Abstract
Background
Walk‐in clinics are growing in popularity around the world as a substitute for traditional medical care delivered in physician offices and emergency rooms, but their clinical efficacy is unclear.
Objectives
To assess the quality of care and patient satisfaction of walk‐in clinics compared to that of traditional physician offices and emergency rooms for people who present with basic medical complaints for either acute or chronic issues.
Search methods
We searched CENTRAL, MEDLINE, Embase, six other databases, and two trials registers on 22 March 2016 together with reference checking, citation searching, and contact with study authors to identify additional studies. We applied no restrictions on language, publication type, or publication year.
Selection criteria
Study design: randomized trials, non‐randomized trials, and controlled before‐after studies. Population: standalone physical clinics not requiring advance appointments or registration, that provided basic medical care without expectation of follow‐up. Comparisons: traditional primary care practices or emergency rooms.
Data collection and analysis
We used standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group.
Main results
The literature search identified 6587 citations, of which we considered 65 to be potentially relevant. We reviewed the abstracts of all 65 potentially relevant studies and retrieved the full texts of 12 articles thought to fit our study criteria. However, following independent author assessment of the full texts, we excluded all 12 articles.
Authors' conclusions
Controlled trial evidence about the mortality, morbidity, quality of care, and patient satisfaction of walk‐in clinics is currently not available.
Plain language summary
Comparing walk‐in clinics to physician offices and emergency rooms
What is the aim of this review?
This review sought to compare the quality of care and patient satisfaction between walk‐in clinics and other medical practice settings.
Key messages
Walk‐in clinics are growing in popularity around the world, but it is unclear if the medical care provided by walk‐in clinics is comparable to that of physicians' offices or emergency rooms.
What was studied in the review?
Frequently offering extended hours, shorter wait times, and lower prices, retail clinics have become popular alternatives to traditional physician offices and emergency rooms for people with low acuity illnesses. Despite their growing popularity, walk‐in clinics have been controversial. Surveys have shown that some doctors in the UK, Canada, and Australia are concerned that walk‐in clinics may provide lower quality care than physician offices. In the US, prominent physician groups have voiced similar concerns. A systematic review of the research literature on the quality and patient satisfaction of walk‐in clinics as compared to physician offices and emergency rooms would give patients, practitioners, and health policymakers an objective understanding of this increasingly important but controversial healthcare resource.
What are the main results of the review?
An extensive search found no studies addressing this question that fit our study criteria.
How up‐to‐date is this review?
The review authors searched for studies that had been published up to March 2016.
Background
Description of the condition
While the health systems of different countries vary significantly with regard to reimbursement schemes (e.g. universal coverage versus private insurance markets) and care delivery structures (e.g. publicly funded hospital systems versus free markets of for‐profit and non‐profit hospitals), many are confronting a shortage in healthcare workers in the face of aging populations and growing chronic disease burden (WHO 2013; Laurant 2009).
In an effort to better utilize existing workers, reduce healthcare costs, and improve access to care, a number of countries have begun shifting medical duties traditionally performed by physicians in high‐intensity care settings (e.g. emergency rooms) into lower‐intensity settings (e.g. outpatient clinics) (Bell 1992; Jenkins‐Clarke 1998; Whitecross 1999; Szafran 2000). In this context, walk‐in clinics have risen in popularity as health systems attempt to provide lower cost, more accessible care for the diagnosis, and treatment of low acuity conditions (Enright 2014).
Description of the intervention
For the purposes of this study, walk‐in clinics will be defined as standalone physical clinics not requiring advance appointments or registration, that provide basic medical care without expectation of follow‐up, and are not traditional primary care practices or emergency rooms. Basic medical care means conditions that do not require advanced laboratory or imaging for diagnosis or complex procedures for treatment (Mehrotra 2009). Lack of follow‐up means that walk‐in clinics provide medical care primarily for acute conditions or occasionally one‐off issues in people with chronic disease but not ongoing, comprehensive management of chronic issues via a longitudinal patient‐provider relationship as a primary care office would (Cassel 2012).
Like all medical service units, walk‐in clinics vary from country to country in design but do have several key characteristics, as described above, that make these clinics unique from other practice settings such as traditional physician offices and emergency rooms (Cassel 2012; Stroke Unit Trialists' Collaboration 2013).
Traditional primary care physician offices are led by doctors with ancillary support staff including nurses and medical assistants. These offices are equipped to handle both acute and chronic medical conditions, and typically have limited hours and require advance appointment booking. Physicians in these practices typically take responsibility and are a stable source of care for a large group of people over a long‐term period, building a longitudinal relationship with each person over repeated office visits. Emergency rooms are medical units designed to diagnose and treat acute medical conditions that require immediate medical attention.
Similar to physician offices, emergency rooms are typically led by doctors with ancillary support staff. Most often attached to tertiary care facilities, emergency rooms are able to handle higher levels of medical acuity with ready access to in‐house laboratories, imaging facilities, and specialty consults. Explicitly designed to stabilize and triage people to the level of care they require, emergency rooms do not offer longitudinal care services. Once people are deemed clinically stable, they are transferred elsewhere for ongoing or follow‐up care.
By contrast, walk‐in clinics are outpatient medical units designed to provide acute treatment for low‐risk conditions such as common coughs and colds. Walk‐in clinics can also augment chronic disease management as an accessible setting for one‐off issues but are generally not suited for ongoing monitoring or prevention of long‐term complications. Compared to traditional physician offices and emergency rooms, walk‐in clinics typically offer a more convenient experience in terms of location (typically a retail or community setting, not associated with a hospital), service (e.g. no appointments required; transparent pricing), and hours (open after hours on evenings and weekends) (Ahmed 2010; Weinick 2010).
Many countries have developed walk‐in centers as a lower‐cost and more accessible alternative to traditional sources of care. In Canada, walk‐in clinics were first established in Ontario in 1984 as an inexpensive way to reduce long waiting times for physician appointments (Hutchison 2003). In the UK, nurse‐run walk‐in centers began in 2001 and now see about seven million visits a year (Salisbury 2002; NHS 2013). Australia adopted its first nurse‐run walk‐in clinics in 2010 (Desborough 2013). In the US, walk‐in clinics were introduced in 1973 and have experienced enormous growth since the mid‐2000s (Jones 2000). From 2007 to 2009, visits to US retail clinics, one type of walk‐in clinic, increased from 1.48 million to 5.97 million annually (Mehrotra 2012). With the Affordable Care Act expected to extend coverage to 25 million new Americans over the next 10 years, without a corresponding increase in the supply of physicians, walk‐in clinics seem to be poised for even greater volume in the US (CBO 2014). While these visits still represent a small share overall of outpatient visits around the world, walk‐in clinics are growing in importance around the globe (WHO 2013).
How the intervention might work
The proliferation of walk‐in clinics could divert people with uncomplicated illnesses away from traditional physician offices and emergency rooms (Ashwood 2011). By doing so, they have the potential to reduce healthcare costs, improve access to care, and reduce medical workforce pressures (Cassel 2012). However, there is concern that they could provide lower‐quality care.
Why it is important to do this review
Despite their growing popularity, walk‐in clinics have been controversial. One survey of UK general practitioners revealed concern that walk‐in centers may provide lower‐quality care than traditional physician offices due to less‐trained personnel and lack of continuity of care (Pope 2005). In Canada, surveys show physicians view walk‐in clinics as inferior sources of care compared to emergency rooms or family physician offices (Hutchison 2003). Surveys of Australian doctors show similar concerns (Parker 2012). In the US, prominent physician groups such as the American Medical Association, American Academy of Family Physicians, and the American Academy of Pediatrics have raised concerns that the quality of care delivered by walk‐in clinics may be lacking, and that walk‐in clinics may disrupt physician‐patient relationships and continuity of care (AAFP 2013). A systematic review of the research literature on the care quality and patient satisfaction of walk‐in clinics as compared to physician offices and emergency rooms would give patients, practitioners, and health policymakers an objective understanding of this increasingly important but controversial healthcare resource.
Objectives
To assess the quality of care and patient satisfaction of walk‐in clinics compared to that of traditional physician offices and emergency rooms for people who present with basic medical complaints for either acute or chronic issues.
Methods
Criteria for considering studies for this review
Types of studies
Because there are few randomized trials available for walk‐in clinics, we planned to also include non‐randomized trials and controlled before‐after studies.
Randomized trials: random or quasi‐random allocation of participants to walk‐in clinics or a control (i.e. physician offices or emergency rooms), in which participants in each group differed only in their exposure to a different source of medical care. Factors that might affect the outcomes of interest were equally distributed between the two groups.
Non‐randomized trials: participants who were treated by walk‐in clinics and prospectively compared to participants treated in physician offices or emergency rooms.
Controlled before‐after studies: participants seen in a walk‐in clinic compared with participants seen in a doctor's office or emergency room, but the participants were not randomized to each intervention site. Clinical outcomes before and after participants sought medical attention were compared (e.g. participants rate their symptoms on a standardized scale before and after their healthcare visit, and the difference between sites was compared).
All studies were to meet the inclusion criteria for studies outlined by the Cochrane Effective Practice and Organisation of Care (EPOC) Group (EPOC 2013a). We planned to include both individually and cluster‐randomized trials. To be included, controlled before‐after studies had to include at least two intervention groups and two comparable control groups. We also planned to exclude randomized studies with only one intervention or control site.
