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》

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》

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 quality, safety and governance of telephone triage and advice services - an overview of evidence from systematic reviews.

Lake R ，Georgiou A ，Li J ，Li L ，Byrne M ，Robinson M ，Westbrook JI ... -  《BMC HEALTH SERVICES RESEARCH》

Safety of telephone consultation for "non-serious" emergency ambulance service patients.

Dale J ，Williams S ，Foster T ，Higgins J ，Snooks H ，Crouch R ，Hartley-Sharpe C ，Glucksman E ，George S ... -  《-》