Comparison study shows U.S. low in primary care physician visits

Andrew Bindman, MD

The average American spends a total of about 30 minutes a year with a primary care physician in a system that is less comprehensive than that of Australia or New Zealand, according to a new study comparing primary care practice in the three countries.

Findings showed patient-physician time in the US is about half the average of New Zealand and one-third of Australia.

“The substantially shorter time per capita in the US was the biggest difference we saw in our study.  Such a severe shortfall impacts preventive care and management of chronic conditions in the US and could explain why the US does not achieve health outcomes that correspond to its higher level of investment in health care,” said study lead author Andrew Bindman, MD, of the University of California, San Francisco.

The US primary care average is inadequate for meeting the preventive, acute and chronic needs of the population, he emphasized, noting that it does not even meet the recommendation for preventive care of the Centers for Disease Control and Prevention. This recommendation is for an average of 40 minutes per year for adults and 37 minutes for children. Individuals with chronic care needs are estimated to need an average 20-40 minutes of additional time per condition in primary care. 

Previous cross-national research has demonstrated that a strong primary care infrastructure is associated with better health outcomes and lower health costs, said Bindman, who is professor of medicine, epidemiology and biostatistics at UCSF and chief of general internal medicine at San Francisco General Hospital Medical Center. 

The new study findings are reported in the online edition of the “British Medical Journal” (http://www.bmj.com/cgi/rapidpdf/bmj.39203.658970.55v1)
and will appear in the journal’s June 16, 2007 print issue.  Most country-comparison studies have focused on hospital-based care and procedures, and there has been limited research on the clinical content and duration of visits in primary care, according to the study team.

The researchers used data from an independent survey of primary care physicians in each country and compared mix of patients, diagnoses, scope of practice, and duration of patient visits.  Duration of a visit was counted as face-to-face time between the patient and physician and excluded time spent waiting, receiving care from someone other than the physician, and documenting care in a medical record.

Other study findings include:

• The types of medical problems seen in primary care practice were very similar in all three countries, but the US has a higher proportion of visits for obesity, diabetes, high cholesterol, and cardiovascular disease.

• Of the three countries, Australia has the greatest number of primary care physicians per 100,000 population (112) and the largest proportion (56 percent) trained in primary care specialties.  The US percentage is 36 percent, which Bindman notes is “a relatively low number that most likely contributes to the lower rates of exposure to primary care in the US.”

• In each country, primary care physicians dealt with an average of 1.4 problems per visit.

• The range of problems managed in primary care is narrower in the US than in the other two countries, a finding that Bindman and his research team expected because of the greater proportion of specialists in the US healthcare system.

• In the US, 46 conditions accounted for 75 percent of problems managed in primary care, compared with 52 in Australia and 57 in New Zealand.

• The average duration of a visit was about 10 percent longer in the US (16.5 minutes) in comparison to New Zealand (15 minutes) and Australia (14.9 minutes), but Americans had fewer visits, making the US annual per capita average the lowest of the three countries.

One of the fundamental questions in analyzing how health care is organized and funded is the role of primary care, and comparison among countries presents the opportunity to learn from “natural experiments” on how primary care can contribute to effective health care systems, the research team noted in their summary of the study.

Bindman said there is an impending crisis in primary care in the US with a growing pay disparity between generalists and specialists and fewer US medical school graduates entering the field. The availability of primary care in the US to perform recommended care is likely to worsen over time if steps are not taken to better support this component of the healthcare system.

The study covered data from 79,790 office-based visits for primary care in Australia, 10,064 in New Zealand, and 25,838 in the US.

The research was funded by the Commonwealth Fund.  Co-investigators were Christopher B. Forrest, Children’s Hospital of Philadelphia; Helena Britt, University of Sydney, Australia; Peter Crampton, Wellington School of Medicine and Health Sciences, New Zealand; and Azeem Majeed, Imperial College, London.

UCSF is a leading university that advances health worldwide by conducting advanced biomedical research, educating graduate students in the life sciences and health professions, and providing complex patient care.