Skip to main content


Log in

A value-based comparison of the management of respiratory diseases in walk-in clinics and emergency departments

  • Original Research
  • Published:
Canadian Journal of Emergency Medicine Aims and scope Submit manuscript



Our aim was to compare some of the health outcomes and costs associated with value of care in emergency departments (ED) and walk-in clinics for ambulatory patients presenting with an acute respiratory disease.


A health records review was conducted from April 2016 through March 2017 in one ED and one walk-in clinic. Inclusion criteria were: (i) ambulatory patients at least 18 years old, (ii) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. Primary outcome was the proportion of patients returning to any ED or walk-in clinic within three and seven days of the index visit. Secondary outcomes were the mean cost of care and the incidence of antibiotic prescription for URTI patients. The cost of care was estimated from the Ministry of Health’s perspectives using time-driven activity-based costing.


The ED group included 170 patients and the walk-in clinic group 326 patients. The return visit incidences at three and seven days were, respectively, 25.9% and 38.2% in the ED vs. 4.9% and 14.7% in the walk-in clinic (adjusted relative risk (arr) of 4.7 (95% CI 2.6–8.6) and 2.7 (1.9–3.9)). The mean cost ($Cdn) of the index visit care was 116.0 (106.3–125.7) in the ED vs. 62.5 (57.7–67.3) in the walk-in clinic (mean difference of 56.4 (45.7–67.1)). Antibiotic prescription for URTI was 5.6% in the ED vs. 24.7% in the walk-in clinic (arr 0.2, 0.01–0.6).


This study is the first in a larger research program to compare the value of care between walk-in clinics and the ED. The potential advantages of walk-in clinics over EDs (lower costs, lower incidence of return visits) for ambulatory patients with respiratory diseases should be considered in healthcare planning.



Notre objectif était de comparer certains des résultats sanitaires et des coûts associés à la valeur des soins dans les services d'urgence et les cliniques sans rendez-vous pour les patients ambulatoires souffrant d'une maladie respiratoire aiguë.


Une revue des dossiers médicaux a été réalisée d'avril 2016 à mars 2017 dans un service d'urgence et une clinique sans rendez-vous. Les critères d’inclusion étaient les suivants : (i) patients ambulatoires âgés d’au moins 18 ans, (ii) renvoyés chez eux avec un diagnostic d’infection des voies respiratoires supérieures (IVRS), de pneumonie, d’asthme aigu ou d’exacerbation aiguë de la maladie pulmonaire obstructive chronique. Le résultat primaire était la proportion de patients retournant à un service d'urgence ou à une clinique sans rendez-vous dans les trois et sept jours suivant la visite de référence. Les résultats secondaires étaient le coût moyen des soins et l'incidence de la prescription d'antibiotiques pour les patients atteints d'IVRS. Le coût des soins a été estimé à partir des perspectives du ministère de la santé, en utilisant la méthode de calcul des coûts par activité en fonction du temps.


Le groupe des urgences comprenait 170 patients et le groupe des cliniques sans rendez-vous 326 patients. Les incidences des visites de retour à trois et sept jours étaient respectivement de 25,9 % et 38,2 % dans le service des urgences contre 4,9 % et 14,7 % à la clinique sans rendez-vous (risque relatif ajusté (arr) de 4,7 (IC à 95 % 2,6 à 8,6) et 2,7 (1,9-3,9)). Le coût moyen ($CAN) de la visite de référence était de 116,0 (106,3-125,7) aux urgences contre 62,5 (57,7-67,3) dans la clinique sans rendez-vous (différence moyenne de 56,4 (45,7-67,1)). La prescription d'antibiotiques pour l’IVRS était de 5,6 % aux urgences contre 24,7 % dans la clinique sans rendez-vous (arr 0,2, 0,01-0,6).


Cette étude est la première d'un programme de recherche plus vaste visant à comparer la valeur des soins entre les cliniques sans rendez-vous et les urgences. Les avantages potentiels des cliniques sans rendez-vous par rapport aux services d'urgence (coûts moindres, incidence plus faible des visites de retour) pour les patients ambulatoires souffrant de maladies respiratoires devraient être pris en compte dans la planification des soins de santé.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

Data availability

All data requests should be submitted to the corresponding author (Dr S. Berthelot) for consideration. Access to anonymised data may be granted for non-commercial research at the discretion of the corresponding author.


