Telephone triage by GPs in out-of-hours primary care in Denmark: a prospective observational study of efficiency and relevance.

In the UK, telephone triage in out-of-hours primary care is mostly managed by nurses, whereas GPs perform triage in Denmark. To describe telephone contacts triaged to face-to-face contacts, GP-assessed relevance, and factors associated with triage to face-to-face contact. A prospective observational study in Danish out-of-hours primary care, conducted from June 2010 to May 2011. Information on patients was collected from the electronic patient administration system and GPs completed electronic questionnaires about the contacts. The GPs conducting the face-to-face contacts assessed relevance of the triage to face-to-face contacts. The authors performed binomial regression analyses, calculating relative risk (RR) and 95% confidence intervals. In total, 59.2% of calls ended with a telephone consultation. Factors associated with triage to a face-to-face contact were: patient age >40 years (40-64: RR = 1.13; >64: RR = 1.34), persisting problem for 12-24 hours (RR = 1.15), severe problem (RR = 2.60), potentially severe problem (RR = 5.81), and non-severe problem (RR = 2.23). Face-to-face contacts were assessed as irrelevant for 12.7% of clinic consultations and 11.7% of home visits. A statistically significantly higher risk of irrelevant face-to-face contact was found for a persisting problem of >24 hours (RR = 1.25), contact on weekday nights (RR = 1.25), and contact <2 hours before the patient's own GP's opening time (RR = 1.80). Around 12% of all face-to-face consultations in the study are assessed as irrelevant by GP colleagues, suggesting that GP triage is efficient. Knowledge of the factors influencing triage can provide better education for GPs, but future studies are needed to investigate other quality aspects of GP telephone triage.

Huibers L ，Moth G ，Carlsen AH ，Christensen MB ，Vedsted P ... -  《-》

Medical appropriateness of adult calls to Danish out-of-hours primary care: a questionnaire-based survey.

Optimal utilisation of the out-of-hours primary care (OOH-PC) services remains a concern in public health policy. We need more knowledge on potentially avoidable contacts. This study examines the frequency of medically assessed inappropriate OOH-PC calls from adults, explores factors associated with such assessment, and examines the relation to patient-assessed severity of health problem and fulfilment of expectations. We performed secondary analyses of data from a large cross-sectional survey on contacts to Danish OOH-PC. As access to Danish OOH-PC is provided through telephone triage delivered by a general practitioner (GP), we included only telephone contacts. A contact was characterised as medically inappropriate when the triage GP assessed that the request from a medical perspective should have been directed to daytime primary care. Appropriateness was examined in relation to patient characteristics, reason for encounter, time of contact, and whether the contact was triaged to a face-to-face consultation, and in relation to patient-assessed severity of the health problem and fulfilment of expectations. Associations were estimated with odds ratios (ORs) using multivariate analysis. Of all contacts, 23.7% were assessed as medically inappropriate. Such assessment was associated with: younger age, longer symptom duration, exacerbation of chronic condition, and contact only few hours away from own GP's office hours. Of medically inappropriate contacts, 31.3% were from patients aged 18-30 years, 41.5% concerned symptoms of > 24 h, 19.4% concerned exacerbation of chronic condition, and 21.3% were calls < 3 h away from own GP's regular office hours. Medicine request was the most frequent reason for an inappropriate contact (14.3% of medically inappropriate contacts). In 53.4% of contacts assessed as inappropriate, the health problem was considered as severe by patients and medical assessed inappropriateness was significantly associated with unfulfilled patient expectations. One in four OOH-PC calls was considered medically inappropriate. Future efforts to reduce suboptimal use of OOH-PC should focus on the types of contacts with the highest optimisation potential, e.g., medication requests, long-lasting symptoms, and exacerbations. Such interventions should aim at bridging the gap between the GP's medical assessment and the patient's expectations to appropriate OOH-PC use.

Nørøxe KB ，Huibers L ，Moth G ，Vedsted P ... -  《BMC Family Practice》

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 ... -  《-》

Out-of-hours primary care: a population-based study of the diagnostic scope of telephone contacts.

GPs answer all patient calls to the out-of-hours primary care (OOH-PC) services in Denmark. Knowledge is scarce on how the triage-GPs act on the specific reasons for encounter (RFE). This study aims to describe the RFEs, the applied diagnoses and the severity of health problems presented in calls to the OOH-PC. This was a 1-year cross-sectional study based on IT-integrated pop-up questionnaires addressing patients' health problems. We included only telephone contacts that were categorized according to their triage outcome as telephone consultations, direct admissions to hospital or referrals for face-to-face contact. The GP-assessed severity was calculated for age groups and types of outcome. We identified the 20 most frequent primary RFEs and diagnoses for each type of contact termination. We included 7810 telephone calls. Calls considered non-severe made up two-thirds of the calls terminated as telephone consultations, whereas calls considered potentially severe made up the main part of referrals (52.3%). Overall, the 20 most frequent RFEs accounted for 45.2% of all RFEs, fever being the most frequent (10.0%). Some RFEs were terminated mostly as telephone consultations [e.g. insect bite/sting (75.9%)], whereas others were most often referred for a face-to-face contact [i.e. dyspnoea (79.1%)] or directly to hospital [i.e. chest pain (29.4%)]. The distribution of the RFEs on triage outcomes, dominated by more severe diagnoses in referrals indicates a suitable referral level. However, future research on factors related to the demanding task of telephone triage is highly relevant for postdoctoral training of GPs.

Moth G ，Huibers L ，Christensen MB ，Vedsted P ... -  《-》

Preschool children in out-of-hours primary care - a questionnaire-based cross-sectional study of factors related to the medical relevance of health problems.

Out-of-hours primary care (OOH-PC) is intended to provide medical care services for health problems that cannot wait until normal office hours. Children under five years of age represent about 19% of all OOH-PC contacts in Denmark, and the frequency of calls assessed as severe by health professionals is markedly lower for children than for other age groups. Several studies have questioned the appropriateness of the parents' use of OOH-PC. We aimed to identify factors associated with calls from parents of pre-school children concerning perceived non-severe health problems that were ranked by the triaging GPs as more appropriate for GP office hours (defined as 'medically irrelevant'). We used data from a cross-sectional study performed in the Central Denmark Region for a 1-year period during 2010-2011. GPs in the OOH-PC assessed random contacts, and a questionnaire was subsequently sent to registered patients. Associations between different factors and the medical irrelevance of contacts were estimated with a generalised linear model to calculate the prevalence ratio (PR). Among all included 522 telephone consultations and 1226 face-to-face consultations, we identified 71 (13.6%) telephone consultations and 95 (7.8%) face-to-face consultations that were both assessed as non-severe by the parents and more appropriate for GP office hours by the GPs. For telephone consultations, contacts at other times than 4-8 pm on weekdays were statistically significantly associated with medical irrelevance. Additionally, symptoms of longer duration than 24 h were statistically significantly associated medical irrelevance. A large part of the calls to the Danish OOH-PC concern children. The results indicate that some of these calls are made for other than strictly medical reasons. To achieve more effective use of available resources, it might seem relevant to aim at directing more contacts directly to daytime care. However, future studies to enhance our knowledge on parents' motivation and behaviour would be recommendable.

Moth G ，Huibers L ，Ovesen A ，Christensen MB ，Vedsted P ... -  《BMC Family Practice》