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Time Allocation in Primary Care Office Visits

Time Allocation in Primary Care Office Visits

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Time Allocation in Primary Care Office Visits

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  1. Time Allocation in Primary Care Office Visits Tai-Seale, McGuire, and Zhang, HSR 2007

  2. Acknowledgement • NIMH (MH01935) , NIA (AG15737) for funding • Comments from Margarita Alegria, John Z. Ayanian, Howard Beckman, Richard Frankel, Richard Kravitz, Rachel Moser, Joseph Newhouse, Richard Street, Jr. and Suojin Wang • Editors Hal Luft, Jose Escarce, and two anonymous reviewers • Research assistants AcademyHealth 2008

  3. Motivation • Medical office visit is the foundation of medical care • It is one of the most important professional activities of primary care physicians • Evidence continues to show a gap between science and clinical practice • Racial minority patients fare even worse AcademyHealth 2008

  4. Realities of Practice • Time is scarce in primary care, 2,000 – 3,000 patients/physician, 15 min/visit • Competing demands abound • Under pressure to be “productive” and have short visits • Quality of care often falls short (McGlynn 2003) • Proliferation of practice guidelines • Availability of guidelines does not translate into guideline concordant practice nor positive patient health outcome AcademyHealth 2008

  5. Some Physicians’ Analogies • “Hamster” wheel (NYT) • Doc on roller skates • Push the current patient as quickly as possible so the next patient can be seen (Callahan 2006) AcademyHealth 2008

  6. Selected Literature • Beckman and Frankel (1984) • Patients spoke for 18 seconds before interruption • Marvel et al (1999) • Patients spoke for 23 seconds before interruption AcademyHealth 2008

  7. Our Main Goal • Characterize patient-physician relationship in a new way • Study how physicians and patients allocate the scarce resource of visit time to deal with complex issues in office visits AcademyHealth 2008

  8. Methodological Requirements • Examinations of complex reality require suitable empirical research methods • Herbert Simon and Amos Tversky advocated collecting data from observations of actual behavior • Lisa Cooper stressed the need for triangulating surveys with direct observation of the actual encounter AcademyHealth 2008

  9. Direct observation AcademyHealth 2008

  10. To Err is Human • This is a very critical way of studying physician behavior. • Humility and self-reflection are needed on the part of the researcher. AcademyHealth 2008

  11. Research Questions • What was the length of primary care office visits • What topics were discussed • How many topics were discussed in each visit • How much time was devoted to each topic • What factors influenced the length of • Discussion on topics • Visits AcademyHealth 2008

  12. Data • Videotapes • 392 patient visits • 35 primary care physicians • 3 types of practice settings • 1999-2000 • Patient survey • Physician survey

  13. What does a visit look like Physician's 0.28 haircut Patient Talks 3.98 Anxiety about Physician Talks heart failure Elevated blood 1.32 pressure 1.62 Ibuprofen refill Patient's church- 1.75 related travel plan Physician's home 2.40 remodeling project Time End of Visit Beginning AcademyHealth 2008

  14. Findings – Median Lengths AcademyHealth 2008

  15. Median Lengths of Time AcademyHealth 2008

  16. Duration Analysis • Analyze the likelihood that the topic or visit would end, given how much time had already been spent on it. • To test duration dependence, we use the Weibull proportional hazard function (Cleves 2004). • At the topic level: h(t|xi)=h0(t)exp(β'xi) (1) AcademyHealth 2008

  17. Duration Analysis Results AcademyHealth 2008

  18. Summary • Six topics per visit, all competed for visit time • Time spent by patient and physician on a topic responded to many factors • Length of the visit overall responded little to the nature of topics in visits and to patient’s health status • Organizational/financial factors were dominant determinants of visit length AcademyHealth 2008

  19. AcademyHealth 2008

  20. Popular Press AcademyHealth 2008

  21. Two-Minute Mental Health Care for Elderly Patients:Inside Primary Care Visits Tai-Seale, McGuire, Colenda, Rosen, Cook Journal of American Geriatric Society 2007

  22. Introduction • Late-life mental disorders are common (Charney et al. 2003) • Elder suicide crisis (Kaplan 2001) • PCPs deliver most mental health treatment, esp. for elderly patients (Wang et al. 2006) • Practice guidelines call for a set number of office visits in which MH is discussed (Young et al 2001: 4v/5m)

  23. Study Questions • What happens in a visit in which mental health problems are discussed? • How much time is spent on addressing mental health issues? • How is that time spent?

  24. Methods • Mixed Method Approach • Quantitative • How much time • Qualitative • How is the time spent • Critical discourse analysis • Constant comparison

  25. MH Topics: How Long? Median =1.9 min. Mean =3.9 min.

  26. What Mattered?One Parameter Logit/Duration AcademyHealth 2008

  27. What Mattered?One Parameter Logit/Duration AcademyHealth 2008

  28. How Was the Time Used • Theme 1: biopsychosocial • Patient indicated emotional distress • MD took the time to investigate the disease, the person, and the lived life • MD Recognized mental disorder • Inadequate treatment • Theme 2: narrowly biomedical • Patient indicated emotional distress • Physician did not follow up AcademyHealth 2008

  29. D: (inaudible). What you been up to? P: I have just been crying my eyes out. D: Why? P: I don’t know. I can’t help it. D: Why? P: And then people ask me how I am, I just cry. D: Oh, (pause.) Well I am not going to ask you that anymore. (pause 2 seconds.) Why? Do you think you are puny? P: No. D: No. Do they care, the people that ask? P: Yep. AcademyHealth 2008

  30. Select Responses • Two U.S. Senate Hearings • WA State Attorney General • Media/Press coverage AcademyHealth 2008

  31. January 8, 2008 Vital Signs Aging: Mental Health Overlooked in Care of Elderly Patients By ERIC NAGOURNEY Depression and other mental illnesses are common among the elderly, and when they get treatment, it usually comes from their primary care doctors. But a new study suggests that those doctors may devote too little time to talking about those ailments. When researchers reviewed videotapes of 385 appointments with elderly patients in three separate areas, they found the median time spent discussing mental health was just two minutes. The study, which appeared in the December issue of The Journal of the American Geriatrics Society, was led by Ming Tai-Seale of the School of Rural Public Health at Texas A&M. More than half the patients whose survey responses suggested they were depressed never spoke with their doctors at all about their emotional state. The subject came up in about a fifth of the visits over all. But even when patients let their doctors know about their problems, the study found, the responses were often ineffective or worse. AcademyHealth 2008

  32. Fruits for Thoughts • The busy car mechanic • Come back in one week, two weeks, etc. • You and your insurance, (employer, CMS, etc.) pay each time you go, no matter how much good was done in each visit • Wonderful • Awful AcademyHealth 2008