Daily Dose: Association of Primary Care Visit Length With Inappropriate Prescribing Patterns

Patient Care brings primary care clinicians a lot of medical news every day—it’s easy to miss an important study. The Daily Dose provides a concise summary of one of the website's leading stories you may not have seen.

On March 16, 2023, we reported on a study published in JAMA Health Forum that aimed to investigate variations in primary care visit length and quantify the association between visit length and potentially inappropriate prescribing decisions by primary care physicians.

The study

Cross-sectional study that used data from electronic health record systems in primary care offices across the US to analyze adult primary care visits occurring in calendar year 2017. Analysis was conducted from March 2022 through January 2023.

First, researchers examined patient clinical and sociodemographic characteristics correlated with visit length. After controlling for these factors, they determined within-physician changes in potentially inappropriate prescribing decisions by primary care visit duration. The study examined 3 outcomes reflective of potentially inappropriate prescribing:

1. Inappropriate antibiotics for upper respiratory tract infections
2. Coprescribing of opioids and benzodiazepines
3. Potentially inappropriate prescribing for older adults.

The final sample included 8 119 161 visits among 4 360 445 patients, with 8091 US primary care physicians.

The results

The duration of visits varied significantly between and within primary care physicians. The median physician in the sample spent an average 18.9 minutes with each patient. In the top quartile for visit duration, clinicians averaged ≥24.6 minutes with each patient, while those in the bottom quartile saw each patient for an average of ≤14.1 minutes.

When the researchers analyzed prescribing decisions, they found that:

• 55.7% of 222 667 visits for upper respiratory tract infections involved an inappropriate antibiotic prescription

• 3.4% of 1 571 935 visits for painful conditions involved coprescribing opioids and benzodiazepines

• 1.1% of 2 756 365 visits for adults aged ≥65 years involved the prescription of medications contraindicated by the Beers criteria)

For every additional minute of visit length, the likelihood of inappropriate antibiotic prescribing decreased by 0.11% and the likelihood of opioid and benzodiazepine coprescribing decreased by 0.01%. Potentially inappropriate prescribing among older adults increased slightly as a function of visit length (0.004%).

The investigators found that visit length was significantly associated with “nearly every patient and visit characteristic.” Longer visits were more complex (ie, more diagnoses recorded and/or more chronic conditions coded). Shorter visits were more frequent among established vs new patients, men vs women, younger vs older patients, non-Hispanic Black and patients from other racial and ethnic groups vs non-Hispanic White patients, and patients with public insurance vs commercial insurance.

Note from authors

"Our analyses highlight the fundamental tension between the volume incentives embedded in fee-for-service reimbursement systems and quality of care. While our results do not suggest an optimal visit length, they do suggest that physicians’ time is not always allocated based on patient complexity. Such findings suggest opportunities for a more equitable distribution.”

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