Accuracy of telephone triage in primary care patients with chest discomfort: a cross-sectional study

Shortness of breath as a diagnostic factor for acute coronary syndrome in male and female callers to out-of-hours primary care

OBJECTIVE

Chest discomfort and shortness of breath (SOB) are key symptoms in patients with acute coronary syndrome (ACS). It is, however, unknown whether SOB is valuable for recognising ACS during telephone triage in the out-of-hours primary care (OHS-PC) setting.

METHODS

A cross-sectional study performed in the Netherlands. Telephone triage conversations were analysed of callers with chest discomfort who contacted the OHS-PC between 2014 and 2017, comparing patients with SOB with those who did not report SOB. We determine the relation between SOB and (1) High urgency allocation, (2) ACS and (3) ACS or other life-threatening diseases.

RESULTS

Of the 2195 callers with chest discomfort, 1096 (49.9%) reported SOB (43.7% men, 56.3% women). In total, 15.3% men (13.2% in those with SOB) and 8.4% women (9.2% in those with SOB) appeared to have ACS. SOB compared with no SOB was associated with high urgency allocation (75.9% vs 60.8%, OR: 2.03; 95% CI 1.69 to 2.44, multivariable OR (mOR): 2.03; 95% CI 1.69 to 2.44), but not with ACS (10.9% vs 12.0%; OR: 0.90; 95% CI 0.69 to 1.17, mOR: 0.91; 95% CI 0.70 to 1.19) or 'ACS or other life-threatening diseases' (15.0% vs 14.1%; OR: 1.07; 95% CI 0.85 to 1.36, mOR: 1.09; 95% CI 0.86 to 1.38). For women the relation with ACS was 9.2% vs 7.5%, OR: 1.25; 95% CI 0.83 to 1.88, and for men 13.2% vs 17.4%, OR: 0.72; 95% CI 0.51 to 1.02. For 'ACS or other life-threatening diseases', this was 13.0% vs 8.5%, OR: 1.60; 95% CI 1.10 to 2.32 for women, and 7.5% vs 20.8%, OR: 0.81; 95% CI 0.59 to 1.12 for men.

CONCLUSIONS

Men and women with chest discomfort and SOB who contact the OHS-PC more often receive high urgency than those without SOB. This seems to be adequate in women, but not in men when considering the risk of ACS or other life-threatening diseases.

Displaying concerns within telephone triage conversations of callers with chest discomfort in out-of-hours primary care: A conversation analytic study

OBJECTIVES

In primary care out of hours service (OHS-PC), triage nurses ask questions to assign urgency level for medical assessment. A semi-automatic decision tool (the Netherlands Triage Standard, NTS) facilitates triage nurses with key questions, but does not leave much room for paying attention to callers' concerns. We wanted to understand how callers with chest pain formulate their concerns and are helped further during telephone triage.

METHODS

We conducted a conversation analytic study of 68 triage calls from callers with chest discomfort who contacted OHS-PC of which we selected 35 transcripts in which concerns were raised. We analyzed expressions of concerns and the corresponding triage nurse response.

RESULTS

Due to the task-oriented nature of the NTS, callers' concerns were overlooked. For callers, however, discussing concerns was relevant, stressed by the finding that the majority of callers with chest discomfort expressed concerns.

CONCLUSIONS

Interactional difficulties in concern-related discussions arised directly after expressed concerns if not handled adequately, or during the switch to the counseling phase.

PRACTICE IMPLICATIONS

When callers display concerns during telephone triage, we recommend triage nurses to explore them briefly and then return to the sequence of tasks described in the NTS-assisted triage process.

Evaluation of the Marburg Heart Score and INTERCHEST score compared to current telephone triage for chest pain in out-of-hours primary care

INTRODUCTION

Chest pain is a common and challenging symptom for telephone triage in urgent primary care. Existing chest-pain-specific risk scores originally developed for diagnostic purposes may outperform current telephone triage protocols.

METHODS

This study involved a retrospective, observational cohort of consecutive patients evaluated for chest pain at a large-scale out-of-hours primary care facility in the Netherlands. We evaluated the performance of the Marburg Heart Score (MHS) and INTERCHEST score as stand-alone triage tools and compared them with the current decision support tool, the Netherlands Triage Standard (NTS). The outcomes of interest were: C‑statistics, calibration and diagnostic accuracy for optimised thresholds with major events as the reference standard. Major events are a composite of all-cause mortality and both cardiovascular and non-cardiovascular urgent underlying conditions occurring within 6 weeks of initial contact.

