The role of patients and providers in the timing of follow-up visits

OBJECTIVE: Although the decision about how frequently to see outpatients ha s a direct impact on a provider's workload and may impact health care costs , revisit intervals have rarely been a topic of investigation. To begin to understand what factors are correlated with this decision, we examined base line data from a Department of Veterans Affairs (VA) Cooperative Study desi gned to evaluate telephone care. DESIGN: Observational study based on extensive patient data collected durin g enrollment into the randomized trial. Providers were required to recommen d a revisit interval (e.g., "return visit in 3 months") for each patient be fore randomization, under the assumption that the patient would be receivin g clinic visits as usual. POPULATON/SETTING: Five hundred seventy-one patients over age 55 cared for by one of the 30 providers working in three VA general medical clinics, Pat ients for whom immediate follow-up (less than or equal to 2 weeks) was reco mmended were excluded. MEASUREMENTS: Mean revisit interval was adjusted for patient factors using a regression model that accounted for patients being nested within provider s and providers being nested within sites. Four patient-level variable bloc ks (illness burden-patient, travel time, illness burden-physician, and prio r utilization) were sequentially entered into a linear model to determine t heir role in explaining the variance in revisit intervals. Physician identi ty was also entered after four blocks. MAIN RESULTS: Recommended revisit intervals ranged from 1 month to over 1 y ear with the most common recommended intervals being 2, 3, or 6 months. Abo ut 10% of the variance in revisit interval was explained by illness measure s independent of provider (e.g., general health perception) and travel time . Adding other illness measures (e.g., diagnoses, medications) and prior ut ilization (e.g., clinic visits) doubled the variance explained (R-2 = .21), Finally, the identification of individual provider doubled the explained v ariance again (R-2 = .45). After adjusting for patient factors, the average revisit interval for individual providers ranged from 8 to 26 weeks (8 to 19 weeks when restricted to the 16 staff physicians). There were also subst antial differences across the three sites (adjusted means: 14, 17, and 11 w eeks). CONCLUSIONS:Even after adjusting for a detailed array of patient-level data , primary care providers have different practice styles regarding the timin g of return visits. These may, in turn, reflect the local "culture" in whic h they practice. How many patients providers are able to care for may be de termined by the providers' inclinations toward the timing of follow-up visi ts.