Higher investment of physicians' time may be required to deliver high-quality care

Adult primary care visits have increased in quality, duration and frequency between 1997 and 2005, according to a report in the November 9 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

"Two of the most pressing goals for the U.S. health care system are to deliver higher-quality care and to lower costs," according to background information in the article. Primary care physicians are being held to these goals while patient populations have grown older and more complex. Additionally, primary care physicians' net incomes have decreased by more than 10 percent from 1995 to 2003, raising concerns that physicians would respond by shortening the time they spend on each visit in order to see more patients. Research suggests that a higher investment of primary care physicians' time may be required to deliver high-quality care.

Lena M. Chen, M.D, M.S., then of the Veterans Affairs Boston Healthcare System and now of the University of Michigan Health System, Ann Arbor, and colleagues conducted a retrospective analysis of 46,250 U.S. visits to primary care physicians by adults age 18 and older between 1997 and 2005. Researchers set out to determine changes in visit duration and if visit duration is associated with quality of care. Quality of care was evaluated using nine medical, counseling or screening quality indicators used in previous studies.

From 1997 to 2005, U.S. adult primary care visits to physicians increased by 10 percent, from an estimated 273 million to 338 million annually. The average visit duration increased from 18 minutes to 20.8 minutes. For general medical examinations, visit duration increased by 3.4 minutes and for the three most common primary diagnoses visit duration increased by 4.2 minutes for diabetes mellitus, by 3.7 minutes for essential hypertension and by 5.9 minutes for arthropathies (joint diseases).

"Comparing the early period (1997 to 2001) with the late period (2002 to 2005), quality of care improved for one of three counseling or screening indicators and for four of six medication indicators," the authors write. Visits for counseling or screening generally took 2.6 to 4.2 minutes longer than visits in which patients did not receive these services, while providing appropriate medication therapy was not associated with longer visit duration.

"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 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."

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