Am J Public Health 93(4): 635-641

Primary Care: Is There Enough Time for Prevention?

All of the authors are with the Department of Community and Family Medicine, Duke University Medical Center, Durham, NC. Kimberly S. H. Yarnall and Kathryn I. Pollak are also with the Cancer Prevention, Detection, and Control Program, Duke University Medical Center.

Requests for reprints should be sent to Kimberly S. H. Yarnall, MD, Box 3886, Duke University Medical Center, Durham, NC 27710 (e-mail: ude.ekud.cm@100anray).

Accepted May 17, 2002.

Abstract

Objectives. We sought to determine the amount of time required for a primary care physician to provide recommended preventive services to an average patient panel.

Methods. We used published and estimated times per service to determine the physician time required to provide all services recommended by the US Preventive Services Task Force (USPSTF), at the recommended frequency, to a patient panel of 2500 with an age and sex distribution similar to that of the US population.

Results. To fully satisfy the USPSTF recommendations, 1773 hours of a physician’s annual time, or 7.4 hours per working day, is needed for the provision of preventive services.

Conclusions. Time constraints limit the ability of physicians to comply with preventive services recommendations.

Abstract

Despite evidence of the effectiveness of preventive services and the development of published national guidelines,1,2 actual rates of delivery of preventive health care services remain low.3 In a recent study of family practices in Michigan, completion of all relevant cancer screening tests, including breast, cervical, colorectal, and prostate cancer screening, was achieved for only 3% of women and 5% of men aged 50 and older.4 Nationwide, rates of preventive services delivery are also low, with 77% of women having had a Papanicolaou test in the past 3 years and only 56% of women aged 50 years and older having had a breast examination and mammogram in the preceding 1 to 2 years. Only 30% of adults aged 50 years and older have undergone fecal occult blood testing within the previous 2 years, and only 33% have ever received proctosigmoidoscopy.5

Several studies have investigated why preventive services delivery rates are low. The most common barriers identified are lack of time during the office visit, inadequate insurance reimbursement, patient refusal to discuss or comply with recommendations, and lack of physician expertise in counseling techniques.6–10 Consistent with the finding that time is a salient barrier, Zyzanski and colleagues have shown that high-volume physicians perform fewer preventive services.11 Although a recent study showed that time spent in office visits has increased slightly in the past decade,12 physicians continue to claim that not having enough time is a barrier to performing preventive services.13–15

Most patients require more than 1 or 2 preventive services each year. In a study of patients in a family practice waiting room, an average of 25 services were due at the time of the visit for each patient, according to recommendations of the US Preventive Services Task Force (USPSTF).16 Furthermore, the number of recommended preventive services is increasing as new tests are developed and research shows the value of preventive care for chronic diseases. Some national agencies (e.g., the American Cancer Society) have created their own guidelines, increasing the number of screening tests to be considered. Given competing financial demands to see a greater number of patients while providing increasing levels of preventive services, it is worth examining whether providing the recommended preventive services for the patients in a practice can be reasonably accomplished.

Delivery of preventive services obviously consumes physician time, but no study has estimated how much time is required to provide each service or, more importantly, the time needed to deliver these services to all patients in a practice. In this study we examined the following questions: To fully achieve current recommendations for the provision of preventive services, how much time would be required for a practicing physician to provide the recommended services to all patients? What percentage of the physician’s available work hours would need to be spent delivering these services?

Acknowledgments

This study was funded in part by National Cancer Institute grants CA14236 and P01-CA72099, and in part by National Institute of Mental Health grant 5 R01 MH56846–03 with the Group Health Cooperative of Puget Sound.

Human Participant Protection

No protocol approval was needed for this study, as there were no human participants.

Acknowledgments

Notes

K. S. H. Yarnall directed the study and wrote the article. K. I. Pollak and T. Østbye directed the study design and data analysis, and contributed to the writing and revision of the article. K. M. Krause collected and organized the data, and contributed to the writing and revision of the article. J. L. Michener provided the original concept, and contributed to the writing and revision of the article.

