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Free clinic oversight and outcomes in the United States: a scoping review protocol

Worth, Grace1,2; Martin, Tina1,2; Christian, Robin1,2; Palokas, Michelle1,2

Author Information
doi: 10.11124/JBISRIR-D-19-00176
  • Free



In 2016, an estimated 27.3 million people were without health insurance in the United States (US).1 With a rise in the cost of health care and a decrease in employment-covered care, the disparity of the uninsured has continued to climb.2 Approximately 87% of uninsured persons are between the ages of 18 and 64 years.1 Uninsured persons most likely have a high school diploma or less and are also more prone to be living in poverty.1

Health care coverage and insurance varies widely throughout the world, with many developed countries providing universal free health care to all citizens. The US health insurance system has seen systemic changes in recent years in efforts to provide widespread affordable coverage to the population.3 Despite reforms, an estimated 23 million people still remain without health care coverage in the US, and many of those patients rely on free health care clinics for their care.3 An example of this is the state of Massachusetts, which has seen an increase in the utilization of free clinics by the uninsured since the passage of major health care reform in recent years.3

Free clinics are defined as non-profit, community-based clinics that provide free or low-cost services such as primary or secondary medical care; dental care; and pharmaceutical, laboratory, and/or psychiatric services.2 The term “free clinic” can include hospital or privately owned and operated community clinics, or federally qualified health centers.2,4 Free clinics offer health care screenings, treatments, and other services to the under-insured or uninsured at low to no cost.4

Free clinics were first established in the US in 1967 in an effort to support the uninsured while shifting the burden from the health care system. The goal of a free clinic is to decrease overall health disparities among the population, as well as remove the financial burden of the uninsured on the health care system by decreasing emergency room visits and hospital stays.2 Prior to the implementation of free clinics, hospital emergency rooms were the only institution to provide care for the uninsured as they cannot refuse treatment to patients seeking care.5 Today, it is estimated that there are more than 1000 free clinics operating in the US caring for more than 1.8 million patients annually.6 Almost 60% of free clinics in the US receive no government funding.6

Nearly half of patients treated at free clinics come from rural areas, and free clinic patients are over two times as likely to be uninsured and six times as likely to be impoverished as compared with the general population of the US.3 The most common conditions treated at free clinics include cardiovascular disease, hypertension, and diabetes.7

Free clinics have evolved since their inception and are now an integral part of the health care system in the US.6 More recent acceptance and support of free clinics was seen in 1994 when the American Medical Association validated them as a means of formal health care and a part of the health care safety net to protect those individuals who are uninsured or under-insured.6 In 1996, the Health Insurance Portability and Accountability Act gave medical malpractice coverage for health care professionals volunteering at free medical clinics.6 Though mean operational costs for free clinics nationwide is $287,810, more than half receive no government funding or oversight.6 Medical, community, or faith-based organizations often sponsor free medical clinics, but details of oversight are rarely reported, and regulatory and accountability standards are unclear.8

Free clinics serve a unique role in American health care; however, their function is highly understudied.9 There are limited cumulative data about free clinic oversight, and the outcomes seen in uninsured and under-insured patients who are treated at free health clinics. This review aims to provide information on clinic oversight, and health outcomes of uninsured and under-served patients using free clinics.

A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and the JBI Database of Systematic Reviews and Implementation Reports was conducted in November 2019, and no current or in-progress systematic reviews on the topic were identified.

The objective of this review is to explore existing literature related to free clinic oversight and patient and health outcomes reported with use of free clinics in the US, to examine and conceptually map the evidence, and to identify any gaps.

Review questions

  • i) Which governing bodies provide oversight for free clinics in the US?
  • ii) Which patient and health outcomes are reported with patient use of free clinics in the US?

Inclusion criteria


The review will consider studies that include hospital or privately owned and operated community free clinics, and adults and children who utilize free clinics in the US.


This scoping review will consider studies that evaluate patient and health outcomes of those persons utilizing free clinics in the US.


Studies will be included that discuss free clinics as clinics that are non-profit and provide free or decreased cost health care to patients, regardless of patient insurance or socioeconomic status in the US. Clinic types will include privately owned and operated free health centers, federally qualified health centers, and student-run clinics. Patient outcomes to be considered include disease course and management metrics (such as mortality and morbidity risk and prevalence, chronic disease control, and medication management) and patient satisfaction. Health outcomes to be considered include hospitalization rates and emergency room visit rates.

Types of sources

This scoping review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs including case series, individual case reports, and descriptive cross-sectional studies for inclusion.

Studies that focus on qualitative data including designs such as phenomenology, grounded theory, ethnography, qualitative description, action research, and feminist research will also be considered. In addition, systematic reviews and text and opinion papers that meet the inclusion criteria will also be considered.

