Background
Average consultation length is the time that medical personnel spends with patients in the process of consultation, including history taking, treatment planning, discussing substance use, health education, and so on, which is a quality indicator of promoting safe and cost-effective use of drugs around the world as suggested by the World Health Organization (WHO) and the International Network for the Rational Use of Drugs (INRUD) [
1‐
3]. Studies indicated that consultation length might become a proxy measure of the quality of care and influence the delivery of health care [
4,
5]. The optimum WHO/INRUD value for average consultation time is ≥ 10 min, which was taken as the standard by most scholars in developing countries, for example in Pakistan [
6], Kenya [
7], Ethiopia [
8], Kuwait [
9], and so on. The Royal College of General Practitioners has recommended that primary care appointments be at least 15 min long, including examinations [
10]. In addition, Egypt recommends 30 min per patient as the optimum consultation length in primary care [
11]. However, in two recent systematic reviews based on WHO/INRUID patient care indicators, only two studies were consistent with WHO/INRUID recommended average consultation, and the average consultation time was 18.16 and 10.46 min, respectively [
12,
13]. A review of studies involving 67 countries reported that the average consultation length ranged from 48 s in Bangladesh to 22.5 min in Sweden.
Consultation length is a crucial aspect of patient-physician interaction [
14], and Irving et al. (2017) [
2] found significant positive associations between longer consultation length and higher healthcare spending per capita, reduced hospital admissions for diabetes, higher primary care physician density, higher physician efficiency, and higher physician satisfaction. Research on consultation length and its impact has been conducted in a range of international primary care settings [
15]. However, the impact of consultation length on health outcomes in general practice has long been debated. A systematic review by Wilson et al. (2002) [
16] explored associations between consultation length, process and outcomes and found that doctors who had longer average consultation lengths prescribed less and were more likely to include lifestyle advice and preventive activities. Another review suggested that there was evidence of an improved diagnosis of psychological problems in longer consultations, and time is a significant barrier to treating depression [
17]. Crucially, longer consultation lengths could also benefit physicians, including reduced burnout and improved job satisfaction [
18]. While a Cochrane systematic review of clinical trials reported that there was insufficient evidence to say whether increasing consultation length provides patient benefit; several aspects of doctors’ behavior (prescribing, referral, investigation, and reconsultation) remained unchanged despite significant changes in appointment length [
19,
20]. A review on the association between consultation length and patient’s perception of care concluded that it was not the length of the consultation but instead the patient's psychosocial factors that improved consultation outcome [
21]. Therefore, the potential association between consultation length and quality of care needs to be further explored.
Common methods for measuring health care quality included direct clinical observations, patient exit interviews, chart abstraction, vignettes or written case simulations, standardized patients (SPs), etc. [
22,
23]. The standardized patients (SPs) method is widely regarded as the “gold standard” for measuring the medical practice of providers and can avoid the "Hawthorne effect" [
24‐
29]. Existing studies have used the SPs method to explore the relationship between consultation length and health care quality. For example, Gao et al. (2022) [
30] and Goedhuys et al. (2001) [
31] found that longer consultation time resulted in higher patient satisfaction; Goedhuys et al. (2001) [
31] indicated longer consultations were also rated higher for the quality of the communication; Epstein et al. (2005) [
32] also noted patient-centered communication is associated with increased visit length; Banerjee et al. (2020) [
33] and Wang et al. (2022) [
4] found that providers who spent more time with patients were significantly more likely to adherence more checklist items of recommended questions and examinations; besides, Wang et al. (2022) [
4] found providers who consulted longer time with patients were more likely to give a correct diagnosis. In conclusion, the relationship between consultation length and health care quality has been reasonably well established in face-to-face interactions.
The COVID-19 crisis has presented multiple barriers to health care, including patients’ and providers’ fears of acquiring infection through travel to healthcare facilities [
34]. Direct-to-consumer (DTC) telemedicine addresses the diagnosis, treatment, and monitoring of patients by means of electronic technology, which is well suited for scenarios in which infrastructure remains intact and clinicians are available to see patients online to provide synchronous and asynchronous support for patients who require routine clinical services [
34‐
36]. Electronic consultations (E-consults), as a means of asynchronous communication between clinicians and patients, improve patient access to specialist care [
37,
38]. The utility and feasibility of E-consults have been demonstrated across multiple specialties, including cardiology, gastroenterology, endocrinology, infectious disease, nephrology, and dermatology [
38]. Nevertheless, no research on consultation duration and its impact has been found in the E-consults setting, so it is unclear whether the established relationship between the two in face-to-face interactions exists in the E-consults setting.
By December 2021, the number of online medical users had reached 298 million in China, accounting for 28.9 percent of the total online users [
39]. With the increasing demand for E-consults with better outcomes, this study examines the association between consultation length and the quality of E-consults services to get new insights for potential policies and practices that could improve online health service quality in China.
