EVIDENCE -BASED HE ALTHCARE MANAGEMENT
Longer consultations may be associated with improved outcomes in primary care Abstracted from: Wilson A, Childs S.The relationship between consultation length, process and outcomes in general practice: a systematic review. Br J Gen Practice 2002; 52: 1012^1020.
BACKGROUND General practice consultations in the United Kingdom and United States are often brief. Short consultations may not allow doctors time to meet patients’ needs or to ful¢l health promotion and chronic disease management objectives. In the United Kingdom, appointment length has been proposed as a performance indicator for general practice. There is some evidence that consultation length may be related to patient outcomes. OBJECTIVE To assess the relationship between consultation length, consultation processes and health outcomes in primary care. METHOD Systematic review. SEARCH STRATEGY The authors searched MEDLINE (1966 to 1999), EMBASE (1981 to 1999), the NHS National Research Register (spring 2000) and the reference lists of retrieved studies for published English language papers reporting original research or systematic reviews. The authors contacted experts for additional studies. INCLUSION/EXCLUSION CRITERIA All research designs that assessed the relationship between average consultation length and any objectively measured process or outcome in primary care were
1462-9410/03/$ - see front matter & 2003 Published by Elsevier Science Ltd. doi:10.1016/S1462-9410(03)00038 -X
eligible. The authors excluded studies examining the association between consultation length and a speci¢c type of problem or patient. Ten observational studies were included. OUTCOMES Objectively measured process and healthcare outcomes. MAIN RESULTS Longer average consultations were associated with reduced prescribing and increased health promotion. Longer consultations may have positive e¡ects on patient enablement and satisfaction. There was no clear association between consultation length and rates of investigation or referral. AUTHORS’ CONCLUSIONS Observational studies suggest that longer consultations in primary care are associated with increased health promotion and patient satisfaction. Interventional studies are needed. Sources of funding: Scienti¢c Foundation Board of the UK Royal College of General Practitioners. Correspondence to: AWilson, Department of General Practice and Primary Care, University of Leicester, Leicester General Hospital, UK. Email: [email protected]
Abstract provided by Bazian Ltd, London
Evidence-based Healthcare (2003) 7, 75^76
Commentary Relevance Consultation length is a topic of great interest for both doctors and patients. Wilson and colleagues examined relationships between consultation length and patient outcomes. They describe two designs.The f|rst group of studies compared processes, outcomes, or both for general practitioners with different average consultation lengths. The second group of studies investigated average consultation length as a predictor of specif|c processes or outcomes. Only 10 studies were identif|ed. This suggests that, although consultation length is measured in many studies, relation-to-outcome measurements are seldom undertaken.
Caveats The review suggests that research on the relationship between consultation length and patient outcome is relatively weak. The authors acknowledge methodological limitations, including possible bias in the selection of doctors, indirect methods of assessing consultation length and the exclusion of possible confounding factors. Consultation length and processes may only be measured reliably using audio or videotaping. Using video offers the opportunity to look at the communicative behaviour of doctors and patients and their interactions. Moreover, assessments of prescribing, health promotion and referrals may be more reliable. Although video recording does not alter doctors’ behaviour,1 it remains relatively unaccepted as a research tool. Some studies in the review do not include details about individual consultation lengths, instead referring to mean consultation lengths above (‘slow’) or below average (‘fast’). Reducing the amount of time a doctor spends with individual patients to an average consultation time and def|ning them as slow or fast compared to others may be simplistic.These types of studies are also diff|cult to interpret.For instance, if a doctor is interested in psychosocial problems and treats many people with psychological problems, mean consultation lengths may be longer.2 This does not mean that the doctor is ‘slow.’ We need to know the reason for the encounter with each patient to interpret the relationship between consultation length and outcome measurements. Prescribing less, increasing health promotion and referring less should be studied in relation to specif|c problems. None of the studies considered interactions between doctor and patient. Several studies,3^5 not included in this review, describe the relationship between how the doctor perceives the patient and his or her prescription rates. For instance, if the doctor thinks the patient wants a prescription for an antibiotic, the likelihood of giving the prescription will increase.
Implications Research on consultation length seems to suggest that longer is better. Time is certainly needed to develop rapport with the
Evidence-based Healthcare (2003) 7, 75^76
patient, provide information and refer in an adequate way. Concluding that longer consultations will automatically result in better communicative behaviour or raise the quality of the consultation seems an exaggeration, however. The relationship between quality and length of the consultation is mediated by the communicative and medical skills of the doctor, which can themselves influence the length of the consultation. Extending the length of the consultation has economic consequences. As Wilson and colleagues note, it is surprising that none of the studies include a health economic analysis. Other actions can be taken to improve quality of care. Communication should be effective even in short consultations. Some studies suggest that doctors sometimes spend time on issues patients do not want to consider.5 Several communicative consultation models have been trialled that do not alter consultation length, but that may increase effectiveness.6 Good communication skills can shorten the consultation. If the practitioner listens to the reason for encounter, they can take appropriate action quickly.7 Even psychosocial problems, known to be time consuming, can be dealt with effectively with good communication skills.6 Future research on consultations could focus on the quality of the interaction between doctor and patient and the overall quality of the medical encounter. This article by Wilson and colleagues is of great importance, not only because it suggests that the relationship between consultation length and outcome measurements is seldom studied, but also because it indicates the need for further investigation.To gain more understanding of this complex issue, studies are needed that accurately measure consultation length, consider interactions between variables and assess communicative interactions between doctor and patient. Myriam Deveugele and Anselm Derese Department of General Practice and Primary Health Care Ghent University, Belgium Literature cited 1. Pringle M, Stewart-Evans C. Does the awareness of being video recorded affect doctors’ consultation behaviour? Br J Gen Pract 1990, 40: 455^ 458. 2. Deveugele M, Derese A, Brink-MuinenVan Den et al. Consultation length in general practice: cross sectional study in six European countries. BMJ 2002; 325: 472^ 477. 3. Butler CC, Rollnick S, Pill R et al.Understanding the culture of prescribing: qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats. BMJ 1998; 317: 637^ 642. 4. Barry CA, Bradley CP, Britten N et al. Patients’ unvoiced agendas in general practice consultations: qualitative study. BMJ 2000; 320: 1246 ^1250. 5. Britten N, Stevenson FA, Barry CA et al. Misunderstandings in prescribing decisions in general practice: qualitative study. BMJ 2000; 320: 484 ^ 488. 6. Roter D, Hall J, Kern D et al. Improving physicians’ interviewing skills and reducing patients’ emotional distress. Arch Intern Med 1995; 155: 1877^1884. 7. Okkes IM. Op het spreekuur. Oordelen van pati.enten over huisartsconsulten (At the GP’s surgery.Views of patients about seeing their GP). University of Amsterdam PhD thesis. Meditekst, Lelystad,1991.