Primary care visits
The primary care visit remains the principal opportunity for health care providers to address patient’s needs. The results of the Israel Central Bureau of Statistics (ICBS) for 2009 indicate that the annual average number of visits to the primary care physician (PCP) is 6.2 in the general population of Israel and 16.1 for ages 65 and over. Age and the number of visits of patients with chronic diseases were found to be factors that significantly increase the annual average number of visits [1]. The most recent data found by us suggests that the mean duration of a visit with an Israeli PCP is 10.4 min [2].
The annual average number of visits can vary substantially across countries. One study in the United States calculated a mean of 1.6 PCP (defined as visits to a general practitioner, family physician, pediatrician, geriatrician, or general internist) yearly visits per person as of 2008 [3]. In the WHO European Region, the average outpatient contacts per person per year in 2006 was 7.85, and country specific averages for 2006 or the latest available year were 7.0 in Germany, 9.5 in Spain, 5.4 in the United Kingdom, 5.7 in the Netherlands, 6.6 in Belgium and 11.0 in Switzerland [4].
There is also significant cross-country variation in visit duration. In the United States, 2006 data from the Centers for Disease Control and Prevention (CDC) found that the mean duration of face-to-face visits with PCPs (general or family practice) was 19.5 min [5]. In Europe, it was found that the mean length of a visit with a PCP (general practitioner) was 7.6 min in Germany, 7.8 min in Spain, 9.4 min in the United Kingdom, 10.2 min in the Netherlands, 15.0 min in Belgium and 15.6 min in Switzerland [6]. A study by Bindman et al. found in a 2001–2 cross-sectional analysis that the average duration of a face-to-face visit with a PCP in the US (general internists, general pediatricians, and family practitioners) was 16.5 min, about 10% longer than with general practitioners in Australia (14.9 min) and New Zealand (15 min). Visit lengths were longer in the US for all age and gender groups. Because the average number of primary care visits per capita was greater in New Zealand and Australia, however, the mean per capita annual exposure to primary care physicians in the US (29.7 min) was about half of that in New Zealand (55.5 min) and about a third of that in Australia (83.4 min) [7].
Studies from various countries have found that the length of an ambulatory visit with PCPs is influenced by increasing age, presence of psychosocial problems [8], gender (women) and greater number of new problems discussed in the visit [6].
Visit duration and patient outcomes
Research in the matter has shown that longer PCP visits were associated with a range of better patient outcomes [9, 10], including more statements about health education and prevention [11], as well as higher rates of preventive medical measures such as vaccinations [12, 13], and mammography referrals [14]. The duration of PCP care was also associated with lower costs of inpatient and outpatient care and with a lower risk of hospitalizations [15]. Wilson et al. first concluded that a PCP with a higher average visit length is more likely to provide visits that include important aspects of care, and that longer visit length can therefore be used as a quality indicator [16]. They later conducted a systemic review, which found that in interventional studies that had been performed by altering same physicians’ visit length the above mentioned effect had not been demonstrated. However, their findings were not sufficient to support or resist a policy of altering PCP visit length, and due to many limitations of the study, it was difficult for them to define length as a marker of quality of care [17].
When analyzing the primary care setting, one aspect of the visit is its content. A study by Tai-Seale et al. found that visit length was insensitive to the content of a visit - longer time spent on major topics seemed to have been compensated by limiting the time allocated to minor topics, therefore leaving the visit length more or less the same. Instead, organizational structure, physicians’ practice settings and payment incentives appeared to have more influence on visit length [18]. However, other research suggested that there was a positive association between the number of problems discussed and the mean length of visits. It was found that on average, PCPs spend 11.9 min dealing with 2.5 problems, and a linear relationship was seen at least up to six problems, with the length of visits increasing by an average of 2 min for each additional problem above a baseline of 9 min for the first problem [19]. Abbo et al. found that the number of clinical items addressed during a PCP visit increased from 5.4 in 1997 to 7.1 in 2005, resulting in a decrease in minutes spent per clinical item from 4.4 to 3.8 [20]. Approximately 8% of PCP visit duration was found to be attributable to eight-related conditions included diabetes, hypertension, hyperlipidemia, obesity, cardiovascular disease, osteoarthritis, and low back pain [21]. Chen et al.’s findings suggested that the relationship between quality of care and physician visit duration depends on the type of quality indicator being measured, namely, medication quality indicators vs counseling or screening quality indicators. In their research, they found a clear and consistent relationship between visit duration and provision of counseling and screening-based care [22].
Moreover, nearly one half of a primary care physician’s workday was found to be spent on activities outside the examination room, predominately focused on follow-up and documentation of care for patients not physically present. In the United States, Gottschalk et al. found that national estimates of visit duration overestimate the combination of face-to-face time and time spent on visit-specific work outside the examination room by 41% [23].
However, despite evidence that increasing visit length is more likely to improve primary care, and that longer visit length can therefore be used as a quality indicator, to our knowledge and according to the literature review, we did not find a study that defined the optimal annual accumulated time (complementary to the number of visits) that should be spent with a patient to achieve better quality of care.
The potential implications for resource allocation
In many countries, the allocation of financial resources among regions and/or among care providers is based on capitation formulae which try to reflect how the composition of populations served affect the need for health care services. For example, as older people tend to use more health care services, regions and providers serving populations with higher concentrations of the elderly are often given more financial resources per capita. This is done so that they will have enough resources to provide quality care and to eliminate any incentive to avoid caring for elderly persons.
In Israel, for example, when Israel distributes the National Health Insurance monies among health plans, it uses a capitation formula which includes mainly age, gender and other minor affecting parameters. In developing that formula, the government examines how age and gender are related to resource use for the key types of care consumed – hospital care, community services, and medications. As its measure of community service use, the government currently uses the number of physician visits. However, if visit duration varies significantly by age or gender, then the number of physician visits would not be a good indicator of resource use, and AADT would be a more appropriate measure to use. If visit duration does not vary significantly by age or gender then it would make sense to continue to base the capitation formula on the number of visits, as it is easier for the government to collect survey data on the number of visits than on the AADT. When the health plans distribute funds among their regions they also take into account various demographic characteristics (including location) and their relationship to service use. They too face a decision of whether to use the number of visits or AADT in resource allocation decisions, and hence they too have interest in knowing whether visit duration varies by demographic characteristics, as well as by location.
We conducted a cross-sectional study based on the electronic medical records of the largest Health Maintenance Organization (HMO) in Israel to investigate the characteristics of the concept of Accumulated Annual Duration of Time (AADT) that the PCP spends with a patient. This is an important first step towards using AADT in resource planning and allocation, and perhaps even determining the optimum level of AADT.