番茄社区

There literally aren't enough hours in a single day for primary care physicians (PCPs) to provide the full gamut of basic, guideline-based care, according to a simulation study.

PCPs would need an "infeasible" 26.7 hours each day to provide preventive, chronic disease, and acute care for a typical panel of U.S. adult patients, Justin Porter, MD, of the University of Chicago, and colleagues, reported in the .

Porter's group estimated that the 26.7 hours per day would consist of:

• 14.1 hours for preventive care
• 7.2 hours for chronic disease care
• 2.2 hours for acute care
• 3.2 hours for documentation and inbox management

"I think that the results kind of confirmed what doctors have anecdotally felt for a very long time, which is that there's kind of an unreasonable amount of work that's expected to be done," Porter told 番茄社区.

The authors looked at hypothetical panels of 2,500 patients from 2017-2018 National Health and Nutrition Examination Survey (NHANES) data, and measured the "mean time required for a PCP to provide guideline-recommended preventive, chronic disease and acute care to the hypothetical patient panels. Estimates were also calculated for visit documentation time and electronic inbox management time. Times were re-estimated in the setting of team-based care."

In addition, they calculated the total annual time for each service based on U.S. Preventive Services Task Force (USPSTF) guidelines, the research on which task force guidelines are based, and an original literature search "describing their annual visit frequency and time per visit."

The authors noted that their estimate for preventive care time, at 14.1 hours, was higher than those from a (7.4 hours) and a (8.6 hours). The latter study actually took the USPSTF to task, declaring that "the time required to deliver recommended preventive care places unrealistic expectations on already overwhelmed providers and leaves patients at risk."

But Porter and colleagues did offer a ray of hope in this otherwise gloomy scenario, reporting that with a team-based model, in which non-PCPs (RNs and medical assistants, for example) take on components of care, PCPs could bring their working hours down to 9.3 per day, and those time savings would largely be in preventive care services and chronic disease care.

They found that in an "idealized" team-based model, non-PCP team members could partially or completely perform 29 preventive care tasks, which left about 2 hours of preventive care tasks per day for the PCP. "The majority of time reduction was due to 10.8 h of counseling tasks being transferred to dietitians or counselors," the authors wrote.

Co-author Neda Laiteerapong, MD, MS, also of the University of Chicago, told 番茄社区 that the team-based model "makes things better ... back to like 9 or 10 hours [a day], which is how long the average primary care doctor's day was in when this [type of research] was last done."

But the team approach "doesn't solve everything," she cautioned.

Porter noted that some practices already incorporate elements of team-based care, such as a nurse delivering screenings for tobacco and alcohol use, possible domestic violence, or family health history, before the PCP arrives. "The reality is, every clinic that we go to might fit somewhere on that spectrum," he said.

The authors stressed that the unreasonable time demands on PCPs are endemic to the U.S. healthcare system: "If time pressures are driving a gap between guideline-based and clinical medicine, it might explain why national health outcomes are worse than expected."

Porter also pointed out that there is a manpower shortage in primary care, in part because PCPs aren't compensated as well as specialists. Also, many of the time-intensive recommended preventive services, such as counseling for diet and nutrition, aren't reimbursed by insurance companies under certain circumstances -- and may not happen at the "gold standard" guideline level at all.

"Medicare or Medicaid and often, by extension, private insurance, often won't give funding for a particular intervention unless it's done by the primary care provider," Porter noted.

Porter said he hopes to reach policymakers with the study, eventually leading to higher pay for PCPs, better compensation for non-PCPs, and shift from a fee-for-service to a value-based care model.

"All these things are very complicated, very sticky, and very challenging," he said. "So although the problem is easy to identify, I think the solutions are harder."

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