International variations in primary care physician consultation time: a systematic review of 67 countries.
TL;DR: In this article, 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 length was conducted.
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.
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Harvard University1, New York University2, World Bank3, Mexican Social Security Institute4, Wellcome Trust5, Inter-American Development Bank6, University of Ibadan7, Northwestern University8, Bill & Melinda Gates Foundation9, Malawi University of Science and Technology10, University of London11, Duke University12, University of Bergen13, Public Health Foundation of India14, Centers for Disease Control and Prevention15, Stanford University16, Kathmandu17
TL;DR: High-quality health systems in the Sustainable Development Goals era: time for a revolution.
1,434 citations
174 citations
TL;DR: POCUS has the potential to be an important tool for the general practitioner and may possibly reduce health care costs, and future research should aim to assess the quality of ultrasound scans in broader groups of general practitioners.
Abstract: PURPOSE Ultrasound examinations are currently being implemented in general practice. This study aimed to systematically review the literature on the training in and use of point-of-care ultrasound (POCUS) by general practitioners. METHODS We followed the Cochrane guidelines for conduct and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting. We searched the databases MEDLINE (via PubMed), EMBASE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials using the key words ultrasonography and general practice in combination and using thesaurus terms. Two reviewers independently screened articles for inclusion, extracted data, and assessed the quality of included studies using an established checklist. RESULTS We included in our review a total of 51 full-text articles. POCUS was applied for a variety of purposes, with the majority of scans focused on abdominal and obstetric indications. The length of training programs varied from 2 to 320 hours. Competence in some types of focused ultrasound scans could be attained with only few hours of training. Focused POCUS scans were reported to have a higher diagnostic accuracy and be associated with less harm than more comprehensive scans or screening scans. The included studies were of a low quality, however, mainly because of issues with design and reporting. CONCLUSIONS POCUS has the potential to be an important tool for the general practitioner and may possibly reduce health care costs. Future research should aim to assess the quality of ultrasound scans in broader groups of general practitioners, further explore how these clinicians should be trained, and evaluate the clinical course of patients who undergo scanning by general practitioners.
122 citations
TL;DR: Why care for low back pain that is concordant with guidelines requires system-wide changes is discussed and policies that, by shifting resources from unnecessary care to guideline-concordant care forLow back pain, could be cost-neutral and have widespread impact are suggested.
Abstract: Low back pain is the leading cause of years lived with disability globally. In 2018, an international working group called on the World Health Organization to increase attention on the burden of low back pain and the need to avoid excessively medical solutions. Indeed, major international clinical guidelines now recognize that many people with low back pain require little or no formal treatment. Where treatment is required the recommended approach is to discourage use of pain medication, steroid injections and spinal surgery, and instead promote physical and psychological therapies. Many health systems are not designed to support this approach. In this paper we discuss why care for low back pain that is concordant with guidelines requires system-wide changes. We detail the key challenges of low back pain care within health systems. These include the financial interests of pharmaceutical and other companies; outdated payment systems that favour medical care over patients' self-management; and deep-rooted medical traditions and beliefs about care for back pain among physicians and the public. We give international examples of promising solutions and policies and practices for health systems facing an increasing burden of ineffective care for low back pain. We suggest policies that, by shifting resources from unnecessary care to guideline-concordant care for low back pain, could be cost-neutral and have widespread impact. Small adjustments to health policy will not work in isolation, however. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change.
110 citations
TL;DR: Simply providing more resources for universal coverage is not enough to improve health, and the government also needs to ensure good quality of care, argue Jishnu Das and colleagues.
Abstract: Simply providing more resources for universal coverage is not enough to improve health, argue Jishnu Das and colleagues. We also need to ensure good quality of care
77 citations
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TL;DR: The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.
Abstract: Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.
4,011 citations
TL;DR: To examine the extent to which experienced family physicians in various practice settings elicit the agenda of concerns patients bring to the office, a cross-sectional survey of 264 patient-physician interviews is conducted.
