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North F, Jensen TB, Pecina J, Miller NE, Duvall M, Nelson EM, Thompson MC, Johnson BJ, Crum BA, Stroebel R. Online Self-Triage of Ear or Hearing Concerns in a Patient Portal: Comparison of Subsequent Diagnoses and Hospitalizations to National Emergency Department and National Ambulatory Ear or Hearing Visits. Health Serv Res Manag Epidemiol 2023; 10:23333928231186209. [PMID: 37529764 PMCID: PMC10387706 DOI: 10.1177/23333928231186209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/22/2023] [Accepted: 06/06/2023] [Indexed: 08/03/2023] Open
Abstract
Background Although online self-triage is easily accessible, little is known about the patients who use self-triage or their subsequent diagnoses. We compared ear/hearing self-triage subsequent diagnoses to ear/hearing visit diagnoses in emergency departments (ED) and ambulatory clinics across the United States. Methods We compared International Classification of Diseases version 10 (ICD10) coded diagnoses following online self-triage for ear/hearing concerns with those from national ED and ambulatory clinic samples. We used data from the Centers for Disease Control (CDC) National Hospital Ambulatory Medical Care Survey (NHAMCS) and National Ambulatory Medical Care Survey (NAMCS) for comparison. Using matched ear/hearing diagnostic categories for those aged 1 and over, we compared self-triage diagnosis frequencies with national ED and ambulatory diagnosis frequencies. Results Following ear/hearing self-triage, there were 1092 subsequent office visits with a primary diagnosis code. For five frequently diagnosed ear/hearing conditions (i.e., suppurative and nonsuppurative otitis media [OM], otalgia, otitis externa, and cerumen impaction), there was a strong correlation between diagnosis counts made following self-triage and estimated counts of national ED visit diagnoses (r = 0.94; CI 95% [0.37 to 0.99]; p = .016, adjusted r2 = 0.85). Seven diagnoses were available to compare with the national ambulatory sample; correlation was r = 0.79; CI 95% [0.08 to 0.97]; p = .037, adjusted r2 = 0.54. For ages 1 and over, estimated hospital admissions from the national ED visits for ear/hearing were 0.76%, CI 95% [0.28-2.1%]; estimated total national ear/hearing ED visits were 7.5 million (for 4 years, 2016 through 2019). Conclusion The strong correlation of ear-related self-triage diagnoses with national ED diagnoses and the low hospitalization risk for these diagnoses suggests that there is an opportunity for self-triage of ear/hearing concerns to decrease ED visits for these symptoms.
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Affiliation(s)
- Frederick North
- Department of Medicine, Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN, USA
- Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Teresa B Jensen
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jennifer Pecina
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Michelle Duvall
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elissa M Nelson
- Enterprise Office of Access Management, Mayo Clinic, Rochester, MN, USA
| | | | - Brenda J Johnson
- Enterprise Office of Access Management, Mayo Clinic, Rochester, MN, USA
| | - Brian A Crum
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Robert Stroebel
- Department of Medicine, Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN, USA
- Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
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North F, Jensen TB, Stroebel RJ, Nelson EM, Johnson BJ, Thompson MC, Pecina JL, Crum BA. Self-Triage Use, Subsequent Healthcare Utilization, and Diagnoses: A Retrospective Study of Process and Clinical Outcomes Following Self-Triage and Self-Scheduling for Ear or Hearing Symptoms. Health Serv Res Manag Epidemiol 2023; 10:23333928231168121. [PMID: 37101803 PMCID: PMC10123887 DOI: 10.1177/23333928231168121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
Background Self-triage is becoming more widespread, but little is known about the people who are using online self-triage tools and their outcomes. For self-triage researchers, there are significant barriers to capturing subsequent healthcare outcomes. Our integrated healthcare system was able to capture subsequent healthcare utilization of individuals who used self-triage integrated with self-scheduling of provider visits. Methods We retrospectively examined healthcare utilization and diagnoses after patients had used self-triage and self-scheduling for ear or hearing symptoms. Outcomes and counts of office visits, telemedicine interactions, emergency department visits, and hospitalizations were captured. Diagnosis codes associated with subsequent provider visits were dichotomously categorized as being associated with ear or hearing concerns or not. Nonvisit care encounters of patient-initiated messages, nurse triage calls, and clinical communications were also captured. Results For 2168 self-triage uses, we were able to capture subsequent healthcare encounters within 7 days of the self-triage for 80.5% (1745/2168). In subsequent 1092 office visits with diagnoses, 83.1% (891/1092) of the uses were associated with relevant ear, nose and throat diagnoses. Only 0.24% (4/1662) of patients with captured outcomes were associated with a hospitalization within 7 days. Self-triage resulted in a self-scheduled office visit in 7.2% (126/1745). Office visits resulting from a self-scheduled visit had significantly fewer combined non-visit care encounters per office visit (fewer combined nurse triage calls, patient messages, and clinical communication messages) than office visits that were not self-scheduled (-0.51; 95% CI, -0.72 to -0.29; P < .0001). Conclusion In an appropriate healthcare setting, self-triage outcomes can be captured in a high percentage of uses to examine for safety, patient adherence to recommendations, and efficiency of self-triage. With the ear or hearing self-triage, most uses had subsequent visit diagnoses relevant to ear or hearing, so most patients appeared to be selecting the appropriate self-triage pathway for their symptoms.
