Cost analysis of nurse telephone consultation in out of hours primary care: evidence from a randomised controlled trial.

To undertake an economic evaluation of nurse telephone consultation using decision support software in comparison with usual general practice care provided by a general practice cooperative. Cost analysis from an NHS perspective using stochastic data from a randomised controlled trial. General practice cooperative with 55 general practitioners serving 97 000 registered patients in Wiltshire, England. All patients contacting the service, or about whom the service was contacted during the trial year (January 1997 to January 1998). Costs and savings to the NHS during the trial year. The cost of providing nurse telephone consultation was 81 237 pound sterling per annum. This, however, determined a 94 422 pound sterling reduction of other costs for the NHS arising from reduced emergency admissions to hospital. Using point estimates for savings, the cost analysis, combined with the analysis of outcomes, showed a dominance situation for the intervention over general practice cooperative care alone. If a larger improvement in outcomes is assumed (upper 95% confidence limit) NHS savings increase to 123 824 pound sterling per annum. Savings of only 3728 pound sterling would, however, arise in a scenario where lower 95% confidence limits for outcome differences were observed. To break even, the intervention would have needed to save 138 emergency hospital admissions per year, around 90% of the effect achieved in the trial. Additional savings of 16 928 pound sterling for general practice arose from reduced travel to visit patients at home and fewer surgery appointments within three days of a call. Nurse telephone consultation in out of hours primary care may reduce NHS costs in the long term by reducing demand for emergency admission to hospital. General practitioners currently bear most of the cost of nurse telephone consultation and benefit least from the savings associated with it. This indicates that the service produces benefits in terms of service quality, which are beyond the reach of this cost analysis.

Lattimer V ，Sassi F ，George S ，Moore M ，Turnbull J ，Mullee M ，Smith H ... -  《-》

Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial. The South Wiltshire Out of Hours Project (SWOOP) Group.

To determine the safety and effectiveness of nurse telephone consultation in out of hours primary care by investigating adverse events and the management of calls. Block randomised controlled trial over a year of 156 matched pairs of days and weekends in 26 blocks. One of each matched pair was randomised to receive the intervention. One 55 member general practice cooperative serving 97 000 registered patients in Wiltshire. All patients contacting the out of hours service or about whom contact was made during specified times over the trial year. A nurse telephone consultation service integrated within a general practice cooperative. The out of hours period was 615 pm to 1115 pm from Monday to Friday, 1100 am to 1115 pm on Saturday, and 800 am to 1115 pm on Sunday. Experienced and specially trained nurses received, assessed, and managed calls from patients or their carers. Management options included telephone advice; referral to the general practitioner on duty (for telephone advice, an appointment at a primary care centre, or a home visit); referral to the emergency service or advice to attend accident and emergency. Calls were managed with the help of decision support software. Deaths within seven days of a contact with the out of hours service; emergency hospital admissions within 24 hours and within three days of contact; attendance at accident and emergency within three days of a contact; number and management of calls in each arm of the trial. 14 492 calls were received during the specified times in the trial year (7308 in the control arm and 7184 in the intervention arm) concerning 10 134 patients (10.4% of the registered population). There were no substantial differences in the age and sex of patients in the intervention and control groups, though male patients were underrepresented overall. Reasons for calling the service were consistent with previous studies. Nurses managed 49.8% of calls during intervention periods without referral to a general practitioner. A 69% reduction in telephone advice from a general practitioner, together with a 38% reduction in patient attendance at primary care centres and a 23% reduction in home visits was observed during intervention periods. Statistical equivalence was observed in the number of deaths within seven days, in the number of emergency hospital admissions, and in the number of attendances at accident and emergency departments. Conclusions Nurse telephone consultation produced substantial changes in call management, reducing overall workload of general practitioners by 50% while allowing callers faster access to health information and advice. It was not associated with an increase in the number of adverse events. This model of out of hours primary care is safe and effective.

Lattimer V ，George S ，Thompson F ，Thomas E ，Mullee M ，Turnbull J ，Smith H ，Moore M ，Bond H ，Glasper A ... -  《-》

NHS Direct versus general practice based triage for same day appointments in primary care: cluster randomised controlled trial.

Richards DA ，Godfrey L ，Tawfik J ，Ryan M ，Meakins J ，Dutton E ，Miles J ... -  《BMJ-British Medical Journal》

Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care.

Venning P ，Durie A ，Roland M ，Roberts C ，Leese B ... -  《-》

Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs.

Richards DA ，Meakins J ，Tawfik J ，Godfrey L ，Dutton E ，Richardson G ，Russell D ... -  《BMJ-British Medical Journal》