• Posted March 13, 2023

Primary Care Visits Shorter, More Prone to Error for Non-White Patients: Study

Do all patients get the same amount of face-to-face time when visiting their primary care doctor?

Apparently not, claims a new study that found Black and Hispanic patients -- as well as patients with public health insurance like Medicaid or Medicare -- tend to get the short end of the stick when it comes to the length of office visits.

In some cases, shorter visits can potentially dangerous consequences, investigators found, upping the risk for poor prescribing practices involving antibiotics, painkillers and/or sedatives.

"While many studies have documented the fact that Black patients have fewer primary care visits relative to white patients, per year, I believe ours is the first to explore variation in visit length by race/ethnicity and other demographic characteristics,"said study author Hannah Neprash. She's an assistant professor in the University of Minnesota's School of Public Health.

On one hand, Neprash and her team noted that the average primary care visit lasts about 18 minutes.

On the other hand, they point to prior research suggesting that a primary care doctor would actually need 27 hours to fully convey all the critical information required to prevent chronic disease, while also addressing all of a patient's specific issues.

The huge gap between need and reality seems to please nobody, with surveys indicating that both patients and doctors wish they had less rushed experiences.

But Neprash and her colleagues wanted to know if some groups of patients routinely get less face time with their doctor than others, and how shorter visits might impact their care.

To do that, the team pored over electronic health records that covered more than 8 million visits to more than 8,000 primary care doctors that took place across the United States in 2017.

In all, the visits involved more than 4.3 million adult patients. About 10% were Black and nearly 8% were Hispanic. Roughly 68% were white.

After reviewing time stamps, "we found that visit length varies by a lot of the characteristics one might expect. For example, visits with more diagnoses, topics or concerns are longer, [and] visits for new patients are longer than visits for established patients,"Neprash said.

But the team also found that a patient's race/ethnicity and insurance status seemed to play a role, "with shorter visits observed among patients of color and patients with public insurance coverage, [such as] Medicaid and Medicare, rather than commercial insurance," she said. Younger patients also tended to have shorter visits.

Neprash acknowledged that differences by race and/or insurance were not enormous, with visits involving Black, Hispanic and publicly insured patients tending to last 30 to 60 seconds less.

Still, she stressed that even that level of difference "can add up, especially when the average primary care visit is only a bit longer than 15 minutes."

To explore how shorter visits might translate into worse care, Neprash and her colleagues then honed in on three subsets of patients: the roughly 223,000 visits that involved an upper respiratory tract infection diagnosis; the approximately 1.6 million visits that resulted in a pain-related diagnosis, and more than 2.75 million visits involving seniors.

Investigators determined that more than half (nearly 56%) of visits involving an upper respiratory tract infection resulted in an inappropriate antibiotic prescription.

They also found that 3.4% of pain-related visits resulted in the potentially lethal co-prescribing of both an opioid painkiller and a benzodiazepine sedative (such as Valium or Xanax). Taking both types of medications together ups the risk for an overdose, as both cause breathing suppression and sedation.

Just over 1% of visits involving seniors involved the prescribing of medications that do not adhere to public health guidelines.

The findings were published March 10 in the journal JAMA Health Forum.

Dr. Alice Hawkins is chief resident in the Department of Neurology at Mount Sinai West/Mount Sinai Beth Israel's Icahn School of Medicine in New York City.

Hawkins, who was not involved with the study, said she is "sadly not too surprised at the findings that face-time with providers is decreased for Black patients, given the body of evidence of disparities in primary care to date.

"The contributors to health disparities are numerous and complex, no doubt, and involve social, financial and interpersonal factors,"she added. "Primary care clinics are often faced with financial pressure regarding insurance reimbursements, and thus may have limited hours for patients with certain insurance types. This surely contributes to health disparities as illustrated by this study.

"I hope that moving forward, health care delivery organizations that care about providing equitable care will measure visit length, and take steps to make sure that differences in visit length are driven by clinical, rather than demographic, characteristics of patients,"Hawkins said.

More information

There's more on racial biases in health care at the American Bar Association.

SOURCES: Hannah Neprash, PhD, assistant professor, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis; Alice Hawkins, MD, chief resident, Department of Neurology, Mount Sinai West/Mount Sinai Beth Israel, Icahn School of Medicine, New York City; JAMA Health Forum, March 10, 2023