Table 4.

Studies on physicians’ work load in ambulatory medical care, length of consultations, number of contacts and contacted physicians per year, referral frequency to specialist care with special reference to high use among the (multimorbid) elderly

	Authors	Country	Sample/age	Year	Patients per week (consultation length in minutes)	Contacts per year	Contacted physi-cians per year	Referrals to specialists per year	Definition of contact In- and exclusions Definition high use
1	van den Brink-Muinen et al. [60, 61]	Seven	General practice patients age ≥ 18 (mean age: 40–48)	1997–1998	GE: 309 (7.6) BE: 149 (15.0) SWI: 126 (15.6) ES: 183 (7.8) NL: 189 (10.2) UK: 205 (9.4)	Not examined	Not examined	17.9 % (ES) −5.6 % (GE) of consultations	Encounters in practice premises, plus twice the number of home visits, plus half the number of telephone contacts; high use not examined
2	Koch et al. [40]	Eleven (seven reported here)	Survey among PCP	2009	GE: 242 (9.1) FR: 110 (22.2) IT: 171 (10.3) SWE: 53 (28.8) NL: 123 (15.0) UK: 130 (13.3) USA: 96 (22.5)	Not examined	Not examined	Not examined	“Visits”; no further specification of contact type; high use not examined
3	Starfield et al. [7]	USA	5 % Medicare sample age ≥65 according to 3 comorbidity degrees	1999	Not examined	Lowest comorbidity degree: 3.9 (2.1 PCP, 1.8 NPCP) highest comorbidity degree: 15.6 (6.6 PCP, 9.0 NPCP)	Not examined	Not examined	PCP: geriatricians included; contacts in physician practice + ED + OPD were counted highest comorbidity degree: persons with ≥ 10 chronic conditions
4	Starfield et al. [42]	USA	patients aged ≥65 in Medicare managed care	2001	Not examined	11.6 (2.7 PCP, 8.9 NPCP)	4.8 (0.8 PCP, 4.0 NPCP)	Not examined	GPs and internists included (same year hospitalized patients excluded); high use not examined
5	National Center for Health Statistics [44]	USA	National sample aged ≥65	2000	18.1 min	7 (all physicians in practice; 6.1; OPD + ED: 0,9)	Not examined	Not examined	High use not examined
6	NAMCS [62]	USA	Survey of national sample of physicians	2008–2009	Not examined	3.4 (1.9 PCP, 1.5 NPCP) patient age ≥ 65: 7,4	Not examined	Referral rate. 10.7 of visits	Visits to practices and CHCs only; telephone contacts and (nursing) home visits excluded; high use not examined
7	Barnett et al. [63]	USA	National sample aged ≥65	2009	Not examined	3.7	Not examined	All physicians: 8.6 % (PCP: 9.9 %, NPCP: 7.3 %) OPD: 16.6 %	Contacts in physician practices + OPD were counted; institutionalized patients excluded; high use not examined
8	NIVEL [37]	Netherlands	National sample aged ≥ 15 years with ≥ 1 chronic condition	2008	Not examined	2008: 9,7 (PCP: 4,6; NPCP 5,1)	Not examined	80 % referred	GPs + GP-assistants; no further specification of contact type; high use not examined
9	Cardol et al. [64]	Netherlands	Primary care patients ≥65	2000–2002	PCP: 10,2 min	Age ≥65: PCP 16.4 (age 65–74: PCP 11.6)	Not examined	Not examined	Visits + home visits + telephone + paperwork by GP + GP-assistants (telephone contacts account for 11 %); high use not examined
10	van Oostrom [38]	Netherlands	Primary care patients, age ≥65	2006–2008	Not examined	≥2 chronic conditions + age 65–74: PCP 19.6 + age ≥ 75: PCP 24.0	Not examined	mm: 36 % referred with 0,5 referrals/year	Consultations, telephone contacts (9.8 % for mm) and home visits; high use not examined
11	van den Berg [65]	Netherlands	Primary care patients; all ages	1987 & 2001	2001: 9.8 min	Not examined	Not examined	Not examined	Practice consultations only; high use not examined
12	Nie et al. [39]	Canada (Ontario)	Insured population aged ≥ 65	2005–2006	Not examined	10.3 (=6.2 PCP, 4.1 NPCP + ED); hu = 43.6 (PCP 20.7, NPCP 22.9)	Not examined	Not examined	“Office visits”; no further specification of contact type; hu-cutoff: ≥ 26 contacts (≥15 PCP visits, ≥ 11 NPCP visits, ≥ 5 ED visits) = 5,5 % of study population
13	Demers [26]	Canada (Quebec)	Insured general population	1991	Not examined	5.5 (PCP 3.6, NPCP 1.9)	3 (PCP 2, NPCP 1)	Not examined	“Encounters” not further specified; hu-cutoff: contacts with > 20 physicians (=0.06 % of patients)
