Adult Primary Care Visit Frequency, Quality, and Duration Increasing

Laurie Barclay, MD

September 18, 2010

November 9, 2009 — Adult primary care visit frequency, quality, and duration increased between 1997 and 2005, with modest relationships noted between visit duration and quality of care, according to the results of a retrospective analysis reported in the November 9 issue of the Archives of Internal Medicine.

"Two of the most pressing goals for the US health care system are to deliver higher-quality care and to lower costs," write Lena M. Chen, MD, MS, who was with the Veterans Affairs Boston Healthcare System, Massachusetts, at the time of the study and is now with the University of Michigan Health System, Ann Arbor, and colleagues. "It is unclear if increasing pressure on primary care physicians to be more efficient has affected visit duration or quality of care. We sought to describe changes in the duration of adult primary care visits and in the quality of care provided during these visits and to determine whether quality of care is associated with visit duration."

Using a nationally representative sample of office-based primary care physicians in the United States, the investigators found that between 1997 and 2005, primary care visits by adults aged 18 years or older increased from 273 million to 338 million each year, or 10% on a per capita basis. Mean visit duration increased from 18.0 to 20.8 minutes (P < .001 for trend), with a 3.4-minute increase for general medical examinations.

For the 3 most common primary diagnoses, visit duration increased by 4.2 minutes for diabetes mellitus (P = .002 for trend), 3.7 minutes for essential hypertension (P < .001 for trend), and 5.9 minutes for arthropathies (P < .001 for trend).

For the early period (1997 – 2001) compared with the late period (2002 – 2005), quality of care improved for 1 of 3 counseling or screening indicators and for 4 of 6 medication indicators. Time needed to provide appropriate counseling or screening was typically 2.6 to 4.2 minutes, whereas providing appropriate medication therapy was not associated with longer visit duration.

"Adult primary care visit frequency, quality, and duration increased between 1997 and 2005," the study authors write. "Modest relationships were noted between visit duration and quality of care. Providing counseling or screening required additional physician time, but ensuring that patients were taking appropriate medications seemed to be independent of visit duration."

Limitations of this study include an inability to determine the factors associated with racial/ethnic differences in time spent per visit, duration of the outpatient visit self-reported by physicians or staff, inadequate capture of illness complexity and severity, and limited quality measures.

"Although it is possible that physicians have become less efficient over time, it is far more likely that visit duration has increased because it takes more resources or time to care for an older and sicker population," the study authors conclude. "Improvements in quality of care will likely require a combination of investments in systems such as electronic health records, greater use of other professionals such as nurse practitioners, and better reimbursement to primary care physicians for the extra time spent."

The Massachusetts Veterans Epidemiology Research and Information Center, Veterans Affairs Boston Healthcare System, supported this study. The study authors have disclosed no relevant financial relationships.

Arch Intern Med. 2009;169:1866–1872.

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