Peer Reviewed

Notes

Peer Reviewed

References

1. US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996.
2. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington DC: US Dept of Health and Human Services; 1991. DHHS publication PHS 91-50212.
3. Anderson LM, May DSHas the use of cervical, breast, and colorectal cancer screening increased in the United States? Am J Public Health. 1995;85:840–842. [Google Scholar]
4. Ruffin MT, Gorenflo DW, Woodman BPredictors of screening for breast, cervical, colorectal, and prostatic cancer among community-based primary care practices. J Am Board Fam Pract. 2000;13:1–10. [[PubMed][Google Scholar]
5. National Center for Health Statistics. Healthy People 2000 Review, 1998–99. Hyattsville, Md: US Dept of Health and Human Services; 1999. DHHS publication PHS 99-1256.
6. Burack RCBarriers to clinical preventive medicine. Prim Care. 1989;16:245–250. [[PubMed][Google Scholar]
7. Kottke TE, Brekke ML, Solberg LIMaking “time” for preventive services. Mayo Clin Proc. 1993;68:785–791. [[PubMed][Google Scholar]
8. McPhee SJ, Richard RJ, Solkowitz SNPerformance of cancer screening in a university general internal medicine practice: comparison with the 1980 American Cancer Society Guidelines. J Gen Intern Med. 1986;1:275–281. [[PubMed][Google Scholar]
9. Spitz MR, Chamberlain RM, Sider JG, Fueger JJCancer prevention practices among Texas primary care physicians. J Cancer Educ. 1992;7:55–60. [[PubMed][Google Scholar]
10. Wender RC. Cancer screening and prevention in primary care. Obstacles for physicians. Cancer. 1993;72(3 suppl):1093–1099. [[PubMed]
11. Zyzanski SJ, Stange KC, Langa D, Flocke SATrade-offs in high-volume primary care practice. J Fam Pract. 1998;46:397–402. [[PubMed][Google Scholar]
12. Mechanic D, McAlpine DD, Rosenthal MAre patients’ office visits with physicians getting shorter? N Engl J Med. 2001;344:198–204. [[PubMed][Google Scholar]
13. Campion EWA symptom of discontent. N Engl J Med. 2001;344:223–225. [[PubMed][Google Scholar]
14. Collins KS, Schoen C, Sandman DR. The Commonwealth Fund Survey of Physician Experiences with Managed Care. New York, NY: The Commonwealth Fund; 1997.
15. Hadley J, Mitchell JM, Sulmasy DP, Bloche MGPerceived financial incentives, HMO market penetration, and physicians’ practice styles and satisfaction. Health Serv Res. 1999;34:307–321. [Google Scholar]
16. Medder JD, Kahn NB Jr, Susman JLRisk factors and recommendations for 230 adult primary care patients, based on US Preventive Services Task Force guidelines. Am J Prev Med. 1992;8:150–153. [[PubMed][Google Scholar]
17. Murray M, Tantau CSame-day appointments: exploding the access paradigm. Fam Pract Manag. 2000;7:45–50. [[PubMed][Google Scholar]
18. US Census Bureau. Statistical Abstract of the United States: 1999. Available at: . Accessed October 11, 2002.[PubMed]
19. Centers for Disease Control and PreventionBirths: final data for 1997. Natl Vital Stat Rep.April 29, 1999;47(18). [PubMed][Google Scholar]
20. Centers for Disease Control and PreventionRecommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR Morb Mortal Wkly Rep. 1998;47(RR-19):1–39. [[PubMed][Google Scholar]
21. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, Md: Public Health Service, US Dept of Health and Human Services; 2000.
22. Barton MB, Harris R, Fletcher SW. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA. 1999;282:1270–1280. [[PubMed]
23. Adams A, Ockene JK, Wheller EV, Hurley TGAlcohol counseling: physicians will do it. J Gen Intern Med. 1998;13:692–698. [Google Scholar]
24. Austoker JReducing alcohol intake. BMJ. 1994;308:1549–1552. [Google Scholar]
25. McIntosh MC, Leigh G, Baldwin NJ, Marmulak J. Reducing alcohol consumption. Comparing three brief methods in family practice. Can Fam Physician. 1997;43:1959–1962.
26. Ockene JK, Adams A, Hurley TG, Wheeler EV, Hebert JRBrief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work? Arch Intern Med. 1999;159:2198–2205. [[PubMed][Google Scholar]
27. WHO Brief Intervention Study GroupA cross-national trial of brief interventions with heavy drinkers. Am J Public Health. 1996;86:948–955. [Google Scholar]
28. Groveman HD, Sanowski RA, Klauber MRTraining primary care physicians in flexible sigmoidoscopy—performance evaluation of 17,167 procedures. West J Med. 1988;148:221–224. [Google Scholar]
29. Johnson RA, Quan M, Rodney WMContinued assessment of flexible sigmoidoscopy in a family practice residency. J Fam Pract. 1984;18:723–727. [[PubMed][Google Scholar]
30. Lewan RB, Baskin WN, Sharon MW, Greenlaw RL, Frakes JT, Vidican DEA supervised training program in flexible sigmoidoscopy: evaluating skills from residency training to clinical practice. Fam Med. 1989;21:25–29. [[PubMed][Google Scholar]
