Time allocation in primary care office visits

OBJECTIVES: To use an innovative videotape analysis method to examine how clinic time was spent during elderly patients' visits to primary care physicians. Secondary objectives were to identify the factors that influence time allocations. DATA SOURCES: A convenience sample of 392 videotapes of routine office visits conducted between 1998 and 2000 from multiple primary care practices in the United States, supplemented by patient and physician surveys. RESEARCH DESIGN: Videotaped visits were examined for visit length and time devoted to specific topics--a novel approach to study time allocation. A survival analysis model analyzed the effects of patient, physician, and physician practice setting on how clinic time was spent. PRINCIPAL FINDINGS: Very limited amount of time was dedicated to specific topics in office visits. The median visit length was 15.7 minutes covering a median of six topics. About 5 minutes were spent on the longest topic whereas the remaining topics each received 1.1 minutes. While time spent by patient and physician on a topic responded to many factors, length of the visit overall varied little even when contents of visits varied widely. Macro factors associated with each site had more influence on visit and topic length than the nature of the problem patients presented. CONCLUSIONS: Many topics compete for visit time, resulting in small amount of time being spent on each topic. A highly regimented schedule might interfere with having sufficient time for patients with complex or multiple problems. Efforts to improve the quality of care need to recognize the time pressure on both patients and physicians, the effects of financial incentives, and the time costs of improving patient-physician interactions.     

Effects of educational intervention in waiting room on patient satisfaction

This study examines the effects of a low-cost educational intervention designed to occupy the waiting time in the clinic on patient satisfaction with the clinic visit. Patients waiting for appointments were randomly assigned to two groups: (1) educational intervention in the clinic waiting room (n = 160) and (2) usual clinic care (no structured education during the waiting time in the clinic; n = 160). There were significant negative correlations between satisfaction with the visit overall and the time patients waited in the clinic waiting room (r = -.17, p = .003) and their total wait time (r = -.16, p = .005). Patients who were taught while they waited in the clinics were more satisfied with their education than the control group (t = 4.26, df = 318, p < 0.001).     

Are continuity clinic patients less satisfied when residents have a heavy inpatient workload?

The purpose of this study was to assess the influence of resident non-clinic workload on the satisfaction of continuity clinic patients. Over a 2-month period in 2002, residents and patients were surveyed at the University of Kentucky internal medicine continuity clinic. Residents provided a self-report of their non-clinic workload as light or medium versus heavy or extremely heavy. Patient satisfaction was assessed with a 7-item, 10-point scale with items derived from commonly used patient satisfaction instruments. In 168 patient encounters, patients were significantly less satisfied with their clinic visit if they were seen by a resident who had a heavier workload. In addition, these patients gave significantly lower ratings with regard to the amount of time spent with the patient during the visit, and how well the resident listened and paid attention. Although alternative explanations exist, we propose that heavy hospital workload is associated with decreased patient satisfaction in resident continuity clinic.     

The impact of obesity on primary care visits

OBJECTIVE: To investigate the influence of patient obesity on primary care physician practice style. RESEARCH METHODS AND PROCEDURES: This was a randomized, prospective study of 509 patients assigned for care by 105 primary care resident physicians. Patient data collected included sociodemographic information, self-reported health status (Medical Outcomes Study Short Form-36), evaluation for depression (Beck Depression Index), and satisfaction. Height and weight were measured to calculate the BMI. Videotapes of the visits were analyzed using the Davis Observation Code (DOC). RESULTS: Regression equations were estimated relating obesity to visit length, each of the 20 individual DOC codes, and the six DOC Physician Practice Behavior Clusters, controlling for patient health status and sociodemographics. Obesity was not significantly associated with the length of the visit, but influenced what happened during the visit. Physicians spent less time educating obese patients about their health (p = 0.0062) and more time discussing exercise (p = 0.0075). Obesity was not related to discussions regarding nutrition. Physicians spent a greater portion of the visit on technical tasks when the patient was obese (p = 0.0528). Mean pre-visit general satisfaction for obese patients was significantly lower than for non-obese patients (p = 0.0069); however, there was no difference in post-visit patient satisfaction. DISCUSSION: Patient obesity impacts the medical visit. Further research can promote a greater understanding of the relationships between obese patients and their physicians.     