RESULTS

We included 1433 patients, 57.6% women, with a median age of 55.0 years. Major events occurred in 16.4% (n = 235), of which acute coronary syndrome accounted for 6.8% (n = 98). For predicting major events, C‑statistics for the MHS and INTERCHEST score were 0.74 (95% confidence interval: 0.70-0.77) and 0.76 (0.73-0.80), respectively. In comparison, the NTS had a C-statistic of 0.66 (0.62-0.69). All had appropriate calibration. Both scores (at threshold ≥ 2) reduced the number of referrals (with lower false-positive rates) and maintained equal safety compared with the NTS.

CONCLUSION

Diagnostic risk stratification scores for chest pain may also improve telephone triage for major events in out-of-hours primary care, by reducing the number of unnecessary referrals without compromising triage safety. Further validation is warranted.

Evaluation of telephone triage among chest pain patients in out-of-hours primary care in the Netherlands (TRACE)

BACKGROUND

Telephone triage is fully integrated in Dutch out-of-hours primary care (OOH-PC). Patients presenting with chest pain are initially assessed according to a standardized protocol ("Netherlands Triage Standard" [NTS]). Nevertheless, little is known about its (diagnostic) performance, nor on the impact of subsequent clinical judgements made by triage assistants and general practitioners (GPs).

OBJECTIVE

To evaluate the performance of the current NTS chest pain protocol.

METHODS

Observational, retrospective cohort study of adult patients with chest pain who contacted a regional OOH-PC facility in the Netherlands, in 2017. The clinical outcome measure involved the occurrence of a "major event," which is a composite of all-cause mortality and urgent cardiovascular and noncardiovascular conditions, occurring ≤6 weeks of initial contact. We assessed the performance using diagnostic and discriminatory properties.

RESULTS

In total, 1,803 patients were included, median age was 54.0 and 57.5% were female. Major events occurred in 16.2% of patients with complete follow-up, including 99 (6.7%) cases of acute coronary syndrome and 22 (1.5%) fatal events. NTS urgency assessment showed moderate discriminatory abilities for predicting major events (c-statistic 0.66). Overall, NTS performance showed a sensitivity and specificity of 83.0% and 42.4% with a 17.0% underestimated major event rate. Triage assistants' revisions hardly improved urgency allocation. Further consideration of the clinical course following OOH-PC contact did generate a more pronounced improvement with a sensitivity of 89.4% and specificity of 61.9%.

CONCLUSION

Performance of telephone triage of chest pain appears moderate at best, with acceptable safety yet limited efficiency, even after including further work-up by GPs.

Development and validation of a prediction rule for patients suspected of acute coronary syndrome in primary care: a cross-sectional study

OBJECTIVE

To develop and validate a symptom-based prediction rule for early recognition of acute coronary syndrome (ACS) in patients with acute chest discomfort who call out-of-hours services for primary care (OHS-PC).

DESIGN

Cross-sectional study. A diagnostic prediction rule was developed with multivariable regression analyses. All models were validated with internal-external cross validation within seven OHS-PC locations. Both age and sex were analysed as statistical interaction terms, applying for age non-linear effects.

SETTING

Seven OHS-PC in the Netherlands.

PARTICIPANTS

2192 patients who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2017. Backed up recordings of telephone triage conversations were analysed.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Diagnosis of ACS retrieved from the patient's medical records in general practice, including hospital specialists discharge letters. Performance of the prediction rules was calculated with the c-statistic and the final model was chosen based on net benefit analyses.

RESULTS

Among the 2192 patients who called the OHS-PC with acute chest discomfort, 8.3% females and 15.3% males had an ACS. The final diagnostic model included seven predictors (sex, age, acute onset of chest pain lasting less than 12 hours, a pressing/heavy character of the pain, radiation of the pain, sweating and calling at night). It had an adjusted c-statistic of 0.77 (95% CI 0.74 to 0.79) with good calibration.

CONCLUSION

The final prediction model for ACS has good discrimination and calibration and shows promise for replacing the existing telephone triage rules for patients with acute chest discomfort in general practice and OHS-PC.

TRIAL REGISTRATION NUMBER

NTR7331.

Optimising telephone triage of patients calling for acute shortness of breath during out-of-hours primary care: protocol of a multiple methods study (Opticall)

INTRODUCTION

Callers with acute shortness of breath (SOB) are a challenge for telephone triage at out-of-hours primary care (OHS-PC) as SOB could be the sign of a potentially life-threatening disease, yet mostly is a symptom of a broad range of self-limiting disorders. Current telephone triage practice is mainly expert based and clear evidence on accuracy, safety and efficiency of the use of the Netherlands Triage Standard (NTS) by triage nurses based on the eventual clinical outcome is lacking for this domain.