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Affiliation(s)
- Frederick North
- Department of Medicine, Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN, USA
- Frederick North, Department of Medicine, Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN 55905, USA.
| | - Teresa B Jensen
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert J Stroebel
- Department of Medicine, Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN, USA
| | - Elissa M Nelson
- Enterprise Office of Access Management, Mayo Clinic, Rochester, MN, USA
| | - Brenda J Johnson
- Enterprise Office of Access Management, Mayo Clinic, Rochester, MN, USA
| | | | | | - Brian A Crum
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Sexton V, Dale J, Bryce C, Barry J, Sellers E, Atherton H. Service use, clinical outcomes and user experience associated with urgent care services that use telephone-based digital triage: a systematic review. BMJ Open 2022; 12:e051569. [PMID: 34980613 PMCID: PMC8724705 DOI: 10.1136/bmjopen-2021-051569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate service use, clinical outcomes and user experience related to telephone-based digital triage in urgent care. DESIGN Systematic review and narrative synthesis. DATA SOURCES Medline, Embase, CINAHL, Web of Science and Scopus were searched for literature published between 1 March 2000 and 1 April 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies of any design investigating patterns of triage advice, wider service use, clinical outcomes and user experience relating to telephone based digital triage in urgent care. DATA EXTRACTION AND SYNTHESIS Two reviewers extracted data and conducted quality assessments using the mixed methods appraisal tool. Narrative synthesis was used to analyse findings. RESULTS Thirty-one studies were included, with the majority being UK based; most investigated nurse-led digital triage (n=26). Eight evaluated the impact on wider healthcare service use following digital triage implementation, typically reporting reduction or no change in service use. Six investigated patient level service use, showing mixed findings relating to patients' adherence with triage advice. Evaluation of clinical outcomes was limited. Four studies reported on hospitalisation rates of digitally triaged patients and highlighted potential triage errors where patients appeared to have not been given sufficiently high urgency advice. Overall, service users reported high levels of satisfaction, in studies of both clinician and non-clinician led digital triage, but with some dissatisfaction over the relevance and number of triage questions. CONCLUSIONS Further research is needed into patient level service use, including patients' adherence with triage advice and how this influences subsequent use of services. Further evaluation of clinical outcomes using larger datasets and comparison of different digital triage systems is needed to explore consistency and safety. The safety and effectiveness of non-clinician led digital triage also needs evaluation. Such evidence should contribute to improvement of digital triage tools and service delivery. PROSPERO REGISTRATION NUMBER CRD42020178500.
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Affiliation(s)
- Vanashree Sexton
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jeremy Dale
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | - Carol Bryce
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | - James Barry
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | - Elizabeth Sellers
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Atherton
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
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Njeru JW, Damodaran S, North F, Jacobson DJ, Wilson PM, St Sauver JL, Radecki Breitkopf C, Wieland ML. Telephone triage utilization among patients with limited English proficiency. BMC Health Serv Res 2017; 17:706. [PMID: 29121920 PMCID: PMC5679138 DOI: 10.1186/s12913-017-2651-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 11/02/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Communication between patients with limited English proficiency (LEP) and telephone triage services has not been previously explored. The purpose of this study was to determine the utilization characteristics of a primary care triage call center by patients with LEP. METHODS This was a retrospective cohort study of the utilization of a computer-aided, nurse-led telephone triage system by English proficiency status of patients empaneled to a large primary care practice network in the Midwest United States. Interpreter Services (IS) need was used as a proxy for LEP. RESULTS Call volumes between the 587 adult patients with LEP and an age-frequency matched cohort of English-Proficient (EP) patients were similar. Calls from patients with LEP were longer and more often made by a surrogate. Patients with LEP received recommendations for higher acuity care more frequently (49.4% versus 39.0%; P < 0.0004), and disagreed with recommendations more frequently (30.1% versus 20.9%; P = 0.0004). These associations remained after adjustment for comorbidities. Patients with LEP were also less likely to follow recommendations (60.9% versus 69.4%; P = 0.0029), even after adjusting for confounders (adjusted odds ratio [AOR] = 0.65; 95% confidence interval [CI], 0.49, 0.85; P < 0.001). CONCLUSION Patients with LEP who utilized a computer-aided, nurse-led telephone triage system were more likely to receive recommendations for higher acuity care compared to EP patients. They were also less likely to agree with, or follow, recommendations given. Additional research is needed to better understand how telephone triage can better serve patients with LEP.