Can physicians improve patient satisfaction with long waiting times?

The purpose of our study was to determine how time spent with the physician might be related to patient dissatisfaction with their waiting time. During a 2-month period, patients in our internal medicine resident continuity clinic completed a survey assessing their satisfaction with their waiting time and their estimates of their waiting time and time spent with the resident physician. For patients with long waiting times (more than 15 min in the waiting room or more than 10 min in the exam room), patient dissatisfaction with waiting time was associated with a shorter physician visit (48% were dissatisfied if the physician spent less than 15 min vs. 18% if the physician spent more than 15 min with them, p = .03). These data suggest that physicians can mediate the negative effects of long waiting times by spending more time with their patients. Future studies on patient satisfaction should consider this interaction.     

Medical students in ENT outpatient clinics: appointment times, patient satisfaction and student satisfaction

OBJECTIVES: Outpatient clinics are increasingly important in medical education. The effect of students on clinic times and patient satisfaction, as well as their own satisfaction, were studied. DESIGN: A prospective, non-randomized, controlled study using adult patient questionnaires, medical student questionnaires and clinic time sheets. SETTING: Two teaching hospital ENT clinics. SUBJECTS: Medical students and adult patients. RESULTS: Three hundred and twenty-five patient questionnaires were collected (77% response), including 135 student encounters. Students did not affect appointment durations (19 min +/- 0.48 (standard error)) except at centre B (35 min +/- 1.1, P < 0.0001) where patient numbers were cut for teaching. Patient satisfaction, generally high, was not affected by students, appointment duration or gender of doctor or patient. It was slightly higher in the lower social classes (rs = 0.20, P = 0. 003) and older patients (rs = 0.17, P = 0.002). Student acceptability scores were not affected by student numbers (up to four), social class or time spent alone with students. They were higher if time was spent alone with the doctor (75.3% +/- 4.9) than not (63.0% +/- 1.8, P = 0.024). Thirty-six per cent of patients preferred to have a student present; only 9% preferred not. Student satisfaction was higher at centre B (73.7% +/- 2.3) where appointments were longer and students spent more time alone with patients than centre A (64.3% +/- 2.3, P = 0.0052). CONCLUSIONS: Clinic appointments are not necessarily longer in the presence of students. When students have the chance to see patients alone during longer consultations, student satisfaction is higher. Patient satisfaction, generally high, is not altered by the presence of students, but patients given time alone with their doctor are more accepting of students. These findings have resource implications for the planning of NHS clinics in teaching hospitals.     

Visit satisfaction and tailored health behavior communications in primary care

BACKGROUND: Although studies suggest that computer-tailored health communications can help patients improve health behaviors, their effect on patient satisfaction, when used in healthcare settings, has yet to be examined. METHODS: A stand-alone computer application was developed to provide tailored, printed feedback for patients and physicians about two of the most common adverse health behaviors seen in primary care: smoking and physical inactivity. Ten primary care providers and 150 of their patients were recruited to use the program in the office before their visit. After the visit, patients completed a self-report survey that addressed demographics, computer use history, satisfaction with the visit, and the extent to which the physician addressed the reports during the visit. All data presented were collected between October 2001 and February 2002. RESULTS: Most patients were female (67.6%), approximately half (46.0%) were seen for a routine exam, most (63.3%) had at least one chronic illness, and fewer than one third (31.3%) had ever used the Internet or e-mail. Most (81.1%) patients reported that the program was easy to use, but fewer than half of the doctors looked at the report in front of the patient (49.2%) or discussed the report with the patient (44.3%). Multivariate modeling showed that visit satisfaction was significantly greater among those whose doctor examined the report. This effect of the doctor examining the report on satisfaction was even greater for those who reported a chronic illness. CONCLUSIONS: Physicians who incorporate computer tailored messaging programs into the primary care setting, but who do not address the feedback reports that they create may contribute to patients being less satisfied with their care.     

Comparison of patient satisfaction with ambulatory visits in competing health care delivery settings in Geneva, Switzerland.

