Pediatric telephone call centers: how do they affect health care use and costs?

Distances to emergency departments and non-urgent utilization of medical services: a systematic review

BACKGROUND

The use of Emergency Departments (EDs) for non-urgent medical conditions is a global public health concern.

OBJECTIVES

A systematic review, guided by a registered protocol (PROSPERO: CRD42023398674), was conducted to interpret the association between distance as a measure of healthcare access and the utilization of EDs for non-urgent care in high- and middle-income countries.

METHODS

The search was conducted on 22 August 2023 across five databases using controlled vocabulary and natural language keywords. Eligibility criteria included studies that examined non-urgent care, and featured concepts of emergency departments, non-urgent health services and distance, reported in English. Articles and abstracts where patients were transported by ambulance/paramedic services, referred/transferred from another hospital to an ED, or those that measured distance to an ED from another health facility were excluded. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework informed the quality of evidence.

RESULTS

Fifteen articles met the inclusion criteria. All studies demonstrated satisfactory quality with regard to study design, conduct, analysis and presentation of results. Eight (53.3%) of the studies (1 paediatric, 4 all ages/adult, 3 ecological) found a moderate level of evidence of an inverse association between distance and ED visit volume or utilization for non-urgent medical conditions, while the remaining studies reported very low or low evidence.

CONCLUSIONS

Half of the studies reported non-urgent ED use to be associated with shortest distance traveled or transportation time. This finding bears implications for healthcare policies aiming to reduce ED use for non-urgent care.

Reducing post-operative caregiver after-hours phone calls to pediatric urology providers: A quality improvement study

INTRODUCTION

Caregiver phone calls are an important part of caring for pediatric patients. At our institution, residents respond to after-hours caregiver calls. While it is critical for families to be able to reach us for urgent concerns, the ease of access has led to overutilization with many phone calls not meeting the urgent nature that is intended for these calls. The primary aim of this quality improvement project was to decrease the number of non-urgent caregiver calls after-hours. Our secondary aim was to improve compliance with telephone encounter documentation and to standardize the documentation content.

STUDY DESIGN

We conducted a single institution, multiphase quality improvement project. This started with a preintervention phase which included evaluation of our current state, identifying that most calls were for post-operative patients and that our discharge instructions inadequately detailed when caregivers should call. Notes were also inconsistently documented with no standard format. In the first PDSA cycle, launched on November 1, 2021, a standardized note template was created for documentation of caregiver telephone encounters. The PDSA cycle began on January 1, 2022 and included updates to our post-operative instructions with explicit guidance detailing when to call after-hours. Call data from September 2021 to February 2022 was reviewed including variables such as caller demographics, reason for call, and operative details. Primary outcomes were proportion of post-operative calls within 30 days and non-urgent calls. Secondary outcome was proportion of calls documented appropriately. Phases were categorized as current state (Sep/Oct 2021), PDSA cycle 1 (Nov/Dec 2021), PDSA cycle 2 (Jan/Feb 2022).

RESULTS

In our current state, the majority of the calls (66%) were for post-operative patients and 59% of all calls during this period were non-urgent. The proportion of post-operative phone calls stayed stable at 67% during PDSA cycle 1, but decreased to 38% with PDSA cycle 2 with implementation of updated post-operative instructions (Summary figure) (p < 0.001). The proportion of non-urgent calls was similar (current state - 68%, PDSA cycle 1 - 72%, PDSA cycle 2-73%, p = 0.39) (Summary figure). Call documentation was also similar with a documentation rate of 79% pre-intervention and 87% post-intervention (p = 0.21) (Summary figure).

CONCLUSIONS

With interventions focused on post-operative caregiver instructions, the number of post-operative phone calls decreased. Standardization of documentation was achieved. However, the overall call volume did not change, nor the proportion of non-urgent calls.

