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Revisiting the Time Needed to Provide Adult Primary Care

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Abstract

Background

Many patients do not receive guideline-recommended preventive, chronic disease, and acute care. One potential explanation is insufficient time for primary care providers (PCPs) to provide care.

Objective

To quantify the time needed to provide 2020 preventive care, chronic disease care, and acute care for a nationally representative adult patient panel by a PCP alone, and by a PCP as part of a team-based care model.

Design

Simulation study applying preventive and chronic disease care guidelines to hypothetical patient panels.

Participants

Hypothetical panels of 2500 patients, representative of the adult US population based on the 2017–2018 National Health and Nutrition Examination Survey.

Main Measures

The mean time required for a PCP to provide guideline-recommended preventive, chronic disease and acute care to the hypothetical patient panels. Estimates were also calculated for visit documentation time and electronic inbox management time. Times were re-estimated in the setting of team-based care.

Key Results

PCPs were estimated to require 26.7 h/day, comprising of 14.1 h/day for preventive care, 7.2 h/day for chronic disease care, 2.2 h/day for acute care, and 3.2 h/day for documentation and inbox management. With team-based care, PCPs were estimated to require 9.3 h per day (2.0 h/day for preventive care and 3.6 h/day for chronic disease care, 1.1 h/day for acute care, and 2.6 h/day for documentation and inbox management).

Conclusions

PCPs do not have enough time to provide the guideline-recommended primary care. With team-based care the time requirements would decrease by over half, but still be excessive.

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References

  1. Grade Definitions - US Preventive Services Task Force. Accessed September 30, 2019. https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions

  2. O’Connor PJ. Adding value to evidence-based clinical guidelines. JAMA. 2005;294(6):741-743. https://doi.org/10.1001/jama.294.6.741

    Article  Google Scholar 

  3. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-2645. https://doi.org/10.1056/NEJMsa022615

    Article  Google Scholar 

  4. Campion EW. A Symptom of Discontent. N Engl J Med. 2001;344(3):223-225. https://doi.org/10.1056/NEJM200101183440311

    Article  CAS  Google Scholar 

  5. Heponiemi T, Hyppönen H, Kujala S, et al. Predictors of physicians’ stress related to information systems: a nine-year follow-up survey study. BMC Health Serv Res. 2018;18(1):284. https://doi.org/10.1186/s12913-018-3094-x

    Article  Google Scholar 

  6. Yarnall KSH, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93(4):635-641. https://doi.org/10.2105/ajph.93.4.635

    Article  Google Scholar 

  7. Privett N, Guerrier S. Estimation of the time needed to deliver the 2020 USPSTF preventive care recommendations in primary care. Am J Public Health. 2021;111(1):145-149. https://doi.org/10.2105/AJPH.2020.305967

  8. Østbye T, Yarnall KSH, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3(3):209-214. https://doi.org/10.1370/afm.310

    Article  Google Scholar 

  9. Creating Patient-centered Team-based Primary Care. :27.

  10. The role of patient care teams in chronic disease management | The BMJ. Accessed October 10, 2019. https://www.bmj.com/content/320/7234/569

  11. Swankoski KE, Peikes DN, Palakal M, Duda N, Day TJ. Primary care practice transformation introduces different staff roles. Ann Fam Med. 2020;18(3):227-234. https://doi.org/10.1370/afm.2515

    Article  Google Scholar 

  12. Implementing High-Quality Primary Care | National Academies. Accessed April 26, 2022. https://www.nationalacademies.org/our-work/implementing-high-quality-primary-care

  13. Dai M, Ingham R, Peterson L. Scope of practice and patient panel size of family physicians who work with nurse practitioners or physician assistants. Fam Med. 2019;51(4):311-318. https://doi.org/10.22454/FamMed.2019.438954

    Article  Google Scholar 

  14. Angstman KB, Horn JL, Bernard ME, et al. Family medicine panel size with care teams: impact on quality. J Am Board Fam Med. 2016;29(4):444-451. https://doi.org/10.3122/jabfm.2016.04.150364

    Article  Google Scholar 

  15. Shekelle PG, Paige NM, Apaydin EA, et al. What is the Optimal Panel Size in Primary Care? A Systematic Review [Internet]. Washington (DC): Department of Veterans Affairs (US); 2019 Aug. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553674/

  16. NHANES - National Health and Nutrition Examination Survey Homepage. Published February 4, 2021. Accessed February 14, 2021. https://www.cdc.gov/nchs/nhanes/index.htm

  17. National Health and Nutrition Examination Survey, 2015−2018: Sample Design and Estimation Procedures. (2020, April 1). National Center for Health Statistics. Accessed February 14, 2021. https://www.cdc.gov/nchs/data/series/sr_02/sr02-184-508.pdf

  18. Buttorff, Christine, Teague Ruder, and Melissa Bauman, Multiple Chronic Conditions in the United States. Santa Monica, CA: RAND Corporation, 2017. https://www.rand.org/pubs/tools/TL221.html

  19. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127-e248.

