The 15 minute visit compared to the 30 minute visit

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The 30 minute visit: Does it improve patient compliance and outcome compared to the 15 minute visit?

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With the push for quantity, is there a loss of quality? With the push for quantity, is there a lack of positive outcome, compliance, and satisfaction for the patient? A search for evidence to answer the question, does the 15 minute visit result in poor outcome and compliance? Is the occupation of medicine destroying the art of medicine? Questions:

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Time is a resource that is not renewable. Physicians are facing a standoff on behalf of increasing administrative requirements versus patient-provider relationships. These demands threaten to encroach on the already rationed time average of 15 minutes per patient visit. Implementation of the Affordable Care Act will further burden the time constraints of the primary care provider. More so, chronic disease is presumed to be managed within the primary care setting with anticipated closer management that reduce hospitalizations. With the influx of more insured individuals under the Affordable Care Act, there will be a further crux on the primary care provider’s already stressed time constraint. Countless clinicians report the average visit time per patient at less than 20 minutes and fear that the future will push them to shorten the visit time even more. Undoubtedly it looks as if health care, in particularly, the primary care setting, is about to undergo many changes. Sought to be answered is the question, is quality care and patient outcome suffering with the 15 minute visit compared to the 30 minute visit? The answer is hoped to be found in this research. Compared to

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Keywords : Chronic disease management, barriers in primary care, multidisciplinary team approach, efficiency in primary practice, physician satisfaction, patient satisfaction, consultation time, satisfaction, time, improving health outcomes, the 15 minute visit, barriers to patient compliance, more patients seen in less time Data Sources: PubMed, Cochrane Review, University of Florida, Google Scholar The Search Strategy

The Problem Presented:

The Problem Presented The American College of Preventative Medicine (2011) report, “The most significant barriers at the system level are: lack of time with patients”. Bodenheimer (2008) writes, “The optimal number of patients for a primary care provider panel should number 1,800 at a maximum. Yet, the average primary care provider in the United States today is responsible for 2,300 patients.” “Considerable evidence suggests that a reduction in payment rates leads physicians to increase the volume and intensity of services they perform. This leads to shorter visits and less doctor-patient face time. It forces doctors to race through medical appointments so they can fit as many into the daily schedule as possible” (Fodeman, 2012).

Comparing Global Primary Care Visit Lengths:

Comparing Global Primary Care Visit Lengths “The United States and 6 European countries reveal differences in mean visit length ranging from 7.5 minutes in Germany to 18 minutes in the United States” (Mauksch, Dugdale, Dodson, & Epstein, 2008).

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Real Time: 8.96 Perceived Time: 8.37 Preferred Time: 8.85

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Accuracy of Perceived Time: Accurate=17% Underestimate=51.7% Overestimated=31.3%

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Preferred Versus Real Time : Satisfied=12% Want Less=43.1 % Want More=44.9%

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Preferred Versus Perceived Time: Satisfied=62.5% Want Less=11.1% Want More=26.4%

Synthesizing the Evidence:

Synthesizing the Evidence “ The majority of patients underestimated how long the consultation had taken, and patients were split in terms of whether they would have preferred more or less time than they really got” (Ogden , Bavalia, Bull, Goldie, Gosslau, Jones, Kumar & Vasant, 2008 ). When patients were asked to describe how the doctor instructed them to take medication, “50% didn’t understand how to take it and took it differently than prescribed” (Bodenheimer, 2012).

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“The central institution of primary care is the 15 minute visit. During this 15 minutes the provider is expected to provide acute chronic and preventive care to their patients while building meaningful relationships with those patients, and managing multiple diagnosis according to a host of evidenced based guidelines” (Bodenheimer, 2009). “Medicare’s physician reimbursement regimen is characterized by underpayments and perverse incentives. The brunt of Medicare’s declining reimbursements is shifted to patients in the form of decreased access to physicians and inferior care. Rather than trying to reform this flawed reimbursement system, which jeopardizes patient safety, the PPACA expands its scope to more people” (Fodeman, 2012). “It would take 7.4 hours per working day to provide all recommended preventive care to a panel of 2,500 patients, plus 10.6 hours to adequately manage this panel’s chronic conditions” (Bodenheimer, 2009). Visit length is definitely changing in the U.S. Yet, with the decreasing visit time is the quality of care changing as well?