Video triage in calls concerning children with fever at an out-of-hours medical helpline: a prospective quality improvement study

BACKGROUND

Parents often contact out-of-hours services due to worry concerning febrile children, despite the children rarely being severely ill. As telephone triage of children is challenging, many children are referred to hospital assessment. This study investigated if video triage resulted in more children staying at home. Secondary aims included safety, acceptability and feasibility of this new triage tool.

METHODS

In this prospective quality improvement study, nurse call-handlers enrolled febrile children aged 3 months-5 years to video or telephone triage (1:1), with follow-up within 48 h after call. The setting was an out-of-hours call-center for non-urgent illness in Copenhagen, Denmark, receiving over 1 million calls annually and predominately staffed by registered nurses. Main outcome measure was difference in number of children assessed at hospital within 8 h after call between video-and telephone triage group. Rates of feasibility, acceptability and safety (death, lasting means, transfer to intensive care unit) were compared between the triage groups.

RESULTS

There was no difference in triage outcome (home care vs. hospital referral) or number of patients assessed at hospital between triage groups. However, more video triaged patients received in-hospital treatment, testing and hospitalization.

CONCLUSION

Video triage was feasible to conduct, acceptable to parents and as safe as telephone triage. The study did not show that more children stayed at home after video triage, possibly because the allocation strategy was not upheld, as video triage sometimes was chosen in cases of complex and severe symptoms, and this likely has changed study outcome.

TRIAL REGISTRATION

Clinicaltrials.gov.: Id NCT04074239. Registered 2019-08-30. https://clinicaltrials.gov/ct2/show/study/NCT04074239.

"EM Doc On Call:" A Pilot Study to Improve Interhospital Transfers in Rwanda

INTRODUCTION

Treatment of seriously ill patients is often complicated by prolonged or complex transfers between hospitals in sub-Saharan Africa. Difficulties or inefficiency in these transfers can lead to poor outcomes for patients. "On-call" triage systems have been utilized to facilitate communication between facilities and to avoid poor outcomes associated with patient transfer. This study attempts to examine the effects of a pilot study to implement such a system in Rwanda.

METHODS

Data collection occurred prospectively in two stages, pre-intervention and intervention, in the emergency department (ED) at Kigali University Teaching Hospital (CHUK). All patients transferred during the pre-determined timeframe were enrolled. Data were collected by ED research staff via a standardized form. Statistical analysis was performed using STATA version 15.0. Differences in characteristics were assessed using χ2 or Fisher's exact tests for categorical variables and independent sample t-tests for normally distributed continuous variables.

RESULTS

During the "on call" physician intervention, the indication for transfer was significantly more likely to be for critical care (P <.001), transfer times were faster (P <.001), patients were more likely to be displaying emergency signs (P <.001), and vital signs were more likely to be collected prior to transport (P <.001) when compared to the pre-interventional phase.

CONCLUSION

The "[Emergency Medicine] EM Doc On Call" intervention was associated with improved timely interhospital transfer and clinical documentation in Rwanda. While these data are not definitive due to multiple limitations, it is extremely promising and worthy of further study.

Improving Utilization of an After-Hours Phone Triage Service: A Resident Quality Improvement Initiative

BACKGROUND/OBJECTIVE

Phone triage systems are increasingly used by primary care clinics to improve patient satisfaction and direct low-acuity patients to appropriate care settings. Despite the prevalence of telephone triage, the majority of pediatric training programs do not include this practice in their curricula. Our aim was to increase the volume of after-hours patient phone calls per week by 25% and to secondarily reduce "treat and release" emergency department (ED) visits by 5% over the course of a 9-month quality improvement (QI) study.

METHODS

A resident-led QI project was conducted from 2017 to 2019 at a mixed faculty-resident pediatric primary care practice providing care for an urban, primarily immigrant, underserved population. Eight Plan-Do-Study-Act cycles were developed on the basis of identified key drivers and included efforts to increase the visibility of the call service to patient families. After-hours calls were tracked and compared with similar practices, and ED visits for the first week of each month were reviewed using the electronic medical record system.