OBJECTIVES: To measure satisfaction with medical visits in various health care settings and to assess the extent to which differences in satisfaction scores between health care settings can be attributed to patients' characteristics. DESIGN: This was a cross sectional survey to measure seven dimensions of patient satisfaction. SETTINGS: Ambulatory visits to 'gatekeepers' or specialists in a newly established managed care organisation, a private group practice, or a university hospital outpatient clinic in Geneva, Switzerland. PATIENTS: There were altogether 1027 adult patients (81% participation rate). RESULTS: Patients who consulted physicians in the private group practice reported higher levels of satisfaction (overall mean 83.2 on a scale between 0 and 100) than university clinic patients (79.7), patients of independent specialists within the managed plan (78.5), and patients of managed plan gatekeepers (69.8, intergroup differences p < 0.001). Differences between settings were reduced after adjustment for sex, age, country of origin, general practitioner versus specialist visit, and scheduled versus urgent visit (adjusted scores: 80.8, 78.8, 77.6, and 72.7 in the four settings, p < 0.001). Intergroup differences were largest for general satisfaction, but small and non-significant for satisfaction with explanations given by the physician and for time spent with the patient. CONCLUSIONS: Patient satisfaction varied widely between health care settings. Differences in satisfaction ratings could be ascribed only partly to disparities in patient populations. Patients of managed plan gatekeepers were least satisfied, presumably because they could not choose their physician freely. Comparison of patient satisfaction across health care settings can provide a basis for targeted quality improvement initiatives.     

Effects of physician awareness of symptom-related expectations and mental disorders. A controlled trial

OBJECTIVE: To study whether physician awareness of symptom-related expectations and mental disorders reduces unmet expectations or improves patient satisfaction. DESIGN: Prospective, before-after trial, with control (n = 250) and intervention (n = 250) groups. Outcomes were assessed immediately after the index office visit, at 2 weeks, and at 3 months. SETTING: Ambulatory walk-in clinic. PARTICIPANTS: Five hundred adults with physical complaints. Exclusion criteria included upper respiratory tract infection and dementia. Follow-up was accomplished in 100% immediately after the visit, 92.6% at 2 weeks, and 82.6% at 3 months. INTERVENTIONS: Two-hour physician workshop followed by information provided before each visit on patient expectations, illness worry, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorders. MEASUREMENTS: Symptom-related expectations, satisfaction with care, symptom improvement, functional status, physician-perceived difficulty of the encounter, visit costs, and use of health care services. RESULTS: Serious illness worry (64%), 1 or more specific expectations (98%), or a DSM-IV disorder (29%) were commonly present in study patients. Intervention patients were less likely to report unmet expectations (odds ratio, 0.52; 95% confidence interval [CI], 0.43-0.97) immediately after the visit and at 2 weeks, less likely to be perceived as difficult by their physician (odds ratio, 0.49; 95% CI, 0.24-0.98), and more likely to be fully satisfied at 2 weeks (odds ratio, 1.63; 95% CI, 1.14-2.00). By 3 months, groups were similar in terms of satisfaction and residual expectations. Symptom improvement occurred in most patients by 2 weeks (70.5%) and 3 months (81.2%), regardless of study group. There was also no difference in patients' serious illness worry during the follow-up. The intervention did not increase visit costs or use of health care services. CONCLUSION: Identifying symptom-related expectations and mental disorders in patients presenting with physical complaints may improve satisfaction with care at 2-week follow-up and physician-perceived difficulty of the encounter.     

A work-sampling tool to measure the effect of electronic medical record implementation on health care workers

This article presents baseline work sampling data from an outpatient oncology clinic prior to an electronic medical record implementation. The physicians and medical office assistants spent 29% and 39% of their time, respectively, entering and retrieving information from medical records. The physicians and medical office assistants spent 43% and 17% of their time, respectively, on direct patient contact. Using scheduled outpatient counts to measure the productivity of the physicians and medical office assistants failed to capture 19% and 29% of their workload.     

