Shorter primary care visits linked to greater likelihood of inappropriate prescribing

Key takeaways:

• For each extra minute of visit length, the likelihood of an inappropriate antibiotic prescription changed by -0.11 percentage points.
• For each extra minute, the likelihood of coprescribing opioids and benzodiazepines changed by -0.01 percentage points.
• Visits that were scheduled for 30 minutes were only 4 minutes longer than those scheduled for 10 minutes.

Shorter primary care visits were associated with an increased likelihood of inappropriate antibiotic prescribing and coprescribing opioids and benzodiazepines, a recent study found.

Previous research has shown that primary care physicians lack the necessary time to perform guideline-recommended acute, chronic and preventative disease care.

Hannah T. Neprash, PhD, an assistant professor in the division of health policy and management at the University of Minnesota, and colleagues, wrote in JAMA Health Forum that “it is widely believed that shorter visits are associated with lower-quality care for patients.”

“In particular, there is concern that clinicians make less-appropriate prescribing decisions in shorter visits since it takes time to make diagnoses, discuss existing treatment regimens, identify potential medication conflicts, and deprescribe as necessary,” they wrote. “Clinicians may view some prescriptions as quick fixes when discussion of alternatives would take additional time and effort or as a strategy to resolve a tense patient interaction.”

The researchers conducted a cross-sectional study to examine the impact of visit duration on prescribing trends. They utilized electronic health record data on 8,119,161 primary care visits made by 4,360,445 patients (56.6% women) in the United States in 2017.

Among the visits, 68.2% were made by non-Hispanic white patients and 10.4%were made by non-Hispanic Black patients.

Neprash and colleagues looked for three specific visit outcomes: inappropriate antibiotic prescribing for upper respiratory tract infection, coprescribing of opioids and benzodiazepines for painful conditions and potentially inappropriate prescribing for older adults.

The researchers found that visit lengths were longer for women compared with men (17.2 vs. 17 minutes); adults aged 65 years or older compared with those aged 22 to 44 years (17.2 vs. 16.8 minutes); and for non-Hispanic white patients compared with Hispanic (16.8 minutes) and non-Hispanic Black (17.2 vs. 16.7 minutes) patients.

“When examining within-physician variation in visit length, we found that visit length was significantly associated with nearly every patient and visit characteristic,” the researchers wrote.

For each additional minute of visit length, the likelihood of the visit resulting in an inappropriate antibiotic prescription changed by -0.11 percentage points (95% CI, -0.14 to -0.09), while the likelihood of coprescribing opioids and benzodiazepines changed by -0.01 percentage points (95% CI, -0.01 to -0.009).

There was also a positive association between visit length and inappropriate prescriptions for older adults (0.004 percentage points; 95% CI, 0.003-0.006), although it was deemed unlikely to be clinically meaningful by the researchers.

Neprash and colleagues pointed out that many of the associations show that patients with more complex medical issues received more time with their physician, “which may be expected.” They also noted that visits scheduled for 30 minutes were only 4 minutes longer than those scheduled for 10 minutes.

“This finding suggests that scheduled visit times do not necessarily represent clinical workflows accurately and points to the challenges that primary care physicians may face in adhering to scheduled visit times to care for a wide range of patients with diverse needs,” they wrote.

The researchers acknowledged that the study could not determine the reasons for racial differences in visit lengths, though it “should motivate organizations and policy makers to detect, interrogate, and address underlying systemic causes such as structural racism.”

Overall, the findings “suggest opportunities for additional research and operational improvements to visit scheduling and quality of prescribing decisions in primary care,” Neprash and colleagues concluded.