Studies published since 1967 and in English will be included. The date limit is set at 1967 as the first free clinic opened that year.4


The proposed scoping review will be conducted in accordance with JBI methodology.10

Search strategy

The search strategy will aim to locate both published and unpublished studies. An initial limited search of MEDLINE and CINAHL was undertaken in November 2019 to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for PubMed (see Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists of articles selected for full-text review will be screened for additional papers.

Information sources

The databases to be searched include PubMed (PubMed), CINAHL (EBSCO), Cochrane Library, Embase (Elsevier), Scopus (Elsevier), Web of Science, and Clinical Trials Registry (EBSCO). Sources of unpublished studies and gray literature to be searched include Papers First, ProQuest Dissertations and Theses, and MedNar.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote v7 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full-text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA-ScR) flow diagram.11

Data extraction

Data will be extracted from papers included in the scoping review by two independent reviewers using a data extraction tool developed by the reviewers. The data extracted will include specific details about the population, concept, context, study methods, and key findings relevant to the review objective. A draft charting table is provided (see Appendix II). The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included study. Modifications will be detailed in the full scoping review report. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Data presentation

The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objective of this scoping review. A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the review's objective and questions.

Appendix I: Search strategy

Search conducted in PubMed.

1. “free clinic” OR “free health clinic” OR “community clinic” OR “community health clinic” OR “federally qualified clinic” OR “federally qualified health clinic” OR “safety net clinic” OR “safety net health clinic” OR “safety-net clinic” OR “safety-net health clinic” OR “safety-net providers”[MeSH] – 3146 hits returned with lower date limit of 1967 Jan 01 and English language only limitation

2. “Outcome Assessment (Health Care)”[MeSH] OR “Outcome and Process Assessment (Health Care)”[MeSH] OR “Patient Outcome Assessment”[MeSH] OR “Patient Reported Outcome Measures”[MeSH] OR “Patient outcome” OR “treatment outcome”[MeSH] OR “Government Regulation”[Mesh] OR oversight OR regulation OR “hospitalization rate” OR “emergency room visit rate” OR “disease course” OR “Disease Progression”[Mesh] OR “disease progression” OR “disease exacerbation” OR “clinical deterioration”[MeSH] OR “Disease Management”[Mesh] OR “disease management” OR “Patient Satisfaction”[Mesh] OR “patient satisfaction” – 3,162,497 hits returned with lower date limit of 1967 Jan 01 and English language only limitation

3. #1 AND #2 – 848 records retrieved with lower date limit of 1967 Jan 1 and English language only limitation

Appendix II: Data extraction instrument


Elizabeth Hinton, MSIS, AHIP, librarian, for assistance in the development of search strategies of database systems.

This scoping review will contribute toward a Doctor of Nursing Practice (DNP) degree for GW.


1. Berchick E. Who are the uninsured? [Internet]. United States Census Bureau; 2017 [cited 9 Feb 2020]. Available from:
2. Notaro SJ, Khan M, Bryan N, Kim C, Osunero T, Senseng MG, et al. Analysis of the demographic characteristics and medical conditions of the uninsured utilizing a free clinic. J Community Health 2012; 37 (2):501–506.
3. Rosenbaum S, Jones E, Shin P, Tolbert J. Community health centers: Opportunities and challenges of health reform [Internet]. The Henry Journal of Kaiser Family Foundation 2010.
4. Nadkarni MM, Philbrick JT. Free clinics: a national survey. Am J Med Sci 2005; 330 (1):25–31.
5. Gertz AM, Frank S, Blixen CE. A survey of patients and providers at free clinics across the United States. J Community Health 2011; 36 (1):83–93.
6. Darnell JS. Free clinics in the United States: a nationwide survey. Arch Intern Med 2010; 170 (11):946–953.
7. Redlener I, Grant R. America's safety net and health care reform—what lies ahead? N Engl J Med 2009; 361 (23):2201–2204.
8. American Health Lawyers Association, American Medical Association Foundation. The free medical clinic: a practical handbook for health care providers [Internet]. 2016 [cited 17 Jan 2020]. Available from:
9. Hwang W, Liao K, Griffin L, Foley KL. Do free clinics reduce unnecessary emergency department visits? The Virginian experience. J Health Care Poor Underserved 2012; 23:1189–1204.
10. Peters MDJ, Godfrey C, McInerney P, Baldini Soares C, Khalil H, Parker D. Aromataris E, Munn Z. Chapter 11: Scoping reviews. JBI, JBI Reviewer's Manual [Internet]. Adelaide:2017.
11. Tricco AC, Lillie E, Zarin W, O’Brien K, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 169(7):467–473.

federally qualified clinic; free clinic; government regulation; health outcomes; patient outcomes

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