A study of US medical record data found that shorter primary care visits were linked to a higher likelihood of inappropriate antibiotic prescribing for respiratory infections.
The findings, published today in JAMA Health Forum, are part of a larger study investigating whether clinicians make less-appropriate prescribing decisions in shorter visits. In addition to a higher likelihood of inappropriate antibiotics, the researchers also found that shorter visits were associated with a higher likelihood of inappropriate co-prescribing of opioids and benzodiazepines for pain, which can increase the risk of overdose.
But with each additional minute of visit length, the likelihood of an inappropriate prescription declined, most significantly for antibiotics. The authors say that finding suggests that when clinicians have more time to discuss a diagnosis with patients, they are less likely to reach for a quick fix.
Do shorter visits reduce quality of care?
To try and answer the question of whether shorter primary care visits are associated with lower-quality care, researchers from the University of Minnesota and Harvard Medical School analyzed submitted insurance claims and electronic health record (EHR) data from primary care offices across the United States. They included all adult visits to primary care physicians in 2017, using time stamps to measure visit length.
The study focused on inappropriate prescribing for three outcomes: inappropriate antibiotics for upper respiratory tract infections (which are frequently caused by viruses and don't require antibiotics), co-prescribing of opioids and benzodiazepines for pain-related diagnoses, and medications that are potentially inappropriate for older adults. The analysis included physician fixed effects and controlled for patient and visit characteristics.
The study sample included 8,119,161 visits for 4,360,445 patients (43.4% men and 56.6% women) seeing 8,091 primary care clinicians. Of the visits, 7.7% were Hispanic patients, 10.4% were Black patients, 68.2% were White patients, 5.5% were other race and ethnicity, and 8.3% had missing race and ethnicity data.
The median physician visit was 18.9 minutes. Visits with more diagnoses were longer. After controlling for scheduled visit duration and measures of visit complexity, younger, publicly insured, Hispanic, and Black patients had shorter visits.
Of the 222,667 visits for upper respiratory tract infections, 55.7% involved an inappropriate antibiotic prescription, while 3.4% of 1,571,935 visits for painful conditions involved co-prescribing benzodiazepines and opioids, and 1.1% of 2,756,365 visits by patients aged 65 and older involved the prescription of medications contraindicated by the Beers criteria (a list of medications to avoid in older patients).
Our findings suggest that lengthening upper respiratory tract infection visits may be a promising strategy to lower inappropriate antibiotic prescribing, which has been a persistent population health concern for decades.
After adjusting for all patient covariates, the likelihood that a visit for an upper respiratory tract infection involved an inappropriate antibiotic prescription declined as visit length increased, falling by –0.11 percentage points (95% confidence interval [CI], –0.14 to –0.09) for each additional minute. The likelihood of benzodiazepine and opioid co-prescribing fell by –0.01 percentage points (95% CI, –0.01 to –0.009) with each additional minute of visit length.
Potentially inappropriate prescribing in older adults, on the other hand, increased with each additional minute (0.004 percentage points; 95% CI, 0.003 to 0.006) spent with a physician.
Regarding inappropriate antibiotic prescribing for upper respiratory tract infection, the authors say antibiotic stewardship advocates should take note of the findings, as they indicate that taking more time to discuss the diagnosis with patients may result in discussion of alternative treatment options.
"Our findings suggest that lengthening upper respiratory tract infection visits may be a promising strategy to lower inappropriate antibiotic prescribing, which has been a persistent population health concern for decades," they wrote.