A taxonomy of requests by patients (TORP): a new system for understanding clinical negotiation in office practice

BACKGROUND: The goal of our investigation was to facilitate research on clinical negotiation between patients and physicians by developing a reliable and valid classification system for patients' requests in office practice. METHODS: We developed the Taxonomy of Requests by Patients (TORP) using input from researchers, clinicians, and patient focus groups. To assess the system's reliability and validity, we applied TORP to audiotaped encounters between 139 patients and 6 northern California internists. Reliability was assessed with the kappa statistic as a measure of interrater agreement. Face validity was assessed through expert and patient judgment of the coding system. Content validity was examined by monitoring the incidence of unclassifiable requests. Construct validity was evaluated by examining the relationship between patient requests and patient health status; patient request fulfillment and patient satisfaction; and patient requests and physician perceptions of the visit. RESULTS: The 139 patients made 772 requests (619 requests for information and 153 requests for physician action). Average interrater agreement across a sample of 40 cases was 94% (kappa = 0.93; P <.001). Patients with better health status made fewer requests (r = -0.17; P = .048). Having more chronic diseases was associated with more requests for physician action (r = 0.32; P = .0002). Patients with more unfulfilled requests had lower visit satisfaction (r = -0.32; P <.001). More patient requests was also associated with physician reports of longer visit times (P = .016) and increased visit demands (P = .006). CONCLUSIONS: Our study provides evidence that TORP is a reliable and valid system for capturing and categorizing patients' requests in adult primary care. Further research is needed to confirm the system's validity, expand its applicability, and explore its usefulness as a tool for studying clinical negotiation.     

The physician's role in educating patients. A comparison of mailed versus physician-delivered patient education

BACKGROUND: Patients value receiving educational information during office visits, but physicians often lack the time or training to satisfy this need. We examined whether an increased physician role in educating patients is an effective means of improving patient satisfaction. METHODS: Using a nonrandomized controlled research design, we compared patient satisfaction with self-care information provided by traditional direct-mail approaches and by physicians during routine office visits. We also studied a control group of patients receiving usual care. RESULTS: Patients who received a medical self-care book from a physician were significantly more likely to be satisfied with their office visit than those who received the book in the mail or those who experienced usual care. The intervention group reported greater satisfaction with 11 out of 13 variables related to physician-patient communication and quality of care. There were no significant differences between the control group and the direct-mail group. CONCLUSIONS: The patients who received self-care information from their physicians were significantly more satisfied with their care and their physician-patient communication experience than those in either the direct-mail group or the control group. Our findings lend support to the growing evidence that patients informed by their physicians are more satisfied with their care.     

Incorporating physical activity advice into primary care: physician-delivered advice within the activity counseling trial

INTRODUCTION: The Activity Counseling Trial (ACT) was designed to compare the effectiveness of physician advice alone with physician advice plus behavioral counseling, provided by ACT-trained health educators, to increase levels of physical activity in healthy, sedentary patients. The objective was to determine health care providers' adherence to the ACT protocol for delivering initial "physician" advice on physical activity and to determine providers' satisfaction with the protocol. METHODS: Fifty-four physicians or physician assistants from 11 primary care practices located in California, Texas, and Tennessee volunteered to participate as ACT-trained physicians. Providers were trained to integrate 3 to 4 minutes of initial physical activity advice into the routine office visits of sedentary patients, aged 35 to 75 years, with no acute or serious chronic conditions. This advice included assessment of current physical activities, advising the patient about an appropriate physical activity goal, and referring the patient to the health educator. Providers initialed forms to document delivery of advice, and ACT health educators recorded their advice on a computerized tracking system. A provider survey measured length of time spent advising patients about physical activity and provider satisfaction with the program. RESULTS: Ninety-nine percent of patients received the initial physician advice about physical activity. Eighty-three percent of the providers spent less than 5 to 6 minutes, and 46% spent the recommended 3 to 4 minutes providing advice. Sixty-three percent said the advice resulted in little or no increase in the length of an office visit, and 83% said participation was an asset to their clinics. CONCLUSIONS: Providers incorporated brief physical activity advice into routine primary care visits with little disruption. Their response to the ACT advice protocol was positive and participation in the study was viewed as beneficial.     