RESULTS

After promoting the service via various modalities, the number of after-hours calls increased by 30%, from an average of 6.5 calls per week to 8.5. Treat and release ED visits decreased by 6%, from a baseline of 64.3 to 60.3 visits per week.

CONCLUSIONS

The increased patient awareness of and availability of a reliable after-hours call service in pediatric practices are promising tools for reducing unnecessary ED visits, leveraging resident direction and implementation to promote the service through varying modalities.

Office "Phone First" Systems Reduce Emergency Department/Urgent Care Utilization by Medicaid-Enrolled Children

BACKGROUND

Emergency department and urgent care (ED/UC) visits for common conditions can be more expensive with less continuity than office care provided by primary care physicians.

METHODS

We used quality-improvement methods to enhance telephone triage for pediatric patients by adding additional "Phone First" services including: 1) enhanced office-hours telephone triage and advice with available same-day appointments, 2) follow-up calls to parents of children self-referred to an ED/UC, and 3) parent education to telephone the office for advice prior to seeking acute care. We hypothesized that enhanced office services would reduce ED/UC utilization and cost. We compared changes in ED/UC encounter rates between intervention and regional practices for 4 years (2014-2017) using general linear models, and evaluated balancing measures (after-hour phone calls, acute care phone calls, acute care visits, well child visits) for Medicaid-enrolled and commercially-insured children.

RESULTS

The study practices dramatically increased office-hours acute care phone triage and advice which correlated with 23.8% to 80.5% (P < 0.001) reductions in ED/UC rates for Medicaid-enrolled children. Office acute care visits decreased modestly. ED/UC visits did not decrease for children in the comparison region. In phone surveys, 94% of parents indicated satisfaction with the ED/UC follow-up call. The decrease in ED/UC visits resulted in an estimated annual cost of care savings for Medicaid-enrolled children in 2017 of $12.61 per member per month which projected to $169 million cost of care savings in Colorado and $6.8 billion in the United States.

CONCLUSION

"Phone First" services in pediatric practices during office-hours reduced ED/UC encounters and cost of care for Medicaid-enrolled children.

Régulation médicale de la dyspnée de l’enfant : intérêt d’une régulation pédiatrique

Introduction :L’évaluation téléphonique du patient pédiatrique peut être difficile à la régulation médicale du Samu-Centre 15 (aide médicale urgente [AMU] ou permanence de soins [PDS]). La dyspnée est un motif d’appel fréquent dans cette population et présente des particularités importantes comparée à la population adulte. Nous avons voulu évaluer la pertinence de l’évaluation téléphonique de la dyspnée en pédiatrie selon la qualification du médecin régulateur (urgentiste, généraliste ou pédiatre).

Matériel et méthode :Il s’agit d’une étude observationnelle rétrospective monocentrique menée au Samu de Haute-Garonne entre le 1er décembre 2018 au 31 janvier 2019. Les critères d’inclusion étaient un appel pour tout patient avec un âge inférieur à dix ans pour dyspnée. Le critère de jugement principal était le surtriage.

Résultats : Nous avons analysé 717 appels pour dyspnée pédiatrique sur la période. La non-adéquation entre la décision médicale et le devenir du patient était retrouvée chez 174 patients (24 %) : 173 patients (99 %) étaient surtriés et un patient était sous-trié (< 1 %). En analyse multivariée, les facteurs protecteurs de surtriage étaient l’âge de six mois à trois ans (OR = 0,56 ; IC 95 % = [0,36–0,86]) comparé à un âge jeune (≤ 6 mois ; référence) et l’évaluation par un régulateur de PDS (OR = 0,38 ; IC 95 % = [0,23–0,62]) ou pédiatre (OR = 0,54 ; IC 95 % = [0,34–0,86]) comparé à un régulateur de l’AMU (référence). L’appel nocturne était un facteur de risque de surtriage (OR = 1,98 ; IC 95 % = [1,39–2,84]).