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“More time does not guarantee better communication, as evidenced by patient perception of time use and poor communication found in 30 to 60 minute health maintenance visits” (Mauksch, Dugdale, Dodson, & Epstein, 2008). “One large study in the United States found no significant difference in visit length across the biomedical to psychosocial continuum Mauksch, Dugdale, Dodson, & Epstein, 2008). “Adherence is critical to patient outcomes but is often hard to achieve. Improving adherence Is a complex and variable process. The most effective physician strategy is to build patient trust and better communicate the benefits of taking medication as directed” (American College of Preventive Medicine, 2011).

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The Verdict The Cochrane Collaboration (2009) states, there was no evidence that changing to longer appointments led to greater patient satisfaction although there is evidence from one study that patient enablement may increase with greater availability of time, though further studies revealed that more focused interventions and improvement in consultation skills were related to more time being spent with the patient. Chen (2013), concluded from a nationally prepared study that there is no evidence for the commonly held belief that physicians are spending less time with their patients or that the quality of care has diminished. In fact, patients spent more time with their primary care provider during office visits than they did almost a decade earlier, and overall they received better care. Better performance on medication quality measures did not seem to require extra time while better performance on counseling or screening indicators were associated with longer visit duration, concluding that improvements in quality of care will likely require a combination of investments in systems such as EMR, greater use of ARNP and PA’s as well as ancillary staff.

So, What is the Real Problem? What is Really Happening during the 15 Minute Visit in Many Clinics?:

So, What is the Real Problem? What is Really Happening during the 15 Minute Visit in Many Clinics? “Doctors interrupt their patients on average within 23 seconds from the time the patient begins explaining his symptoms” “25% of visits, the doctor never even asked the patient what was bothering him” “34 physicians during more than 300 visits with patients, spent on average 1.3 minutes conveying crucial information about the patient’s condition and treatment, and most of the information they provided was far too technical for the average patient to grasp; these same doctors thought they had spent more than eight minutes” “Three out of four doctors failed to give clear instructions on how to take medication” “Half of the patients have no idea what they are supposed to do” “Both patients and doctors agreed that about 30% of the time doctors forget important information their patients tell them” “Study of physicians’ performance, patients received only 55% of recommended care for 3 different medical conditions” (Brownlee, 2012)

The Root of the Problem :

The Root of the Problem Inefficiency Poor Communication Lack of Teamwork Wasting Time

The Answer to the Problem:

The Answer to the Problem Team Work Electronic Medical Record Focused Communication Efficient Use of Time

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Perceived lack of time Poorly trained support staff Inefficient electronic medical records Inappropriate scheduling “overbooking” Poor listening skills by provider Lack of focused visits

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Summary of Findings No such evidence to support the fact that longer visits improve patient outcome or compliance. Further research is needed to discuss specific outcome compliance with visits less than 15 minutes Data exists to support average global visit length and patient satisfaction. Data exists to support inefficient wasting of precious time and inappropriate usage of support staff.

Application in Practice:

Application in Practice Teamwork and Efficiency Utilizing team members Pre visit Post visit Group visits Efficient EMR system Problem focus and prioritize Provide educational handouts Listen S.I.M.P.L.E. S-simplify the regimen I-impart knowledge M-modify patient beliefs and human behavior P-provide communication and trust L-leave the bias E-evaluate adherence ( American College of Preventive Medicine, 2011)

References:

References American College of Preventive Medicine. (2011). Barriers to enhancing counseling performance. In American College of Preventive Medicine. Bodenheimer, T. (2008). Primary care-will it survive?.  The New England Journal of Medicine ,  355 (9), 861-866. Bodenheimer, T. (2009). Making primary care work for patients and clinicians: the "teamlet" model . Department of Family and Community Medicine University of California at San Francisco , Brownlee, S. (2012). why your doctor has no time to see you . Newsweek , Chen, P. (2013). for new doctors, 8 minutes per patient.  NY Times Company ,

References:

References Mauksch, L., Dugdale, D., Dodson, S., & Epstein, R. (2008). Relationship, communication, and efficiency in the medical encounter.  American Medical Association , Retrieved from http://jamanetwork.net/on10/04/2013 Ogden, J., Bavalia, K., Bull, M., Goldie, C., Gosslau, M., Jones, A., Kumar, S., & Vasant, K. (2008). “I want more time with my doctor": a quantitative study of time and the consultation.  Family Practice ,  21 (5), Cochrane Collaboration. (2009). Effects of interventions aimed at changing the length of primary care physicians' consultation.  Cochrane Collaboration, John Wiley & Sons, Ltd. , Fodeman, J. (2012). The new health law: bad for doctors, awful for patients.  The Institute for HealthCare Consumerism ,

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