Evaluation of health care needs and patient satisfaction among hepatitis C patients treated at a hospital-based, viral hepatitis clinic

OBJECTIVE: To define self-reported hepatitis C knowledge, health care needs, and patient satisfaction in a representative cohort of hepatitis C virus (HCV)-infected adults treated at a university hospital-based viral hepatitis clinic in Canada. METHODS: A questionnaire package evaluating HCV knowledge, health care needs, and patient satisfaction was administered to 111 consecutive consenting HCV patients during their first and 10-month follow-up HCV clinic visits. RESULTS: At their first HCV clinic visit, 52% of patients rated their current HCV knowledge as "fair" or "poor". Patients identified HCV education, quality medical care, medication coverage, and psychological counselling as important HCV health care needs. Health care satisfaction outcome data at 10-month follow-up indicated that patients felt significantly better informed, more satisfied, and more actively involved in their HCV health care. CONCLUSION: A bio-psychosocial framework in which medical, psychological, educational, and social issues are addressed is desirable for optimal HCV health care.     

Using patient surveys to measure the quality of outpatient care in Kraków, Poland.

OBJECTIVE: To test the feasibility of using patient reported information to create indicators of quality (access, patient experience--including satisfaction, and clinical quality) with the goal of providing Kraków city clinic managers (and potentially other audiences) with information about the quality of outpatient care in selected clinics. Setting and methods. Almost 2,000 patients from 19 outpatient clinics in Kraków, Poland were surveyed in November and December 1997 and January 1998. We prepared a self-completed questionnaire to capture data about the patient's experience with access to services, interactions with registration staff, communication with the doctor, information received from the doctor, and receipt of preventive services. RESULTS: Access varied across clinics. For example, 84% of patients waited less than 10 minutes at registration, whereas only 53% of patients waited less than 30 minutes to see the doctor. Among those who tried to register by telephone, only 72% were successful. Satisfaction was highest with the doctor visit (satisfaction=79, on a scale of 1-100) and lowest with telephone registration (satisfaction = 59). Preventive health care screening was generally disappointing, particularly for Papanicolaou smear and clinical breast examination, although frequent users of a clinic (with more opportunities for screening) generally had higher rates of screening. CONCLUSION: We demonstrated the feasibility of constructing indicators of multiple dimensions of the quality of outpatient care using patient-reported information. Quality dimensions captured by survey included access, patient experience and clinical quality. Results were successfully summarized in easy to read and understand formats for clinic managers and city health department officials.     

The effectiveness of family planning clinics in serving adolescents

Data from surveys conducted by The Alan Guttmacher Institute (AGI) in 1981 have been used to create three indicators of the effectiveness of family planning clinics in serving teenagers: the mean delay between first intercourse and first clinic visit (which for teenage clinic patients is 13.2 months); teenage patient retention (67 percent; and the average excess of patient satisfaction over dissatisfaction with clinic policies and services (33 percent). Clinics run by Planned Parenthood are more effective than other types of facility, according to the mean delay indicator, whereas other clinics, such as those associated with community action programs and neighborhood health centers, rank highest in levels of patient satisfaction and patient retention. All three measures indicate that clinics serving 1,000-2,499 family planning patients per year are more effective in serving teenagers than either smaller or larger clinics, and that nonmetropolitan clinics are more effective in providing services than those in cities. Regression analysis shows that clinic administrators might take a number of actions to shorten the mean delay among teenagers between first intercourse and first clinic visit. These include offering community education programs for teenagers, enlisting the support of local churches, developing relationships with local youth groups, opening the clinic during evenings and weekends, accepting more teenagers as walk-in patients and locating a clinic in or near neighborhoods where many teenagers live. Two of the same factors--developing an active relationship with youth groups and opening the clinic to teenagers on evenings and weekends--were also found to be particularly effective in keeping teenagers as clinic patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Patient satisfaction with nurse-led telephone follow-up in women with lower urinary tract symptoms

We assessed the clinical effectiveness and patient satisfaction with nurse-led telephone follow-up of women with lower urinary tract symptoms. Participants were offered telephone follow-up with a nurse instead of a conventional outpatient appointment. Suitability was decided by the doctor who saw the women at her last visit. The consultation was conducted using the same principles as a routine clinic visit. Patient satisfaction was evaluated by postal questionnaire and they were also sent a standard urinary continence questionnaire, the Kings Health Questionnaire (KHQ), to evaluate their current symptoms. In total, 116 women were included. The mean number of telephone consultations was 2 (range 1-12). The mean overall satisfaction score was 77 (maximum 100, where a higher score indicates greater satisfaction). Only 16 patients (17%) did not prefer telephone follow-up to a clinic visit. Women who had been discharged via the telephone follow-up clinic expressed similar mean satisfaction scores to those whose next visit was a clinic visit (80 and 82, respectively). The KHQ also indicated that the patients had been appropriately discharged or given a further follow-up appointment. Nurse-led telephone follow-up is associated with high satisfaction and has the advantages of consistent follow-up by the same clinician, convenience to the patient and cost-savings.     

