Abstract
BACKGROUND
Primary care physicians report that there is insufficient time to meet patients’ needs during clinical visits, but visit time has increased over the past decade.
OBJECTIVE
To determine whether the number of clinical items addressed during the primary care visit has increased, and if so, whether this has been associated with changes in visit length and the pace of clinical work.
DESIGN
Analysis of non-hospital-based adult primary care visits from 1997 to 2005, as reported in the National Ambulatory Medical Care Survey.
PARTICIPANTS
A total of 46,431 adult primary care visits.
MEASUREMENTS
We assessed changes over time for the total number of clinical items addressed per visit (including diagnoses, medications, tests ordered, and counseling), visit duration, and average available time per clinical item. In adjusted analyses we controlled for patient and physician characteristics.
RESULTS
The number of clinical items addressed per visit increased from 5.4 to 7.1 from 1997 to 2005 (p < 0.001). Visit duration concurrently increased from 18.0 to 20.9 min (p < 0.001). The increase in the number of clinical items outpaced the increase in duration, resulting in a decrease in time per clinical item from 4.4 to 3.8 (p = 0.04). These changes occurred across patient age and payer status and were confirmed in adjusted analyses.
CONCLUSIONS
The volume of work associated with primary care visits has increased to a greater extent than has visit duration, resulting in less available time to address individual items. These findings have important implications for reimbursing physician time and improving the quality of care.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
McGlynn EA, Asch SM, Adams J. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635–45.
Ma J, Stafford RS. Quality of US outpatient care: temporal changes and racial/ethnic disparities. Arch Intern Med. 2005;165:1354–61.
Grant RW, Buse JB, Meigs JB. Quality of diabetes care in U.S. academic medical centers: low rates of medical regimen change. Diabetes Care. 2005;28:337–442.
Stafford RS, Radley DC. The underutilization of cardiac medications of proven benefit, 1990 to 2002. J Am Coll Cardiol. 2003;41:56–61.
Kassirer JP. Doctor discontent. N Engl J Med. 1998;339:1543–5.
Mechanic D. Physician discontent: challenges and opportunities. JAMA. 2003;290:941–6.
Center for Studying Health System Change. So much to do, so little time: physician capacity constraints 1997–2001; 2003. http://www.hschange.com/CONTENT/556/556.pdf. Accessed September 2, 2008.
Weeks WB, Wallace AE. Time and money: a retrospective evaluation of the inputs, outputs, efficiency, and incomes of physicians. Arch Intern Med. 2003;163:944–8.
Mechanic D, McAlpine DD, Rosenthal M. Are patients’ office visits with physicians getting shorter? N Engl J Med. 2001;344:198–204.
Grant RW, Pirraglia PA, Meigs JB, Singer DE. Trends in complexity of diabetes care in the United States from 1991 to 2000. Arch Intern Med. 2004;164:1134–9.
Cherry D, Burt CW, Woodwell DA. Advance data from the vital and health statistics: National Ambulatory Medical Care Survey (NAMCS) 2001 data summary, number 337. National Center for Health Statistics; 2003. http://www.cdc.gov/nchs/data/ad/ad337.pdf. Accessed September 2, 2008.
National Center for Health Statistics. National ambulatory medical care survey. Public-use files and documentation. Hyattsville, MD; 1997, 1998, 1999, 2000, 2001, 2002, 2003.
Department of Health and Human Services. International classification of diseases, Ninth Edition, Clinical Modification (ICD-9-CM).
Food and Drug Administration. National Drug Code Directory. http://www.fda.gov/cder/ndc/. Accessed September 2, 2008.
Wilson IB, Schoen C, Neuman P. Physician-patient communication about prescription medication nonadherence: a 50-state study of America’s seniors. J Gen Intern Med. 2007;22:6–12.
Lasker RD, Marquis MS. The intensity of physicians’ work in patient visits-implications for the coding of patient evaluation and management services. N Engl J Med. 1999;341:337–41.
Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93:635–41.
Tai-Seale M, McGuire TG, Zhang W. Time allocation in primary care office visits. Health Serv Res. 2007;42:1871–94.
Casalino LP. Disease management and the organization of physician practice. JAMA. 2005;293:485–8.
Goodson JD, Bierman AS, Fein O, Rask K, Rich EC, Selker HP. The future of capitation: the physician role in managing change in practice. J Gen Intern Med. 2001;16:250–6.
Grumbach K, Bodenheimer T. A primary care home for Americans: putting the house in order. JAMA. 2002;288:889–93.
Barr M, Ginsburg J. The advanced medical home: a patient-centered, physician-guided model of health care. American College of Physicians; 2006. http://www.acponline.org/ppvl/policies/e001092.html. Accessed September 2, 2008.
Weiss KB. Managing complexity in chronic care: an overview of the VA state-of-the-art (SOTA) conference. J Gen Intern Med. 2007;22Suppl 3374–8.
Whittle J, Bosworth H. Studying complexity is complex. J Gen Intern Med. 2007;22Suppl 3379–81.
Werner RM, Greenfield S, Fung C, Turner BJ. Measuring quality of care in patients with multiple clinical conditions: summary of a conference conducted by the Society of General Internal Medicine. J Gen Intern Med. 2007;22:1206–11.
Safford MM, Allison JJ, Kiefe CI. Patient complexity: more than comorbidity. the vector model of complexity. J Gen Intern Med. 2007;22Suppl 3382–90.
Safford MM, Shewchuk R, Qu H. Reasons for not intensifying medications: differentiating “clinical inertia” from appropriate care. J Gen Intern Med. 2007;22:1648–55.
Gottschalk A, Flocke SA. Time spent in face-to-face patient care and work outside the examination room. Ann Fam Med. 2005;3:488–93.
Gilchrist V, McCord G, Schrop SL. Physician activities during time out of the examination room. Ann Fam Med. 2005;3:494–9.
Gilchrist VJ, Stange KC, Flocke SA, McCord G, Bourguet CC. A comparison of the National Ambulatory Medical Care Survey (NAMCS) measurement approach with direct observation of outpatient visits. Med Care. 2004;42:276–80.
Stange KC, Zyzanski SJ, Jaen CR. Illuminating the ‘black box’. A description of 4454 patient visits to 138 family physicians. J Fam Pract. 1998;46:377–89.
Mokdad AH, Ford ES, Bowman BA. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA. 2003;289:76–9.
Acknowledgements
This study was supported by a Chicago Center of Excellence in Health Promotion Economics Pilot Grant (Drs. Abbo, Zhang, Zelder, and Huang) from a grant from the Centers for Disease Control and Prevention (1 P30 CD000147–01) a National Institutes of Aging Career Development Award (Dr. Huang, K23-AG021963), and a grant from the National Institute of Child Health and Human Development (Dr. Zhang, 1R03-HD056073). This work was presented in preliminary form at the 29th Annual Meeting of the Society for General Internal Medicine in Los Angeles, California, April, 2006.
Conflict of Interest
None disclosed.
Author information
Authors and Affiliations
Corresponding author
Electronic supplementary material
Below is the link to the electronic supplementary material.
ESM
Abstraction of visit data from NAMCS by survey design (DOC 148 KB).
Rights and permissions
About this article
Cite this article
Abbo, E.D., Zhang, Q., Zelder, M. et al. The Increasing Number of Clinical Items Addressed During the Time of Adult Primary Care Visits. J GEN INTERN MED 23, 2058–2065 (2008). https://doi.org/10.1007/s11606-008-0805-8
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-008-0805-8