Discussion
Principal finding
Our study used SPs to evaluate consultation length and quality of tele-dermatology E-consults in China. To the best of our knowledge, this is the first study to explore the impact of consultation length on the quality of E-consults. Traditional measurements of consultation length in in-person visits cannot reflect the time doctors spent directly with the patient, nor can the process of doctor-patient interaction online due to the asynchronous nature of E-consults. Instead, we use six related indicators as proxies for consultation length. In our study, three main findings were present. First, providers who responded more quickly were more likely to provide lifestyle modification advice and receive satisfaction from patients without compromising the process, diagnosis, and prescribing quality. Second, providers who spent more time with patients were likely to adhere to clinical checklists. Third, we found that the total times and words of provider’s responses positively impacted the quality of tele-dermatology E-consults.
Many studies have demonstrated the clear inverse relationship between waiting time and patient satisfaction [
43‐
45], and the same results were found in teledermatology [
46]. Consistent with previous findings, our data also showed that visits with an average waiting time of ≤ 1 h were 4.85 times more likely to receive satisfaction from patients than those of > 1 h, and the same result was also found for waiting time of first response. Moreover, we found an inverse relationship between waiting time and providing lifestyle modification advice. Shorter waiting times mean that providers are more motivated to respond, and those physicians may exhibit more effective behaviors such as concern, encouragement, reassurance, empathy, and sympathy, driving them to provide lifestyle modification advice.
Furthermore, we found that visits with time for consultation of > 1 day were 4.20 times more likely to adhere to clinical checklists than those of ≤ 1 day. Under time pressure, adherence to guidelines concerning history taking was compromised; that is, physicians asked significantly fewer questions concerning presenting symptoms than the ones indicated by the guidelines [
47]. A systematic review suggested that patients seeking help from a doctor who spent more time with them were more likely to have a consultation that included essential elements of care [
16]. A study using standardized patients to examine the role of consultation length in delivering process quality and diagnosis quality in China also showed that the longer consultation led to better process and diagnosis quality in primary care [
4]. However, these studies were set in face-to-face visits, and the measured consultation length was the time providers and patients spent during a patient's visit. Due to the asynchronous E-consults conducted in this study, time for consultation cannot represent the direct interaction between doctors and patients, which may be affected by both patient and doctor's responses.
Considering E-consults services as a new service form, no study has been found on the association between consultation length and service quality. To find alternative indicators of consultation length, we included three other indicators, namely total times of provider’s responses, total words of provider’s all responses, and average words of provider’s each response, to analyze their impact on E-consults services quality. The results showed a significant association between these three indicators and E-consults services quality among specialty care providers. Providers with more times and words of responses were significantly more likely to adhere to a clinical checklist (adequate consultation process), provide an accurate diagnosis, appropriate prescription, and lifestyle modification advice; additionally, they were more likely to obtain satisfaction from patients. Therefore, we believe that these three indicators can be used as proxies of consultation length for asynchronous online consultation. Medical consultation is always a complex temporal event [
48]. The number of times and words in a provider’s responses determines how much attention has been given to patients and how much information the provider knows about the patients [
16]. Thus, providers with more times and words of responses are more likely to find health problems and therefore provide higher quality care [
14,
49,
50].
Our study presents excellent reasons to increase the consultation length of E-consults and has potential implications for further research and medical practice. Building on previous offline studies, we confirmed the relationship between consultation length and service quality in the setting of E-consults, which open up a massive data source for further work. In addition to standardized patients, a large amount of real-world data, i.e., online consultation data from real patients, can be used for multiple purposes and to collect other elements in the interaction between providers and patients. Of note, we found that 77% (10/13) of Internet hospital platforms have limitations on the time of doctor-patient interaction. For example, 7.7% (1/13) platforms require doctors to respond to patients three times with a maximum of 300 words; 15.4% (2/13) platforms require the asynchronous interaction between doctors and patients should be completed within 24 h. These rules may significantly limit the consultation length of E-consults and thus affect service quality. Our study underscores the importance and urgency of establishing health service rules on reliable consultation length of E-consults to ensure adequate interaction between patients and providers. To further standardize online medical care, promote its healthy development, and ensure medical quality and safety, the National Health Commission of People’s Republic of China issued the "Rules on Supervision of Internet Diagnosis and Treatment (Consultative Draft)" in October 2021. In this regard, we suggest that affordable and reliable consultation length, response times and words of E-consults is required to clarify to continuously adapt to the potential challenges of digital health.
Limitations
This study has several limitations. First, we only investigated tele-dermatology E-consults, which results in our findings may not be generalizable to wider samples of the healthcare system due to the enormous variability among different diseases. Further research is underway on other conditions, including chronic diseases such as diabetes and mental disorder such as depressive disorders. Second, our survey was set in regions with a better development level of DTC telemedicine in China, and the research conclusion cannot represent the overall situation in China. Our follow-up investigation will further extend to other regions of China. Third, we did not analyze the impact of patient behavior on outcomes, mainly because we used standardized patients trained to visit the physician online strictly according to a standard script. However, real-world data may be affected by the behavior of real patients, and patient characteristics and response should be included as control variables.
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