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Affiliation(s)
- Jane W Njeru
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Swathi Damodaran
- Mayo Medical School, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Frederick North
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Debra J Jacobson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Rochester, MN, USA
| | - Patrick M Wilson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Rochester, MN, USA
| | - Jennifer L St Sauver
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | | | - Mark L Wieland
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Turbitt E, Freed GL. Use of a telenursing triage service by Victorian parents attending the emergency department for their child's lower urgency condition. Emerg Med Australas 2015; 27:558-562. [DOI: 10.1111/1742-6723.12477] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2015] [Indexed: 01/31/2023]
Affiliation(s)
- Erin Turbitt
- Centre for Health Policy, Melbourne School of Population and Global Health; The University of Melbourne; Melbourne Victoria Australia
| | - Gary L Freed
- Centre for Health Policy, Melbourne School of Population and Global Health; The University of Melbourne; Melbourne Victoria Australia
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Wheeler SQ, Greenberg ME, Mahlmeister L, Wolfe N. Safety of clinical and non-clinical decision makers in telephone triage: a narrative review. J Telemed Telecare 2015; 21:305-22. [PMID: 25761468 DOI: 10.1177/1357633x15571650] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 11/20/2014] [Indexed: 11/17/2022]
Abstract
Patient safety is a persistent problem in telephone triage research; however, studies have not differentiated between clinicians' and non-clinicians' respective safety. Currently, four groups of decision makers perform aspects of telephone triage: clinicians (physicians, nurses), and non-clinicians (emergency medical dispatchers (EMD) and clerical staff). Using studies published between 2002-2012, we applied Donabedian's structure-process-outcome model to examine groups' systems for evidence of system completeness (a minimum measure of structure and quality). We defined system completeness as the presence of a decision maker and four additional components: guidelines, documentation, training, and standards. Defining safety as appropriate referrals (AR) - (right time, right place with the right person), we measured each groups' corresponding AR rate percentages (outcomes). We analyzed each group's respective decision-making process as a safe match to the telephone triage task, based on each group's system structure completeness, process and AR rates (outcome). Studies uniformly noted system component presence: nurses (2-4), physicians (1), EMDs (2), clerical staff (1). Nurses had the highest average appropriate referral (AR) rates (91%), physicians' AR (82% average). Clerical staff had no system and did not perform telephone triage by standard definitions; EMDs may represent the use of the wrong system. Telephone triage appears least safe after hours when decision makers with the least complete systems (physicians, clerical staff) typically manage calls. At minimum, telephone triage decision makers should be clinicians; however, clinicians' safety calls for improvement. With improved training, standards and CDSS quality, the 24/7 clinical call center has potential to represent the national standard.
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Affiliation(s)
- Sheila Q Wheeler
- Assistant Clinical Professor Northern Arizona University 3895 N. Business Center Dr. Ste 120 Tucson, Arizona 85705, USA
| | - Mary E Greenberg
- President, Mahlmeister and Associates Clinical Professor University of California San Francisco San Francisco, California 1567 Winding Way Belmont, California 94002, USA
| | | | - Nicole Wolfe
- Department of Social and Behavioral Sciences 3333 California St, Suite 455 San Francisco, CA 94118, USA
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North F, Crane SJ, Stroebel RJ, Cha SS, Edell ES, Tulledge-Scheitel SM. Patient-generated secure messages and eVisits on a patient portal: are patients at risk? J Am Med Inform Assoc 2013; 20:1143-9. [PMID: 23703826 DOI: 10.1136/amiajnl-2012-001208] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Patient portals are becoming increasingly common, but the safety of patient messages and eVisits has not been well studied. Unlike patient-to-nurse telephonic communication, patient messages and eVisits involve an asynchronous process that could be hazardous if patients were using it for time-sensitive symptoms such as chest pain or dyspnea. METHODS We retrospectively analyzed 7322 messages (6430 secure messages and 892 eVisits). To assess the overall risk associated with the messages, we looked for deaths within 30 days of the message and hospitalizations and emergency department (ED) visits within 7 days following the message. We also examined message content for symptoms of chest pain, breathing concerns, and other symptoms associated with high risk. RESULTS Two deaths occurred within 30 days of a patient-generated message, but were not related to the message. There were six hospitalizations related to a previous secure message (0.09% of secure messages), and two hospitalizations related to a previous eVisit (0.22% of eVisits). High-risk symptoms were present in 3.5% of messages but a subject line search to identify these high-risk messages had a sensitivity of only 15% and a positive predictive value of 29%. CONCLUSIONS Patients use portal messages 3.5% of the time for potentially high-risk symptoms of chest pain, breathing concerns, abdominal pain, palpitations, lightheadedness, and vomiting. Death, hospitalization, or an ED visit was an infrequent outcome following a secure message or eVisit. Screening the message subject line for high-risk symptoms was not successful in identifying high-risk message content.
