The Increasing Number of Clinical Items Addressed During the Time of Adult Primary Care Visits

  • Elmer D. Abbo
  • Qi Zhang
  • Martin Zelder
  • Elbert S. Huang
Original Article



Primary care physicians report that there is insufficient time to meet patients’ needs during clinical visits, but visit time has increased over the past decade.


To determine whether the number of clinical items addressed during the primary care visit has increased, and if so, whether this has been associated with changes in visit length and the pace of clinical work.


Analysis of non-hospital-based adult primary care visits from 1997 to 2005, as reported in the National Ambulatory Medical Care Survey.


A total of 46,431 adult primary care visits.


We assessed changes over time for the total number of clinical items addressed per visit (including diagnoses, medications, tests ordered, and counseling), visit duration, and average available time per clinical item. In adjusted analyses we controlled for patient and physician characteristics.


The number of clinical items addressed per visit increased from 5.4 to 7.1 from 1997 to 2005 (p < 0.001). Visit duration concurrently increased from 18.0 to 20.9 min (p < 0.001). The increase in the number of clinical items outpaced the increase in duration, resulting in a decrease in time per clinical item from 4.4 to 3.8 (p = 0.04). These changes occurred across patient age and payer status and were confirmed in adjusted analyses.


The volume of work associated with primary care visits has increased to a greater extent than has visit duration, resulting in less available time to address individual items. These findings have important implications for reimbursing physician time and improving the quality of care.


adult primary care clinical items visit duration 

Supplementary material

11606_2008_805_MOESM1_ESM.doc (148 kb)
ESMAbstraction of visit data from NAMCS by survey design (DOC 148 KB).


