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The Duration of Office Visits in the United States, 1993 to 2010

Meredith K. Shaw; Scott A. Davis, MA; Alan B. Fleischer, Jr, MD; and Steven R. Feldman, MD, PhD
Nationally representative data show that outpatient office visits to both primary care physicians and specialists grew longer over the period from 1993 to 2010.
Visit duration increased in all types of visits tested, except for those during which a procedure was performed. While duration of visits increased in all primary care specialties, duration of visits for 6 types of specialists increased, while the duration of visits for 2 specialties (psychiatry and ophthalmology) showed significant decreases, and the visit duration for 2 others (cardiology and neurology) showed nonsignificant decreases. The multivariate linear regression of the data confirmed our initial analysis that visit durations were increasing; we saw that later year has a large effect upon visit duration, even after controlling for all other variables. The increase in visit duration over time appears independent from greater patient complexity, changes in specialties seen, or any other factors analyzed. The multivariate regression provided new analysis in comparison to what Mechanic et al had analyzed, and allowed us to conclude that once these external variables were taken into account, the increase in the duration of visits to general physicians and specialists was consistent with the original analysis.

CONCLUSION

One possible explanation for the increase in visit duration could be an increase in discussions between patients and their physicians. According to a National Research Corporation Survey, patients listed “willingness to explain things” as the most important factor in selecting a physician.11 Recent surveys estimate that about 86% of the adults who have access to the Internet use it to seek health information.12,13 With patients’ expanded access to Internet resources, they are able now, more than ever, to research any problems they may be experiencing and the multitude of treatment options available to them14—options they may be discussing with their physicians. Visit duration may be increasing due to these more thorough discussions.

The use of care managers, or other nonphysician extender personnel, might allow for physicians to spend more time with their patients, as these personnel are able to oversee other work that would have been previously performed by physicians and limited the amount of time for physicians to interact with their patients. Additionally, as the use of the EMR increases, physicians may be spending an increasing portion of the time spent with their patients documenting their assessments of patient health.15 However, the regression analysis of visits without the use of the EMR are also increasing in duration, so the use of the EMR cannot be the sole reason for the increase.

One limitation of this study is the cross-sectional nature of the NAMCS; we could not follow visit durations of individual patients over time. Although the NAMCS provides considerable detail on characteristics of office visits, it does not provide information on how much time was devoted to examination versus discussion and patient education, which might further explain the increase in visit duration if patients have increased the amount of time they spend talking to their physicians. Additionally, the NAMCS does not provide information about Work Relative Value Units, so it is difficult to quantify specifically if more is being done during individual visits than in the past. The control of the number of diagnoses per visits was an attempt to monitor this; however, it is possible that patient complexity is increasing, and as a result more is being done in each visit without accruing extra diagnoses. The study was not able to directly assess the amount of useful time spent by physicians, and future research may be able to provide insight on how much is spent on tasks that might be more efficiently assigned to other healthcare workers.

A potential bias for the data collected by the NAMCS would be the type of physicians who agreed to participate in the survey. Those physicians who agree to the NAMCS survey often have to fill out a significant amount of paperwork associated with it; therefore, one could assume that those physicians who truly feel pressed for time with their patients would not agree to participate in the survey. However, with the NAMCS covering such a significant number of physicians over the entire country, we feel that the data presented should still be an excellent representation of the average time physicians are spending with their patients.

By 2020, the Association of American Medical Colleges projects that there will be a shortage of 91,500 doctors in the United States.16,17 This shortage is in part attributed to the severely limited number of residency positions available, and in part to the dramatic increase in the number of insured Americans under the Patient Protection and Affordable Care Act.16-18 During the span of the survey, the total number of physicians eligible for NAMCS increased from 359,598 in 1993 to 511,517 in 2010, resulting in a 42% increase in the number of doctors over the span of the survey. Thus, while the number of physicians is growing, the number of visits to physicians is growing at an even greater rate and could overwhelm the number of physicians available. Consequently, it would be prudent to continue to monitor the durations of visits as a measure of determining if physicians are able to continue to provide the high standard of quality care that we have come to expect in the United States.

