Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis.
Harvard Medical School, Boston, Massachusetts.
JAMA Health Forum. 2023 Mar 3;4(3):e230052. doi: 10.1001/jamahealthforum.2023.0052.
Time is a valuable resource in primary care, and physicians and patients consistently raise concerns about inadequate time during visits. However, there is little evidence on whether shorter visits translate into lower-quality care.
To investigate variations in primary care visit length and quantify the association between visit length and potentially inappropriate prescribing decisions by primary care physicians.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study 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.
Regression analyses quantified the association between patient visit characteristics and visit length (measured using time stamp data) and the association between visit length and potentially inappropriate prescribing decisions, including inappropriate antibiotic prescriptions for upper respiratory tract infections, coprescribing of opioids and benzodiazepines for painful conditions, and prescriptions that were potentially inappropriate for older adults (based on the Beers criteria). All rates were estimated using physician fixed effects and were adjusted for patient and visit characteristics.
This study included 8 119 161 primary care visits by 4 360 445 patients (56.6% women) with 8091 primary care physicians; 7.7% of patients were Hispanic, 10.4% were non-Hispanic Black, 68.2% were non-Hispanic White, 5.5% were other race and ethnicity, and 8.3% had missing race and ethnicity. Longer visits were more complex (ie, more diagnoses recorded and/or more chronic conditions coded). After controlling for scheduled visit duration and measures of visit complexity, younger, publicly insured, Hispanic, and non-Hispanic Black patients had shorter visits. For each additional minute of visit length, the likelihood that a visit resulted in an inappropriate antibiotic prescription changed by -0.11 percentage points (95% CI, -0.14 to -0.09 percentage points) and the likelihood of opioid and benzodiazepine coprescribing changed by -0.01 percentage points (95% CI, -0.01 to -0.009 percentage points). Visit length had a positive association with potentially inappropriate prescribing among older adults (0.004 percentage points; 95% CI, 0.003-0.006 percentage points).
In this cross-sectional study, shorter visit length was associated with a higher likelihood of inappropriate antibiotic prescribing for patients with upper respiratory tract infections and coprescribing of opioids and benzodiazepines for patients with painful conditions. These findings suggest opportunities for additional research and operational improvements to visit scheduling and quality of prescribing decisions in primary care.
时间是初级保健的宝贵资源，医生和患者一直对就诊时间不足表示担忧。然而，关于较短的就诊时间是否会转化为较低质量的护理，几乎没有证据。
调查初级保健就诊时间的变化，并量化就诊时间与初级保健医生做出潜在不适当处方决策之间的关联。
设计、地点和参与者：这项横断面研究使用了美国各地初级保健办公室电子健康记录系统中的数据，分析了 2017 年日历年度发生的成年初级保健就诊情况。分析于 2022 年 3 月至 2023 年 1 月进行。
回归分析量化了患者就诊特征与就诊时间（使用时间戳数据测量）之间的关联，以及就诊时间与潜在不适当处方决策之间的关联，包括上呼吸道感染的不适当抗生素处方、疼痛情况下阿片类药物和苯二氮䓬类药物的联合处方，以及根据 Beers 标准对老年人可能不适当的处方。所有比率均使用医生固定效应进行估计，并根据患者和就诊特征进行调整。
这项研究包括 8119161 次由 4360445 名患者（56.6%为女性）进行的初级保健就诊，涉及 8091 名初级保健医生；7.7%的患者为西班牙裔，10.4%为非西班牙裔黑人，68.2%为非西班牙裔白人，5.5%为其他种族和民族，8.3%的患者种族和民族信息缺失。较长的就诊时间更复杂（即记录了更多的诊断和/或更多的慢性疾病编码）。在控制了预约就诊时间和就诊复杂性的措施后，年轻、有公共保险、西班牙裔和非西班牙裔黑人患者的就诊时间较短。就诊时间每增加 1 分钟，就诊结果为不适当抗生素处方的可能性降低 0.11 个百分点（95%CI，-0.14 至-0.09 个百分点），阿片类药物和苯二氮䓬类药物联合处方的可能性降低 0.01 个百分点（95%CI，-0.01 至-0.009 个百分点）。就诊时间与老年人潜在不适当处方之间存在正相关（0.004 个百分点；95%CI，0.003-0.006 个百分点）。
在这项横断面研究中，较短的就诊时间与上呼吸道感染患者更有可能开出不适当的抗生素处方以及疼痛患者更有可能开出阿片类药物和苯二氮䓬类药物联合处方相关。这些发现表明有机会进一步研究和改进初级保健的就诊时间安排和处方决策质量。
