Disparities in Time Spent Seeking Medical Care in the United States

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.

Methods

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 from2006 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.

Results

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).

Table 1.

Adjusted Total Time, Clinic Time, and Travel Time by Individual and Visit Characteristics^a

Characteristics	Respondents	Time, Minutes (95% CI)
		Total	P Value	Clinic	P Value	Travel	P Value
Overall	3787	123 (121–126)	NA	86 (83–88)	NA	38 (37–39)	NA
Individual
Race/ethnicity
Non-Hispanic, white	2672	117 (113–120)	[Reference]	80 (78–83)	[Reference]	36 (34–37)	[Reference]
Non-Hispanic, black	509	146 (137–154)	<.001b	99 (92–106)	<.001b	45 (40–50)	<.001b
Hispanic	142	150 (141–160)	<.001b	105 (97–113)	<.001b	45 (41–50)	<.001b
Other	464	123 (107–140)	.45	83 (72–95)	.54	39 (29–48)	.56
Education
High school or less	1470	130 (124–135)	[Reference]	91 (87–95)	[Reference]	39 (37–41)	[Reference]
Started college	1096	119 (114–125)	.01b	84 (79–88)	.36	35 (33–38)	.03
Completed any college	745	121 (114–128)	.06	83 (77–89)	.36	38 (35–41)	.68
Graduate school	476	116 (109–124)	.005b	76 (71–81)	<.001b	40 (37–44)	.53
Residencec
Urban (metropolitan)	3143	122 (119–125)	[Reference]	85 (82–87)	[Reference]	38 (36–39)	[Reference]
Rural (nonmetropolitan)	617	130 (122–139)	.08	91 (84–98)	.13	40 (36–43)	.25
Hourly incomed
Unemployed or not in labor force	1988	134 (130–139)	[Reference]	94 (90–98)	[Reference]	41 (38–43)	[Reference]
Quartile
1 (Lowest)	386	116 (107–126)	.002b	80 (72–88)	.004b	36 (33–40)	.05
2	436	115 (106–125)	<.001b	81 (73–90)	.008b	34 (31–37)	.001b
3	489	112 (104–119)	<.001b	75 (70–81)	<.001b	36 (32–41)	.09
4 (Highest)	488	105 (98–113)	<.001b	72 (65–78)	<.001b	34 (30–37)	.002b
Sex
Male	1152	132 (127–138)	[Reference]	92 (87–98)	[Reference]	40 (38–43)	[Reference]
Female	2635	119 (116–123)	<.001b	83 (80–85)	.002b	37 (35–38)	.01b
Age, y
18–24	147	119 (103–136)	[Reference]	89 (75–102)	[Reference]	31 (25–37)	[Reference]
25–44	1197	124 (118–130)	.56	86 (81–91)	.68	38 (36–41)	.03
45–64	1357	132 (127–136)	.16	90 (87–94)	.80	41 (39–44)	.005b
≥65	1086	114 (108–120)	.54	79 (74–84)	.20	35 (33–38)	.23
Visit
When occurred
Weekday 8:00 AM–5:00 PM	2930	121 (117–124)	[Reference]	82 (80–85)	[Reference]	38 (37–40)	[Reference]
Weekday after hours	405	143 (123–154)	<.001b	106 (96–115)	<.001b	38 (34–41)	.68
Weekend	452	131 (122–141)	.03	99 (90–107)	<.001b	33 (29–36)	.005b
Patient relationship to respondent
Self	2839	120 (116–123)	[Reference]	85 (83–88)	[Reference]	34 (33–36)	[Reference]
Child	526	135 (126–143)	.001b	84 (77–91)	.68	51 (47–55)	<.001b
Other adult	422	138 (127–150)	.003b	91 (82–99)	.25	48 (42–60)	<.001b

Abbreviation: NA, not applicable.

^aMultivariable linear regression included all individual and visit characteristics listed in table and accounted for survey design and weights. After fitting model, predictive margins were used to generate the adjusted time for each characteristic.

^bIndicates significance at P < .025 and was determined using false discovery method to account for multiple comparisons.

^cRural or urban status was missing for 0.7% (n = 27) of respondents and were not included in multivariable model.

^dIncome was imputed for employed individuals without reported wages (n = 330).

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).

Table 2.

Adjusted Face-to-Face Time With Physician by Individual Characteristics^a

Individual Characteristics	Respondents, No.	Face-to-Face Time With Physician, Minutes (95% CI)	P Value
Overall	150 022	20.5 (20.0–21.1)	NA
Race/ethnicity
Non-Hispanic white	97 163	20.4 (20.0–20.7)	[Reference]
Non-Hispanic black	14 436	20.5 (19.8–21.1)	.80
Hispanic	31 530	19.9 (19.2–20.5)	.12
Other	6893	20.3 (19.5–21.1)	.80
Neighborhood educationb
Quartile
1	32 296	19.4 (18.9–19.9)	[Reference]
2	32 355	19.9 (19.5–20.4)	.08
3	35 879	20.0 (19.6–20.4)	.04
4	40 402	21.5 (20.9–22.1)	<.001c
Rural or urbanb
Urban (metropolitan)	122 508	20.3 (20.0–20.6)	[Reference]
Rural (nonmetropolitan)	21 785	20.1 (19.1–21.2)	.77
Neighborhood incomeb
Quartile
1	31 600	20.8 (20.2–21.5)	[Reference]
2	32 525	20.2 (19.7–20.7)	.05
3	35 498	20.2 (19.7–20.6)	.08
4	41 309	20.0 (19.6–20.5)	.05
Sex
Female	86 562	20.2 (19.9–20.5)	[Reference]
Male	63 460	20.4 (20.0–20.8)	.06
Patient age, y
0–17	25 775	18.3 (17.8–18.7)	[Reference]
18–24	7989	19.7 (19.2–20.1)	<.001c
25–44	31 240	20.6 (20.1–21.0)	<.001c
45–64	45 588	21.2 (20.8–21.6)	<.001c
≥65	39 430	20.5 (20.1–21.1)	<.001c

^aMultivariable linear regression included all individual characteristics listed in the table and was adjusted for survey design and weights. After fitting the model, predictive margins were used to generate the adjusted time for each characteristic.

^bRural or urban status and/or neighborhood variables were missing from 6% (n = 9097) of visits; these visits were not included in multivariable model.

^cIndicates significance at P < .025 (determined using false discovery method to account for multiple comparisons).

Discussion

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 paper work, 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.