Conclusion : La régulation par un pédiatre ou un médecin de la PDS permet de réduire le surtriage dans un centre où les régulateurs AMU n’ont pas d’activité pédiatrique clinique.

Calling an Oncological Emergency Telephone to Seek Advice: An Interview Study

BACKGROUND

Cancer treatment is increasingly provided on an outpatient basis, which may challenge patients and caregivers coping with illness and adverse effects at home. A telephone consultation is an accepted type of healthcare provision to support patients and prevent adverse outcomes when their capacity to self-manage is inadequate. Whether this option for help sufficiently supports patients needs further investigation.

OBJECTIVES

The aim of this study was to explore patients' and caregivers' experience of calling an oncological emergency telephone.

METHODS

The study applies a phenomenological hermeneutic approach with 12 semistructured interviews. Patients and caregivers who had called the oncological emergency telephone within the last 2 months were included. The interview texts were analyzed by content analysis.

RESULTS

Patients and caregivers perceive the emergency telephone as a lifeline that they consider calling when the patient's condition changes from what they understand as normal to what they perceive as abnormal. They would rather call "one time too many than one time too few" if their resources are inadequate to ensure their safety. The tone, attitude, and professional competency of healthcare providers affect patients' experience of the call.

CONCLUSIONS

The value of calling the oncological emergency telephone depends on the healthcare providers' professional competences and skills to establish a relationship that makes patients feeling accommodated and taken care of.

IMPLICATIONS FOR PRACTICE

Patients' and caregivers' perceptions of what constitutes a good telephone consultation represent significant knowledge that contributes to a more comprehensive and practice-based understanding of what is required to advise patients and caregivers in an oncological emergency telephone.

Tele-Triage Outcomes For Patients With Chest Pain: Comparing Physicians And Registered Nurses

We took advantage of a change in protocol in an integrated delivery system's telephone consultation service-routing callers complaining of chest pain to physicians instead of registered nurses, whenever feasible-to explore whether tele-triage outcomes differed by staffing type. Comparing outcomes of 11,315 physician-directed calls to those of an equal number of nurse-directed calls in 2013, we found that the physician-directed calls were briefer (eight minutes versus thirteen minutes), produced fewer ED referrals (10 percent versus 16 percent), and resulted in higher patient adherence to the providers' site-of-care recommendation (86 percent versus 82 percent). Mortality rates at seven days were low for both physician- and nurse-directed calls (0.1 percent). We suspect that providers' immediate access to callers' comprehensive electronic health records and patients' rapid access to outpatient care likely contributed to the program's success. Our findings suggest that tele-triage can be used to safely and effectively manage an emergent complaint, and that physicians' expertise may bring additional efficiency to the process.

Telephone triage utilization among patients with limited English proficiency

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.

Telephone counselling by nurses in Norwegian primary care out-of-hours services: a cross-sectional study

Background

The primary care out-of-hours (OOH) services in Norway are characterized by high contact rates by telephone. The telephone contacts are handled by local emergency medical communication centres (LEMCs), mainly staffed by registered nurses. When assessment by a medical doctor is not required, the nurse often handles the contact solely by nurse telephone counselling. Little is known about this group of contacts. Thus, the aim of this study was to investigate characteristics of encounters with the OOH services that are handled solely by nurse telephone counselling.

Methods

Nurses recorded ICPC-2 reason for encounter (RFE) codes and patient characteristics of all patients who contacted six primary care OOH services in Norway during 2014. Descriptive statistics and frequency analyses were applied.

Results

Of all telephone contacts (n = 61,441), 23% were handled solely by nurse counselling. Fever was the RFE most frequently handled (7.3% of all nurse advice), followed by abdominal pain, cough, ear pain and general symptoms. Among the youngest patients, 32% of the total telephone contacts were resolved by nurse advice compared with 17% in the oldest age group. At night, 31% of the total telephone contacts were resolved solely by nurse advice compared with 21% during the day shift and 23% in the evening. The share of nurse advice was higher on weekdays compared to weekends (mean share 25% versus 20% respectively).

