Primary care visit length, quality, and satisfaction for standardized patients with depression.

Abstract

BACKGROUND: The contribution of physician and organizational factors to visit length, quality, and satisfaction remains uncertain, in part, because of confounding by patient presentation. OBJECTIVE: To determine associations among visit length, quality, and satisfaction when patient presentation is controlled. DESIGN: A factorial experiment using standardized patients to make primary care visits presenting with either major depression or adjustment disorder, and a musculoskeletal complaint. PARTICIPANTS: One hundred fifty-two primary care physicians, each seeing 2 standardized patients. MEASUREMENTS: Visit length was determined from surreptitiously obtained audiorecordings. Other key measures were derived from physician and standardized patient report. RESULTS: Mean visit length for 294 completed encounters was 22.3 minutes (range = 5.8-72.2, SD = 9.4). Key factors associated with visit length were: physician style (rho = 0.68 and 0.54 after multivariate adjustment), nonprofessional experience with depression (11% longer, 95% CI = 0-23%), practicing within an HMO (26% shorter, 95% CI = 61-90%), and greater practice volume (those working >9 half-day clinic sessions/week had 15% shorter visits than those working fewer than 6, 95% CI = 0-27%, and those seeing >12 patients/half-day had 27% shorter visits than those seeing <10 patients/half-day, 95% CI = 13-39%). Suicidal inquiry (a process-based quality-of-care measure for depression) was not associated with adjusted visit length. Satisfaction was linearly associated with visit length but not with suicide inquiry or follow-up interval. CONCLUSIONS: Despite experimental control for clinical presentation, wide variation in visit length persists, largely reflecting individual physician styles. Visit length is a significant determinant of standardized patient satisfaction.