Types of participants
People who presented to a walk‐in clinic with a medical complaint were eligible for inclusion in the intervention group. People who presented to a physician office or emergency room with a medical complaint was eligible for inclusion in the control group.
Types of interventions
Our focus was on comparing the outcomes achieved in walk‐in clinics (the intervention group) compared to traditional physician offices or emergency rooms (control groups) in treating both acute and chronic conditions. Acute conditions referred to diseases with symptoms that arose over days to weeks and, with appropriate medical intervention, were expected to fully resolve within days to weeks. Typically, a single care episode was all the medical attention required. Examples of common acute conditions included upper respiratory infections, sinusitis, bronchitis, otitis media, pharyngitis, conjunctivitis, and urinary tract infections. Chronic conditions referred to diseases with symptoms that typically arose over months and for which there was typically no curative medical therapy that could achieve total disease resolution. For such conditions, long‐term medical management was often required. Common chronic conditions included asthma, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease.
Studies with a definition of walk‐in clinics meeting all four criteria described above were eligible for the review (see Description of the intervention. For each included study, we planned to complete a data extraction form documenting that the definition of walk‐in clinic met the inclusion criteria (see Data extraction and management). We planned to include these tables in an appendix. We also planned to do a sensitivity analysis that excluded studies which met partial but not full criteria to evaluate the impact on the results (see Sensitivity analysis).
Types of outcome measures
Primary outcomes
Mortality.
Morbidity.
Quality of care (specifically adverse events and adherence to practice guidelines).
We planned to report in our findings of how the primary outcome for each study were selected. Primary outcomes were only to include objective measures.
Secondary outcomes
Participant satisfaction scores
Participant preference for return to walk‐in clinics.
Secondary outcomes were only to include objective measures.
Search methods for identification of studies
Electronic searches
The EPOC Information Specialist in consultation with the authors developed a sensitive search strategy designed to retrieve trials studies from electronic bibliographic databases. We searched the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects (DARE) for related systematic reviews and the following databases from inception to 22 March 2016:
Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2);
MEDLINE via Ovid (from 1946);
Embase via Ovid (from 1974);
CINAHL via EBSCO (from 1981);
PubMed (www.ncbi.nlm.nih.gov/pubmed/);
PubMed Central (www.ncbi.nlm.nih.gov/pmc/);
Health Technology Assessment Database (HTA; 2016 Issue 1);
NHS Economic Evaluation Database (NHSEED; 2015, Issue 2).
The search terms combined MeSH and free‐text words as shown in the MEDLINE strategy in Appendix 1. The MEDLINE strategy was translated using appropriate syntax and vocabulary for other databases. Results were limited by two methodological filters: the Cochrane Highly Sensitive and Precision Maximising filter for MEDLINE and Embase to identify randomized trials (Lefebvre 2011), and an EPOC methodology filter (version 2.6) to identify non‐randomized designs. We applied no restrictions on language, publication type, or publication year.
Searching other resources
Grey Literature
We conducted a grey literature search on 22 March 2016 to identify studies not indexed in the databases listed above. Sources were:
Joanna Briggs Institute (www.joannabriggs.edu.au/Search.aspx);
World Health Organization (WHO) International Clinical Trials Registry Platform (apps.who.int/trialsearch/); and
ClinicalTrials.gov (www.clinicaltrials.gov).
If we identified any additional grey literature sources, we planned to report them in the review. We reviewed the reference lists of all papers and relevant reviews identified by the electronic database searches. We contacted authors and field experts for any additional published or unpublished data. We planned to contact authors of active or completed trials for provisional results if they had not yet been published.
Data collection and analysis
Selection of studies
Two review authors (CTC and CEC) independently reviewed the title and abstract of all potential citations, and excluded any that did not meet inclusion criteria using the screening questions outlined in Appendix 2. Two review authors (CTC and CEC) read the remaining studies in full and independently assessed them to determine whether they met the eligibility criteria. We resolved differences between the review authors by consensus and discussion with third review author (JH). We documented full‐text papers that were excluded, along with the reasons for exclusion (see Characteristics of excluded studies table). We planned to extract studies that generated more than one manuscript as one, and for manuscripts that reported more than one study, to extract each study separately.
Data extraction and management
Two review authors (CEC and CTC) independently extracted data from each study using a modified EPOC data collection form (Appendix 3). The data extraction form included the walk‐in clinic definition, study design, demographics, and outcome measures. We planned to resolve discrepancies by consensus and discussion with third review author (JH).
Assessment of risk of bias in included studies
We planned to use the Cochrane 'Risk of bias' tool (Higgins 2011), and the EPOC‐specific criteria (EPOC 2013b) to assess the risk of bias in the included studies. For randomized trials, non‐randomized trials, and controlled before‐after studies, these nine criteria included: sequence generation, concealment, outcome measurement, baseline characteristics, incomplete outcome data, blinding, contamination protection, selective outcome reporting, and other bias.
Based on these Cochrane and EPOC‐specific criteria, two review authors planned to independently determine whether each study had a low, high or unclear risk of bias for each domain. If the two review authors disagreed, a third review author was to review the study and resolve the discrepancy through discussion. For studies that met inclusion criteria, we planned to describe the risk of bias for each domain with a descriptive summary justifying our decision. We also intended to measure risk of bias across studies for each primary and secondary outcome, considering the magnitude and direction of basis, as well as likelihood of whether bias was affecting the findings.
Measures of treatment effect
We planned to measure treatment effect based on the prespecified outcome variables and follow the framework as outlined by the Cochrane EPOC Group (EPOC 2013c). For all effect estimates, we intended to calculate the corresponding 95% confidence interval (CI). For dichotomous outcomes (e.g. mortality), we planned to use logit regression to calculate the adjusted odds ratio (OR) as the difference in outcome for patients treated by walk‐in clinics (intervention group) versus patients treated by physician offices or emergency rooms (control group). An OR greater than one would indicate a higher likelihood of mortality among participants seen by walk‐in clinics compared to the control sites; an OR of less than one would indicate a lower likelihood of mortality among participants seen by walk‐in clinics compared to traditional medical sources of care. For continuous outcomes (e.g. participant satisfaction scores), we planned to use standardized mean differences between the intervention and control groups, which would provide a 'scale‐free' effect estimate of each study which could be pooled across studies regardless of the original scale of measurement used (Laird 1990). If a study used both dichotomous and continuous measures to measure the same outcome, we planned to report both outcomes. If studies did not provide full information (e.g. standard error was not reported), we planned to contact the study's original author. If this was unsuccessful, then we planned to clearly documented the events and exclude the study from measurement of treatment effect analysis of that outcome.
Unit of analysis issues
To avoid unit of analysis errors, we planned to perform analyses at the same level as the allocation to treatment or control group. For clustered designs, we planned to perform an analysis adjusting for clustering, and reanalyze extracted results that did not adjust for clustering using an estimate of the intracluster correlation coefficient. If a study reported unit of analysis errors and there was insufficient information to reanalyze results, we planned to contact the original study authors to obtain necessary data. If these data were not available, we planned to not report CIs or P values and annotate them as a 'unit of analysis' error.
Dealing with missing data
We planned to seek missing information from the corresponding author of each paper. If we were unable to obtain missing data from a published study, we planned to report this on the data collection form and explicitly state any assumptions made about the missing data. For example, some data might be missing at random whereas other missing data might be associated with a particular outcome. We planned to conduct sensitivity analysis to assess how sensitive the results were to reasonable changes in any assumptions made, and discuss the potential impact of any missing data in the 'Discussion' section.
Assessment of heterogeneity
We planned to investigate heterogeneity by visual examination of forest plots and the Chi2 test. If these tests were suggestive of differences that were likely to be greater than those due to chance alone, we planned to assess the magnitude of heterogeneity using the I2 statistic. If the I2 statistic showed no substantial heterogeneity, we planned to perform meta‐analysis as appropriate. If there was substantial heterogeneity, we planned to explore potential explanations using subgroup and sensitivity analyses (see Subgroup analysis and investigation of heterogeneity).
Assessment of reporting biases
To reduce possible publication bias, we attempted to include relevant unpublished studies by searching the grey literature and prospective trial registries. If there were fewer than 10 studies available for a particular outcome, we planned to report that we were unable to assess publication bias. If there were greater than 10 studies available for a particular outcome, we planned to construct funnel plots to make a visual assessment of whether reporting bias might be present and use statistical tests to evaluate funnel plot asymmetry. If there was funnel plot asymmetry, we planned to investigate potential causes, including possible reporting biases, poor methodological quality, outlier data, and true statistical heterogeneity.
Data synthesis
We planned to pool data for meta‐analysis when studies were reasonably similar in terms of populations, interventions, characteristics, and outcomes. We intended to perform meta‐analyses for outcomes for which there were data from at least three randomized trials, since meta‐analysis of fewer than three randomized trials is unlikely to add value beyond a semi‐quantitative analysis. We planned to analyze outcomes with data from fewer than three randomized trials using semi‐quantitative analysis. We planned to perform meta‐analyses using a random‐effects model, because there may be natural heterogeneity between studies due to different study settings (e.g. walk‐in clinics in urban versus rural areas or in different countries). We planned to perform meta‐analysis of dichotomous outcomes using the Mantel‐Haenszel method and of continuous outcomes using the inverse variance method. We planned to prepare a table for studies of each type of intervention, which was to include study identification, outcome results including standard errors and ranges of effects, and key explanatory factors (see Appendix 3). Where multiple primary outcomes were reported for a single study, we planned to determine the primary outcome for the study by ranking the intervention effect estimates of the outcomes and selecting the outcome with the median estimate (Brennan 2009).