Acknowledgments

The authors would like to gratefully acknowledge Karen E. Huang, MS, for statistical assistance.

Author Affiliations: Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC (MKS, SAD, ABF, SRF).

Funding Source: The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories, LP. However, the funding source had no role in the study.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MKS, SAD, ABF, SRF); acquisition of data (SAD); analysis and interpretation of data (MKS, SAD, ABF, SRF); drafting of the manuscript (MKS); critical revision of the manuscript for important intellectual content (MKS, SAD, ABF, SRF); statistical analysis (SAD); administrative, technical, or logistic support (ABF, SRF); and supervision (SAD, ABF, SRF).

Address correspondence to: Scott A. Davis, MA, Department of Dermatology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: scdavis@wakehealth.edu.
REFERENCES

1. Kottke TE, Brekke ML, Solberg LI. Making "time" for preventive services. Mayo Clin Proc. 1993;68(8):785-791.

2. French MT, Homer JF, Klevay S, Goldman E, Ullmann SG, Kahn BE. Is the United States ready to embrace concierge medicine? Popul Health Manag. 2010;13(4):177-182.

3. Linz AJ, Haas PF, Fallon LF Jr, Metz RJ. Impact of concierge care on healthcare and clinical practice. J Am Osteopath Assoc. 2005;105(11):515-520.

4. Dorr Goold S, Lipkin M Jr. The doctor-patient relationship: challenges, opportunities, and strategies. J Gen Intern Med. 1999;(14, suppl 1):S26-S33.

5. McGlynn EA, Asch SM, Adams J et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-2645.

6. Mechanic D, McAlpine DD, Rosenthal M. Are patients’ office visits with physicians getting shorter? N Engl J Med. 2001;344(3):198-204.

7. Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey Participants Homepage. http://www.cdc.gov/nchs/ahcd/namcs_participant.htm. Published June 28, 2013. Accessed July 25, 2013.

8. National Ambulatory Medical Care Survey Data Collection and Processing. CDC website. http://www.cdc.gov/nchs/ahcd/ahcd_data_collection.htm#namcs_collection. Published August 15, 2011. Accessed February 28, 2013.

9. Paul Mackun, Steven Wilson. Population distribution and change: 2000 to 2010. http://www.census.gov/prod/cen2010/briefs/c2010br-01.pdf. Published March 2011. Accessed January 31, 2013.

10. Population Estimates Program, Population Division, US Census Bureau. Monthly estimates of the United States population: April 1, 1980 to July 1, 1999, with short-term projections to November 1, 2000. http://www.census.gov/population/estimates/nation/intfile1-1.txt. Published January 2, 2001. Accessed January 31, 2013.

11. Prakash B. Patient satisfaction. J Cutan Aesthet Surg. 2010;3(3):151-155.

12. Mallappa Saroja CS, Hanji Chandrashekar S. Polycystic ovaries: review of medical information on the Internet for patients. Arch Gynecol Obstet. 2010;281(5):839-843.

13. Fox S. (2011). Health Topics. Pew Internet and American Life Project. http://pewinternet.org/Reports/2011/HealthTopics.aspx. Accessed September 29, 2014.

14. Danquah G, Mittal V, Solh M, Kolachalam RB. Effect of Internet use on patients’ surgical outcomes. Int Surg. 2007;92(6):339-343.

15. Hing E, Hsiao CJ. Electronic medical record use by office-based physicians and their practices: United States, 2007. Natl Health Stat Report. 2010;(23):1-11.

16. Arvantes J. Increasing primary care residency positions critical to alleviating physician shortages, says AAMC. AAFP News. http://www.aafp.org/news/education-professional-development/20121030aamcworkforcepaper.html. Published October 30, 2012. Accessed January 31, 2013.

17. AAMC physician workforce policy recommendations. Association of American Medical Colleges website. https://www.aamc.org/download/304026/data/2012aamcworkforcepolicyrecommendations.pdf. Published September 2012. Accessed January 31, 2013.

18. National Resident Matching Program. Results and data: specialties matching service 2012 appointment year. http://www.nrmp.org/wp-content/uploads/2013/08/resultsanddatasms2012.pdf. Published February 2012. Accessed January 31, 2013.
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