ORIGINAL ARTICLE

Turnaround Time of Consults in a

Primary Care System in Rural Philippines:
A Descriptive Retrospective Cohort Study
April Faye P. Barbadillo, MD,1 Leonila F. Dans, MD, MSc,1 Carol Stephanie C. Tan-Lim, MD,2
Cara Lois T. Galingana, BS,3 Josephine T. Sanchez, BS,3 Maria Rhodora N. Aquino,3 Arianna Maever L. Amit,3
Regine Ynez H. De Mesa, BA,3 Mia P. Rey, PhD,4 Janelle Micaela S. Panganiban,3 Karl Engelene E. Poblete,3
Nanette B. Sundiang, MD, MBA-H3 and Antonio L. Dans, MD, MSc3,5
1
Department of Pediatrics, Philippine General Hospital, University of the Philippines Manila
2
Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila
3
Philippine Primary Care Studies, Center for Integrative and Development Studies, University of the Philippines Diliman
4
Department of Accounting and Finance, Cesar E.A. Virata School of Business, University of the Philippines Diliman
5
Institute of Clinical Epidemiology, National Institutes of Health, University of the Philippines Manila

ABSTRACT

Background. Turnaround time is an integral component of primary healthcare and is a key performance indicator of
healthcare delivery. It is defined as the time patients spend during a healthcare facility visit. In this study, turnaround
time is defined as the time elapsed from registration to the end of consultation.

Objectives. This study aimed to determine the turnaround time of consults in the primary care system in a rural site
in the Philippines, and compare turnaround time during the pre-pandemic and COVID-19 pandemic periods.

Methods. This is a retrospective cohort study of patients seen at the primary care facility under the Philippine Primary
Care Studies (PPCS) rural site from April 2019 to March 2021. Patients included in this study were chosen through
random sampling. Electronic medical records (EMR) of these patients were reviewed. Turnaround time was computed
electronically from time of registration to end of consultation. Descriptive statistics was used to summarize data and
report turnaround time. The turnaround time before and during the pandemic was compared using an independent
sample t-test (if normally distributed) or Mann Whitney U test (if not normally distributed). A p-value of <0.05 was
considered statistically significant.

Results. A random sample of 342 patients out of the total 45,501 patient consults seen at the rural primary healthcare
facility from April 2019 to March 2021 were included in this study. The median turnaround time was 29.0 minutes
(interquartile range [IQR] 68.3), with range of 0.9 to
437.2 minutes. During the pre-pandemic period, the
median turnaround time of consults is 29.3 minutes (IQR
70.4) which is 1.8 minutes longer than the pandemic
period which showed median turnaround time of 27.5
minutes (IQR 72.7). The difference between the two
time periods was not statistically significant (P = 0.39).

Conclusion. The study showed that the median

eISSN 2094-9278 (Online)
Published: October 15, 2024 turnaround time of medical consults was 29.0 minutes,
[Link] which was shorter by 80 minutes compared to other
Copyright: The Author(s) 2024 published Philippine studies. The turnaround time
did not differ significantly in the pandemic and pre-
Corresponding author: April Faye P. Barbadillo, MD
Department of Pediatrics pandemic period, despite new policies and systems that
Philippine General Hospital were implemented during the pandemic.
University of the Philippines Manila
Taft Avenue, Ermita, Manila 1000, Philippines Keywords: turnaround time, primary care, electronic medical
Email: aprilfayebarbadillo@[Link]
ORCiD: [Link]
records, pandemic, Philippines

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 Turnaround Time of Consults in a Primary Care System in Rural Philippines