When summarizing the findings of the review, we intended to assess the certainty of the evidence using the GRADE criteria. We planned to judge the certainty of the evidence for each outcome as high, moderate, low, or very low based on the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) and present our assessment in a 'Summary of findings' table (MECIR 2013).
Subgroup analysis and investigation of heterogeneity
We planned to perform subgroup analysis comparing:
walk‐in clinics that had physicians versus walk‐in clinics with non‐physician medical staff;
walk‐in clinics that offer care for acute conditions versus walk‐in clinics that offer care for chronic conditions; and
walk‐in clinics that were managed by traditional healthcare delivery systems versus walk‐in clinics that were managed by other organizations.
The rationale for the first subgroup analysis was to determine whether differing levels of training among staff affects quality of care. Some research has suggested that in primary care, nurses can provide as high quality care as physicians along with high levels of patient satisfaction (Laurant 2009). However, these studies have typically compared nurses in walk‐in clinics to physicians in traditional offices. Because walk‐in clinics are designed for greater patient convenience, it is unclear whether the higher satisfaction scores are due to the clinical setting or the clinical provider. By comparing nurses and physicians in the same clinical setting, we may be able to make a more valid comparison.
The rationale behind the second subgroup analysis was that the episodic, non‐continuous care offered by walk‐in clinics may be more conducive to caring for acute conditions than chronic conditions. Chronic conditions require multiple visits and medical interventions over time, and are thought to be best managed via longitudinal relationships with primary physicians (AAFP 2013). Thus, the quality of care at walk‐in clinics may differ between acute and chronic conditions.
The rationale behind the third subgroup analysis was that walk‐in clinics are operated by different entities. In the US, walk‐in clinics are primarily operated by independent organizations such as retail organizations, whereas in other countries they may be supported by traditional healthcare entities (e.g. the National Health Service in the UK) (NHS 2013). Walk‐in clinics operated by traditional healthcare entities may offer either better quality care (i.e. by drawing on organizational expertise) or worse care (i.e. due to diversion of resources away from walk‐in clinics to traditional hospitals and clinics).
Sensitivity analysis
We planned to perform sensitivity analysis to assess the effect of imputing missing data with replacement values. We intended to repeat meta‐analyses to assess how sensitive results were to reasonable changes in the assumptions that were made. We planned to perform sensitivity analysis to investigate the impact of excluding studies that meet a partial but not full definition of walk‐in clinics. We also planned to conduct sensitivity analyses to assess the impact of excluding studies with a high risk of bias. Finally, if there were one or more very large studies, we planned to do a sensitivity analysis excluding those studies to determine if these studies dominated the results.
Results
Description of studies
We found no studies.
Results of the search
The initial searches identified 6587 citations; we considered 65 citations potentially relevant. We independently reviewed the abstracts and retrieved the full texts of 12 studies. We excluded all 12 after independent author assessment. The 12 studies did not meet one or both of two key criteria: they were either nurse‐led clinics but not walk‐in clinics, as defined by our criteria, or did not meet study type criteria (Figure 1).
1.
In the grey literature, we identified no ongoing or recruiting studies that met our inclusion criteria.
Because we did not have any papers that met study criteria, we did not conduct sensitivity analysis of studies that met the partial but not full definition of walk‐in clinics.
Included studies
We found no studies.
Excluded studies
We excluded 12 potentially relevant studies (see Characteristics of excluded studies table).
Risk of bias in included studies
We found no studies.
Allocation
We found no studies.
Blinding
We found no studies.
Incomplete outcome data
We found no studies.
Selective reporting
We found no studies.
Other potential sources of bias
We found no studies.
Effects of interventions
We found no studies.
Discussion
Walk‐in clinics are a widely discussed topic, as demonstrated by the large number of potentially relevant articles in our literature search. However, we identified no articles that met our inclusion criteria.
Summary of main results
We found no studies.
Overall completeness and applicability of evidence
The review is complete.
Quality of the evidence
We found no studies.
Potential biases in the review process
We do not believe our review process was biased. The Cochrane EPOC Information Specialist conducted the search, and there were no deviations from the review protocol.
Agreements and disagreements with other studies or reviews
Given the lack of included studies, we cannot compare our conclusions to that of other studies or reviews.
Authors' conclusions
Implications for practice.
Various stakeholders have made a variety of claims about the relative clinical efficacy of walk‐in clinics as policymakers and providers debate their proper role within healthcare delivery systems. Our review suggests that many of these claims, on both sides of the debate, may not be based on controlled trial evidence.
Implications for research.
Despite the increasing popularity of walk‐in clinics, there is currently no controlled trial evidence for their quality of care or patient satisfaction with regards to either urgent care or chronic disease management. While we are unable to draw conclusions based on the lack of evidence base, we hope that our review draws attention to the growing importance of walk‐in clinics to healthcare delivery around the world and need for research into this area.
The research to date on walk‐in clinics has focused on database and registry studies. This is likely due to the technical and ethical complexity of conducting a real‐world randomized trial, non‐randomized trial, or controlled before‐after study.
The ideal of a randomized study design is likely to be challenging in the setting of walk‐in clinics. Future research in this field should therefore consider non‐randomized studies of walk‐in clinics compared with traditional primary care and emergency room settings. If these controlled studies are powered adequately in terms of size and population, they should provide important data on mortality, morbidity, quality of care, and patient satisfaction.
Acknowledgements
We are grateful to the Cochrane EPOC Group editorial base for their thoughtful assistance in the preparation of this review. We are grateful to Michelle Fiander and Paul Miller for their help with the search strategy.
National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to the Effective Practice and Organisation of Care (EPOC) Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, National Health Service, or the Department of Health.
Appendices
Appendix 1. Search strategies
MEDLINE (Ovid)
Ovid MEDLINE(R) In‐Process & Other Non‐Indexed Citations and Ovid MEDLINE(R) 1946 to 22 March 2016
| No. | Search terms | Results |
| 1 | (walk‐in or walk‐ins).ti. | 470 |
| 2 | (walk‐in adj3 (appointment? or clinic? or center? or centre or centres or care or facility or facilities or healthcare or primary care or nurse led or (led adj2 physician? assistant?) or visit?)).ab. | 490 |
| 3 | (drop‐in adj3 (appointment? or clinic? or center or centers or centre or centres or care or healthcare or nurse led or (led adj2 physician? assistant?))).ti,ab. | 340 |
| 4 | ((as needed or unscheduled or patient scheduled or (self‐schedul* adj6 patient?)) adj2 (appointment? or visit?)).ti,ab. | 631 |
| 5 | ((weekend? or after‐hours or out of hours or week‐end? or evening) adj2 (care or health care or clinic? or consultation? or appointment?)).ti,ab. | 686 |
| 6 | ((patient? or primary) adj2 (care or healthcare) adj10 (walk‐in? or unschedul*)).ti,ab. | 105 |
| 7 | (mobile health clinic? or mobile health* centre? or mobile health* center?).ti,ab. and (urgent or out of hours or after hours or scheduling or appointment? or unscheduled or emergency or emergencies).ti,ab,hw. | 4 |
| 8 | Mobile Health Units/ and (urgent or out of hours or after hours or scheduling or appointment? or unscheduled or emergency or emergencies).ti,ab,hw. | 571 |