  20. Stone Neil J., Robinson Jennifer G., Lichtenstein Alice H., et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. Circulation. 2014;129(25_suppl_2):S1-S45. https://doi.org/10.1161/01.cir.0000437738.63853.7a

    Article  Google Scholar 

  21. Ng CWM, How CH, Ng YP. Managing depression in primary care. Singapore Med J. 2017;58(8):459-466. https://doi.org/10.11622/smedj.2017080

    Article  Google Scholar 

  22. Standards of Medical Care in Diabetes—2018 abridged for primary care providers. Clin Diabetes Publ Am Diabetes Assoc. 2018;36(1):14-37. https://doi.org/10.2337/cd17-0119

  23. National Collaborating Centre for mental health. Generalised Anxiety Disorder in Adults: The NICE Guidelines on Management in Primary, Secondary and Community Care. RCPsych Publications; 2011.

  24. Expert Panel Report 3 (EPR-3): Guidelines for the diagnosis and management of asthma–summary report 2007. J Allergy Clin Immunol. 2007;120(5, Supplement). https://doi.org/10.1016/j.jaci.2007.09.029

  25. 2013 ESC guidelines on the management of stable coronary artery disease. The Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Rev Esp Cardiol Engl Ed. 2014;67(2):135. https://doi.org/10.1016/j.rec.2013.11.008

  26. Hueston WJ. Treatment of hypothyroidism. Am Fam Physician. 2001 Nov 15;64(10):1717-24. Erratum in: Am Fam Physician 2002 Jun 15;65(12):2438. PMID: 11759078

  27. Siafakas NM, Vermeire P, Pride NB, et al. Optimal assessment and management of chronic obstructive pulmonary disease (COPD). The European Respiratory Society Task Force. Eur Respir J. 1995;8(8):1398-1420.

    Article  CAS  Google Scholar 

  28. Chou SC, Venkatesh AK, Trueger NS, Pitts SR. Primary care office visits for acute care dropped sharply in 2002-15, while ed visits increased modestly. Health Aff Proj Hope. 2019;38(2):268-275. https://doi.org/10.1377/hlthaff.2018.05184

    Article  Google Scholar 

  29. Chen LM, Farwell WR, Jha AK. Primary care visit duration and quality: does good care take longer? Arch Intern Med. 2009;169(20):1866-1872. https://doi.org/10.1001/archinternmed.2009.341

    Article  Google Scholar 

  30. Tai-Seale M, Olson CW, Li J, et al. Electronic health record logs indicate that physicians split time evenly between seeing patients and desktop medicine. Health Aff (Millwood). 2017;36(4):655-662. https://doi.org/10.1377/hlthaff.2016.0811

    Article  Google Scholar 

  31. Akbar F, Mark G, Warton EM, et al. Physicians’ electronic inbox work patterns and factors associated with high inbox work duration. J Am Med Inform Assoc. 2020;(ocaa229). https://doi.org/10.1093/jamia/ocaa229

  32. Independent Evaluation of the Comprehensive Primary Care Plus (CPC+): Third Annual Report. Mathematica. Accessed February 21, 2021. https://www.mathematica.org/our-publications-and-findings/publications/independent-evaluation-of-the-comprehensive-primary-care-plus-cpc-third-annual-report

  33. PART 1300 NURSE PRACTICE ACT : Sections Listing. Accessed July 15, 2019. http://www.ilga.gov/commission/jcar/admincode/068/06801300sections.html

  34. Academy of Nutrition and Dietetics: Scope of Practice for the Registered Dietitian. J Acad Nutr Diet. 2013;113(6):S17-S28. https://doi.org/10.1016/j.jand.2012.12.008

    Article  Google Scholar 

  35. National Society of Genetic Counselors : Model Legislative Provisions. Accessed February 26, 2020. https://www.nsgc.org/p/cm/ld/fid=18#scope

  36. AMHCA Standards - American Mental Health Counselors Association. Accessed February 26, 2020. https://www.amhca.org/publications/standards