  1. Gonçalves-Bradley D, Khangura JK, Flodgren G, Perera R, Rowe BH, Shepperd S. Primary care professionals providing non-urgent care in hospital emergency departments. Cochrane Database Syst Rev. 2018;2:2097.

    Google Scholar 

  2. Vertesi L. Does the canadian emergency department triage and acuity scale identify non-urgent patients who can be triaged away from the emergency department? Can J Emerg Med. 2004;6(5):337–42.

    Article  Google Scholar 

  3. Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J EMJ. 2003;20(5):402–5.

    Article  CAS  PubMed  Google Scholar 

  4. Canadian Institute for Health Information. Sources of potentially avoidable emergency department visits. Nov. 2014.

  5. Hutchison B, Levesque JF, Strumpf E, Coyle N. Primary health care in canada: systems in motion. Milbank Q. 2011;89(2):256–88.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Weinkauf DJ, Kralj B. Medical service provision and costs: do walk-in clinics differ from other primary care delivery settings? Can Public Policy Anal Polit. 1998;24(4):471–84.

    Article  Google Scholar 

  7. Smulowitz PB, Honigman L, Landon BE. A novel approach to identifying targets for cost reduction in the emergency department. Ann Emerg Med. 2013;61(3):293–300.

    Article  PubMed  Google Scholar 

  8. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477–81.

    Article  CAS  PubMed  Google Scholar 

  9. Van den Heede K, Van de Voorde C. Interventions to reduce emergency department utilisation: a review of reviews. Health Policy. 2016;120(12):1337–49.

    Article  PubMed  Google Scholar 

  10. Uscher-Pines L, Pines J, Kellermann A, Gillen E, Mehrotra A. Emergency department visits for nonurgent conditions: systematic literature review. Am J Manag Care. 2013;19(1):47–59.

    PubMed  PubMed Central  Google Scholar 

  11. Campbell MK, Silver RW, Hoch JS, Østbye T, Stewart M, Barnsley J, et al. Re-utilization outcomes and costs of minor acute illness treated at family physician offices, walk-in clinics, and emergency departments. Can Fam Physician. 2005;51(1):82–3.

    PubMed  PubMed Central  Google Scholar 

  12. Jones M. Walk-in primary medical care centres: lessons from Canada. BMJ. 2000;321(7266):928–31.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Ashwood JS, Gaynor M, Setodji CM, Reid RO, Weber E, Mehrotra A. Retail clinic visits for low-acuity conditions increase utilization and spending. Health Aff (Millwood). 2016;35(3):449–55.

    Article  PubMed  Google Scholar 

  14. Berthelot S, Breton M, Guertin JR, Archambault PM, Berger Pelletier E, Blouin D, et al. A value-based comparison of the management of ambulatory respiratory diseases in walk-in clinics, primary care practices, and emergency departments: protocol for a multicenter prospective cohort study. JMIR Res Protoc. 2021;10(2):e25619.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.

    Article  CAS  PubMed  Google Scholar 

  16. Perkins AJ, Kroenke K, Unützer J, Katon W, Williams JW, Hope C, et al. Common comorbidity scales were similar in their ability to predict health care costs and mortality. J Clin Epidemiol. 2004;57(10):1040–8.

    Article  PubMed  Google Scholar 

  17. Grief SN. Upper respiratory infections. Prim Care. 2013;40(3):757–70.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Hodder R, Lougheed MD, Rowe BH, FitzGerald JM, Kaplan AG, McIvor RA. Management of acute asthma in adults in the emergency department: nonventilatory management. CMAJ. 2010;182(2):E55-67.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Clinical guides in antibiotic treatment - 1st series [Internet]. INESSS. [cité 15 juill 2021]. Disponible sur: Accessed July 2021

  20. Lougheed MD, Lemiere C, Ducharme FM, Licskai C, Dell SD, Rowe BH, et al. Canadian thoracic society 2012 guideline update: diagnosis and management of asthma in preschoolers, children and adults. Can Respir J. 2012;19(2):127–64.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Development of a consensus on evidence-based quality of care indicators for Canadian emergency departments [Internet]. [cité 14 juill 2021]. Disponible sur: Accessed July 2021

  22. Halls A, Van’t Hoff C, Little P, Verheij T, Leydon GM. Qualitative interview study of parents’ perspectives, concerns and experiences of the management of lower respiratory tract infections in children in primary care. BMJ Open. 2017;7(9):e015701.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Thomas LE, Li F, Pencina MJ. Overlap Weighting: a propensity score method that mimics attributes of a randomized clinical trial. JAMA. 2020;323(23):2417–8.