| 9 | ((flexible adj2 (appointment? or care or healthcare or schedul*)) and (patient? or (primary adj2 (care or health care or healthcare)))).ti,ab. | 206 |
| 10 | minor injur* unit?.ti,ab. | 106 |
| 11 | (urgent care centre? or urgent care center?).ti,ab. | 222 |
| 12 | (walk‐in adj3 service?).ab. | 70 |
| 13 | (nurse‐led adj2 (clinic? or care or centre or centres or center or centers or healthcare or patient care)).ti,ab. | 564 |
| 14 | (nurse? adj2 managed adj3 (clinic? or center or centers or centre or centres or care or healthcare)).ti,ab. | 382 |
| 15 | ((nurse or nurses) adj2 run adj3 (clinic? or care or centre or centres or center or centers or healthcare or patient care)).ti,ab. | 90 |
| 16 | ((physician? assistant? or feldsher? or nonphysician? or non‐physician? or allied health or doctor? assistant?) adj3 (clinic or clinics or care or centre or centres or center or centers or healthcare or health care or patient care)).ti,ab. | 960 |
| 17 | (((care adj2 (centre or center? or centres)) or clinic?) adj4 (without adj3 (physician? or doctor?))).ti,ab. | 18 |
| 18 | (((care adj2 (centre or center? or centres)) or clinic?) adj4 non‐physician?).ti,ab. | 12 |
| 19 | free standing clinic?.ti,ab. | 39 |
| 20 | ((clinic? or healthcare or (health adj2 care) or (primary adj2 care)) adj10 (mall or malls or retail or shopping centre? or shopping or department store or department stores)).ti,ab. | 394 |
| 21 | (retail adj5 (health* adj2 (facility or facilities))).ti,ab. | 9 |
| 22 | ((quick or quickly or convenient*) adj2 (care or health care or healthcare or clinic?)).ti,ab. | 293 |
| 23 | (appointment? adj2 (no or none or last minute)).ti,ab. | 204 |
| 24 | (curaquick or healthstop or smartcare or takecare or quickcare).ti,ab. | 29 |
| 25 | (medicentre? or medicenter?).ti,ab. | 6 |
| 26 | ((walmart or walgreens) adj3 clinic?).ti,ab. | 0 |
| 27 | ((drug store? or pharmacy or ((community or neighbo?rhood) adj2 pharmacies)) adj4 (clinic? or care center? or care centre or care centres or healthcare centre? or healthcare center?)).ti,ab. | 337 |
| 28 | or/1‐27 | 6824 |
| 29 | randomized controlled trial.pt. | 409,862 |
| 30 | controlled clinical trial.pt. | 90,286 |
| 31 | multicenter study.pt. | 196,335 |
| 32 | pragmatic clinical trial.pt. | 269 |
| 33 | (randomis* or randomiz* or randomly).ti,ab. | 640,964 |
| 34 | groups.ab. | 1,528,474 |
| 35 | (trial or multicenter or multi center or multicentre or multi centre).ti. | 173,361 |
| 36 | (intervention? or effect? or impact? or controlled or control group? or (before adj5 after) or (pre adj5 post) or ((pretest or pre test) and (posttest or post test)) or quasiexperiment* or quasi experiment* or pseudo experiment* or pseudoexperiment* or evaluat* or time series or time point? or repeated measur*).ti,ab. | 7,242,472 |
| 37 | non‐randomized controlled trials as topic/ | 45 |
| 38 | interrupted time series analysis/ | 122 |
| 39 | controlled before‐after studies/ | 110 |
| 40 | or/29‐39 | 8,102,807 |
| 41 | exp animals/ | 19,943,765 |
| 42 | humans/ | 15,740,211 |
| 43 | 41 not (41 and 42) | 4,203,554 |
| 44 | review.pt. | 2,079,608 |
| 45 | meta analysis.pt. | 62,641 |
| 46 | news.pt. | 174,946 |
| 47 | comment.pt. | 655,439 |
| 48 | editorial.pt. | 396,546 |
| 49 | cochrane database of systematic reviews.jn. | 11949 |
| 50 | comment on.cm. | 655,439 |
| 51 | (systematic review or literature review).ti. | 71,074 |
| 52 | or/43‐51 | 7,212,549 |
| 53 | 40 not 52 | 5,574,675 |
| 54 | 28 and 53 | 2973 |
Embase (Ovid)
Embase 1974 to 21 March 2016
| No. | Search terms | Results |
| 1 | (walk‐in or walk‐ins).ti. | 541 |
| 2 | (walk‐in adj3 (appointment? or clinic? or center? or centre or centres or care or facility or facilities or healthcare or primary care or nurse led or (led adj2 physician? assistant?) or visit?)).ab. | 666 |
| 3 | (drop‐in adj3 (appointment? or clinic? or center or centers or centre or centres or care or healthcare or nurse led or (led adj2 physician? assistant?))).ti,ab. | 455 |
| 4 | ((as needed or unscheduled or patient scheduled or (self‐schedul* adj6 patient?)) adj2 (appointment? or visit?)).ti,ab. | 1049 |
| 5 | ((weekend? or after‐hours or out of hours or week‐end? or evening) adj2 (care or health care or clinic? or consultation? or appointment?)).ti,ab. | 852 |
| 6 | ((patient? or primary) adj2 (care or healthcare) adj10 (walk‐in? or unschedul*)).ti,ab. | 140 |
| 7 | (mobile health clinic? or mobile health* centre? or mobile health* center?).ti,ab. and (urgent or out of hours or after hours or scheduling or appointment? or unscheduled or emergency or emergencies).ti,ab,hw. | 4 |
| 8 | ((flexible adj2 (appointment? or care or healthcare or schedul*)) and (patient? or (primary adj2 (care or health care or healthcare)))).ti,ab. | 320 |
| 9 | minor injur* unit?.ti,ab. | 110 |
| 10 | (urgent care centre? or urgent care center?).ti,ab. | 317 |
| 11 | (walk‐in adj3 service?).ab. | 114 |
| 12 | (nurse‐led adj2 (clinic? or care or centre or centres or center or centers or healthcare or patient care)).ti,ab. | 1034 |
| 13 | (nurse? adj2 managed adj3 (clinic? or center or centers or centre or centres or care or healthcare)).ti,ab. | 393 |
| 14 | ((nurse or nurses) adj2 run adj3 (clinic? or care or centre or centres or center or centers or healthcare or patient care)).ti,ab. | 122 |
| 15 | ((physician? assistant? or feldsher? or nonphysician? or non‐physician? or allied health or doctor? assistant?) adj3 (clinic or clinics or care or centre or centres or center or centers or healthcare or health care or patient care)).ti,ab. | 1206 |
| 16 | (((care adj2 (centre or center? or centres)) or clinic?) adj4 (without adj3 (physician? or doctor?))).ti,ab. | 24 |
| 17 | (((care adj2 (centre or center? or centres)) or clinic?) adj4 non‐physician?).ti,ab. | 16 |
| 18 | free standing clinic?.ti,ab. | 44 |
| 19 | ((clinic? or healthcare or (health adj2 care) or (primary adj2 care)) adj10 (mall or malls or retail or shopping centre? or shopping or department store or department stores)).ti,ab. | 458 |
| 20 | (retail adj5 (health* adj2 (facility or facilities))).ti,ab. | 13 |
| 21 | ((quick or quickly or convenient*) adj2 (care or health care or healthcare or clinic?)).ti,ab. | 353 |
| 22 | (appointment? adj2 (no or none or last minute)).ti,ab. | 331 |
| 23 | (curaquick or healthstop or smartcare or takecare or quickcare).ti,ab. | 51 |
| 24 | (medicentre? or medicenter?).ti,ab. | 8 |
| 25 | ((walmart or walgreens) adj3 clinic?).ti,ab. | 3 |
| 26 | ((drug store? or pharmacy or ((community or neighbo?rhood) adj2 pharmacies)) adj4 (clinic? or care center? or care centre or care centres or healthcare centre? or healthcare center?)).ti,ab. | 610 |
| 27 | or/1‐26 | 8722 |
| 28 | randomized controlled trial/ | 397,653 |
| 29 | controlled clinical trial/ | 392,529 |
| 30 | quasi experimental study/ | 2811 |
| 31 | pretest posttest control group design/ | 253 |
| 32 | time series analysis/ | 16,687 |
| 33 | experimental design/ | 12,220 |
| 34 | multicenter study/ | 133,639 |
| 35 | (randomis* or randomiz* or randomly).ti,ab. | 866,722 |
| 36 | groups.ab. | 2,035,364 |
| 37 | (trial or multicentre or multicenter or multi centre or multi center).ti. | 239,290 |
| 38 | (intervention? or effect? or impact? or controlled or control group? or (before adj5 after) or (pre adj5 post) or ((pretest or pre test) and (posttest or post test)) or quasiexperiment* or quasi experiment* or pseudo experiment* or pseudoexperiment* or evaluat* or time series or time point? or repeated measur*).ti,ab. | 9,188,776 |
| 39 | or/28‐38 | 10,259,816 |
| 40 | (systematic review or literature review).ti. | 86,795 |
| 41 | "cochrane database of systematic reviews".jn. | 3771 |
| 42 | exp animals/ or exp invertebrate/ or animal experiment/ or animal model/ or animal tissue/ or animal cell/ or nonhuman/ | 22,801,580 |
| 43 | human/ or normal human/ or human cell/ | 16,986,271 |
| 44 | 42 not (42 and 43) | 5,862,073 |
| 45 | 40 or 41 or 44 | 5,951,836 |
| 46 | 39 not 45 | 7,746,246 |
| 47 | 27 and 46 | 4644 |
The Cochrane Library (Wiley)
| No. | Search terms | Results |
| #1 | ("walk‐in" or "walk‐ins"):ti,ab | 142 |
| #2 | ("drop‐in" near/3 (appointment* or clinic* or center or centers or centre or centres or care or healthcare or "nurse led" or (led near/2 physician* assistant*))):ti,ab | 38 |
| #3 | (("as needed" or unscheduled or "patient scheduled" or (self‐schedul* near/6 patient*)) near/2 (appointment* or visit*)):ti,ab | 191 |
| #4 | ((weekend* or after‐hours or "out of hours" or week‐end* or evening) near/2 (care or health care or clinic* or consultation* or appointment*)):ti,ab | 55 |
| #5 | ((patient* or primary) near/2 (care or healthcare) near/10 (unschedul*)):ti,ab | 11 |
