‘The doctor will see you now… Briefly!’

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DocAppointmentPrimary care consultations last less than 5 minutes for half the world’s population, but range from 48 seconds in Bangladesh to 22.5 minutes in Sweden, reveals the largest international study of its kind.

Shorter consultation times have been linked to poorer health outcomes for patients and a heightened risk of burnout for doctors. And as demand for primary health care rises around the globe, the length of a consultation has increasingly come under pressure.

To tease out the potential impact on patients and the wider healthcare system, the researchers reviewed the data on consultation length from 178 relevant studies covering 67 countries and more than 28.5m consultations.

They included both peer reviewed research and the ‘grey literature’ – research produced outside of traditional academic or commercial channels – published between 1946 and 2016 in English, Chinese, Japanese, Spanish, Portuguese and Russian.

The results showed that average consultation length varied widely, from 48 seconds in Bangladesh, to 22.5 minutes in Sweden. In 15 countries, which represent around half of the world’s population, the appointment lasted less than 5 minutes. And it lasted under 10 minutes in a further 25.

“Little can be achieved in less than 5 minutes unless the focus is largely on detection and management of gross disease,” suggest the researchers. “An average of 5 minutes may be the limit below which consultations amount to little more than triage and the issue of prescriptions.”

In developed countries, average consultation time seemed to steadily increase: by 12 seconds a year to over 20 minutes in the US; and by just over 4 seconds a year to 10 minutes in the UK. However, the UK started from a low baseline, and on current trends it will only reach a length of 15 minutes by 2086, the researchers point out.

Of more concern, they say, is that consultation length seems to be shortening in some low- and middle-income countries, which may have important implications for population growth and the expansion of treatment options.

Several key findings emerged from the data analysis. Length of consultation was significantly associated with: national spend on healthcare per head of the population; the number of primary care doctors per 1000 of the population; and doctor burnout and ‘depersonalisation’.

But it was not associated with: the number of consultations per patient in a given year; the number of diagnostic tests requested by the doctor; and the number of attendances at emergency care departments.

Shorter consultation length has also been associated with multiple drugs prescribed to a patient (polypharmacy), overuse of antibiotics, and poor communication with patients, the researchers add.

Although this is the largest international review of consultation length to date, the researchers highlight that the quality of the evidence was graded ‘good’ in less than half the included studies. And differences between rural and urban, and public and private practices, were not taken into account.

But they conclude: “Average time is an established measure of quality and used by the (World Health Organisation) and the (International Network for Rational Use of Drugs) as a measure to promote the safe and cost effective use of drugs – it should be universally and regularly reported, and over time, be accepted as an essential measure on the quality of health services around the world.”

Abstract
Objective: To describe the average primary care physician consultation length in economically developed and low-income/middle-income countries, and to examine the relationship between consultation length and organisational-level economic, and health outcomes.
Design and outcome measures: This is a systematic review of published and grey literature in English, Chinese, Japanese, Spanish, Portuguese and Russian languages from 1946 to 2016, for articles reporting on primary care physician consultation lengths. Data were extracted and analysed for quality, and linear regression models were constructed to examine the relationship between consultation length and health service outcomes.
Results: One hundred and seventy nine studies were identified from 111 publications covering 28 570 712 consultations in 67 countries. Average consultation length differed across the world, ranging from 48 s in Bangladesh to 22.5 min in Sweden. We found that 18 countries representing about 50% of the global population spend 5 min or less with their primary care physicians. We also found significant associations between consultation length and healthcare spending per capita, admissions to hospital with ambulatory sensitive conditions such as diabetes, primary care physician density, physician efficiency and physician satisfaction.
Conclusion: There are international variations in consultation length, and it is concerning that a large proportion of the global population have only a few minutes with their primary care physicians. Such a short consultation length is likely to adversely affect patient healthcare and physician workload and stress.

Authors
Greg Irving, Ana Luisa Neves, Hajira Dambha-Miller, Ai Oishi, Hiroko Tagashira, Anistasiya Verho, John Holden

BMJ Open material
BMJ Open abstract


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