Association for Public Policy Analysis & Management

Primary care providers increasingly face time pressure. Workforce statistics imply a growing shortage of PCPs, and PCPs have lamented the limited time they have with their patients. Inadequate time for primary care encounters may reduce the opportunity for thorough examination, diagnosis, communication, and shared decision making between the PCP and the patient and may result in poorer quality of care and less-favorable health outcomes. This paper explores the effects of unanticipated changes to a PCP’s schedule as a source of random variation in time pressure. We focus on the effect of time pressure on antibiotic prescriptions for acute respiratory tract infections, which the American College of Physicians and the CDC have recently emphasized as inappropriate due to being ineffective in most cases and causing significant negative health consequences by leading to a relatively high rate of adverse events and contributing to the public health threat of antibiotic resistance.

Whether or not a PCP experiences time pressure in a clinical encounter is inherently subjective, influenced by multiple factors, and difficult to directly assess. We therefore use unique Electronic Health Record (EHR) data from a large healthcare provider organization to measure variation in unanticipated time pressure driven by the flow of no-shows, same-day cancellations, and same-day appointments. We employ a causal research design that exploits these unanticipated changes in the amount of time a PCP has scheduled for treating patients during a given shift as a random determinant of the amount of time pressure a PCP faces during pre-scheduled, anticipated appointments, controlling for other determinants of visit outcomes. We estimate how changes in these unanticipated determinants of time pressures affect inappropriate care within primary care encounters. This project provides important insight into the behavior of PCPs and how external constraints affect patient health.