| #6 | ("mobile health" next (clinic* or centre* or center*)):ti,ab and (urgent or "out of hours" or "after hours" or scheduling or appointment* or unscheduled or emergency or emergencies):ti,ab,kw | 0 |
| #7 | [mh "mobile health units"] and (urgent or out of hours or after hours or scheduling or appointment* or unscheduled or emergency or emergencies):ti,ab,kw | 18 |
| #8 | ((flexible near/2 (appointment* or care or healthcare or schedul*)) and (patient* or (primary near/2 (care or health care or healthcare)))):ti,ab | 53 |
| #9 | minor next injur* next unit*:ti,ab | 5 |
| #10 | ("urgent care" next (centre* or center*)):ti,ab | 9 |
| #11 | (nurse‐led near/2 (clinic* or care or centre or centres or center or centers or healthcare or patient care)):ti,ab | 171 |
| #12 | (nurse* near/2 managed near/3 (clinic* or center or centers or centre or centres or care or healthcare)):ti,ab | 20 |
| #13 | ((nurse or nurses) near/2 run near/3 (clinic* or care or centre or centres or center or centers or healthcare or patient care)):ti,ab | 17 |
| #14 | ((physician* assistant* or feldsher* or nonphysician* or non‐physician* or allied health or doctor* assistant*) near/3 (clinic or clinics or care or centre or centres or center or centers or healthcare or health care or patient care)):ti,ab | 42 |
| #15 | (((care near/2 (centre or center* or centres)) or clinic*) near/4 (without near/3 (physician* or doctor*))):ti,ab | 4 |
| #16 | (((care near/2 (centre or center* or centres)) or clinic*) near/4 non‐physician*):ti,ab | 9 |
| #17 | free standing clinic*:ti,ab | 370 |
| #18 | ((clinic* or healthcare or (health near/2 care) or (primary near/2 care)) near/10 (mall or malls or retail or shopping centre* or shopping or "department store" or "department stores")):ti,ab | 9 |
| #19 | (retail near/5 (health* near/2 (facility or facilities))):ti,ab | 0 |
| #20 | ((quick or quickly or convenient*) near/2 (care or health care or healthcare or clinic*)):ti,ab | 47 |
| #21 | (appointment* near/2 (no or none or last minute)):ti,ab | 31 |
| #22 | (curaquick or healthstop or smartcare or takecare or quickcare):ti,ab | 20 |
| #23 | (medicentre* or medicenter*):ti,ab | 0 |
| #24 | ((walmart or walgreens) near/3 clinic*):ti,ab | 0 |
| #25 | ((drug store* or pharmacy or ((community or neighbo*) near/2 pharmacies)) near/4 (clinic* or care center* or care centre or care centres or healthcare centre* or healthcare center*)):ti,ab | 145 |
| #26 | {or #1‐#25} | 1386 |
CINAHL (EBSCO)
| No. | Search terms | Results |
| S1 | TI walk‐in or walk‐ins | 1914 |
| S2 | AB (walk‐in N3 (appointment? or clinic? or center? or centre or centres or care or facility or facilities or healthcare or primary care or nurse led or (led N2 physician? assistant?) or visit?)) | 180 |
| S3 | TI ( drop‐in N3 (appointment? or clinic? or center or centers or centre or centres or care or healthcare or nurse led or (led N2 physician? assistant?)) ) OR AB ( drop‐in N3 (appointment? or clinic? or center or centers or centre or centres or care or healthcare or nurse led or (led N2 physician? assistant?)) ) | 207 |
| S4 | TI ( ((as needed or unscheduled or patient scheduled or (self‐schedul* N6 patient?)) N2 (appointment? or visit?)) ) OR AB ( ((as needed or unscheduled or patient scheduled or (self‐schedul* N6 patient?)) N2 (appointment? or visit?)) ) | 317 |
| S5 | TI ( (weekend? or after‐hours or out of hours or week‐end? or evening) N2 (care or health care or clinic? or consultation? or appointment?) ) OR AB ( (weekend? or after‐hours or out of hours or week‐end? or evening) N2 (care or health care or clinic? or consultation? or appointment?) ) | 284 |
| S6 | TI ( (patient? or primary) N2 (care or healthcare) N10 (walk‐in? or unschedul*) ) OR AB ( (patient? or primary) N2 (care or healthcare) N10 (walk‐in? or unschedul*) ) | 18 |
| S7 | urgent or out of hours or after hours or scheduling or appointment? or unscheduled or emergency or emergencies | 137,659 |
| S8 | (MH "Mobile Health Units") | 1185 |
| S9 | TI ( mobile health clinic? or mobile health* centre? or mobile health* center? ) OR AB ( mobile health clinic? or mobile health* centre? or mobile health* center? ) | 24 |
| S10 | S8 OR S9 | 1195 |
| S11 | S7 AND S10 | 204 |
| S12 | TI ( ((flexible N2 (appointment? or care or healthcare or schedul*)) and (patient? or (primary N2 (care or health care or healthcare)))) ) OR AB ( ((flexible N2 (appointment? or care or healthcare or schedul*)) and (patient? or (primary N2 (care or health care or healthcare)))) ) | 64 |
| S13 | TI minor injur* unit? OR AB minor injur* unit? | 54 |
| S14 | TI ( urgent care centre? or urgent care center? ) OR AB ( urgent care centre? or urgent care center? ) | 63 |
| S15 | AB walk‐in N3 service? | 13 |
| S16 | TI ( nurse‐led N2 (clinic? or care or centre or centres or center or centers or healthcare or patient care) ) OR AB ( nurse‐led N2 (clinic? or care or centre or centres or center or centers or healthcare or patient care) ) | 499 |
| S17 | TI ( nurse? N2 managed N3 (clinic? or center or centers or centre or centres or care or healthcare) ) OR AB ( nurse? N2 managed N3 (clinic? or center or centers or centre or centres or care or healthcare) ) | 47 |
| S18 | TI ( (nurse or nurses) N2 run N3 (clinic? or care or centre or centres or center or centers or healthcare or patient care) ) OR AB ( (nurse or nurses) N2 run N3 (clinic? or care or centre or centres or center or centers or healthcare or patient care) ) | 74 |
| S19 | TI ( (physician? assistant? or feldsher? or nonphysician? or non‐physician? or allied health or doctor? assistant?) N3 (clinic or clinics or care or centre or centres or center or centers or healthcare or health care or patient care) ) OR AB ( (physician? assistant? or feldsher? or nonphysician? or non‐physician? or allied health or doctor? assistant?) N3 (clinic or clinics or care or centre or centres or center or centers or healthcare or health care or patient care) ) | 363 |
| S20 | TI ( (((care N2 (centre or center? or centres)) or clinic?) N4 (without N3 (physician? or doctor?))) ) OR AB ( (((care N2 (centre or center? or centres)) or clinic?) N4 (without N3 (physician? or doctor?))) ) | 0 |
| S21 | TI ( (((care N2 (centre or center? or centres)) or clinic?) N4 non‐physician?) ) OR AB ( (((care N2 (centre or center? or centres)) or clinic?) N4 non‐physician?) ) | 0 |
| S22 | TI free standing clinic? OR AB free standing clinic? | 9 |
| S23 | TI ( ((clinic? or healthcare or (health N2 care) or (primary N2 care)) N10 (mall or malls or retail or shopping centre? or shopping or department store or department stores)) ) OR AB ( ((clinic? or healthcare or (health N2 care) or (primary N2 care)) N10 (mall or malls or retail or shopping centre? or shopping or department store or department stores)) ) | 237 |
| S24 | TI ( (retail N5 (health* N2 (facility or facilities))) ) OR AB ( (retail N5 (health* N2 (facility or facilities))) ) | 0 |
| S25 | TI ( ((quick or quickly or convenient*) N2 (care or health care or healthcare or clinic?)) ) OR AB ( ((quick or quickly or convenient*) N2 (care or health care or healthcare or clinic?)) ) | 220 |
| S26 | TI ( (appointment? N2 (no or none or last minute)) ) OR AB ( (appointment? N2 (no or none or last minute)) ) | 30 |
| S27 | TI ( curaquick or healthstop or smartcare or takecare or quickcare ) OR AB ( curaquick or healthstop or smartcare or takecare or quickcare ) | 6 |
| S28 | TI ( medicentre? or medicenter? ) OR AB ( medicentre? or medicenter? ) | 1 |
| S29 | TI ( ((walmart or walgreens) N3 clinic?) ) OR AB ( ((walmart or walgreens) N3 clinic?) ) | 2 |
| S30 | TI ( ((drug store? or pharmacy or ((community or neighbo?rhood) N2 pharmacies)) N4 (clinic? or care center? or care centre or care centres or healthcare centre? or healthcare center?)) ) OR AB ( ((drug store? or pharmacy or ((community or neighbo?rhood) N2 pharmacies)) N4 (clinic? or care center? or care centre or care centres or healthcare centre? or healthcare center?)) ) | 57 |
| S31 | S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR S23 OR S24 OR S25 OR S26 OR S27 OR S28 OR S29 OR S30 | 4707 |
| S32 | S31 Limiters ‐ Exclude MEDLINE records | 2125 |
| S33 | PT randomized controlled trial | 30,405 |
| S34 | PT clinical trial | 52,721 |
| S35 | PT research | 987,546 |
| S36 | (MH "Randomized Controlled Trials") | 25,829 |
| S37 | (MH "Clinical Trials") | 84,167 |
| S38 | (MH "Intervention Trials") | 5972 |
| S39 | (MH "Nonrandomized Trials") | 168 |
| S40 | (MH "Experimental Studies") | 14,765 |
| S41 | (MH "Pretest‐Posttest Design+") | 26,667 |
| S42 | (MH "Quasi‐Experimental Studies+") | 8408 |
| S43 | (MH "Multicenter Studies") | 11,128 |
| S44 | (MH "Health Services Research") | 7348 |
