Shorter primary care office visits were associated with greater likelihood of an inappropriate antibiotic prescription and coprescribing of opioids and benzodiazepines than longer visits, according to findings of a cross sectional study of more than 8 million visits to 8091 US primary care physicians.
The investigators also found that the less time spent with an older patient, the greater the likelihood of a potentially inappropriate prescription being provided.
The study authors, led by Hannah T. Neprash, PhD, assistant professor in the division of health policy and management at the University of Minnesota in Minneapolis, cite research that estimates the length of a contemporary average primary care office visit at 18 minutes. That translates into the need for 27-hour days to allow clinicians to provide the recommended preventive, chronic disease, and acute care services to a typical patient panel. Visit content has grown more complex and has outpaced growth in visit length, Neprash and colleagues add, and that shortened time is now a topic of complaint from both patients and their clinicians.
Concern for quality of care follows naturally from the concern about inadequate time for care. Neprash et al say, however, that evidence for the association is both limited and mixed. Their objective was to investigate variations in the length of primary care visits and then quantify the association between visit length and potentially inappropriate prescribing decisions.
The length of a contemporary average primary care office visit at 18 minutes. That translates into the need for 27-hour days to allow clinicians to provide the recommended preventive, chronic disease, and acute care services to a typical patient panel.
For the cross-sectional study, published in JAMA Health Forum, the Minnesota team utilized electronic health records to gather data from primary care offices across the US. The investigators evaluated adult primary care visits that occurred in the year 2017 and conducted their analyses from March 2022-January 2023.
First, the team 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.
This 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 cohort was 56.6% women. By race and ethnicity, the authors report the group was 68.2% non-Hispanic White, 10.4% non-Hispanic Black, 7.7% Hispanic, 5.5% of another race/ethnicity, and 8.3% with missing race/ethnicity data.
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.
The study findings reflect the concern that shorter visits may lead to prescribing as a "quick fix" vs more time spent to make a diagnosis, discuss treatment options, identify potential drug-drug interactions, and deprescribed where necessary. The results also highlight known disparities in health care delivery, particularly less time spent in visits based on race/ethnicity.
The study findings reflect the concern that shorter visits may lead to prescribing as a "quick fix" vs more time spent to make a diagnosis, discuss treatment options, identify potential drug-drug interactions, and deprescribed where necessary.
“Our analyses highlight the fundamental tension between the volume incentives embedded in fee-for-service reimbursement systems and quality of care,” the authors wrote. “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.”
Reference: Neprash HT, Mulcahy JF, Cross DA, et al. Association of primary care visit length with potentially inappropriate prescribing. JAMA Health Forum. Published online March 10, 2023. doi:10.1001/jamahealthforum.2023.0052