  37. Carey N, Courtenay M. Clark et al. Nurse-led interventions used to improve control of high blood pressure in people with diabetes: a systematic review and meta analysis. Diabet Med. 2012;29(1):154-155. https://doi.org/10.1111/j.1464-5491.2011.03424.x

    Article  CAS  Google Scholar 

  38. Chiang CY, Choi KC, Ho KM, Yu SF. Effectiveness of nurse-led patient-centered care behavioral risk modification on secondary prevention of coronary heart disease: A systematic review. Int J Nurs Stud. 2018;84:28-39. https://doi.org/10.1016/j.ijnurstu.2018.04.012

    Article  Google Scholar 

  39. de Thurah A, Esbensen BA, Roelsgaard IK, Frandsen TF, Primdahl J. Efficacy of embedded nurse-led versus conventional physician-led follow-up in rheumatoid arthritis: a systematic review and meta-analysis. RMD Open. 2017;3(2):e000481. https://doi.org/10.1136/rmdopen-2017-000481

    Article  Google Scholar 

  40. Wells MJ, Owen JJ, McCray LW, et al. Computer-assisted cognitive-behavior therapy for depression in primary care: systematic review and meta-analysis. Prim Care Companion CNS Disord. 2018;20(2):. https://doi.org/10.4088/PCC.17r02196

  41. Wang Q, Shen Y, Chen Y, Li X. Impacts of nurse-led clinic and nurse-led prescription on hemoglobin A1c control in type 2 diabetes. Medicine (Baltimore). 2019;98(23). https://doi.org/10.1097/MD.0000000000015971

  42. Hofmann SG, Smits JAJ. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008;69(4):621-632.

    Article  Google Scholar 

  43. Kuethe MC, Vaessen-Verberne AAPH, Elbers RG, Aalderen WMV. Nurse versus physician-led care for the management of asthma. Cochrane Database Syst Rev. 2013;(2). https://doi.org/10.1002/14651858.CD009296.pub2

  44. Murphy DR, Satterly T, Giardina TD, Sittig DF, Singh H. Practicing clinicians’ recommendations to reduce burden from the electronic health record inbox: a mixed-methods study. J Gen Intern Med. 2019;34(9):1825-1832. https://doi.org/10.1007/s11606-019-05112-5

    Article  Google Scholar 

  45. Lieu TA, Altschuler A, Weiner JZ, et al. Primary care physicians’ experiences with and strategies for managing electronic messages. JAMA Netw Open. 2019;2(12):e1918287. https://doi.org/10.1001/jamanetworkopen.2019.18287

    Article  Google Scholar 

  46. Hung DY, Truong QA, Liang SY. Implementing lean quality improvement in primary care: impact on efficiency in performing common clinical tasks. J Gen Intern Med. 2021;36(2):274-279. https://doi.org/10.1007/s11606-020-06317-9

    Article  Google Scholar 

  47. Laiteerapong N, Huang ES, Chin MH. Prioritization of care in adults with diabetes and comorbidity. Ann N Y Acad Sci. 2011;1243(1):69-87. https://doi.org/10.1111/j.1749-6632.2011.06316.x

    Article  Google Scholar 

  48. Piette JD, Kerr EA. The impact of comorbid chronic conditions on diabetes care. Diabetes Care. 2006;29(3):725. https://doi.org/10.2337/diacare.29.03.06.dc05-2078

    Article  Google Scholar 

  49. O’Connor EA, Perdue LA, Senger CA, et al. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018;320(18):1910. https://doi.org/10.1001/jama.2018.12086

    Article  Google Scholar 

  50. LeBlanc EL, Patnode CD, Webber EM, Redmond N, Rushkin M, O’Connor EA. Behavioral and pharmacotherapy weight loss interventions to prevent obesity-related morbidity and mortality in adults: an updated systematic review for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality (US); 2018. Accessed February 27, 2020. http://www.ncbi.nlm.nih.gov/books/NBK532379/

  51. Recommendation: Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening | United States Preventive Services Taskforce. Accessed March 8, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-for-abnormal-blood-glucose-and-type-2-diabetes

  52. Final Recommendation Statement: Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions - US Preventive Services Task Force. Accessed February 26, 2020. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/obesity-in-adults-interventions1

  53. Marcotte-Chénard A, Deshayes TA, Ghachem A, Brochu M. Prevalence of the metabolic syndrome between 1999 and 2014 in the United States adult population and the impact of the 2007-2008 recession: an NHANES study. Appl Physiol Nutr Metab Physiol Appl Nutr Metab. 2019;44(8):861-868. https://doi.org/10.1139/apnm-2018-0648

    Article  CAS  Google Scholar 

  54. Rowe K, Rowe W, Umbehr J, Dong F, Ablah E. Direct primary care in 2015: a survey with selected comparisons to 2005 survey data. Kans J Med. 2017;10(1):3-6.