| S45 | TI ( randomis* or randomiz* or randomly) OR AB ( randomis* or randomiz* or randomly) | 110,347 |
| S46 | TI (trial or effect* or impact* or intervention* or before N5 after or pre N5 post or ((pretest or "pre test") and (posttest or "post test")) or quasiexperiment* or quasi W0 experiment* or pseudo experiment* or pseudoexperiment* or evaluat* or "time series" or time W0 point* or repeated W0 measur*) OR AB (trial or effect* or impact* or intervention* or before N5 after or pre N5 post or ((pretest or "pre test") and (posttest or "post test")) or quasiexperiment* or quasi W0 experiment* or pseudo experiment* or pseudoexperiment* or evaluat* or "time series" or time W0 point* or repeated W0 measur*) | 757,832 |
| S47 | S33 OR S34 OR S35 OR S36 OR S37 OR S38 OR S39 OR S40 OR S41 OR S42 OR S43 OR S44 OR S45 OR S46 | 1,292,403 |
| S48 | S32 AND S47 | 584 |
PubMed
| Search terms | Results |
| (walk‐in[Title] OR "urgent care"[Title] OR minor injury[Title] OR minor injuries[Title]) AND (appointment*[Title] OR clinic[Title] OR clinics[Title] OR center[Title] OR centers[Title] OR centre[Title] OR centres[Title] OR care[Title] OR unit[Title] OR units[Title] OR service[Title] OR services[Title] OR facility[Title] OR facilities[Title] OR healthcare[Title] OR "primary care"[Title] OR "nurse led"[Title] OR "physician* assistant*"[Title] OR visit[Title] OR visits[Title]) | 619 |
PubMed Central
| Search terms | Results |
| (walk‐in[Title] OR "urgent care"[Title] OR minor injury[Title] OR minor injuries[Title]) AND (appointment*[Title] OR clinic[Title] OR clinics[Title] OR center[Title] OR centers[Title] OR centre[Title] OR centres[Title] OR care[Title] OR unit[Title] OR units[Title] OR service[Title] OR services[Title] OR facility[Title] OR facilities[Title] OR healthcare[Title] OR "primary care"[Title] OR "nurse led"[Title] OR "physician* assistant*"[Title] OR visit[Title] OR visits[Title]) | 132 |
ClinicalTrials.gov
| Search terms | Results |
| walk in OR "urgent care" OR "minor injury" OR "minor injuries" [intervention field] | 44 |
WHO International Clinical Trials Registry Platform (ICTRP)
| Search terms | Results |
| urgent care OR minor injury OR minor injuries OR walk in* | 109 |
Appendix 2. Screening algorithm for titles and abstracts
Did the study compare walk‐in clinics versus either traditional physician offices or emergency rooms, or both?
Did the study meet design criteria for a randomized trial, a non‐randomized trials, or a controlled before‐after study?
-
Did the study address either a primary outcome or a secondary outcome?
Primary outcomes: mortality, morbidity, or quality of care.
Secondary outcomes: participant satisfaction, participant preference for return to walk‐in clinics versus traditional source of care, cost‐effectiveness, and ease of access.
If the answer to all 3 questions was 'yes' or was ambiguous, we extracted the entire text of the paper.
Appendix 3. Data collection form
| Review title or ID |
| Study ID(surname of first author and year first full report of study was published e.g. Smith 2001) |
| Report IDs of other reports of this study(e.g. duplicate publications, follow‐up studies) |
| Notes: |
1. General information
| 1. Date form completed (dd/mm/yyyy) | |
| 2. Name/ID of person extracting data | |
| 3. Report title (title of paper/ abstract/ report that data are extracted from) | |
| 4. Report ID (if there are multiple reports of this study) | |
| 5. Reference details | |
| 6. Report author contact details | |
| 7. Publication type (e.g. full report, abstract, letter) | |
| 8. Study funding source (including role of funders) | |
|
Possible conflicts of interest (for study authors) | |
| 9. Notes: | |
2. Eligibility
| Study characteristics |
Review inclusion criteria (Insert inclusion criteria for each characteristic as defined in the Protocol) |
Yes/No/Unclear |
Location in text (pg & ¶/fig/table) |
||
| 10a. Type of study | Randomized trial | ||||
| Non‐randomized trial | |||||
Controlled before‐after study
|
|||||
| Other design (specify): | |||||
| 10b. Definition of walk‐in clinics: | Does the paper define walk‐in clinics as:
|
||||
| 11. Participants | |||||
| 12. Types of intervention | |||||
| 13. Types of outcome measures | |||||
| 14. Decision: | |||||
| 15. Reason for exclusion | |||||
| 16. Notes: | |||||
DO NOT PROCEED IF STUDY EXCLUDED FROM REVIEW
3. Population and setting
|
Description Include comparative information for each group (i.e. intervention and controls) if available |
Location in text (pg & ¶/fig/table) |
||
| 17. Population description (from which study participants are drawn) |
|||
| 18. Setting (including location and social context) |
|||
| 19. Inclusion criteria | |||
| 20. Exclusion criteria | |||
| 21. Method/s of recruitment of participants | |||
| 22. Notes: | |||
4. Methods
| Descriptions as stated in report/paper |
Location in text (pg & ¶/fig/table) |
||
| 23. Aim of study | |||
| 24. Design (e.g. parallel, cross‐over, non‐RCT) |
|||
| 25. Unit of allocation (by individuals, cluster/ groups or body parts) |
|||
| 26. Start date | |||
| 27. End date | |||
| 28. Duration of participation (from recruitment to last follow‐up) |
|||
| 29. Notes: | |||
5. Risk of bias assessment
See Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions. Additional domains may be required for non‐randomized studies.
| Domain |
Risk of bias Low/ High/Unclear |
Support for judgement |
Location in text (pg & ¶/fig/table) |
|
| 30. Random sequence generation (selection bias) |
||||
| 31. Allocation concealment (selection bias) |
||||
| 32. Blinding of participants and personnel (performance bias) |
Outcome group: All/ | |||
| (if required) | Outcome group: | |||
| 33. Blinding of outcome assessment (detection bias) |
Outcome group: All/ | |||
| (if required) | Outcome group: | |||
| 34. Incomplete outcome data (attrition bias) |
||||
| 35. Selective outcome reporting? (reporting bias) |
||||
| 36. Other bias | ||||
| 37. Notes: | ||||
6. Participants
Provide overall data and, if available, comparative data for each intervention or comparison group.
| Description as stated in report/paper |
Location in text (pg & ¶/fig/table) |
||
| 38. Total no. randomized (or total pop. at start of study for NRCTs) |
|||
| 39. Clusters (if applicable, no., type, no. people per cluster) |
|||
| 40. Baseline imbalances | |||
| 41. Withdrawals and exclusions (if not provided below by outcome) |
|||
| 42. Age | |||
| 43. Sex | |||
| 44. Race/Ethnicity | |||
| 45. Severity of illness | |||
| 46. Comorbidities | |||
| 47. Other treatment received (additional to study intervention) |
|||
| 48. Other relevant sociodemographics | |||
| 49. Subgroups measured | |||
| 50. Subgroups reported | |||
| 51. Notes: | |||
NRCT: non‐ranomized trial.
7. Intervention groups
Copy and paste table for each intervention and comparison group
Intervention group 1
| Description as stated in report/paper |
Location in text (pg & ¶/fig/table) |
||
| 52. Group name | |||
| 53. No. randomized to group (specify whether no. people or clusters) |
|||
| 54. Description (include sufficient detail for replication, e.g. content, dose, components; if it is a natural experiment, describe the preintervention) |
|||
| 55. Duration of treatment period | |||
| 56. Timing (e.g. frequency, duration of each episode) |
|||
| 57. Delivery (e.g. mechanism, medium, intensity, fidelity) |
|||
| 58. Providers (e.g. no., profession, training, ethnicity etc. if relevant) |
|||
| 59. Cointerventions | |||
| 60. Economic variables (i.e. intervention cost, changes in other costs as result of intervention) |
|||
| 61. Resource requirements to replicate intervention (e.g. staff numbers, cold chain, equipment) |
|||
| 62. Notes: | |||
8. Outcomes
Copy and paste table for each outcome.
Outcome 1
| Description as stated in report/paper |
Location in text (pg & ¶/fig/table) |
|||
| 63. Outcome name | ||||
| 64. Time points measured (specify whether from start or end of intervention) |
||||
| 65. Time points reported | ||||
| 66. Outcome definition (with diagnostic criteria if relevant and note whether the outcome is desirable or undesirable if this is not obvious) |
||||
| 67. Person measuring/ reporting | ||||
| 68. Unit of measurement (if relevant) |
||||
| 69. Scales: upper and lower limits (indicate whether high or low score is good) |
||||
| 70. Is outcome/tool validated? | Yes/No/Unclear | |||
| 71. Imputation of missing data (e.g. assumptions made for intention‐to‐treat analysis) |
||||
| 72. Assumed risk estimate (e.g. baseline or population risk noted in Background) |
||||
| 73. Notes: | ||||
9. Results
Copy and paste the appropriate table for each outcome, including additional tables for each time point and subgroup as required.
