Jul-Aug 2000 Table of Contents

Improving Patient Care

High-Volume Practice: Are There Trade-Offs?



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The pressure is on to increase productivity — but at what cost?

Fam Pract Manag. 2000 Jul-Aug;7(7):63-64.

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Many family physicians are under increasing pressure by their employers and managed care organizations to increase “productivity.” A number of factors, such as decreasing reimbursement, higher numbers of employed physicians and the penetration of managed care into new markets, have contributed to this unprecedented focus.

Traditionally, family physicians have varied in the number of patients they see per hour, based on their own work styles and the needs of their communities and patient populations. Now, however, patient volume is a measure of physician productivity. Indeed, the value of family physicians to large health care organizations is often determined by some combination of productivity and “quality,” the latter often assessed by measures of patient satisfaction, preventive service delivery and compliance with disease management guidelines.

What does the growing drive toward productivity mean for the patient visit? Do practice styles differ based on patient volume? Can physicians achieve both “productivity” and “quality” according to the measures described above? These questions were assessed with data from the Direct Observation of Primary Care Study (DOPC),1 in which researchers directly observed 4,454 outpatient visits to 138 family doctors in Northeast Ohio. Physicians observed in the study were divided into low-, medium- and high-volume categories. Low-volume physicians saw an average of 2.1 patients per hour; the middle group saw an average of 3.3 patients per hour; and the high-volume group saw an average of 5.1 patients per hour.

Illuminating the ‘black box’ of primary care

This article continues our series offering practical lessons from the Direct Observation of Primary Care (DOPC) Study, which was funded by the National Institutes of Health and conducted by the Center for Research in Family Practice and Primary Care, with support from the AAFP. The study demonstrates the complexities of the patient visit, the demands of real-world practice and the value of primary care, issues that policymakers, the public and even clinicians have not fully understood. Researchers used a multi-method approach, including direct observation, to study 4,454 patient visits to 138 family physicians in 84 practice sites.

Study results

Although high-volume physicians had 30-percent shorter visits (8.8 minutes on average compared to 12.5 minutes for low-volume physicians), they were able to accomplish the same tasks during their visits as their lower-volume colleagues. Based on 20 different behavioral categories, all three groups of physicians spent similar proportions of time on history taking, physical examination, health education, etc.; however, high-volume physicians spent a larger proportion of time planning treatment (defined as prescribing medications, diagnosing problems or developing treatment plans).

This greater productivity of the high-volume physicians did come at some cost, however. Patients seeing high-volume physicians were less likely to be up-to-date on preventive services, including screenings, immunizations and health-habit counseling. Those patients also reported slightly lower levels of satisfaction and scored their doctors slightly lower on several measures of the doctor-patient relationship, such as the doctor's listening skills, explanations of care and efforts to follow up on past problems. Although the magnitude of these differences was small, it shows that high-volume practice does involve trade-offs, especially in areas that are increasingly viewed as markers for quality.

During the time period of the DOPC Study (1994–1995), most physicians in Northeast Ohio were able to determine their style of practice. Thus, differences between high-and low-volume physicians may now be even more profound in environments in which physicians are forced to increase their volume to meet productivity demands.

Take-away lesson

Family physicians in all kinds of practice settings should pay attention to the balance between volume of patients, patient satisfaction and quality indicators. However, this study shows that patient volume has an impact on what family physicians “produce” during outpatient visits. These trade-offs should be carefully considered by physicians and health care systems in their expectations of productivity.

Dr. Kikano is an associate professor and vice chairman of family medicine at Case Western Reserve University/University Hospitals of Cleveland (CWRU/UHC). Dr. Zyzanski is a professor of family medicine at CWRU/UHC. Robin Gotler is project coordinator in the Family Medicine Research Division of CWRU. Dr. Stange is a professor of family medicine, epidemiology and biostatistics, oncology and sociology at CWRU/UHC. He is also director of the Center for Research in Family Practice and Primary Care, one of three family practice research centers funded by the AAFP.

1. Zyzanski SJ, Stange KC, Langa DM, et al. Trade-offs in high-volume primary care practice. J Fam Pract. 1998;46(5):397–402.

Copyright © 2000 by the American Academy of Family Physicians.
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