INTRODUCTION initiated, actual health needs are identified, and therapeutic

plans are established. The duration of face time with a
A strong primary healthcare system improves the physician is considered to be an important indicator of high-
capacity of a country to provide high quality and cost- quality health care.9 In a systematic review of 67 countries,
effective health services. An ineffective primary care system the average primary care physician consultation length
forces individuals to rely on the resources of potentially ranged from as short as 48 seconds in Bangladesh to 22.5
understaffed emergency departments.1 In the past years, the minutes in Sweden. Alarmingly, short consultation lengths
Philippines had faced several challenges in primary care, were more likely to adversely affect patient healthcare.10
including inequity in health access, shortage of primary care Another study evaluated the strength of primary care in
providers, and inadequate skill mix.2 Europe and showed that patient satisfaction is higher among
The Philippine Primary Care Studies (PPCS) was those with longer consultation time, since it allows more time
launched in 2016 as a pilot health system research in line for the physician to discuss treatment goals and options.11
with the country’s goal towards universal healthcare. This Similarly, a study done at a general practice clinic in Nigeria
research aimed to strengthen primary care facilities by showed that for every unit increase in consultation time,
engaging dedicated primary care providers supported by a there was a corresponding increase in patient satisfaction
centralized electronic database. A rural, urban, and remote level.6 It is generally concluded that longer consultation
site were chosen for the PPCS pilot study. An important times in primary care is linked with better quality of care
component of the PPCS program is the utilization of an and improved health-related outcomes.12 A study done by
Electronic Medical Records (EMR) system. The EMR Aytona and colleagues in 2022 used consultation time as a
contains patient information such as demographic data, variable in computing workload indicators for staffing needs,
consult time, diagnoses, laboratory results, treatment, and highlighting its importance in determining staffing standards
health expenditures. It provides a more efficient system for primary care services.2
of tracking patient visits, provider workloads, and health- In the PPCS, turnaround time includes both patient
related expenses. In the rural PPCS pilot site, the primary waiting time and consultation time, and is considered a
care system was established through a service delivery measure of administrative efficiency.3 Several studies have
network (SDN) composed of the rural health unit (RHU) been conducted to evaluate waiting times and consultation
and 14 barangay health stations (BHS). The health human times in many countries, including neighboring Southeast
resources in the RHU consists of two physicians, 2-3 nurses Asian countries. Local studies are limited.1
and 1-2 midwives per day, while one midwife is available for No actual value has been established as the standard or
each BHS. The EMR system was introduced in April 2019, acceptable turnaround time in primary care settings. This can
which led to accurate documentation of patient visits and be attributed to marked differences in structural characteristics
monitoring of healthcare delivery.3 of health systems as well as in the sociodemographic
The effectiveness of a primary healthcare system is characteristics of patients and physicians across countries. A
evaluated through its impact on healthcare delivery, quality, 2017 study that assessed patient waiting and consultation time
and access. Turnaround time is an integral component of in a primary healthcare clinic in Malaysia based its standards
primary care practice and is a key performance indicator of and target criteria according to the recommendation of the
healthcare delivery. It is defined as the time patients spend Malaysian Ministry of Health.13
during a healthcare facility visit. It may be evaluated in terms A survey conducted by the British Medical Association
of its components – waiting time and consultation time. showed that 95 percent of general physicians perceive that
Waiting time is measured from the time of patient's 10 minutes is insufficient for primary care consultations and
entry to the care facility until the actual consultation time. that at least 15 minutes should be spent in appointments.14
This includes registration and pre-consultation assessment. Several factors affect consultation time. Physician
A study done to assess patient satisfaction to ambulatory factors included sex, age, and specialization. Physicians
care services showed that waiting time is one of the biggest engaged in general practice and mental health care had
contributors to patient satisfaction and influences adherence longer turnaround times.8,15 Patient factors included sex, age,
to management and follow up.4 Long waiting time is ethnicity, and educational attainment. Patients coming in
perceived by patients as a barrier to health services.5 Studies for initial consult, those with multiple health problems, and
done in the primary care setting in Nigeria used a standard those with complaints related to behavioral or psychiatric
of 30 minutes waiting time as recommended by the Institute conditions required longer consultation times.16 In the
of Medicine.6,7 present time when technological advancements are in place,
Consultation time is measured as the time between patients are more engaged in their management. This is
the first greeting and the dismissal of a patient from the evidenced by the longer duration of primary consultation
consultation room.8 It is an integral component of primary care documented over the years, compared to the earliest
care practice and a central factor in medical practice. It is study conducted by Fry and Watts in 1952 which showed an
during this time that the patient-doctor relationship is average consultation time of 5 to 7.2 minutes.8

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Turnaround Time of Consults in a Primary Care System in Rural Philippines

Objectives Sample Size Calculation

The sample size was computed using a formula to
This study aimed to determine the turnaround time compare means from two independent groups. Values were
of consults in the primary care system in a rural site in the derived in reference to two Philippine studies. A study by
Philippines, and compare turnaround time during the pre- Cenizal et al. in 2020 conducted in the pre-pandemic time
pandemic and COVID-19 pandemic period. The results of showed mean turnaround time of 117 minutes with a standard
this study can aid in the development of policies for workforce deviation of 51.5 minutes.17 Another study by Laviña et al.
planning and achieving cost-effective turnaround times, and during the pandemic in 2021 showed a mean turnaround time
provide information on strengths and gaps in primary care of 109 minutes with a standard deviation of 39.2 minutes.18
practice in order to strengthen existing systems. Using the difference between mean turnaround time in the
two studies of 8 minutes, the computed sample size for
METHODS this study is 342 participants divided equally into the pre-
pandemic and pandemic period (171 participants each).
Study Design
This was a retrospective cohort study utilizing a review Description of Study Procedure
of time-stamped EMRs of patients seen at the primary
care system under the PPCS rural site from April 2019 to Data Collection
March 2021. Data was retrieved from the EMR of the PPCS rural site
primary care system. The flow of a patient’s movement during
Study Population a primary care visit is described in Figure 1. Upon arrival at
This study included all adult and pediatric patients at the the healthcare facility, patients were seen at the triage and
PPCS rural site primary care system via face-to-face consult those deemed as emergency cases were immediately sent to
from April 2019 to March 2021. Age restrictions were not a tertiary hospital via an online referral system. Patients for
imposed; thus, patients from all ages, from newborns to consultation were directed to the registration area. First-time
elderly patients were included. The study excluded patients consults were registered into the EMR. Records of patients
whose turnaround times are reflected in the EMR as “8 hours on follow-up consults were retrieved from the EMR using a
or more” and “zero”, since this was attributed to technical unique patient number. This timepoint was recorded as start
difficulties and bugs in the EMR. Both initial and follow- of consult. The end of consult timepoint was recorded upon
up consults were included. pressing of the “End Visit” button by the physician after the
The pre-pandemic period was defined in this study from consultation. Time elapsed is automatically recorded in the
April 2019 to March 2020, since March 15, 2020 was the system as the time from start of consult to the end of consult,
first day that lockdowns were instituted in the country. The and is regarded as the turnaround time in this study. Due to
COVID-19 pandemic period was defined as the period the limitations in the EMR configuration, separate analysis
from April 2020 to March 2021. for the waiting time and consultation time could not be
conducted. Thus, for the purpose of this study, turnaround
time is defined as the total time (in minutes) from registration

Figure 1. Flow chart showing patient’s movement in the primary care system from arrival to departure.

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 Turnaround Time of Consults in a Primary Care System in Rural Philippines

to the end of consultation, and encompasses both waiting aggregate data and no personally identifying information
time and consult time. was used, informed consent was not required. The study was
conducted in compliance with the Data Privacy Act of 2012.
Encoding and Processing All records were anonymized.
Raw data was encoded and tallied in a password-
protected Microsoft Excel file. Each patient was assigned RESULTS
a code to ensure confidentiality of data. Data was stored in
the principal investigator's laptop which was secured by a A total of 45,501 consults were logged at the rural
password accessible to the principal investigator only. primary care system from April 2019 to March 2021. We
excluded 3,200 consults whose turnaround time were logged
Statistical Analysis as “8 hours or more” and 15 consults erroneously logged as
Descriptive statistics was used to summarize data on zero. A total of 23,511 consults were logged during the pre-
turnaround time. Patient details included sociodemographic pandemic period from April 2019 to March 2020. There were
characteristics (age, sex, and place of residence) and clinical 18,775 consults logged during the COVID-19 pandemic
information (primary diagnosis and type of consult). period from April 2020 to March 2021. A total of 171
Categorical data was reported in frequencies and percentages. participants were randomly selected from the pre-pandemic
Continuous variables were reported as mean and standard period and the pandemic period, with a total sample size of
deviation for normally distributed data, and median and 342 participants for this study (Figure 2).
interquartile range (IQR) for data that did not follow normal
distribution. Missing data were reported as “no data” in the Sociodemographic characteristics of patients seen
results section and excluded in the analysis. The turnaround in the primary care system
time before and during the pandemic was compared using Table 1 outlines the sociodemographic characteristics
an independent sample t-test (if normally distributed) or of the 342 study participants. In the pre-pandemic period (n
Mann Whitney U test (if not normally distributed). A p-value = 171), 43% were pediatric patients while 57% were adults.
of <0.05 was considered statistically significant. The participants’ ages ranged from newborn to 97 years old.
Majority of patients (60%) were females. Sixty percent of
Ethical Considerations consultations came from lowland barangays.
The study was done through the provision of PPCS During the pandemic period (n = 171), there was a
as one of the performance indicators for administrative marked decrease in the pediatric consults, with the majority
efficiency. The study is exempted from the University of the of consults (81%) belonging to the adult population. Female
Philippines Manila Research Board (UPMREB) with study patients accounted for 52% of consults. Majority of patients
protocol code number UPMREB 20-15-489-01. Given that (70%) came from lowland barangays.

Figure 2. Flow diagram of study participants.

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Turnaround Time of Consults in a Primary Care System in Rural Philippines