  1. 1.
    McGlynn EA, Asch SM, Adams J. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635–45.PubMedCrossRefGoogle Scholar
  2. 2.
    Ma J, Stafford RS. Quality of US outpatient care: temporal changes and racial/ethnic disparities. Arch Intern Med. 2005;165:1354–61.PubMedCrossRefGoogle Scholar
  3. 3.
    Grant RW, Buse JB, Meigs JB. Quality of diabetes care in U.S. academic medical centers: low rates of medical regimen change. Diabetes Care. 2005;28:337–442.PubMedCrossRefGoogle Scholar
  4. 4.
    Stafford RS, Radley DC. The underutilization of cardiac medications of proven benefit, 1990 to 2002. J Am Coll Cardiol. 2003;41:56–61.PubMedCrossRefGoogle Scholar
  5. 5.
    Kassirer JP. Doctor discontent. N Engl J Med. 1998;339:1543–5.PubMedCrossRefGoogle Scholar
  6. 6.
    Mechanic D. Physician discontent: challenges and opportunities. JAMA. 2003;290:941–6.PubMedCrossRefGoogle Scholar
  7. 7.
    Center for Studying Health System Change. So much to do, so little time: physician capacity constraints 1997–2001; 2003. Accessed September 2, 2008.
  8. 8.
    Weeks WB, Wallace AE. Time and money: a retrospective evaluation of the inputs, outputs, efficiency, and incomes of physicians. Arch Intern Med. 2003;163:944–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Mechanic D, McAlpine DD, Rosenthal M. Are patients’ office visits with physicians getting shorter? N Engl J Med. 2001;344:198–204.PubMedCrossRefGoogle Scholar
  10. 10.
    Grant RW, Pirraglia PA, Meigs JB, Singer DE. Trends in complexity of diabetes care in the United States from 1991 to 2000. Arch Intern Med. 2004;164:1134–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Cherry D, Burt CW, Woodwell DA. Advance data from the vital and health statistics: National Ambulatory Medical Care Survey (NAMCS) 2001 data summary, number 337. National Center for Health Statistics; 2003. Accessed September 2, 2008.
  12. 12.
    National Center for Health Statistics. National ambulatory medical care survey. Public-use files and documentation. Hyattsville, MD; 1997, 1998, 1999, 2000, 2001, 2002, 2003.Google Scholar
  13. 13.
    Department of Health and Human Services. International classification of diseases, Ninth Edition, Clinical Modification (ICD-9-CM).Google Scholar
  14. 14.
    Food and Drug Administration. National Drug Code Directory. Accessed September 2, 2008.
  15. 15.
    Wilson IB, Schoen C, Neuman P. Physician-patient communication about prescription medication nonadherence: a 50-state study of America’s seniors. J Gen Intern Med. 2007;22:6–12.PubMedCrossRefGoogle Scholar
  16. 16.
    Lasker RD, Marquis MS. The intensity of physicians’ work in patient visits-implications for the coding of patient evaluation and management services. N Engl J Med. 1999;341:337–41.PubMedCrossRefGoogle Scholar
  17. 17.
    Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93:635–41.PubMedCrossRefGoogle Scholar
  18. 18.
    Tai-Seale M, McGuire TG, Zhang W. Time allocation in primary care office visits. Health Serv Res. 2007;42:1871–94.PubMedCrossRefGoogle Scholar
  19. 19.
    Casalino LP. Disease management and the organization of physician practice. JAMA. 2005;293:485–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Goodson JD, Bierman AS, Fein O, Rask K, Rich EC, Selker HP. The future of capitation: the physician role in managing change in practice. J Gen Intern Med. 2001;16:250–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Grumbach K, Bodenheimer T. A primary care home for Americans: putting the house in order. JAMA. 2002;288:889–93.PubMedCrossRefGoogle Scholar
  22. 22.
    Barr M, Ginsburg J. The advanced medical home: a patient-centered, physician-guided model of health care. American College of Physicians; 2006. Accessed September 2, 2008.
  23. 23.
    Weiss KB. Managing complexity in chronic care: an overview of the VA state-of-the-art (SOTA) conference. J Gen Intern Med. 2007;22Suppl 3374–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Whittle J, Bosworth H. Studying complexity is complex. J Gen Intern Med. 2007;22Suppl 3379–81.PubMedCrossRefGoogle Scholar
  25. 25.
    Werner RM, Greenfield S, Fung C, Turner BJ. Measuring quality of care in patients with multiple clinical conditions: summary of a conference conducted by the Society of General Internal Medicine. J Gen Intern Med. 2007;22:1206–11.PubMedCrossRefGoogle Scholar
  26. 26.
    Safford MM, Allison JJ, Kiefe CI. Patient complexity: more than comorbidity. the vector model of complexity. J Gen Intern Med. 2007;22Suppl 3382–90.PubMedCrossRefGoogle Scholar
  27. 27.
    Safford MM, Shewchuk R, Qu H. Reasons for not intensifying medications: differentiating “clinical inertia” from appropriate care. J Gen Intern Med. 2007;22:1648–55.PubMedCrossRefGoogle Scholar
  28. 28.
    Gottschalk A, Flocke SA. Time spent in face-to-face patient care and work outside the examination room. Ann Fam Med. 2005;3:488–93.PubMedCrossRefGoogle Scholar
  29. 29.
    Gilchrist V, McCord G, Schrop SL. Physician activities during time out of the examination room. Ann Fam Med. 2005;3:494–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Gilchrist VJ, Stange KC, Flocke SA, McCord G, Bourguet CC. A comparison of the National Ambulatory Medical Care Survey (NAMCS) measurement approach with direct observation of outpatient visits. Med Care. 2004;42:276–80.PubMedCrossRefGoogle Scholar
  31. 31.
    Stange KC, Zyzanski SJ, Jaen CR. Illuminating the ‘black box’. A description of 4454 patient visits to 138 family physicians. J Fam Pract. 1998;46:377–89.PubMedGoogle Scholar
  32. 32.
    Mokdad AH, Ford ES, Bowman BA. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA. 2003;289:76–9.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Elmer D. Abbo
    • 1
    • 5
  • Qi Zhang
    • 2
  • Martin Zelder
    • 3
    • 4
  • Elbert S. Huang
    • 1
  1. 1.Section of General Internal MedicineUniversity of ChicagoChicagoUSA
  2. 2.School of Community and Environmental HealthOld Dominion UniversityNorfolkUSA
  3. 3.Center for Health and the Social SciencesUniversity of ChicagoChicagoUSA
  4. 4.Department of EconomicsNorthwestern UniversityEvanstonUSA
  5. 5.The University of ChicagoChicagoUSA

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