Conclusion

This study shows that nurses make a significant contribution to patient management in the Norwegian OOH services. The findings indicate which conditions nurses should be able to handle by telephone, which has implications for training and routines in the LEMCs. There is the potential for more nurse involvement in several of the RFEs with a currently low share of nurse counselling.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0651-z) contains supplementary material, which is available to authorized users.

Mapeamento do perfil de demanda inadequada nos serviços de saúde pública no Brasil

RESUMO Este artigo investiga o perfil de uso inadequado em serviços de saúde pública no Brasil, através da análise das características do usuário e das circunstâncias de atendimento de usuários de call centers. São utilizadas informações de centrais de aconselhamento médico por telefone. Um modelo de regressão logística binária é proposto para estimar as relações entre o perfil do usuário, as circunstâncias de atendimento e a demanda inadequada. Impactaram significativamente para a probabilidade de demanda inadequada a maior complexidade da intenção inicial do usuário e o uso do sistema de serviço de saúde nas horas finais do dia.

Pursuit of Value in Connected Healthcare

INTRODUCTION

Potential for direct patient care through remote exchange of health-related information has expanded enormously with the proliferation of technologies leveraging ubiquitous connectivity, but implementation of connected care has been slow and controversial.

MATERIALS AND METHODS

This review demonstrates that controversy regarding connected care arises largely from the fact that proponents and critics are generally considering distinctly different care models. Differences are highlighted to mitigate controversy and to distinguish capacities of these different models.

RESULTS

Distinguishing capacities is essential for establishing the evidence base supporting safety, effectiveness, and efficiency. In care of a particular patient's problem, value is achieved when resources allocated meet requirements for diagnosis and intervention but do not exceed them. Robust evidence supports the value of some well-defined connected care models, exemplified by the Health-e-Access Telemedicine Model.

CONCLUSIONS

The pursuit of value in connected care is fundamentally the same as with in-person care. Provider organizations, legislators, regulators, and payers face not only a complex task in defining standards and enabling appropriate use, but also a heavy burden of responsibility for unleashing connected care that will benefit the entire community.

Efficacy of a "contact center-based communication" in optimizing the care of inflammatory bowel diseases

BACKGROUND

Telephone helplines are a useful vehicle for the management of chronic diseases even though data on how these can ease management of inflammatory bowel disease (IBD) is still scarce.

AIM

to analyze our two-years' experience with the first telephone helpline dedicated to IBD in Italy.

METHODS

The main outcomes of using a contact center (CC) at our Unit were analyzed; all data was prospectively collected. Patients' requests were classified into medical or non-medical. The percentage of hospitalized patients in the pre-CC period was compared to that after CC activation, to assess the potential clinical gain of using CC. The calls were divided into 5 categories to evaluate a potential correlation between patients' number of calls and risk of hospitalization.

RESULTS

The CC received 11,080 calls and handled 11,972 requests. In particular, 63% of patients phoned monthly for a medical consultation, and 37% called for non-medical reasons. In 2012, the followed-up patients were 1658 with 230 IBD-caused hospitalizations (14%); in 2014, the followed-up patients were 1962 with 182 hospitalizations (9%) (p<0.01). The risk of hospitalization exponentially increased with the number of calls: from 3% for 0-5 calls to 41% with >30 calls (p<0.01).

CONCLUSION

A dedicated CC could provide additional clinical gain, care, and support for IBD patients.

