Less Time With Patients, More Inappropriate Prescribing

Shorter visits between patients and their primary care physicians may be associated with a higher likelihood of inappropriate prescribing, researchers have found.

The study, published online March 10 in JAMA Health Forum, found that as the duration of visits decreased, doctors more often wrote unwarranted prescriptions of antibiotics for upper respiratory tract infections. They also were more likely to coprescribe opioids and benzodiazepines for patients with pain-related diagnoses, which can increase the risk of a life-threatening overdose.

“Whether it’s patients or whether it’s doctors, everyone feels like they don’t get enough time together,” said Hannah Neprash, PhD, assistant professor at the University of Minnesota School of Public Health and lead author of the study. “So, I really wanted to understand how important that is for the quality of care people get.”

Neprash and colleagues analyzed electronic health record data from more than 8 million primary care visits in 2017. The study included more than 4.3 million patients and 8091 primary care physicians.

The effect of visit length on the possibility of inappropriate prescribing is relatively low but clear. Over the entire sample of primary care visits, each additional minute of visit length decreased the likelihood of an inappropriate antibiotic by 0.11 percentage points, and the likelihood of opioid and benzodiazepine coprescribing changed by 0.01 percentage points.

For example, nearly 57% of visits lasting 10 minutes resulted in inappropriate antibiotic prescribing. The number drops to below 54% for 20-minute visits.

To determine inappropriate antibiotic prescribing, the researchers implemented a widely used definition relying on the presence of an antibiotic prescription linked with the diagnosis of an upper respiratory tract infection. Similarly, they defined opioid and benzodiazepine coprescribing as a visit with a pain-related primary diagnosis and both an opioid and a benzodiazepine prescription linked to the visit.

Overall, younger, publicly insured, Hispanic, and Black patients all had shorter visits with their primary care physicians — by about half a minute, on average. Neprash stressed that although that number looks small, the gap could exacerbate racial and socioeconomic health inequities over time.

“When this is our only 17 or 18 minutes, that can add up over the course of the relationship,” Neprash said. “It could mean a problem that you don’t mention. It’s still concerning because we want everybody to be able to talk about the concerns they have with their primary care doctors.”

Not Enough Time

The study cites that the average primary care visit lasts 18 minutes. A recent estimate suggests clinicians would require a clock-bending 27 hours per day to provide all guideline-recommended care.

The researchers stressed that inappropriate prescribing is not necessarily a conscious decision by primary care physicians but more likely results from a hectic workload. Physicians under pressure to see as many patients as possible may prescribe quick fixes instead of engaging in longer and possibly difficult discussions with patients.

Neprash said prescribing an antibiotic is an easy way to keep a patient happy rather than explaining watchful waiting or telling them an antibiotic will not help a viral infection.

“Prescriptions can be a way to make a patient feel heard,” she said.

Neprash and colleagues said a different approach than the typical fee-for-service model is needed to balance time constraints with what is best for the patient.

“The incentive is to do as many visits as possible and therefore to do them as quickly as possible,” said senior author Ishani Ganguli, MD, a professor of medicine at Harvard Medical School and a primary care physician at Brigham and Women’s Hospital in Boston.

Dung Trinh, MD, founder and chief medical officer at Healthy Brain Clinic in Long Beach, California, said an incomplete patient history in the medical record and a lack of patient education may also be reasons primary care physicians feel rushed.

“If primary care providers do not have enough time to educate their patients on these issues, they may be more likely to prescribe medication as a quick fix,” said Trinh, who was not involved with this study.

Ganguli stressed that taking time to avoid inappropriately prescribed drugs with the potential to do more harm than good is time well spent.

“It’s really worth spending that extra 30 seconds and having that conversation,” Ganguli said.

The study cited multiple limitations, including that the results should not be interpreted causally and that the visit length and the diagnostic codes used for the analysis are an “imperfect proxy” for what physicians and patients discuss during a visit.

Neprash’s research was supported by a pilot grant from the University of Minnesota Life Course Center, which receives funding from the National Institute on Aging. Ganguli was supported in part by a grant from the National Institute on Aging. Ganguli reported receiving grants from the National Institute for Health Care Management during the conduct of the study and receiving personal fees from Cambridge-based venture capital firm F-Prime and grants from public policy philanthropic organization Arnold Ventures and the Agency for Healthcare Research and Quality outside the submitted work. No other disclosures were reported.

JAMA Health Forum. Published online March 10, 2023. Full text

Robert Fulton is a journalist located in Los Angeles.

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