Abstract: ContextPrevious research indicates physicians frequently
choose a patient problem to explore before determining the patient's
full spectrum of concerns.ObjectiveTo examine the extent to which experienced family
physicians in various practice settings elicit the agenda of concerns
patients bring to the office.DesignA cross-sectional survey using linguistic analysis of a
convenience sample of 264 patient-physician interviews.Setting and ParticipantsPrimary care offices of 29
board-certified family physicians practicing in rural Washington
(n=1; 3%), semirural Colorado (n=20;
69%), and urban settings in the United States and Canada
(n=8; 27%). Nine participants had fellowship training
in communication skills and family counseling.Main Outcome MeasuresPatient-physician verbal interactions,
including physician solicitations of patient concerns, rate of
completion of patient responses, length of time for patient responses,
and frequency of late-arising patient concerns.ResultsPhysicians solicited patient concerns in 199 interviews
(75.4%). Patients' initial statements of concerns were completed in
74 interviews (28.0%). Physicians redirected the patient's opening
statement after a mean of 23.1 seconds. Patients allowed to complete
their statement of concerns used only 6 seconds more on average than
those who were redirected before completion of concerns. Late-arising
concerns were more common when physicians did not solicit patient
concerns during the interview (34.9% vs 14.9%). Fellowship-trained
physicians were more likely to solicit patient concerns and allow
patients to complete their initial statement of concerns (44% vs
22%).ConclusionsPhysicians often redirect patients' initial
descriptions of their concerns. Once redirected, the descriptions are
rarely completed. Consequences of incomplete initial descriptions
include late-arising concerns and missed opportunities to gather
potentially important patient data. Soliciting the patient's agenda
takes little time and can improve interview efficiency and yield
increased data.
718 citations
TL;DR: Analysis of videotaped consultations of general practitioners from the Eurocommunication study and of questionnaires completed by doctors and by patients found that consultation length is determined by variables related to the doctor and the doctor's country as well as by those related to patients.
Abstract: Objectives: To compare determinants of consultation length discussed in the literature with those found in consultations with general practitioners from different European countries; to explore the determinants of consultation length, particularly the effect of doctors9 and patients9 perceptions of psychosocial aspects. Design: Analysis of videotaped consultations of general practitioners from the Eurocommunication study and of questionnaires completed by doctors and by patients. Setting: General practices in six European countries. Participants: 190 general practitioners and 3674 patients. Results: In a multilevel analysis with three levels (country, general practitioner, and patient), country and doctor variables contributed a similar amount to the total variance in consultation length (23% and 22%, respectively) and patient variables accounted for 55% of the variance. The variables used in the multilevel analysis explained 25% of the total variation. The country in which the doctor practised, combined with the doctors9 variables, was as important for the variance in consultation length as the variation between patients. Consultations in which psychosocial problems were considered important by the doctor and the patient lasted longer than consultations about biomedical problems only. The doctor9s perception had more influence in this situation than the patient9s. Consultation length is influenced by the patients9 sex (women got longer consultations), whether the practice was urban or rural, the number of new problems discussed in the consultation (the more problems the longer the consultation), and the patient9s age (the older the patient the longer the consultation). As a doctor9s workload increased, the length of consultations decreased. The general practitioner9s sex or age and patient9s level of education were not related to the length of consultation. Conclusion: Consultation length is determined by variables related to the doctor and the doctor9s country as well as by those related to patients. Women consulting in an urban practice with problems perceived as psychosocial have longer consultations than other patients.
487 citations
TL;DR: The authors' findings suggest that English primary care as currently delivered could be reaching saturation point, and a substantial increase in practice consultation rates, average consultation duration, and total patient-facing clinical workload in English general practice is shown.
458 citations
TL;DR: Burnout seems to be a common problem in FDs across Europe and is associated with personal and workload indicators, and especially job satisfaction, intention to change job and the (ab)use of alcohol, tobacco and medication.
Abstract: Introduction. The aim of this study was to determine the prevalence of burnout, and of associatedfactors, amongst family doctors (FDs) in European countries.Methodology. A cross-sectional survey of FDs was conducted using a custom-designed andvalidated questionnaire which incorporated the Maslach Burnout Inventory Human ServicesSurvey (MBI-HSS) as well as questions about demographic factors, working experience, health,lifestyle and job satisfaction. MBI-HSS scores were analysed in the three dimensions of emotionalexhaustion (EE), depersonalization (DP) and personal accomplishment (PA).Results. Almost 3500 questionnaires were distributed in 12 European countries, and 1393 werereturned to give a response rate of 41%. In terms of burnout, 43% of respondents scored high forEE burnout, 35% for DP and 32% for PA, with 12% scoring high burnout in all three dimensions.Just over one-third of doctors did not score high for burnout in any dimension. High burnout wasfound to be strongly associated with several of the variables under study, especially those relativeto respondents’ country of residence and European region, job satisfaction, intention tochange job, sick leave utilization, the (ab)use of alcohol, tobacco and psychotropic medication,younger age and male sex.Conclusions. Burnout seems to be a common problem in FDs across Europe and is associatedwith personal and workload indicators, and especially job satisfaction, intention to change joband the (ab)use of alcohol, tobacco and medication. The study questionnaire appears to bea valid tool to measure burnout in FDs. Recommendations for employment conditions of FDsand future research are made, and suggestions for improving the instrument are listed.Keywords. Burnout, Europe, general practice, job satisfaction, job stress.
421 citations