Nonurgent Use of the Emergency Department by Pediatric Patients: A Theory-Guided Approach for Primary and Acute Care Pediatric Nurse Practitioners

Providing quality, cost-effective care to children and their families in the appropriate setting is the goal of nurse practitioners in primary and acute care. However, increased utilization of the emergency department (ED) for nonurgent care threatens cost-effective quality care, interrupts continuity of care, and contributes to ED overcrowding. To date, descriptive research has identified demographics of those using the ED for nonurgent care, the chief complaints of children seeking nonurgent care, the cost to the health care system of pediatric nonurgent care, and characteristics of associated primary care settings. Using Donabedian's Model of Quality of Healthcare and a Theory of Dependent Care by Taylor and colleagues, acute and primary care pediatric nurse practitioners can incorporate interventions that will channel care to the appropriate setting and educate caregivers regarding common childhood illnesses and the value of continuity of care. By using a theoretical framework as a guide, this article will help both acute and primary care pediatric nurse practitioners understand why parents seek nonurgent care for their children in the ED and actions they can take to ensure that care is provided in an optimal setting.

Methodological challenges collecting parent phone-call healthcare utilization data

Recommendations by the National Institute of Nursing Research and other groups have strongly encouraged nurses to pay greater attention to cost-effectiveness analysis when conducting research. Given the increasing prominence of translational science and comparative effective research, cost-effective analysis has become a basic tool in determining intervention value in research. Tracking phone-call communication (number of calls and context) with cross-checks between parents and healthcare providers is an example of this type of healthcare utilization data collection. This article identifies some methodological challenges that have emerged in the process of collecting this type of data in a randomized controlled trial: Parent education Through Simulation-Diabetes (PETS-D). We also describe ways in which those challenges have been addressed with comparison data results, and make recommendations for future research.

Enhancing Care Coordination Through Patient- and Family-Initiated Telephone Encounters: A Quality Improvement Project

Telehealth activities are often conducted by ambulatory nurses to assist with care coordination; these activities are especially important for children with complex, chronic conditions. This quality-improvement project examines specific components of nursing care delivered to children on the neurology and gastroenterology services through patient-initiated telephone encounters. Metrics and nurse-sensitive indicators explored include the type of services requested, the nurses' ability to resolve patients' concerns while eliminating otherwise unnecessary care, and associated costs with providing this care. The usefulness of a standardized instrument, the care coordination management tool, used in this project is discussed.

Performance analysis and improvement of a typical telephone response system of VA hospitals

Purpose

– Telephone response system is the frontline of hospital operations. The purpose of this paper is to analyze a representative telephone response system of Veterans Affairs (VA) hospitals, address the existing inefficiency issues such as long call waiting time, and improve system resilience to changes.

Design/methodology/approach

– Resource sharing schemes are proposed to improve the system performance in answering calls related to appointment booking and medication renewal. Discrete event simulation is adopted to model the current system and the resource sharing schemes.

Findings

– The resource sharing schemes dramatically improve system performance reflected by the decrease of call waiting time and queue, as well as the extreme high utilization of agents in a key unit. Compared with the less desired alternative of hiring additional employees to mitigate the performance issues, the resource sharing schemes perform at par or even better. Sharing more resource during the peak hours can further balance the agent workload.

Practical implications

– The resource sharing schemes could alleviate staffing shortage, long waiting time, and high-abandonment rate in the bottle-beck unit of the system, and lead to better utilization of scarce resources on the hospital floor. The concept reflects localized centralization efforts in traditionally highly decentralized telephone operations in hospital systems.

Originality/value

– This research provides a structured approach to analyze the operations of a VA telephone response system. The developed simulation model is validated, and this provides a valuable tool for management to analyze the complicated telephone operations of the telephone systems of other VA and non-VA hospitals. Resource sharing constitutes a cost-effective solution for improving system performance and resilience.

Attributes and circumstances that induce inappropriate health services demand: a study of the health sector in Brazil

Background

The current economic and social context has required health systems to provide top quality services and to be efficient in controlling costs. An obstacle to achieve these goals is the inappropriate health services demand. This study aims to present these inappropriate health service demand determinants from data on telephone calls made to a medical advice call centre.