For randomized or non‐randomized trial ‐ dichotomous outcome
| Description as stated in report/paper |
Location in text (pg & ¶/fig/table) |
||||||
| 74. Comparison | |||||||
| 75. Outcome | |||||||
| 76. Subgroup | |||||||
| 77. Time point (specify whether from start or end of intervention) |
|||||||
| 78. Results Note whether: postintervention OR change from baseline and whether adjusted OR unadjusted |
Intervention | Comparison | |||||
| No. events | No. participants | No. events | No. participants | ||||
| 79. Baseline data | Intervention | Comparison | |||||
| No. events | No. participants | No. events | No. participants | ||||
| 80. No. missing participants and reasons | |||||||
| 81. No. participants moved from other group and reasons | |||||||
| 82. Any other results reported | |||||||
| 83. Unit of analysis (e.g. by individuals, health professional, practice, hospital, community) |
|||||||
| 84. Statistical methods used and appropriateness of these methods (e.g. adjustment for correlation) |
|||||||
| 85. Reanalysis required? (if yes, specify why, e.g. correlation adjustment) |
Yes/No/Unclear | ||||||
| 86. Reanalysis possible? | Yes/No/Unclear | ||||||
| 87. Reanalyzed results | |||||||
| 88. Notes: | |||||||
For randomized or non‐randomized trial ‐ continuous outcome
| Description as stated in report/paper |
Location in text (pg & ¶/fig/table) |
||||||||||
| 89. Comparison | |||||||||||
| 90. Outcome | |||||||||||
| 91. Subgroup | |||||||||||
| 92. Time point (specify whether from start or end of intervention) |
|||||||||||
| 93. Postintervention or change from baseline? | |||||||||||
| 94. Results Note whether: postintervention OR change from baseline And whether Adjusted OR Unadjusted |
Intervention | Comparison | |||||||||
| Mean | SD (or other variance) | No. participants | Mean | SD (or other variance) | No. participants | ||||||
| 95. Baseline data | Intervention | Comparison | |||||||||
| Mean | SD (or other variance) | No. participants | Mean | SD (or other variance) | No. participants | ||||||
| 96. No. missing participants and reasons | |||||||||||
| 97. No. participants moved from other group and reasons | |||||||||||
| 98. Any other results reported | |||||||||||
| 99. Unit of analysis (e.g. by individuals, health professional, practice, hospital, community) |
|||||||||||
| 100. Statistical methods used and appropriateness of these methods (e.g. adjustment for correlation) |
|||||||||||
| 101. Reanalysis required? (if yes, specify why) |
Yes/No/Unclear | ||||||||||
| 102. Reanalysis possible? | Yes/No/Unclear | ||||||||||
| 103. Reanalyzed results | |||||||||||
| 104. Notes: | |||||||||||
SD: standard deviation.
For randomized or non‐randomized trial ‐ other outcome
| Description as stated in report/paper |
Location in text (pg & ¶/fig/table) |
||||||
| 105. Comparison | |||||||
| 106. Outcome | |||||||
| 107. Subgroup | |||||||
| 108. Time point (specify whether from start or end of intervention) |
|||||||
| 109. Type of outcome | |||||||
| 110. Results | Intervention result | SD (or other variance) | Control result | SD (or other variance) | |||
| Overall results | SE (or other variance) | ||||||
| 111. No. participant | Intervention | Control | |||||
| 112. No. missing participants and reasons | |||||||
| 113. No. participants moved from other group and reasons | |||||||
| 114. Any other results reported | |||||||
| 115. Unit of analysis (e.g. by individuals, health professional, practice, hospital, community) |
|||||||
| 116. Statistical methods used and appropriateness of these methods | |||||||
| 117. Reanalysis required? (if yes, specify why) |
|||||||
| 118. Reanalysis possible? | |||||||
| 119. Reanalyzed results | |||||||
| 120. Notes: | |||||||
For controlled before‐after study
| Description as stated in report/paper |
Location in text (pg & ¶/fig/table) |
||||||
| 121. Comparison | |||||||
| 122. Outcome | |||||||
| 123. Subgroup | |||||||
| 124. Time point (specify whether from start or end of intervention) |
|||||||
| 125. Postintervention or change from baseline? | |||||||
| 126. Results | Intervention result | SD (or other variance) | Control result | SD (or other variance) | |||
| Overall results | SE (or other variance) | ||||||
| 127. No. participants | Intervention | Control | |||||
| 128. No. missing participants and reasons | |||||||
| 129. No. participants moved from other group and reasons | |||||||
| 130. Any other results reported | |||||||
| 131. Unit of analysis (individuals, cluster/ groups or body parts) |
|||||||
| 132. Statistical methods used and appropriateness of these methods | |||||||
| 133. Reanalysis required? (specify) |
Yes/No/Unclear | ||||||
| 134. Reanalysis possible? | Yes/No/Unclear | ||||||
| 135. Reanalyzed results | |||||||
| 136. Notes: | |||||||
10. Applicability
| 137. Have important populations been excluded from the study? (consider disadvantaged populations, and possible differences in the intervention effect) |
Yes/No/Unclear | |
| 138. Is the intervention likely to be aimed at disadvantaged groups? (e.g. lower socioeconomic groups) |
Yes/No/Unclear | |
| 139. Does the study directly address the review question? (any issues of partial or indirect applicability) |
Yes/No/Unclear | |
| 140. Notes: | ||
11. Other information
| Description as stated in report/paper |
Location in text (pg & ¶/fig/table) |
||
| 141. Key conclusions of study authors | |||
| 142. References to other relevant studies | |||
| 143. Correspondence required for further study information (what and from whom) |
|||
| 144. Further study information requested (from whom, what, and when) |
|||
| 145. Correspondence received (from whom, what, and when) |
|||
| 146. Notes: | |||
Characteristics of studies
Characteristics of excluded studies [ordered by study ID]
| Study | Reason for exclusion |
|---|---|
| Ahmed 2010 | No actual intervention was offered, study was a randomized telephone survey of participants' theoretical preferences. |
| Arain 2013 | Non‐randomized trial, study was a survey to assess satisfaction among people who presented to a single walk‐in clinic. |
| Arain 2015 | Non‐randomized trial, study was a survey to assess satisfaction among people who presented to a single walk‐in clinic. |
| Charlton 2004 | Study intervention did not meet definition of walk‐in clinic, because study intervention involved coordinated follow‐up. |
| Choi 2015 | Study intervention did not meet definition of walk‐in clinic, because study intervention involved coordinated follow‐up. |
| Cleland 2007 | Study intervention did not meet definition of walk‐in clinic, because study intervention involved coordinated follow‐up. |
| Denver 2003 | Study intervention did not meet definition of walk‐in clinic, because study intervention involved coordinated follow‐up. |
| Grant 2002 | Cross‐over study of 15 standardized participants (did not enroll actual participants, instead were simulated encounters). |
| Griffiths 2004 | Study intervention did not meet definition of walk‐in clinic, because study intervention involved coordinated follow‐up. |
| Hutchison 2003 | Non‐randomized trial, non‐controlled, study was a survey of participant satisfaction and evaluation of clinical outcomes of walk‐in clinic compared to family practices and emergency rooms. |
| Johnson 2014 | Study intervention did not meet definition of walk‐in clinic, because study intervention involved coordinated follow‐up. |
| Kernick 2002 | Study intervention did not meet definition of walk‐in clinic, because study intervention involved coordinated follow‐up. |
Differences between protocol and review
We did not search PsycINFO as stated in the protocol we deemed it irrelevant to the study topic. At the time of search, HealthStar was no longer available as a separate database. The CINAHL search was intended to replace ProQuest Nursing & Allied Health Source.
Contributions of authors
All authors devised the study question.
All authors prepared the protocol.
CTC and CEC conducted the searches; prepared the review; and planned to obtain, extract, and synthesize data. They will update the review.
Michelle Fiander, EPOC Trials Search Co‐ordinator, wrote the search protocol.
Sources of support
Internal sources
-
Partners HealthCare, USA.
Salary (CTC)
-
Government of Ontario Ministry of Health and Long Term Care, Canada.
Salary (JH)
-
Harvard Medical School, USA.
Salary (AM)
External sources
No sources of support to be reported, USA.
Declarations of interest
CEC has no relevant interests to declare.
CTC is on the physician staff of Partners HealthCare, a health system based in Boston, Massachusetts that is planning to open several walk‐in clinics.
JH has no relevant interests to declare.
AM has received prior grant support for research on walk‐in clinics from the National Institutes of Health, Robert Wood Johnson Foundation, and the California Health Care Foundation.