    Article  PubMed  Google Scholar 

  24. Diop SA, Duchesne T, Cumming SG, Diop A, Talbot D. Confounding adjustment methods for multi-level treatment comparisons under lack of positivity and unknown model specification. J Appl Stat. 2022;49(10):2570–92.

    Article  PubMed  Google Scholar 

  25. Watson MC, Ferguson J, Barton GR, Maskrey V, Blyth A, Paudyal V, et al. A cohort study of influences, health outcomes and costs of patients’ health-seeking behaviour for minor ailments from primary and emergency care settings. BMJ Open. 2015;5(2):e006261.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Galarraga JE, Mutter R, Pines JM. Costs associated with ambulatory care sensitive conditions across hospital-based settings. Acad Emerg Med Off J Soc Acad Emerg Med. 2015;22(2):172–81.

    Article  Google Scholar 

  27. Martin BC. Emergency medicine versus primary care: a case study of three prevalent, costly, and non-emergent diagnoses at a community teaching hospital. J Health Care Finance. 2000;27(2):51–65.

    CAS  PubMed  Google Scholar 

  28. Chua KP, Fischer MA, Linder JA. Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study. BMJ. 2019;364:k5092.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Palms DL, Hicks LA, Bartoces M, Hersh AL, Zetts R, Hyun DY, et al. Comparison of antibiotic prescribing in retail clinics, urgent care centers, emergency departments, and traditional ambulatory care settings in the United States. JAMA Intern Med. 2018;178(9):1267–9.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Mehrotra A, Gidengil CA, Setodji CM, Burns RM, Linder JA. Antibiotic prescribing for respiratory infections at retail clinics, physician practices, and emergency departments. Am J Manag Care. 2015;21(4):294–302.

    PubMed  Google Scholar 

  31. Huemer M, Mairpady Shambat S, Brugger SD, Zinkernagel AS. Antibiotic resistance and persistence—implications for human health and treatment perspectives. EMBO Rep. 2020;21(12):e51034.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Yun BJ, Prabhakar AM, Warsh J, Kaplan R, Brennan J, Dempsey KE, et al. Time-driven activity-based costing in emergency medicine. Ann Emerg Med. 2016;67(6):765–72.

    Article  PubMed  Google Scholar 

  33. Mbuya-Bienge C, Simard M, Gaulin M, Candas B, Sirois C. Does socio-economic status influence the effect of multimorbidity on the frequent use of ambulatory care services in a universal healthcare system? A population-based cohort study. BMC Health Serv Res. 2021;21(1):202.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Sharp AL, Cobb EM, Dresden SM, Richardson DK, Sabbatini AK, Sauser K, et al. Understanding the value of emergency care: a framework incorporating stakeholder perspectives. J Emerg Med. 2014;47(3):333–42.

    Article  PubMed  Google Scholar 

Download references


This study was supported by the Réseau de recherche en santé respiratoire du Québec (RSRQ), the Fonds de recherche du Québec-Santé (FRQS), the Centre de recherche du CHU de Québec-Université Laval, the Canadian Association of Emergency Physicians (CAEP), and the Département de médecine familiale et de médecine d’urgence de l’Université Laval.

Author information

Authors and Affiliations



SB, PMA, MM and LM designed the study. SB, MM and ML supervised its conduct. MM, TM, JL, NZ, SS, PO, BH, PL, SBl and ML collected the financial, organizational, and clinical data. SB, TM, NS, DS, DT, LM and JRG carried out the statistical analyses and interpreted them. TM drafted the initial manuscript. All authors proofread the manuscript and approved its submitted version. SB assumes responsibility for the integrity of the data used in this study and the accuracy of its analysis.

Corresponding author

Correspondence to Simon Berthelot.

Ethics declarations

Conflict of interest

SB, LM, DT, PMA and JRG reports grant money FRQS research scholarships. TM, PLa, SBl, NS, DS, JL, NZ, SS, BH, PO, MM, MLe, MLa report no conflict of interest.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 30 KB)

Supplementary file2 (DOCX 25 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Marx, T., Moore, L., Talbot, D. et al. A value-based comparison of the management of respiratory diseases in walk-in clinics and emergency departments. Can J Emerg Med 25, 394–402 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: