Higher rates also occurred in VA's with higher staff ratings of leadership quality (p < .001) and marginally higher group (p=.054) and risk-taking cultures (p=.055), while those VA's with higher staff orientation to quality improvement (p < .05) and more primary care-based process action teams (p < .05) had higher rates. CONCLUSION: Achieving more guideline-adherent smoking cessation practices in large, academic medical centers may pose significant challenges for primary care managers, but appears more likely among medical centers with more highly organized primary care practice. Improving counseling rates requires systems approaches to address both structural and provider-related constraints. Our objective was to describe duration of visit to chiropractors (CP) and acupuncturists (AC), the factors associated with these visit times, and to compare visit duration among physicians (MD), CP, and AC. METHODS: A random sample of licensed CP (N=130) from Arizona and Massachusetts, and licensed AC (N=133) from Washington and Massachusetts, was surveyed on consecutive office visits in 1998 ± 99 regarding visit time, patient demographics, reason for visit, acuity of problem, payment source, diagnostic and therapeutic techniques performed. (N=2550 CP encounters, mean age 44.9 years, 57% female; N=2561 AC encounters, mean age 46.2 years, 68% female).