New
References
References to studies excluded from this review
Ahmed 2010 {published data only}
- Ahmed A, Fincham J. Physician office vs retail clinic: patient preferences in care seeking for minor illnesses. Annals of Family Medicine 2010;8(2):117‐23. [DOI] [PMC free article] [PubMed] [Google Scholar]
Arain 2013 {published data only}
- Arain M, Nicholl J, Campbell M. GP‐led walk‐in centre in the UK: another way for urgent healthcare provision. Critical Care 2013;17(Suppl 2):P259. [Google Scholar]
Arain 2015 {published data only}
- Arain M, Campbell M, Nicholl J. Impact of a GP‐led walk‐in centre on NHS emergency departments. Emergency Medicine Journal 2015;32(4):295‐300. [DOI] [PubMed] [Google Scholar]
Charlton 2004 {published data only}
- Charlton J, Mackay L, McKnight J. A pilot study comparing a type 1 nurse‐led diabetes clinic with a conventional doctor‐led diabetes clinic. European Diabetes Nursing 2004;1(1):18‐21. [Google Scholar]
Choi 2015 {published data only}
- Choi E, Ching W, Lam C, Wan EY, Chan AK, Chan KH. Evaluation of the effectiveness of nurse‐led continence care treatments for Chinese primary care patients with lower urinary tract symptoms. PLoS One 2015;10(6):e0129875. [DOI] [PMC free article] [PubMed] [Google Scholar]
Cleland 2007 {published data only}
- Cleland J, Hall S, Price D, Lee A. An exploratory, pragmatic, cluster randomised trial of practice nurse training in the use of asthma action plans. Primary Care Respiratory Journal 2007;16(5):311‐8. [DOI] [PMC free article] [PubMed] [Google Scholar]
Denver 2003 {published data only}
- Denver E, Barnard M, Woolfson R, Earle K. Management of uncontrolled hypertension in a nurse‐led clinic compared with conventional care for patients with type 2 diabetes. Diabetes Care 2003;26(8):2256‐60. [DOI] [PubMed] [Google Scholar]
Grant 2002 {published data only}
- Grant C, Nicholas R, Moore L, Salisbury C. An observational study comparing quality of care in walk‐in centres with general practice and NHS Direct using standardised patients. BMJ 2002;324(7353):1556. [DOI] [PMC free article] [PubMed] [Google Scholar]
Griffiths 2004 {published data only}
- Griffiths C, Foster G, Barnes N, Eldridge S, Tate H, Begum S, et al. Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA). BMJ 2004;328(7432):144. [DOI] [PMC free article] [PubMed] [Google Scholar]
Hutchison 2003 {published data only}
- Hutchison B, Ostbyte T, Barnsley J, Stewart M, Mathews M, Campbell MK, et al. Patient satisfaction and quality of care in walk‐in clinics, family practices and emergency departments: the Ontario Walk‐In Clinic Study. Canadian Medical Association Journal 2003;168(8):977‐83. [PMC free article] [PubMed] [Google Scholar]
Johnson 2014 {published data only}
- Johnson J, Sayah F, Wozniak L, Rees S, Soprovich A, Qiu W, et al. Collaborative care versus screening and follow‐up for patients with diabetes and depressive symptoms: results of a primary care‐based comparative effectiveness trial. Diabetes Care 2014;37(12):3220‐6. [DOI] [PubMed] [Google Scholar]
Kernick 2002 {published data only}
- Kernick D, Powell R, Reinhold D. A pragmatic randomised controlled trial of an asthma nurse in general practice. Primary Care Respiratory Journal 2002;11(1):6‐8. [DOI] [PMC free article] [PubMed] [Google Scholar]
Additional references
AAFP 2013
- American Academy of Family Physicians. Retail clinics. www.aafp.org/about/policies/all/retail‐clinics.html (accessed 29 November 2013).
Ashwood 2011
- Ashwood J, Reid R, Setodji C, Weber E, Gaynor M, Mehrotra A. Trends in retail clinic use among the commercially insured. American Journal of Managed Care 2011;17(11):e443‐8. [PMC free article] [PubMed] [Google Scholar]
Bell 1992
- Bell N, Szafran O. Use of walk‐in clinics by family practice patients. Canadian Family Physician 1992;38:507‐13. [PMC free article] [PubMed] [Google Scholar]
Brennan 2009
- Brennan S, McKenzie J, Whitty P, Buchan H, Green S. Continuous quality improvement: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2009, Issue 4. [DOI: 10.1002/14651858.CD003319.pub2] [DOI] [Google Scholar]
Cassel 2012
- Cassel C. Retail clinics and drugstore medicine. JAMA 2012;307(20):2151‐2. [DOI] [PubMed] [Google Scholar]
CBO 2014
- Congressional Budget Office. The budget and economic outlook: 2014 to 2024. www.cbo.gov/sites/default/files/45010‐Outlook2014_Feb_0.pdf (accessed 15 June 2015).
Desborough 2013
- Desborough J, Parker R, Forrest L. Development and implementation of a nurse‐led walk‐in centre: evidence lost in translation?. Journal of Health Services Research & Policy 2013;18(3):174‐8. [DOI] [PubMed] [Google Scholar]
Enright 2014
- Enright P, Nevin W. Point: should storefront clinics provide case finding and chronic care for COPD? Yes. Chest 2014;145(6):1191‐3. [DOI] [PubMed] [Google Scholar]
EPOC 2013a
- Cochrane Effective Practice and Organisation of Care (EPOC) Group. What study designs should be included in an EPOC review and what should they be called?. epoc.cochrane.org/epoc‐specific‐resources‐review‐authors (accessed 27 January 2017).
EPOC 2013b
- Cochrane Effective Practice and Organisation of Care (EPOC) Group. EPOC 'risk of bias' guideline. epoc.cochrane.org/epoc‐specific‐resources‐review‐authors (accessed 27 January 2017).
EPOC 2013c
- Cochrane Effective Practice and Organisation of Care (EPOC) Group. Analysis in EPOC reviews. epoc.cochrane.org/epoc‐specific‐resources‐review‐authors (accessed 27 January 2017).
Higgins 2011
- Higgins J, Green S, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.
Jenkins‐Clarke 1998
- Jenkins‐Clarke S, Carr‐Hill R, Dixon P. Teams and Seams: skill mix in primary care. Journal of Advanced Nursing 1998;28:1120‐6. [PubMed] [Google Scholar]
Jones 2000
- Jones M. Walk‐in primary medical care centres: lessons from Canada. BMJ 2000;321:928. [DOI] [PMC free article] [PubMed] [Google Scholar]
Laird 1990
- Laird N, Mosteller F. Some statistical methods for combining experimental results. International Journal of Technology Assessment in Health Care 1990;6(1):5‐30. [DOI] [PubMed] [Google Scholar]
Laurant 2009
- Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database of Systematic Reviews 2009, Issue 1. [DOI: 10.1002/14651858.CD001271.pub2] [DOI] [PubMed] [Google Scholar]
Lefebvre 2011
- Lefebvre C, Manheimer E, Glanville J. Chapter 6: Searching for studies. In: Higgins JP, Green S, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.
MECIR 2013
- Chandler J, Churchill R, Higgins J, Lasseron T, Tovey D. Methodological Expectations of Cochrane Intervention Reviews (MECIR). Methodological standards for the conduct of Cochrane Intervention Reviews Version 2.3. The Cochrane Collaboration, 2013. editorial‐unit.cochrane.org/mecir (accessed 27 January 2017).
Mehrotra 2009
- Mehrotra A, Liu H, Adams J, Wang M, Lave J, Thygeson M, et al. Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses. Annals of Internal Medicine 2009;151(5):321‐8. [DOI] [PMC free article] [PubMed] [Google Scholar]
Mehrotra 2012
- Mehrotra A, Lave J. Visits to retail clinics grew fourfold from 2007 to 2009, although their share of overall outpatient visits remains low. Health Affairs (Project Hope) 2012;31(9):2123‐9. [DOI] [PMC free article] [PubMed] [Google Scholar]
NHS 2013
- National Health Service. NHS walk‐in centres. www.nhs.uk/NHSEngland/AboutNHSservices/Emergencyandurgentcareservices/Pages/Walk‐incentresSummary.aspx (accessed 15 October 2013).
Parker 2012
- Parker R, Desborough J, Forrest L. Stakeholder perceptions of a nurse led walk‐in centre. BMC Health Services Research 2012;12:382. [DOI] [PMC free article] [PubMed] [Google Scholar]
Pope 2005
- Pope C, Chalder M, Moore L, Salisbury C. What do other local providers think of NHS walk‐in centres? Results of a postal survey. Public Health 2005;119(1):39‐44. [DOI] [PubMed] [Google Scholar]
Salisbury 2002
- Salisbury C, Chalder M, Scott T, Pope C, Moore L. What is the role of walk‐in centres in the NHS?. BMJ 2002;324(7334):399‐402. [DOI] [PMC free article] [PubMed] [Google Scholar]
Stroke Unit Trialists' Collaboration 2013
- Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews 2013, Issue 9. [DOI: 10.1002/14651858.CD000197.pub3] [DOI] [PMC free article] [PubMed] [Google Scholar]
Szafran 2000
- Szafran O, Bell N. Use of walk‐in clinics by rural and urban patients. Canadian Family Physician 2000;46:114‐9. [PMC free article] [PubMed] [Google Scholar]
Weinick 2010
- Weinick R, Burns R, Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics. Health Affairs (Project Hope) 2010;29(9):1630‐6. [DOI] [PMC free article] [PubMed] [Google Scholar]
Whitecross 1999
- Whitecross L. Collaboration between GPs and nurse practitioners: the overseas experience and lessons for Australia. Australian Family Physician 1999;28:349‐53. [PubMed] [Google Scholar]
WHO 2013
- World Health Organization. Global health workforce shortage to reach 12.9 million in coming decades. News release 11 November 2013. www.who.int/mediacentre/news/releases/2013/health‐workforce‐shortage/en/ (accessed 27 January 2017).