Trade-offs in high-volume primary care practice.

BACKGROUND: With today's emphasis on reducing costs and increasing efficiency, primary care physicians are under pressure to increase patient volume. This study was undertaken to (1) identify factors associated with differences in physician volume, and (2) test for differences in selected clinical outcomes and time use during patient visits.

METHODS: Research nurses directly observed consecutive patient visits during 2 separate days in the offices of 108 community family physicians. Data on the content of 3893 outpatient visits were collected using direct observation, patient and physician questionnaires, and medical record review. Physicians with high-, medium-, and low-volume practices were compared in the rates of preventive services delivery, patient satisfaction, and time use during patient visits as measured with the Davis Observation Code.

RESULTS: High-volume physicians had visits that were 30% shorter, scheduled one third fewer patients for well care, and were more likely to own their practice and to be male than were low-volume physicians. Time use during patient visits was remarkably similar for high- and low-volume physicians. However, after controlling for relevant patient characteristics, patients of high-volume physicians had lower up-to-date rates of preventive services and scored lower on measures of satisfaction and the doctor-patient relationship.

CONCLUSIONS: Physicians with high-volume practices are more efficient than those with low-volume practices in providing similar services in a shorter amount of time. This greater apparent efficiency may come at a cost of lower rates of preventive services delivery, lower patient satisfaction, and a less positive doctor-patient relationship. Health care plans and physicians setting productivity goals should consider the trade-offs inherent in high-volume practice.