METHODS AND DATA ANALYSIS

Multiple methods study in five OHS-PC services in the Utrecht region, the Netherlands. Data will be collected from OHS-PC electronic health records (EHR) and backed up tapes of telephone triage conversations, which will be linked to routine primary care EHR data. In cross-sectional studies, we will (1) validate the NTS urgency classification for adults with SOB against final diagnoses and (2) develop diagnostic prediction models for urgent diagnoses (eg, composite endpoint of urgent diagnoses, pulmonary embolism, acute coronary syndrome, acute heart failure and pneumonia). We will develop improvement measures for the use of the NTS by triage nurses through practice observations and semistructured interviews with patients, triage nurses and general practitioners (GPs). In an action research approach, we will, in collaboration with these stakeholders, implement and evaluate our findings in both GP and triage nurse educational programmes as well as in OHS-PC services.

ETHICS AND DISSEMINATION

The Medical Ethics Review Committee Utrecht, the Netherlands, approved the study protocol (protocol 21/361). We will take into account the 'code of conduct for responsible research' of the WHO, the EU General Data Protection Regulation and the 'Dutch Medical Treatment Contracts Act'. Results will be disseminated in peer-reviewed publications and at (inter)national meetings.

TRIAL REGISTRATION NUMBER

NL9682.

Atypical asthma in children who present with isolated chest tightness: risk factors and clinical features

OBJECTIVE

Asthmatic children presenting with chest tightness as the only symptom have not been widely recognized. This study attempted to find risk factors, summarize clinical features and offer some suggestions for the diagnosis of this atypical asthma.Methods: We studied 94 children, aged 6 to 14 years, who complained only of chest tightness. Data from clinical manifestations and laboratory tests were analyzed. The atypical asthma group (n = 58) showed positive bronchial challenge tests, and symptoms either improved or resolved in response to the bronchodilator. The control group (n = 36) had negative results on the bronchial challenge, diurnal PEF, and BDR tests, and no response to asthma treatment with bronchodilator.Results: Pollution, weather, recent house renovation, and air-conditioning use may be risk factors for children with atypical asthma. These children had more accompanying symptoms of rhinitis and rhinitis family history (P < 0.05), and a higher positive detection rate of inhaled allergens and multiple sensitizations. Parameters of the pulmonary function test were lower in the atypical asthma group than in the control group, and they also had higher FeNO values. If a cutoff value of improvement in FEV1 of BDR were set at 8.9%, sensitivity would be 48.2%, which is higher than a 12% cutoff.Conclusions: Environmental factors appeared to cause development of the isolated chest tightness symptom. Clinical history and laboratory tests could provide partial values for this diagnosis. In the absence of a bronchial challenge test, a margin of improvement in FEV1 of BDR set at 8.9% may be helpful.

Gender-stratified analyses of symptoms associated with acute coronary syndrome in telephone triage: a cross-sectional study

OBJECTIVES

To identify clinical variables that are associated with the diagnosis acute coronary syndrome (ACS) in women and men with chest discomfort who contact out-of-hours primary care (OHS-PC) by telephone, and to explore whether there are indications whether these variables differ among women and men.

DESIGN

Cross-sectional study in which we compared patient and call characteristics of triage call recordings between women with and without ACS, and men with and without ACS.

SETTING

Nine OHS-PC in the Netherlands.

PARTICIPANTS

993 women and 802 men who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2016.

PRIMARY OUTCOME MEASURE

Diagnosis of ACS retrieved from the patient's medical record in general practice, including hospital specialists' discharge letters.

RESULTS

Among 1795 patients (mean age 58.8 (SD 19.5) years, 55.3% women), 15.0% of men and 8.6% of women had an ACS. In both sexes, retrosternal chest pain was associated with ACS (women with ACS vs without 62.3% vs 40.3%, p=0.002; men with ACS vs without 52.5% vs 39.7%, p=0.032; gender interaction, p=0.323), as was pressing/heavy/tightening pain (women 78.6% vs 61.5%, p=0.011; men 82.1% vs 57.4%, p=<0.001; gender interaction, p=0.368) and radiation to the arm (women 75.6% vs 45.9%, p<0.001; men 56.0% vs 34.8%, p<0.001; gender interaction, p=0.339). Results indicate that only in women were severe pain (65.4% vs 38.1%, p=0.006; gender interaction p=0.007) and radiation to jaw (50.0% vs 22.9%, p=0.007; gender interaction p=0.015) associated with ACS.Ambulances were dispatched equally in women (72.9%) and men with ACS (70.0%).

CONCLUSION

Our results indicate there were more similarities than differences in symptoms associated with the diagnosis ACS for women and men. Important exceptions were pain severity and radiation of pain in women. Whether these differences have an impact on predicting ACS needs to be further investigated with multivariable analyses.

TRIAL REGISTRATION NUMBER

NTR7331.