Interactive patient education: the X-Plain model

Responding to competitive pressure to enhance services and patient satisfaction while reducing cost, many healthcare organizations are turning to interactive health communication to enhance their practices. This article reviews computer-based patient education by focusing on a product, X-Plain, and describing how it is used in medical practices. The following benefits of computer-based patient education are discussed: risk management, time saving, enhanced patient satisfactions, and meeting regulatory requirements. Two classes of computer-based patient education systems are distinguished: documentation systems used in the back office to inform patients about their diagnoses and treatments and to document patient education; and public kiosks used in the reception area to provide general information, promote the practice's services, and collect survey data. The advantages of delivering patient education through the Web such as global networking and presentation of customized health information are discussed.     

Women's satisfaction with their on-going primary health care services: a consideration of visit-specific and period assessments

OBJECTIVE: To compare and contrast patient ratings of satisfaction with primary care on the day of visit versus over the last 12 months. Data SOURCES/STUDY SETTING: Survey data were collected from female participants at primary care centers affiliated with the University of Michigan, University of Pittsburgh, and Wake Forest University. STUDY DESIGN: One thousand and twenty-one patients attending a primary care visit with at least one prior visit to the study site were consented on site, enrolled in the study, and surveyed at two time points: pre- and immediately postvisit. DATA COLLECTION: The previsit survey included demographics, self-rated health, visit history (site continuity), and expectations for health care; the postvisit survey focused on patient experiences during the visit, assessment of health care quality using the Primary Care Satisfaction Survey for Women instrument, and global satisfaction with visit and health care over the past 12 months. Expectation discrepancy scores were constructed from the linked expectation-experience ratings. Path analysis and indices of model fit were used to investigate the strength of theoretical links among the variables in an analytic model considering both day-of-visit and past-year ratings with global measures of patient satisfaction as the dependent variables. PRINCIPAL FINDINGS: General health, site continuity and fulfillment of patient expectations for care were linked to global ratings of satisfaction through effects on communication, care coordination, and office staff and administration. Importantly, past-year ratings were mediated largely by care coordination and continuity; day-of-visit ratings were mediated by communication. CONCLUSION: Ratings of health care quality for a specific visit appear to be conceptually distinct from ratings of care over the past 12 months, and thus are not interchangeable.     

The Effect of Eye Drop Technique Education in Patients With Glaucoma

Education about how to administer eye drops may improve a patient’s ability to instill his or her eye drops correctly. Our objectives were to (a) document the methods providers use to educate glaucoma patients about eye drop technique; (b) determine whether eye drop technique education varies by provider and patient characteristics; and (c) evaluate whether education predicts improved patient technique. We conducted an 8-month longitudinal study of 279 glaucoma patients and 15 providers in which we recorded on videotape the content of glaucoma office visits at two time points (baseline and 4- to 6-week follow-up) and videotaped patient eye drop technique at three time points (baseline, 4- to 6-week follow-up, and 8-month follow-up). Mann–Whitney rank sum tests were used to determine whether education was associated with improved patient eye drop technique over time. Ninety-four patients (34%) received technique education at either visit; 31% received verbal education and 10% received a technique demonstration. Only 24 patients (47%) who were new to eye drops received technique education at the baseline visit. Patients who were new to drops at baseline (p = .008) and patients who asked a question about drops (p < .001) were more likely to receive technique education. Education was not associated with improved technique. Eye drop technique education occurs infrequently during glaucoma office visits. Future studies should compare the effectiveness of different educational methods, such as patient demonstration versus provider verbal instruction, to determine which method is best at improving patient eye drop technique.