Turnaround time of medical consults Turnaround time ranged from as short as 0.9 minutes to as
The turnaround time is reported in Table 2. Overall, long as 437.2 minutes.
the median turnaround time in the primary care system is
29.0 minutes (IQR 68.3). There is no significant difference Turnaround time in the primary care system
in the median turnaround time of consults between the pre- In this study, the median turnaround time of consults
pandemic and the pandemic periods (P = 0.39). in the primary care system is 29.0 minutes (IQR 68.3). This
result is almost one-fourth of that reported in two local studies.
DISCUSSION A study by Cenizal et al. in 2020 set in the pre-pandemic
time showed mean turnaround time of 117 minutes while
The PPCS rural site primary care system serves as a another study done during the pandemic by Laviña et al. in
catchment area with a population of 38,302.19 Healthcare 2019 showed a mean turnaround time of 109 minutes.17,18
services are provided through the primary care system This may be attributed to differences in setup, system
composed of the rural health unit (RHU) and its 14 barangay processes, and variances among physicians and patients.
health stations (BHS). Review of EMR showed that In our study, maintenance medication refills, requests for
45,501 face-to-face consults were recorded over two years. medical certification, and interpretation of laboratories were
the usual reasons for consults with shorter turnaround times.
Table 1. Sociodemographic Characteristics of Patients Seen Consults for chief complaints such as respiratory symptoms
at the PPCS Rural Site Primary Care Health System and abdominal pain had longer turnaround times, which is
before and during the COVID-19 Pandemic likely due to the need for more thorough history taking and
Pre-pandemic Pandemic Total physical examination.
n=171 (%) n=171 (%) n=342 (%) Comparison to a study done in another Southeast Asian
Age Group country showed that this study has a shorter turnaround time.
Newborn 10 (5.9) 7 (4.1) 17 (5.0) A study by Ahmad et al. in a primary healthcare clinic in
Under 5 years 26 (15.2) 13 (7.6) 39 (11.4) Malaysia showed an average of 59.3 minutes – broken down
5 to <19 years 37 (21.6) 13 (7.6) 50 (14.6) into 41.1 minutes waiting time and 18.2 minutes consultation
19 to <60 years 64 (37.4) 110 (64.3) 174 (50.9) time. It also showed that the turnaround time varied from
Senior Citizen 34 (19.9) 28 (16.4) 62 (18.1) as short as 0.6 minutes to as long as 477.6 minutes. This
Sex primary healthcare clinic in Malaysia was situated in a large
Male 68 (39.8) 82 (48.0) 150 (43.9) district that catered to 682,996 people, whereas the rural site
Female 103 (60.2) 89 (52.0) 192 (56.1) in this study catered to 35,298 residents across 14 barangays.
Place of Residence Moreover, the Malaysian study identified that the long
Upland barangay 32 (18.7) 45 (26.3) 77 (22.5) waiting time was due to long queues in registration due to
Lowland barangay 102 (59.7) 119 (69.6) 221 (64.6) inadequate staff, where only one staff was in charge of both
No data 37 (21.6) 7 (4.1) 44 (12.8) registration and provision of follow-up appointments.13 In
Employment contrast, one of the strategies implemented by the PPCS
Private employee 8 (4.7) 24 (14.0) 32 (9.4) to improve healthcare services was to augment healthcare
Government employee 2 (1.7) 7 (4.1) 9 (2.8)
providers. The rural primary care facility had three physicians,
Student 33 (19.3) 18 (10.5) 51 (14.9)
16 nurses, 20 midwives, and 100 community health workers.
Others (not specified)* 30 (17.5) 59 (34.5) 89 (26.0)
Registration at the BHS was handled by the midwives.20
No data 98 (57.3) 63 (36.8) 161 (47.1)
Special Populations
Turnaround time in the primary care system during
Indigent 2 (1.2) 0 (0) 2 (0.6)
4Ps** member 4 (2.4) 1 (0.6) 5 (1.5)
the pandemic
Persons with Disabilities 5 (2.9) 1 (0.6) 6 (1.8)
The primary care system saw a decrease in face-to-face
Pregnant 16 (9.4) 7 (4.1) 23 (6.7) consults by 20% in the pandemic period. This is consistent
with findings in a study by Tu et al. across nine countries
* Recorded as “Others” in the EMR but no details provided
** 4Ps – Pantawid Pamilyang Pilipino Program which compared the patient visit volume in the pandemic
period to the pre-pandemic period, showing a decrease in
patient visits by 26% among the Asian countries included.21
Table 2. Turnaround Time of Patients Seen at the PPCS Rural
Site Primary Care Health System before and during Another study in the primary care setting in Germany also
the COVID-19 Pandemic showed a dramatic reduction in the number of consultations
Time Period Median (IQR) in minutes Range in minutes
by 49%. This drop was independent of age, sex, and practice
location.22 The decrease in the number of consults is attributed
Pre-pandemic 29.3 (70.4) 1.7-370.8
to the implementation of protocols aimed to reduce viral
Pandemic 27.5 (72.7) 0.9-437.2
transmission. In the German study, the decrease in in-person
Overall 29.0 (68.3) 0.9-437.2 visits coincided with the shift to virtual consults, which is