31. Rodney WM, Albers GFlexible sigmoidoscopy: primary care outcomes after two types of continuing medical education. Am J Gastroenterol. 1986;81:133–137. [[PubMed][Google Scholar]
32. Kewenter J, Brevinge H, Engaras B, Haglind EThe yield of flexible sigmoidoscopy and double-contrast barium enema in the diagnosis of neoplasms in the large bowel in patients with a positive Hemoccult test. Endoscopy. 1995;27:159–163. [[PubMed][Google Scholar]
33. Rothstein RI, Littenberg B. Disposable, sheathed, flexible sigmoidoscopy: a prospective, multicenter, randomized trial. The Disposable Endoscope Study Group. Gastrointest Endosc. 1995;41:566–572. [[PubMed]
34. Schroy PC III, Wilson S, Afdhal NFeasibility of high-volume screening sigmoidoscopy using a flexible fiberoptic endoscope and a disposable sheath system. Am J Gastroenterol. 1996;91:1331–1337. [[PubMed][Google Scholar]
35. Gordon PEvaluation of an intervention to increase seat belt use. Fam Med. 1989;21:458–460. [[PubMed][Google Scholar]
36. Ockene IS, Hebert JR, Ockene JK, et alEffect of physician-delivered nutrition counseling training and an office-support program on saturated fat intake, weight, and serum lipid measurements in a hyperlipidemic population: Worcester Area Trial for Counseling in Hyperlipidemia (WATCH). Arch Intern Med. 1999;159:725–731. [[PubMed][Google Scholar]
37. American Academy of Family Physicians. Facts About Family Practice. Shawnee Mission, Kans: American Academy of Family Physicians; 1998.
38. Carney PA, Dietrich AJ, Freeman DH Jr, Mott LAThe periodic health examination provided to asymptomatic older women: an assessment using standardized patients. Ann Intern Med. 1993;119:129–135. [[PubMed][Google Scholar]
39. Stange KC, Flocke SA, Goodwin MA. Opportunistic preventive services delivery. Are time limitations and patient satisfaction barriers? J Fam Pract. 1998;46:419–424. [[PubMed]
40. Russell NK, Roter DLHealth promotion counseling of chronic-disease patients during primary care visits. Am J Public Health. 1993;83:979–982. [Google Scholar]
41. Rafferty MPrevention services in primary care: taking time, setting priorities. West J Med. 1998;169:269–275. [Google Scholar]
42. Yeazel MW, Bunner SH, Kofron PM, Weiss PJPut prevention into practice (PPIP): evaluating PPIP in two family practice residency sites. Fam Med. 2002;34:17–22. [[PubMed][Google Scholar]
43. Melnikow J, Kohatsu ND, Chan BKSPut prevention into practice: a controlled evaluation. Am J Public Health. 2000;90:1622–1625. [Google Scholar]
44. McVea K, Crabtree BF, Medder JD, et alAn ounce of prevention? Evaluation of the ‘Put Prevention into Practice’ program. J Fam Pract. 1996;43:361–369. [[PubMed][Google Scholar]
45. Susman JAn ounce of prevention is a ton of work. Fam Med. 2002;34:45–47. [[PubMed][Google Scholar]
46. Maciosek MV, Coffield AB, McGinnis JM, et alMethods for priority setting among clinical preventive services. Am J Prev Med. 2001;21:10–19. [[PubMed][Google Scholar]
47. Coffield AB, Maciosek MV, McGinnis JM, et alPriorities among recommended clinical preventive services. Am J Prev Med. 2001;21:1–9. [[PubMed][Google Scholar]
48. Grumbach K, Coffman JPhysicians and nonphysician clinicians: complements or competitors? JAMA. 1998;280:825–826. [[PubMed][Google Scholar]
49. Cooper RA, Laud P, Dietrich CLCurrent and projected workforce of nonphysician clinicians. JAMA. 1998;280:788–794. [[PubMed][Google Scholar]
50. McCrory DC, Matchar DB, Bastian L, et al. Evaluation of Cervical Cytology. Rockville, Md: Agency for Health Care Policy and Research; 1999. Evidence Report/Technology Assessment 5. AHCPR publication 99-E010.
51. Mayfield D, McLeod G, Hall PThe CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry. 1974;131:1121–1123. [[PubMed][Google Scholar]
52. Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984;252:1905–1907. [[PubMed]
53. Centers for Disease Control and PreventionCigarette smoking among adults—United States, 1997. MMWR Morb Mortal Wkly Rep. 1999;48:993–996. [[PubMed][Google Scholar]
54. Long BJ, Calfas KJ, Wooten W, et alA multisite field test of the acceptability of physical activity counseling in primary care: project PACE. Am J Prev Med. 1996;12:73–81. [[PubMed][Google Scholar]
55. Reid MC, Fiellin DA, O’Connor PGHazardous and harmful alcohol consumption in primary care. Arch Intern Med. 1999;159:1681–1689. [[PubMed][Google Scholar]
56. Peiss B, Kurleto B, Rubenfire MPhysicians and nurses can be effective educators in coronary risk reduction. J Gen Intern Med. 1995;10:77–81. [[PubMed][Google Scholar]