Breaking down a billion visits: Practice trends, one patient at a time

Are more patients streaming through your office door today than 10 years ago? Does every third person seem to have hypertension? Does the waiting room empty out in the summer and fill back up again come fall? If so, you aren't alone.

The Centers for Disease Control and Prevention has charted these and other trends -- in some cases for more than 30 years -- to provide a statistical snapshot of ambulatory care. AMNews asked several physicians how their practices compared with study conclusions and found, for the most part, the findings are on target.

The tally of outpatient office visits has reached new heights, increasing at a pace three times the rate of population growth over the past decade, according to CDC figures. And the agency's "National Ambulatory Medical Care Survey," released in June, showed more than half of those office visits, or 58.5%, were to primary care offices. It's fair to say, then, that physicians who work in these settings have seen a burgeoning amount of foot traffic.

That's no surprise to family physician Ayaz Madraswalla, MD, who has practiced in Storrs, Conn., for 11 years. He is one of five physicians in an office where only two are accepting new patients. "I had to close my practice to new patients after three or four years," he said. "I had really maxed out on how many patients I could take."

"We average 20 to 25 patients a day," said Dr. Madraswalla, who is also president of the Connecticut Academy of Family Physicians. "We leave two emergency openings in each session -- morning and afternoon -- and, by the end of the day, I would say that everybody is full."

"We are definitely seeing more patients," agreed Patricia Sereno, MD, a family physician in Malden, Mass. "I think people are coming to the doctor more often." Chronic conditions such as diabetes and hypertension are driving increases, she said, as doctors step up monitoring efforts.

There are also more options. "We have more medications to treat patients," said Mark Keating, MD, a family physician from Jasper, Ala.

Plus, said Dr. Keating, president of the Alabama Academy of Family Physicians, "We treat things in the office today that, 10 years ago, would have meant an automatic hospital admission."

Overall, his experience closely follows survey findings showing that in 2004, primary care physicians provided 87% of all preventive care.

The big four diagnoses

The survey found that visits for diabetes care increased by 126% over the past 10 years, with other large jumps for arthritis, back problems, cancer and hypertension.

Hypertension, cancer, upper respiratory infections and diabetes were the leading illness-related primary diagnoses reported in 2004. "Hypertension is absolutely No. 1," agreed Paul Martin, DO, a family physician in Dayton, Ohio. His 40-member practice also has seen a jump in the number of patients with diabetes.

"Invariably there are a couple of diagnoses of diabetes, hypertension and hyperlipidemia each day. Those are the three big ones we see in patient after patient. Plus, we're seeing them in younger people because of the amount of obesity in the population," Dr. Martin said.

Several, but not all, doctors noticed the seasonal swings in office visits that the surveyors detected, with a drop during spring and summer and an increase in fall and winter. Data on seasonal variations were collected for the first time in 2004.

"In the summer people are on vacation and don't have time to go to the doctor," said Dr. Sereno, president of the Massachusetts Academy of Family Physicians.

"We always know that July, August and September will be the slowest," Dr. Martin said.

But Dr. Madraswalla disagreed. "We did studies on that years ago and found the volume was the same throughout the year. The diagnoses differ, though. In the fall and winter you do see colds and coughs, and in the spring and summer you see the pre-op visits for elective surgery and the well-child checks for school and sports physicals."

Not surprisingly, respiratory complaints were behind most winter visits, according to the study, and psychological and mental health disorders increased in fall and winter. "A rise in mental health issues before the holidays is pretty classic," Dr. Sereno said. "And the rise in colds and flu in the winter is a given."

Diagnosing this multitude of problems was accomplished in an average of 18.7 minutes per patient in 2004, essentially unchanged since 1994.

Who gets to participate

The data provide important benchmarks for measuring individual and state physician practices, said Esther Hing, MPH, survey statistician with the CDC and lead author of the "National Ambulatory Medical Care Survey: 2004 Summary." Plus, data on diagnosing and treating chronic conditions could prove useful for the new federal focus on improving health care quality, she said.

The survey also found that more than half of all office visits were to doctors in practices with two to nine physicians. This insight has important policy implications, said Michael S. Barr, MD, vice president for practice advocacy and improvement at the American College of Physicians. "When we talk about electronic medical records, for example, we need to help small practices adopt this technology. People have predicted the fall of small practices for many years, but that's not going to happen. We're seeing that people like to receive care in small practices and that physicians like to practice in small practices."

Several medical societies stress the need for accurate data in urging their members to participate in the survey if asked. The American Academy of Family Physicians tells members it makes extensive use of the data in publications. Likewise, the American College of Obstetricians and Gynecologists points to the "useful base" which the data provide "to determine modifications in medical education programs and to provide increased knowledge of disease in the ambulatory setting."

Participating physicians are selected from lists supplied by the AMA and the American Osteopathic Assn. The names of 3,000 physicians are chosen randomly and then narrowed down to include only those who see patients in offices rather than in clinics or hospitals, Hing said.

The selected physicians, totaling 1,372 in 2004, fill out forms for a representative sample of about 30 patients who visit during a randomly chosen week. The information gathered includes the reason for the visit, diagnosis, services or procedures rendered and medications ordered.

Although response rates have been "pretty good" over the years, Hing said, fewer doctors are willing to put in the time involved. In 2002, 71% of physicians who were asked complied at least partially with requirements. That number dropped to 67% in 2003 and 65% in 2004. As an experiment, in 2002, a $5 incentive was offered to encourage participation, Hing said. It made no difference.