Relationship Between Primary Care Visit Duration and Quality of Care

In the discussion of healthcare reform in the United States, primary care physicians have been focused on as the point practitioners in the drive to deliver higher-quality care and to lower costs. Meanwhile, patient populations have increased, growing older and more complex, while net income for primary care physicians dropped by 10.2% between 1995 and 2003. Studies have indicated that greater patient satisfaction is associated with perceived and actual visit duration, and that a poor provider relationship may lead to lesser medication adherence.

The investigators wished to determine whether the duration of primary care office visits for adult patients has decreased over the last decade, to determine which patient or physician characteristics are associated with shorter or longer office visits, and to determine whether there is an association between visit duration and quality of care.

This retrospective analysis [Arch Intern Med. 2009;169(20):1866-1872], conducted by physicians from several Massachusetts institutions, used data from the National Ambulatory Medical Care Survey (NAMCS) as well as the US Census Bureau to establish a nationally representative sample of office-based primary care physicians. Information for patients >18 years of age who made visits to general practitioners, family practitioners, or internists was analyzed. The investigators examined trends in office visit duration for general medical examinations (GMEs) and all visits between December 30, 1996, and December 25, 2005.

The researchers also examined visit duration for the 4 most common primary diagnoses for adult office visits—essential hypertension, diabetes mellitus, spinal disorders, and arthropathies and related disorders. The primary outcome measure was visit duration. Quality performance was measured for 2 periods: an early period (1997-2001) and a late period (2002-2005) that represented similar total numbers of visits.

There were 46,250 adult visits to primary care physicians in the NAMCS database, representing a total of 2.6 billion primary care visits in the United States between 1997 and 2005. There were 273 million visits in 1997 and 338 million visits in 2005, resulting in an increase in per capita adult visits from 1.4 to 1.5 visits per year. Mean visit duration over this 9-year period was 18.9 minutes, and median visit duration was 15 minutes.

Between 1997 and 2005, the mean duration of an adult primary care visit increased from 18.0 to 20.8 minutes (an increase of 16%; P<.001 for trend), and visit duration increased comparably across age groups. Duration of GME visits increased from 21.7 to 25.1 minutes (P=.02 for trend). Visits also lengthened for patients with diabetes mellitus (4.2 minutes; P=.002 for trend), essential hypertension (3.7 minutes; P<.001 for trend), and arthropathies (5.9 minutes; P<.002 for trend).

Patients seen by general internists had visits that were 1.7 minutes longer than those of patients seen by general practitioners or family practitioners. Older patients, new patients, and those in certain regions of the country also had longer visits. Non-Hispanic blacks and Hispanics spent less time with primary care physicians, although this difference reached statistical significance only for GME visits (P=.01).

Between 1997 and 2005, there were improvements in the proportion of eligible visits meeting 4 of 6 medication quality indicators and meeting 1 of 3 counseling or screening quality indicators. Results were similar when adjusting for differences in demographic characteristics (sex, age, and race/ethnicity) between the early period and the late period.

The authors said they had found no evidence that increasing workload and decreasing pay had caused primary care physicians to shorten the time they had spent with their patients. There was a modest relationship between visit duration and quality of care, and monitoring of medication adherence was independent of visit duration.—Kevin L. Carter