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Affiliation(s)
- Frederick North
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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North F, Ward WJ, Varkey P, Tulledge-Scheitel SM. Should you search the Internet for information about your acute symptom? Telemed J E Health 2012; 18:213-8. [PMID: 22364307 DOI: 10.1089/tmj.2011.0127] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine if symptom-related Web sites give sufficient information for users to seek urgent care when warranted. MATERIALS AND METHODS We reviewed 120 Web sites (15 sites for each of eight acute symptoms). Symptom-related sites were identified with Google, Yahoo!®, and Bing™ searches and focused on potentially hazardous symptoms such as chest pain, shortness of breath, abdominal pain, and syncope. We reviewed each symptom-related site for the presence of critical symptom indicators (key symptom characteristics and associated factors) that triage the user to urgent care. RESULTS Of the 120 sites reviewed, 41 (33%) contained no critical symptom indicators. No site contained a complete set of critical symptom indicators. Overall, out of the 1,020 total critical symptoms searched for in the sites, we only found 329 (32%). When present, critical symptom indicators were found on the top half of the first page of the site in only 34%. Specific recommendations for further care were absent in 42% of the cases where critical symptom indicators were identified. CONCLUSIONS Symptom-related sites ranked highly by major search engines lack much of the information needed to make a decision about whether a symptom needs urgent attention. When present, this information is usually not located where users can rapidly access it and often lacks prescriptive guidance for users to seek care. Until more sites contain at least minimal triage advice, relying on an Internet search to help determine the urgency of a symptom could be risky.
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Affiliation(s)
- Frederick North
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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North F, Odunukan O, Varkey P. The value of telephone triage for patients with appendicitis. J Telemed Telecare 2011; 17:417-20. [PMID: 22052965 DOI: 10.1258/jtt.2011.110301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although it has been assumed that telephone triage can directly benefit patients by facilitating early diagnosis and treatment, this potential benefit has not been well documented. Using appendicitis cases ascertained from claims data, we compared telephone triage recommendations with what the callers originally intended to do. Over a two-year period, there were 20,230 calls to a telephone triage centre in the US where insurance information was available. Of these, 12,709 calls (63%) had insurance claims made within seven days of the call. Among these calls, 46 had a diagnosis of appendicitis. In 72% of calls concerning appendicitis, the telephone triage recommendation was for a more rapid evaluation than the caller originally intended (P < 0.0001). In 91% of the appendicitis cases, triage nurses directed callers to care within 8 h, but without triage advice, only 39% of callers stated they would have sought care within 8 h (P < 0.0001). Telephone triage significantly reduced the delay in care for appendicitis in comparison with what the caller would have done. This suggests that telephone triage potentially reduces the morbidity associated with appendicitis.
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Affiliation(s)
- Frederick North
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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North F, Varkey P, Laing B, Cha SS, Tulledge-Scheitel S. Are e-health web users looking for different symptom information than callers to triage centers? Telemed J E Health 2011; 17:19-24. [PMID: 21214306 DOI: 10.1089/tmj.2010.0120] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Telemedicine options for symptom assessment include both telephonic means (call centers) and Internet sites. Although symptom assessment call centers have been available for decades, symptom assessment over the Internet is relatively new. It is not well known what types of symptoms Internet users are seeking assessment for and whether extant telephone triage algorithms would be applicable to Internet users. METHODS Symptom assessments on a heavily used Internet site (MayoClinic.com) were compared with symptom calls to a U.S. call center (Ask Mayo Clinic). RESULTS Internet users sought symptom assessments about adult symptoms 13 times more often than children's symptoms. In contrast, over the telephone, adult symptoms were addressed 2.1 times more frequently than children's symptoms. Despite the differences in frequencies of adult and child symptom assessments, users of the Internet and telephone callers asked about specific symptoms with similar relative frequencies. Analysis of 20 adult symptom types shared by the Web and call center revealed that by excluding only 2 assessments (nasal symptoms and leg pain) the remaining 18 showed a significant correlation in counts of use (r(2) = 0.68, p < 0.001 for linear trend). CONCLUSIONS Internet users have symptoms assessed in similar proportions to callers, with a few exceptions. Compared with callers, Web users are much more likely looking for information about adult symptoms. Callers are proportionally asking more about acute symptoms, whereas Internet users appear more interested in symptom assessment of chronic conditions.
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Affiliation(s)
- Frederick North
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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