Nationally representative data show that outpatient office visits to both primary care physicians and specialists grew longer over the period from 1993 to 2010.
Meredith K. Shaw; Scott A. Davis, MA; Alan B. Fleischer, Jr, MD; and Steven R. Feldman, MD, PhD
Since the expansion of managed care in the 1990s, physicians frequently report a high level of concern about the effects of time constraints on medical practice.1
Many report feeling more and more rushed to see an increasing number of patients. Guidelines recommend that physicians should be providing preventive services, helping to minimize the need for expensive emergency care. However, patient loads for primary care physicians generally contain patient visits that are a response to illness or injury, as opposed to visits that cover preventive care.1,2
Time constraints are one of the most cited reasons by physicians for not providing preventive care as often as guidelines would dictate.1-3
Spending less time with patients makes it more difficult for physicians to obtain a full history, potentially making treatment choices less efficient, and preventing patients from receiving the entirety of the care they need.4
Adult patients in the United States receive a little over half of the healthcare that is recommended to them as outlined by the US Preventive Services Task Force.3,5
The perception that office visits are getting shorter has been common for many years. Responding to the growth in managed care, in 2001 Mechanic, McAlpine, and Rosenthal tested the hypothesis that office visits were becoming shorter, using data from the annual National Ambulatory Medical Care Surveys (NAMCS) from 1989 to 1998.6
They found that contrary to the perception, the average duration of office visits continued to increase. The effect was consistent across both prepaid and non-prepaid visits, suggesting managed care did not cause the longer average visit time.6
The data also did not support the idea that increased patient age or complexity of patient issues caused longer visits.6
Although managed care has now become a less hotly contested issue, time constraints on physicians continue to be a widespread concern. We sought to determine whether the average duration of physician visits has continued to rise, using the most recent available data from NAMCS up to 2010.METHODS
Data from annual surveys from the NAMCS from 1993 through 2010 were analyzed. These surveys obtained a representative sample of visit lengths to nonfederally employed outpatient physicians in all specialties except anesthesiology, pathology, and radiology. The duration of the visit was recorded to be only the amount of time the physician spent in face-to-face contact with the patient, and did not include time spent with physician extenders or nurses. For each visit selected, the physician or a member of the physician’s staff is expected to provide information about the characteristics of the patient, the duration of the visit, the reason for the visit, any diagnoses made, and any tests and procedures performed. Standard errors were adjusted for in the sampling design through the NAMCS survey and through SAS statements “CLUSTER cpsum, and STRATA cstratm.” Populationbased estimates were calculated by dividing the number of NAMCS visits in each year by the US population according to US Census data. This study was approved by the Wake Forest Baptist Hospital Institutional Review Board and under the rules of the Health Insurance Portability and Accountability Act of 1996, which permits physicians to make disclosures of protected health information with patient authorization for public health purposes or for approved research.7
During the declared data recording week, physicians, members of the physicians’ staff, or Census field reporters used an arrival log to keep a daily catalogue of all patient visits.8 Visits included both scheduled and non-scheduled patients, while excluding cancellations and no-shows.8
The CDC website describes that visits from which data were collected were selected “from the list using a random start and a predetermined sampling interval based on the physician’s estimated visits for the week and the number of days the physician was expected to see patients that week.”8
Through this process, the NAMCS was able to produce a systematic random sample of visits from that physician.
The rate of response to the survey varied from 58.3% in 2010 to 73.0% in 1995 and 1993 over the 18-year period, with an average response rate of 65.6%. A systematic random sample of visits to each physician was selected during 1 randomly chosen 1-week period. The number of visits sampled per year ranged from 20,992 visits in 1999 to 36,875 visits in 1995. The estimates presented were calculated with the weighting used by the NAMCS to adjust for nonresponse and to produce nationally representative estimates. All data analysis was performed using SAS 9.1.3 (SAS Institute, Cary, North Carolina).
The data included information about the visit duration for visits to all physicians, including primary care physicians and specialists. In bivariate analyses, duration was also examined separately for those of different age ranges, for individuals who did and did not have a procedure performed, for visits in which patients only saw a physician (without a nurse practitioner or a physician’s assistant present), and for patients who had different numbers of diagnoses. A regression was performed to analyze visits that occurred without the use of the electronic medical record (EMR). A multivariate linear regression was performed to assess simultaneously the impact of age, year, specialty, insurance type, new versus return patient status, procedure status, employment status (owner versus employee or contractor), use of the EMR, and number of diagnoses on visit length. The multivariate analysis was run 3 different times beginning in the years 1993, 1997, and 2003 to allow for the inclusion of variables relating to payment type and employment status (first included in the survey in 1997), and the use of the EMR (first included in 2003).RESULTS
From 1993 to 2010, the total number of physician visits increased from approximately 717 million to 994 million, resulting in an approximate 39% increase in total visits. During this time, there was a 19% increase in the total population of the United States.9,10
The number of visits per physician eligible for NAMCS showed little change, fluctuating from 1993.8 visits per physician in 1993 to 1943.2 visits per physician in 2010. Additionally, the number of annual visits per United States resident increased from 2.7 visits per resident in 1993 to 3.2 visits per resident in 2010. One would assume that in order to compensate for the increase in the number of possible patients and the increase in the number of visits per US resident, the duration of each such visit would need to decrease.
However, based on the data, the average visit duration increased for both primary care physicians and specialists, with an annual increase of 0.17 minutes per visit from 1993 to 2010 for primary care physicians, to give an approximately 3-minute total increase over the 17-year span for general practitioners, family practitioners, internal medicine physicians, and pediatricians (P
<.001, Figure 1
). The annual increase was 0.12 minutes for specialists, to total a 2.1-minute increase per visit from 1993 to 2010 (P
<.001, Figure 1). The increasing duration of office visits was observed across each age group (children, adults, and the elderly, eAppendix
, available at www.ajmc.com
) and for both primary care physicians and specialists. The increase in visit duration remained when patients who saw physician extenders were excluded, and when no procedures were performed (Figure 2
In the multivariate regression for 1993-2010, of the 13 specialties compared with general and family practice, 9 specialties averaged longer visits, with only pediatrics, orthopedic surgery, dermatology, and otolaryngology averaging the same or shorter visits (Table
). Additionally, the positive values demonstrate that higher age, later year, and a greater number of diagnoses are all associated with longer visits (Table). Through these data, we were able to identify a number of factors associated with an increased duration of visits, but after controlling for all of these variables, it was seen that later year has a large effect upon visit duration (0.17 minutes longer per year) (Table). In the 1997-2010 analysis, visits paid by insurance from Medicare (P
= .02, beta= –1.71 minutes) or Medicaid (P
= .006, beta = –1.61 minutes) were associated with shorter visits compared with payers other than Medicare or Medicaid. Visits paid with private insurance were not significantly different from those visits that were paid out of pocket (P
= .09; beta = –1.03). Employment status did not have a significant effect (P
= .26), and the effect of later year was still similar (β = 0.21; P
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