocket, but insurance regularly covers a visit (with a copay). Services offered can differ by clinic, says Lou Ellen Horwitz, executive director of the Urgent Care Association of America; some may have the ability to perform blood work, a chest X-ray, an EKG of the electrical pulses of a patient's heart, or even a CT scan, while others don't.

Patients would be wise to call ahead to be sure their concern can be handled. The menu of offerings at urgent-care centers, too, may be influenced by the type of clinicians who staff them. Those run by doctors trained in emergency medicine might cater more to one-time issues, like a cut or ankle sprain, while those run by doctors trained in family medicine might serve as a regular source of primary care - offering well-baby exams, pap smears, and prescriptions for chronic conditions, like high cholesterol or hypertension.

"I have patients I've seen 50 times," explains Phillip Disraeli, who co-owns Metro Urgent Care in Frisco, Texas, and is director of clinical programs for the Urgent Care Association of America.

Quality: Since the first in-store clinics began to show up in 2000, concern has arisen among physicians (as well as the American Medical Association and the American Academy of Pediatrics) over the quality of care a person could expect to get at these centers, which are staffed by nurse practitioners.

The hope, says Gardener, is that if you go to an in-store clinic you have a clinician astute enough to recognize when something that appears to be simple is actually more serious.

Disraeli's urgent care clinic has relationships with specialists in the community as well as hospitals. If a person goes to an in-store clinic, he says, he'd want the clinic to have a safety net for patients, including relationships with a nearby urgent care clinic, primary-care physicians and hospitals.

Research published in an August issue of the Annals of Internal Medicine suggests that for three common ailments - earache, sore throat, and urinary tract infection - patients get care as good as that delivered by physicians in other settings.

"We are acutely aware of what's safe in our setting and what's not," explains Anne Pohnert, a nurse practitioner at Minute Clinics in Northern Virginia. She points out that many of the basic tests available in ERs and urgent care clinics - urinalysis, rapid strep throat testing, rapid flu testing - are also offered in the in-store clinic setting.

Each Minute Clinic, she explains, has a list of local primary-care physicians taking new patients as well as nearby urgent care centers and hospitals for patient referrals. According to data from Take Care Clinics clinicians refer patients on to a higher level of care about 10 percent of the time (90 percent of which is to a primary-care physician and 1.5 percent of which is to an ER).

Timing: Check hours of operation. Both urgent care centers and in-store clinics have extended hours beyond those of a typical doctor's office - often before or after work during the week plus hours on the weekends. The emergency department, of course, never closes and is federally mandated to take all comers, regardless of their ability to pay.

A little-known truth about the ER, says Gardner, is that it's busiest not on weekend nights when drunk revelers start getting in accidents (though that's a hectic time, too).

"The busiest day is Monday afternoon," she says. The reasons: People couldn't get in to their doctors because the wait was too long, say a week or more, or they got injured over the weekend and waited. "What isn't obvious is that (Monday) is the busiest operating room day in the hospital, and lots of beds are reserved for people coming out of the ORs or doctors' clinics," she explains. So folks who come in through the emergency department and need to be admitted must often wait in the ER.

Cost: If bargain shopping is a motivation in your decision-making process, in-store clinics may have the best deals. In the Annals of Internal Medicine study, the total cost per episode was found to vary by location: with a visit to a retail (or in-store) clinic averaging $110, a visit to a physician's office averaging $166, a visit to an urgent care clinic averaging $156, and a visit to an emergency department averaging $570.