Telephone consultation and triage: effects on health care use and patient satisfaction.

Telephone consultation is the process where calls are received, assessed and managed by giving advice or by referral to a more appropriate service. In recent years there has been a growth in telephone consultation developed, in part, as a response to increased demand for General Practitioner (GP) and Accident and Emergency (A&E) department care. To assess the effects of telephone consultation on safety, service usage and patient satisfaction and to compare telephone consultation by different health care professionals. We searched the Cochrane Central Register of Controlled Trials, the specialised register of the Cochrane Effective Practice and Organisation of Care (EPOC) group, Pubmed, EMBASE, CINAHL, SIGLE, and the National Research Register. We checked reference lists of identified studies and review articles and contacted experts in the field. The search was not restricted by language or publication status. Randomised controlled trials (RCTs), controlled studies, controlled before/after studies (CBAs) and interrupted time series (ITSs) of telephone consultation or triage in a general health care setting. Disease specific phone lines were excluded. Two reviewers independently screened studies for inclusion in the review, extracted data and assessed study quality. Data were collected on adverse events, service usage, cost and patient satisfaction. Due to heterogeneity we did not pool studies in a meta-analysis and instead present a narrative summary of the findings. Nine studies met our inclusion criteria, five RCTs, one CCT and three ITSs. Six studies compared telephone consultation versus normal care; four by a doctor, one by a nurse and one by a clinic clerk. Three studies compared telephone consultation by different types of health care workers; two compared nurses with doctors and one compared health assistants with doctors or nurses. Three of five studies found a decrease in visits to GP's but two found a significant increase in return consultations. In general at least 50% of calls were handled by telephone advice alone. Seven studies looked at accident and emergency department visits, six showed no difference between the groups and one, of nurse telephone consultation, found an increase in visits. Two studies reported deaths and found no difference between nurse telephone triage and normal care. Telephone consultation appears to reduce the number of surgery contacts and out-of-hours visits by general practitioners. However, questions remain about its affect on service use and further rigorous evaluation is needed with emphasis on service use, safety, cost and patient satisfaction.

Bunn F ，Byrne G ，Kendall S 《Cochrane Database of Systematic Reviews》

The effects of telephone consultation and triage on healthcare use and patient satisfaction: a systematic review.

In recent years there has been a growth in the use of the telephone consultation for healthcare problems. This has developed, in part, as a response to increased demand for GP and accident and emergency department care. To assess the effects of telephone consultation and triage on safety, service use, and patient satisfaction. We looked at randomised controlled trials, controlled studies, controlled before/after studies, and interrupted time series of telephone consultation or triage in a general healthcare setting. All healthcare settings were included but the majority of studies were in primary care. We searched the Cochrane Central Register of Controlled Trials, EPOC specialised register, PubMed, EMBASE, CINAHL, SIGLE, and the National Research Register and checked reference lists of identified studies and review articles. Two reviewers independently screened studies for inclusion, extracted data, and assessed study quality. Nine studies met our inclusion criteria: five randomised controlled trials; one controlled trial; and three interrupted time series. Six studies compared telephone consultation with normal care; four by a doctor, one by a nurse, and one by a clinic clerk. Three of five studies found a significant decrease in visits to GPs but two found an increase in return consultations. In general at least 50% (range = 25.5-72.2%) of calls were handled by telephone consultation alone. Of seven studies reporting accident and emergency department visits, six showed no difference between the groups and one--of nurse telephone consultation--found an increase. Two studies reported deaths and found no difference between nurse telephone consultation and normal care. Although telephone consultation appears to have the potential to reduce GP workload, questions remain about its effect on service use. Further rigorous evaluation is needed with emphasis on service use, safety, cost, and patient satisfaction.

Bunn F ，Byrne G ，Kendall S 《BRITISH JOURNAL OF GENERAL PRACTICE》

Substitution of doctors by nurses in primary care.

Demand for primary care services has increased in developed countries due to population ageing, rising patient expectations, and reforms that shift care from hospitals to the community. At the same time, the supply of physicians is constrained and there is increasing pressure to contain costs. Shifting care from physicians to nurses is one possible response to these challenges. The expectation is that nurse-doctor substitution will reduce cost and physician workload while maintaining quality of care. Our aim was to evaluate the impact of doctor-nurse substitution in primary care on patient outcomes, process of care, and resource utilisation including cost. Patient outcomes included: morbidity; mortality; satisfaction; compliance; and preference. Process of care outcomes included: practitioner adherence to clinical guidelines; standards or quality of care; and practitioner health care activity (e.g. provision of advice). Resource utilisation was assessed by: frequency and length of consultations; return visits; prescriptions; tests and investigations; referral to other services; and direct or indirect costs. The following databases were searched for the period 1966 to 2002: Medline; Cinahl; Bids, Embase; Social Science Citation Index; British Nursing Index; HMIC; EPOC Register; and Cochrane Controlled Trial Register. Search terms specified the setting (primary care), professional (nurse), study design (randomised controlled trial, controlled before-and-after-study, interrupted time series), and subject (e.g. skill mix). Studies were included if nurses were compared to doctors providing a similar primary health care service (excluding accident and emergency services). Primary care doctors included: general practitioners, family physicians, paediatricians, general internists or geriatricians. Primary care nurses included: practice nurses, nurse practitioners, clinical nurse specialists, or advanced practice nurses. Study selection and data extraction was conducted independently by two reviewers with differences resolved through discussion. Meta-analysis was applied to outcomes for which there was adequate reporting of intervention effects from at least three randomised controlled trials. Semi-quantitative methods were used to synthesize other outcomes. 4253 articles were screened of which 25 articles, relating to 16 studies, met our inclusion criteria. In seven studies the nurse assumed responsibility for first contact and ongoing care for all presenting patients. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost. In five studies the nurse assumed responsibility for first contact care for patients wanting urgent consultations during office hours or out-of-hours. Patient health outcomes were similar for nurses and doctors but patient satisfaction was higher with nurse-led care. Nurses tended to provide longer consultations, give more information to patients and recall patients more frequently than did doctors. The impact on physician workload and direct cost of care was variable. In four studies the nurse took responsibility for the ongoing management of patients with particular chronic conditions. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost. The findings suggest that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less. While doctor-nurse substitution has the potential to reduce doctors' workload and direct healthcare costs, achieving such reductions depends on the particular context of care. Doctors' workload may remain unchanged either because nurses are deployed to meet previously unmet patient need or because nurses generate demand for care where previously there was none. Savings in cost depend on the magnitude of the salary differential between doctors and nurses, and may be offset by the lower productivity of nurses compared to doctors.