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 Turnaround Time of Consults in a Primary Care System in Rural Philippines

likewise seen in our study setting. The PPCS primary care Another limitation is that the current EMR does not
system opened an online consultation in April 2021 to provide information on the type of consultation, whether
continue addressing community health needs. This service initial or follow-up consult. This is a possible effect modifier
began with an average of 15 to 20 patients per day and that may affect turnaround time. We also could not compare
gradually increased over the course of the pandemic.23 if the proportion of initial and follow-up consults were similar
There is no significant difference in the median for the pre-pandemic and pandemic periods. Other possible
turnaround times before and during the pandemic in effect modifiers, such as age of patient, severity of symptoms,
this study. During the pandemic, new protocols had to be presence of co-morbidities, were also not explored since this
instituted to ensure patient and healthcare personnel safety. is beyond the scope of the study.
For example, healthcare workers had to don appropriate
personal protective equipment (PPE) prior to seeing patients. CONCLUSION AND RECOMMENDATIONS
The whole system also saw a change in the process flows
such as patient pathways and physical set-up. Despite the This study showed a median turnaround time of 29.0
new protocols, there was no significant change in turnaround minutes, which is shorter by 80 minutes compared to other
time from pre-pandemic to pandemic times. This finding local studies. This study can aid in workforce planning in
contrasts to the results of several studies which report that primary care facilities with similar settings, and provide
the COVID-19 pandemic affected health service delivery. information for policies that aim to optimize turnaround
The impact of the pandemic was wide-reaching, with changes times. Evaluation of systems should be done to target optimal
in physical set-up of the clinics, human resource allocation, allocation of workforce according to facility burden. Quality
and process flows to accommodate influx of patients and improvement studies are needed to decrease wait times and
enforce infection control measures.18 Such changes influence increase consult times. The turnaround time did not differ
turnaround times of consults. A study done in a general significantly in the pandemic and pre-pandemic period,
practice clinic in Nigeria showed that any changes to the despite new policies and systems that were implemented
patient flow can increase waiting time, thus affecting the during the pandemic.
overall turnaround time.6 The pandemic turnaround time of Further studies are recommended to analyze determi-
27.5 minutes is shorter compared to a similar study done nants of turnaround time including physician and patient
at the UP Health Service (UPHS) setting of the Philippine factors. Studies focusing on outcomes such as patient
General Hospital (PGH) which showed an average of 108.68 satisfaction, treatment adherence, and health outcomes may
minutes. This may be attributed to additional service areas in also be explored. The EMR can be improved by allowing
the UPHS setting such as swabbing booths and screening healthcare workers to log waiting time separately from consult
tests which were included in their reported turnaround time so that further studies can be done to analyze these
time.18 variables independently. Policies may be developed to target
reduction in waiting time to improve efficiency of service
Limitations delivery. This includes proper allocation and augmentation of
The study was conducted in one rural setting in the human resources. The development of a scheduling system
Philippines hence it may be limited in terms of generalizability for patient visits may help improve process flow and patient
and applicability to other healthcare settings. The study only management. Addition of a field in the EMR to identify the
included a random sample of records (342 out of 45,501 type of consult as initial or follow-up is recommended to
records). Records with turnaround time of “8 hours or more” improve data gathering and analysis.
and “zero” were excluded, since they were likely due to
technical bugs in the EMR.” Data is also limited to retrievable Statement of Authorship
information in the electronic medical records. Instances of All authors certified fulfillment of ICMJE authorship
technological challenges such as internet and electricity criteria.
disruptions on the field may have affected the accuracy of
documentation of turnaround times. Author Disclosure
Another limitation is that the turnaround time was All authors declared no conflicts of interest.
measured as the sum of both waiting time and consultation
time. As seen in related literature, longer waiting time Funding Source
is perceived as a barrier to health service, while longer This study was done through the provisions of Philippine
consultation time is actually linked to better quality of care. Primary Care Studies (PPCS). The PPCS was funded
In this study, both waiting time and consultation time were through the support of the Department of Health (DOH),
considered together as turnaround time as a measure of the Philippine Health Insurance Corporation (PhilHealth),
administrative efficiency. Future studies that can investigate the University of the Philippines Center for Integrative
the individual components of waiting time and consultation and Development Studies (UPCIDS), the Emerging
time are needed. Interdisciplinary Research Program (EIDR), the Philippine

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Turnaround Time of Consults in a Primary Care System in Rural Philippines

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