    Article  Google Scholar 

  55. Lucarelli C, Prince J, Simon K. The welfare impact of reducing choice in Medicare part D: a comparison of two regulation strategies*: reducing choice in medicare part d. Int Econ Rev. 2012;53(4):1155-1177. https://doi.org/10.1111/j.1468-2354.2012.00715.x

    Article  Google Scholar 

  56. USPSTF A and B Recommendations - US Preventive Services Task Force. Accessed July 11, 2019. https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/

  57. Altschuler J, Margolius D, Bodenheimer T, Grumbach K. Estimating a reasonable patient panel size for primary care physicians with team-based task delegation. Ann Fam Med. 2012;10(5):396-400. https://doi.org/10.1370/afm.1400

    Article  Google Scholar 

  58. Reiss-Brennan B, Brunisholz KD, Dredge C, et al. Association of integrated team-based care with health care quality, utilization, and cost. JAMA. 2016;316(8):826. https://doi.org/10.1001/jama.2016.11232

    Article  Google Scholar 

  59. Basu S, Landon BE, Williams JW, Bitton A, Song Z, Phillips RS. Behavioral health integration into primary care: a microsimulation of financial implications for practices. J Gen Intern Med. 2017;32(12):1330-1341. https://doi.org/10.1007/s11606-017-4177-9

    Article  Google Scholar 

  60. Dowling R. Reimbursement for obesity counseling. Medical Economics. Published December 7, 2018. Accessed February 26, 2020. https://www.medicaleconomics.com/article/reimbursement-obesity-counseling

  61. Medical Nutrition Therapy - Manuals. Accessed November 9, 2019. https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/Manuals/preventive%20services%20guide/medical%20nutrition%20therapy%20-%20preventive%20services%20guide/!ut/p/z0/nU9BbgIxDPxKOHBENhQqcYwoiBYhIfWy5FKFxSymwRuy2aX8vlnaQysVDvXJMxrPjMFABkZsw4WNXIp1Ca_N49tQP0_7_QkucLYYon59Gs8HevyAK4QXMEmAN0Zj6zAIy8myAONt3PdYdiVkUlRH2nJuA31b3Mn428IHakgiN6QqCg3nVKmi5i1B9mXtlNQxcPuJinsK1l9UT905gzUfTiejweSlRPqIv3peOYlC5y7-oK_Y1xuXUBtVdfFopbYuLTezkuZfFf272Yzc4XLWnc4nZ8vSWg!!/

  62. Oddone EZ, Boulware LE. Primary care: medicine’s Gordian knot. Am J Med Sci. 2016;351(1):20-25. https://doi.org/10.1016/j.amjms.2015.10.010

    Article  Google Scholar 

  63. Young R, Burge S, Kumar K, Wilson J, Ortiz D. A time-motion study of primary care physicians’ work in the electronic health record era. Family Medicine. https://doi.org/10.22454/FamMed.2018.184803

  64. Huston P, Campbell J, Russell G, et al. COVID-19 and primary care in six countries. BJGP Open. 2020;4(4). https://doi.org/10.3399/bjgpopen20X101128

  65. Morreel S, Philips H, Verhoeven V. Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: A real-time observational study. PLOS ONE. 2020;15(8):e0237629. https://doi.org/10.1371/journal.pone.0237629

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Medicine, University of Chicago, Chicago, IL, USA

    Justin Porter MD

  2. Johns Hopkins School of Medicine, Baltimore, MD, USA

    Cynthia Boyd MD, MPH

  3. Imperial College Business School, Centre for Health Economics & Policy Innovation, Imperial College London, London, UK

    M. Reza Skandari PhD

  4. Departments of Medicine & Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA

    Neda Laiteerapong MD, MS

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  1. Justin Porter MD
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  4. Neda Laiteerapong MD, MS
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Corresponding author

Correspondence to Justin Porter MD.

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Conflict of interest

Cynthia Boyd: Dr. Boyd was funded by NIA K24AG056578.

Neda Laiteerapong: Dr. Laiteerapong was funded by NIDDK P30 DK092949.

Justin Porter: None

M. Reza Skandari: None

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Porter, J., Boyd, C., Skandari, M.R. et al. Revisiting the Time Needed to Provide Adult Primary Care. J GEN INTERN MED 38, 147–155 (2023). https://doi.org/10.1007/s11606-022-07707-x

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