Laurant M ，Reeves D ，Hermens R ，Braspenning J ，Grol R ，Sibbald B ... -  《Cochrane Database of Systematic Reviews》

The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual car

Telephone triage is proposed as a method of managing increasing demand for primary care. Previous studies have involved small samples in limited settings, and focused on nurse roles. Evidence is limited regarding the impact on primary care workload, costs, and patient safety and experience when triage is used to manage patients requesting same-day consultations in general practice. In comparison with usual care (UC), to assess the impact of GP-led telephone triage (GPT) and nurse-led computer-supported telephone triage (NT) on primary care workload and cost, patient experience of care, and patient safety and health status for patients requesting same-day consultations in general practice. Pragmatic cluster randomised controlled trial, incorporating economic evaluation and qualitative process evaluation. General practices (n = 42) in four regions of England, UK (Devon, Bristol/Somerset, Warwickshire/Coventry, Norfolk/Suffolk). Patients requesting same-day consultations. Practices were randomised to GPT, NT or UC. Data collection was not blinded; however, analysis was conducted by a statistician blinded to practice allocation. Primary - primary care contacts [general practice, out-of-hours primary care, accident and emergency (A&E) and walk-in centre attendances] in the 28 days following the index consultation request. Secondary - resource use and costs, patient safety (deaths and emergency hospital admissions within 7 days of index request, and A&E attendance within 28 days), health status and experience of care. Of 20,990 eligible randomised patients (UC n = 7283; GPT n = 6695; NT n = 7012), primary outcome data were analysed for 16,211 patients (UC n = 5572; GPT n = 5171; NT n = 5468). Compared with UC, GPT and NT increased primary outcome contacts (over 28-day follow-up) by 33% [rate ratio (RR) 1.33, 95% confidence interval (CI) 1.30 to 1.36] and 48% (RR 1.48, 95% CI 1.44 to 1.52), respectively. Compared with GPT, NT was associated with a marginal increase in primary outcome contacts by 4% (RR 1.04, 95% CI 1.01 to 1.08). Triage was associated with a redistribution of primary care contacts. Although GPT, compared with UC, increased the rate of overall GP contacts (face to face and telephone) over the 28 days by 38% (RR 1.38, 95% CI 1.28 to 1.50), GP face-to-face contacts were reduced by 39% (RR 0.61, 95% CI 0.54 to 0.69). NT reduced the rate of overall GP contacts by 16% (RR 0.84, 95% CI 0.78 to 0.91) and GP face-to-face contacts by 20% (RR 0.80, 95% CI 0.71 to 0.90), whereas nurse contacts increased. The increased rate of primary care contacts in triage arms is largely attributable to increased telephone contacts. Estimated overall patient-clinician contact time on the index day increased in triage (GPT = 10.3 minutes; NT = 14.8 minutes; UC = 9.6 minutes), although patterns of clinician use varied between arms. Taking account of both the pattern and duration of primary outcome contacts, overall costs over the 28-day follow-up were similar in all three arms (approximately £75 per patient). Triage appeared safe, and no differences in patient health status were observed. NT was somewhat less acceptable to patients than GPT or UC. The process evaluation identified the complexity associated with introducing triage but found no consistency across practices about what works and what does not work when implementing it. Introducing GPT or NT was associated with a redistribution of primary care workload for patients requesting same-day consultations, and at similar cost to UC. Although triage seemed to be safe, investigation of the circumstances of a larger number of deaths or admissions after triage might be warranted, and monitoring of these events is necessary as triage is implemented. Current Controlled Trials ISRCTN20687662. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 13. See the NIHR Journals Library website for further project information.

Campbell JL ，Fletcher E ，Britten N ，Green C ，Holt T ，Lattimer V ，Richards DA ，Richards SH ，Salisbury C ，Taylor RS ，Calitri R ，Bowyer V ，Chaplin K ，Kandiyali R ，Murdoch J ，Price L ，Roscoe J ，Varley A ，Warren FC ... -  《-》

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 ... -  《-》