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Ray KN, Chari AV, Engberg J, Bertolet M, Mehrotra A. Disparities in Time Spent Seeking Medical Care in the United States. JAMA Intern Med. 2015;175(12):1983–1986. doi:10.1001/jamainternmed.2015.4468
Copyright 2015 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
The Institute of Medicine identifies timeliness of care as a key aspect of quality. Racial and socioeconomic disparities exist in receipt of timely appointments and interventions.1 Patient time burden (ie, time spent traveling to, waiting for, and receiving ambulatory medical care) is a separate domain of timeliness. Disparities in this domain have received less attention, although prior work has described inequalities in pediatric emergency department wait time2 and racial disparities in the time adults spend seeking medical care.3 In prior work, using survey data on time associated with medical visits, we estimated that patients incurred $52 billion in opportunity costs obtaining medical care in 2010.4 In this article, we assessed how time associated with medical visits varied across socioeconomic variables and visit characteristics.
The American Time Use Survey data from 2005 to 2013 includes coded single-day 24-hour time diaries for 108 486 respondents 18 years and older.5 We identified respondents reporting clinic time, or time waiting for or obtaining medical care, on their interview day. We excluded respondents reporting more than 6 hours of clinic time as extreme outliers (n = 99), and we also excluded respondents receiving care for multiple individuals on their interview day (n = 101). For the remaining respondents with clinic time (n = 3787), we determined associated travel time, or time spent traveling for care, and total time, or the sum of clinic time and travel time. We compared these time estimates with face-to-face time, or time spent with a physician, collected from 2006 to 2010 by the National Ambulatory Medical Care Survey, a nationally representative survey of office-based physician visits (n = 150 022).
We used linear regression, accounting for survey design and weights, to estimate adjusted associations between total, clinic, travel, and face-to-face times and respondent or patient socioeconomic characteristics and visit characteristics. We adjusted for multiple comparisons using the Benjamini-Hochberg false discovery rate method (P < .025). Using predictive margins, we present adjusted variation in time associated with examined variables. The University of Pittsburgh institutional review board approved this study.
Using American Time Use Survey data, we determined that patients spent on average 123 minutes obtaining medical care, including 86 minutes of clinic time and 38 minutes travel time. Clinic time was significantly longer for racial/ethnic minorities, individuals with less education, and unemployed individuals (Table 1). For example, clinic time for non-Hispanic whites was 80 minutes vs 105 minutes for Hispanic individuals (P < .001). Clinic time was also significantly longer for after-hours visits. In addition, travel time was significantly longer for racial/ethnic minorities and unemployed respondents. For example, travel time for non-Hispanic whites was 36 minutes vs 45 minutes for non-Hispanic blacks (P < .001).
Using National Ambulatory Medical Care Survey data, we determined that patients’ face-to-face time with physicians averaged 20.5 minutes overall and did not vary by patient race/ethnicity, neighborhood income, or rural or urban status (Table 2).
Using nationally representative data, we found that total time burden was 25% to 28% longer for racial/ethnic minorities and unemployed individuals. Differences in travel time were modest relative to differences in clinic time. Face-to-face time with a physician was not longer for those with longer clinic time, suggesting that the observed differences are due to time spent in other activities (eg, completing paperwork, paying bills, interacting with nonphysician staff, and/or waiting).
For individuals, excess time burden may create a disincentive to seeking care. Given that racial/ethnic minorities and unemployed persons disproportionally receive care at community health centers,6 the differences in clinic time may reflect the struggles of these centers to manage clinical appointments efficiently, as well as the consequences of obtaining care in walk-in clinics or emergency departments where appointments are not scheduled. Opportunities to improve the efficiency of care include reengineering clinic processes to streamline visits, patient-centered scheduling, and use of electronic visits and telemedicine consultations.
Our analysis is limited by the data available within the American Time Use Survey, which does not include health status, visit reasons, severity of illness, insurance status, or site of care (eg, emergency department or physician office). Additionally, neither data source allowed estimations of time spent with nonphysician health care providers, such as nurses, nutritionists, or pharmacists. Nor could we determine whether there were disparities in clinic time at individual clinics as opposed to across the health system. Despite these limitations, our results provide an important target for improving patient experience and health care system quality and equity.
Corresponding Author: Kristin N. Ray, MD, MS, University of Pittsburgh School of Medicine, 3414 Fifth St, Third Flr, Pittsburgh, PA 15213 (Kristin.email@example.com).
Published Online: October 5, 2015. doi:10.1001/jamainternmed.2015.4468.
Author Contributions: Dr Ray had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Ray, Engberg, Mehrotra.
Acquisition, analysis, or interpretation of data: Ray, Chari, Engberg, Bertolet.
Drafting of the manuscript: Ray, Bertolet.
Critical revision of the manuscript for important intellectual content: Ray, Chari, Engberg, Bertolet, Mehrotra.
Statistical analysis: Ray, Chari, Bertolet.
Obtained funding: Chari, Mehrotra.
Administrative, technical, or material support: Mehrotra.
Study supervision: Engberg, Mehrotra.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported in part by grants from the California HealthCare Foundation, the Health Resources and Services Administration National Research Service Award for Primary Medical Care (T32HP22240, Dr Ray), the Agency for Healthcare Research and Quality (K12HS022989, Dr Ray), and the National Institutes of Health (UL1TR000005, Dr Bertolet).
Role of the Funder/Sponsor: The California HealthCare Foundation, the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, and the National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.
Previous Presentations: This work was presented in part at the Pediatric Academic Societies meeting; May 5, 2013; Washington, DC; and at the AcademyHealth meeting; June 24, 2013; Baltimore, MD.
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