14	Reid et al. [66]	Canada (Brit. Columbia)	General population ≥ 18 years	1996–1997	Not examined	hu: 50.3, nhu: 9.0	hu: 9, nhu: 2.7	Not examined	“Encounters” not further specified; ED-visits excluded; hu-cutoff: most costly 5 % of users of fee-reimbursed services
15	Broemeling et al. [67]	Canada (Brit. Columbia)	Insured general population ≥ 18 years	2000–2001	Not examined	≥1chronic condition: 11.5 (8,5 PCP + 3.0 NPCP) maximum hu: 28.1 (19.3 PCP + 8.8 NPCP)	Not examined	Not examined	“Visits”; no further specification of contact type; hu-cutoff: 5 % of total population, 11.6 % of persons with chronic conditions
16	Britt et al. [68]	Australia	Survey among GPs	2009–2010	15,3 min	Not examined	8.4 % of encounters with GP	Not examined	Consultations, home visits, nursing home visits included; high use not examined
17	Busato et al. [69]	Switzerland	Primary care sample age ≥ 40	2004	Not examined	3.0 (PCP only)	Not examined	Not examined	Specialist consultations & ED visits excluded; high use not examined
18	Bähler et al. [34]	Switzerland	Helsana Group insurants age ≥ 65	2013	Not examined	All physicians: 13.1 (mm: 15.7, nmm: 4.4) PCPs: 6.1 (mm: 7.4, nmm: 1.9) NPCP: 4.3 (mm: 5.1, nmm: 1.8)	All physicians: 2.9 (mm: 3.3, nmm: 1.5) PCP: 1.1 (mm: 1.2, nmm: 0.6) NPCP: 1.8 (mm: 2.1, nmm: 0.9)	Not examined	Consultations, home visits, OPD contacts, phone contacts (all physicians: 5.7 %) included; nursing home visits excluded mm : ≥ 2 chronic conditions; high use not examined
19	OBSAN [35]	Switzerland	Population sample age ≥ 65	2012	Not examined	8.0 (PCP: 4.2, NPCP: 3.8)	Not examined	Not examined	Visits (“Besuch einer Praxis”) included; no further specification of contact type; high use not examined
20	Neal et al. [36]	United Kingdom	Sample from 4 primary care practice	1991–1995	Not examined	10.7	Not examined	Not examined	Visits and outpatient contacts; no further specification of contact type; high use not examined
21	Salisbury et al. [70]	United Kingdom	Primary care sample age ≥ 18	2005–2008	Not examined	mm: 9.4, nmm: 3.8	Not examined	Not examined
22	Bellón et al. [71]	Spain (Andalousia)	208 hu age ≥ 15 in one health center	2001	Not examined	21.8–22.5	Not examined	Not examined	ED/OPD-contacts excluded; no further specification of contact type hu cut-off: 14.7 for females, 13.8 for men
23	Luciano al. [72]	Spain (Catalonia)	GP sample age ≥ 65 with ≥ 3 chronic conditions	2005–2006	Not examined	23,1 (age ≥ 65: 22.4)	Not examined	Not examined	ED/OPD-contacts excluded; no further specification of contact type hu:10 % highest users = consultation frequency > 12
24	Bergh et al. [73]	Sweden	1 health center sample age ≥ 65	1997–1998	Not examined	GP-contacts: 1.2–1.4 (hu: 5, nhu: 1)	Not examined	Not examined	hu: 10 % highest users
25	Moth et al. [74]	Denmark	Primary care sample age ≥ 40	2009	(>2/3 of contacts <15 min	Not examined	Not examined	Not examined	Contacts = face-to-face, phone, email and home visits (telephone + mail-contacts 39.1 %); high use not examined
26	Drees [75]	France	PCP-population	2002	(PCP 15 min, NPCP 15–30 min)	Not examined	Not examined	Not examined	Practice consultations and home visits, no ED/OPD contacts; high use not examined
27	Health Insurance Authority [76]	Austria	“Care intensive” patients (cip); no age limit	2006–2007	Not examined	All physicians: cip: 39.6, ncip: 7 (PCP: cip: 30, ncip: 5; NPCP: cip: 9.6, ncip: 2)	Not examined	Not examined	No specification of contact type cip: numbers of contacts & services + hospital days (=7 % of population)

Abbreviations GE Germany, BE Belgium, SWI Switzerland, ES Spain, NL Netherlands, UK United Kingdom, FR France, IT Italy, SWE Sweden, USA United Staes of America, PCP primary care physicians, NPCP non-primary care physicians (specialists), ED emergency department, OPD outpatient department, CHC community health center, hu high use, mm multimorbid, nmm non-multimorbid, cip care intensive patients, ncip not care intensive patients