Is Time on Your Side?

Physicians are under mounting pressure to increase efficiency in the provision of medical care. That is, see more patients in less time for less money. But, since speed and accuracy do not always go hand-in-hand, does this increased physician efficiency lead to quality medical care? A recent study published in the Archives of Internal Medicine says “not so fast.”

The retrospective analysis examined the frequency, duration, and quality of primary care visits by adults in the United States. The study population included a nationally representative sample of 46,250 adults who visited primary care physicians between 1997 and 2005. Overall, primary care visits increased during the study period from 273 million to 338 million annually, or 10% per capita. The duration of the visits increased from an average of 18 minutes to almost 21 minutes. The increase in duration was significant for general medical exams (3.4 minutes), as well as the 3 most common diagnoses in primary care: diabetes mellitus (4.2 minutes), hypertension (3.7 minutes), and arthropathies (5.9 minutes).

The authors also assessed the quality of counseling and screening, as well as medication therapy. Overall, appropriate counseling or screening took 2.6 to 4.2 minutes per visit. Of the 3 quality indicators measured for counseling and screening, only 1 improved during the study period. Providing appropriate medication therapy was not associated with longer visits. Of the 6 quality indicators for medication therapy, 4 improved during the study period. The authors admit that overall performance, as assessed by the quality indicators, was poor.

The authors report that only modest relationships between visit duration and quality of care were achieved. Providing counseling did take additional time during the visit, but there was no correlation between the time spent in the visit and the appropriateness of the medication therapy. Related studies have actually shown a correlation between inappropriate medication use and shorter visit durations.

The current study did not address racial or ethnic differences in visit frequency, duration, or quality, which is often associated with disparities in health care provision. The study also could not adequately address the severity and complexity of illnesses or conditions and used limited quality measures.

With an aging population, it is not surprising that more time is required to care for more patients with more diseases than ever before. However, other studies have revealed that, while overall lengths of physician visits have increased, the duration of visits is the same across all age groups. Older patients, often with more medical conditions and on more complicated medication regimens, do not spend more time with physicians than younger, healthier patients. This supports the conclusion of the authors of the Archives study that promotes an interdisciplinary approach to improving medical care; particularly older, higher-risk patients may require additional time with nurse practitioners, pharmacists, and other health care providers to optimize medical care.

Substantially improving the efficiency of the provision of health care requires more than simply increased face time between physicians and patients; it will require enhanced electronic medical record keeping, augmented multidisciplinary approaches to care, and adequate reimbursement for providers spending time with patients. But, for now, physicians and patients alike should remember to always use time wisely, for it is a precious commodity. As William Penn understood, “time is what we want most, but what we use worst.”

References

Olfson, M., Cherry, D., & Lewis-Fernandez, R. (2009). Racial Differences in Visit Duration of Outpatient Psychiatric Visits Archives of General Psychiatry, 66 (2), 214-221 DOI: 10.1001/archgenpsychiatry.2008.523

Chen, L., Farwell, W., & Jha, A. (2009). Primary Care Visit Duration and Quality: Does Good Care Take Longer? Archives of Internal Medicine, 169 (20), 1866-1872 DOI: 10.1001/archinternmed.2009.341

Linder, J. (2003). Association between antibiotic prescribing and visit duration in adults with upper respiratory tract infections Clinical Therapeutics, 25 (9), 2419-2430 DOI: 10.1016/S0149-2918(03)80284-9

Lo, A., Ryder, K., & Shorr, R. (2005). Relationship Between Patient Age and Duration of Physician Visit in Ambulatory Setting: Does One Size Fit All? Journal of the American Geriatrics Society, 53 (7), 1162-1167 DOI: 10.1111/j.1532-5415.2005.53367.x