Area Qualita'



 Un bellissimo articolo su LANCET perche' non ci dicano di fare tutto e troppo in fretta


Should visit length be used as a quality indicator in primary care?

Andrew Wilson and Susan Childs recently reviewed1 the link between the length of the consultation and quality of care in general practice. They conclude that a doctor who consults more slowly is more likely to provide visits that include important aspects of care, and that longer appointment length can therefore be used as a marker for quality. What are the challenges in interpreting the link between visit length and quality of care, and the implications for the broader issue of measuring and improving quality in primary care?

Despite the widespread perception among doctors and others that appointments are more rushed, the length of visits has remained stable or increased modestly over the past decade.2 This discordance, in part, reflects the fact that there is simply so much more clinicians can do, and are expected to do, during an office visit. The past 20 years has simultaneously seen an exponential growth in health technologies3 and in the number of stakeholders who know about, and want a say in, the delivery of those treatments.4 Patients visit their doctor armed with news articles and information from websites and advertisements, expert panels promulgate guidelines and treatment algorithms, and managers demand greater accountability and uniformity in the delivery of care.

In the face of these changes, are longer visits needed to ensure high-quality care? The answer will, of course, not be the same for all patients. Sicker patients need more time than healthy ones, new consultations necessitate more time than follow-up visits, and cases in which a diagnosis is uncertain require more time than those in which it is clear.5 Nor will circumstances be the same for all doctors or practices. Individual doctors vary in the speed and efficiency with which they work, and those in well organised practices are likely to require less time than those who work alone. As Wilson and Childs note, most reports that examine the link between visit length and quality of care have not adjusted for case-mix of the patients, characteristics of the health-care providers, or features of the practices.

Cultural expectations also affect the experience of visit length. The typical US patient, accustomed to visit times of 18-22 min,2 would probably perceive even the "long" visits described by Wilson and Childs (typically closer to 10 min) as too short. Trust and satisfaction are determined not only by the actual time spent in a visit, but also by how that time matches up with expectations and previous experiences.

Even if there were a causal relation between longer visit time and better quality of care, it would be only a starting point in any decision to adopt visit length as a performance indicator. Similar to primary-care doctors, managers are faced with an increasing array of treatment options and limited resources with which to implement them. Mandating longer visits requires either smaller caseloads or more staff. Adding new indicators of quality also costs time and resources. Thus the question for policymakers is not simply whether longer visits might improve care, but what are the clinical and economic tradeoffs between longer visits and other potential strategies for improving quality.

The ability to assess quality in primary care is coming of age. Current indicators of performance include generic and disease-specific measures, as well as surveys that seek to identify and quantify the "active ingredients" of primary care.6,7 To be used in routine practice, these measures must not only be scientifically sound, but also relevant and feasible to implement.8 To make a difference in routine practice, these measures must be meaningful to patients and health-care purchasers, and also salient to the clinicians and managers responsible for providing care.

Quality is increasingly recognised as a property of health systems, and improvement of quality as an enterprise that requires system-wide evaluation and intervention.9 In the care of patients with chronic disorders, researchers and managers are looking beyond performance of individual clinicians, and towards measuring and optimising how well these clinicians function together as part of larger organisations.10,11 In primary care, we need to take a similarly broad view, shifting from a focus on how much time we are spending and towards an understanding of how best to spend that time.

 *Benjamin Druss, David Mechanic

Wilson A, Childs S. The relationship between consultation length, process and outcomes in general practice: a systematic review.  Br J Gen Pract 2002; 52: 1012-20. [PubMed]

Mechanic D, McAlpine DD, Rosenthal M. Are patients' office visits with physicians getting shorter?  N Engl J Med 2001; 344: 198-204. [PubMed]

Cutler D, McClellan M. Is technological change in medicine worth it?  Health Affairs (Millwood) 2001; 20: 11-29. [PubMed]

 Robinson JC The end of asymmetric information.  J Health Polit Policy Law 2001; 26: 1045-53. [PubMed]

 Mechanic D. How should hamsters run? Some observations about sufficient patient time in primary care.  BMJ 2001; 323: 266-68. [PubMed]

 Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Pract. 2001 50: 161-164.

 Safran DG, Kosinski M, Tarlov AR, et al. The Primary Care Assessment Survey: tests of data quality and measurement performance.  Med Care 1998; 36: 728-39. [PubMed]

 NCQA. Desirable attributes of HEDIS measures. 1998: http://www. (accessed on March 26,2003).

 Institute of Medicine. Crossing the quality chasm. Washington, DC: National Academy Press, 2002.

Rundall TG, Shortell SM, Wang MC, et al. As good as it gets? Chronic care management in nine leading US physician organizations.  BMJ 2002; 325: 958-61. [PubMed]

Wagner EH. The role of patient care teams in chronic disease management.  BMJ 2000; 320: 569-72. [PubMed]