Methods

This study used a Brazilian medical advice call centre data sample in the period of November and December 2012 (n = 19690), which supplied data on the user’s initial request, the physician’s recommendation, information on the patient and circumstances (the day and time of the day of the telephone call). The convergence between user intent and medical recommendation consists in adequate demand; otherwise the divergence consists in an inadequate one. In this way, using a logistic regression model, the critical factors that determine inappropriate health services request could be estimated.

Results

In general, the user’s initial intent is the most critical for the inappropriate health system demand occurrence: the greater the complexity of the patient’s initial intent, the greater the chance the intent is wrong: (OR: 1.160; 95% CI: 1.113-1.210). With regard to the social characteristics, men are more likely to make inappropriate requests (OR: 1.102; 95% CI: 1038-1169); as well as youngsters are more likely to use the system incorrectly (OR = .993; 95% CI: .992 - .994). Regarding the circumstances (day and time of the call), requests in the final hours of the day and on days close to the weekend are more likely to be the inappropriate ones (OR: 1.082 for each six hour increase; 95% CI: 1.049-1.116) and weekday (OR: 1.017 for each day increase; 95% CI: 1.002-1.032).

Conclusions

The critical profile for the inappropriate use occurrence consists of males and youngsters, who use the health service in the final hours of the day and at weekends, and mainly want to use more complex services. A practical implication of this research is to provide health systems managers, supporting information to the most critical users in order to assist them in making a decision when asking for health care.

Association between enhanced access services in pediatric primary care and utilization of emergency departments: a national parent survey

OBJECTIVES

To measure the prevalence of enhanced access services in pediatric primary care and to assess whether enhanced access services are associated with lower emergency department (ED) utilization.

STUDY DESIGN

Internet-based survey of a national sample of parents (n = 820, response rate 41%). We estimated the prevalence of reported enhanced access services and ED use in the prior 12 months. We then used multivariable negative binomial regression to assess associations between enhanced access services and ED use.

RESULTS

The majority of parents reported access to advice by telephone during office hours (80%), same-day sick visits (79%), and advice by telephone outside office hours (54%). Less than one-half of parents reported access to their child's primary care office on weekends (47%), after 5:00 p.m. on any night (23%), or by email (13%). Substantial proportions of parents reported that they did not know if these services were available (7%-56%, depending on service). Office hours after 5:00 p.m. on ≥ 5 nights a week was the only service significantly associated with ED utilization in multivariable analysis (adjusted incidence rate ratio: 0.51 [95% CI 0.28-0.92]).

CONCLUSIONS

The majority of parents report enhanced access to their child's primary care office during office hours, but many parents do not have access or do not know if they have access outside of regular office hours. Extended office hours may be the most effective practice change to reduce ED use. Primary care practices should prioritize the most effective enhanced access services and communicate existing services to families.

[Paediatric emergency triage in Spanish primary care using mobile phones. Analysis of a model in a health area]

OBJECTIVES

To conduct a pilot study of telephone consultation in the paediatric population of an urban health centre. To evaluate the telephone consultation as an effective tool when it comes to exercising prior triage of patients requiring urgent attention.

MATERIAL AND METHODS

The study was conducted in two phases. In the first, data were collected from all calls received for six months. In a second phase, we conducted a telephone intervention study to analyse what a random sample of users remembered of the care provided. All those who requested a telephone consultation were included in the study. Demographic, social-welfare, epidemiological, and clinical features, of each patient were recorded. Data were processed using a statistical package SPSS version 17.0 for Windows.

RESULTS

There were 439 telephone inquiries in our pilot project, of which 35.1% were attended by residents, 36% by paediatricians, and 28.9% by paediatric nurses. There were more telephone calls in the afternoons and on weekends. Patients less than or equal to 2 years accounted for 57.9% of cases handled, and there were no differences between sexes. The most frequent reasons for consultation were gastrointestinal symptoms, fever and respiratory problems. The health problem was resolved in 85.8% of cases, requiring only home care instructions, and only 13.3% of children were referred to emergency services. We obtained a mean score of satisfaction of 9.2.

CONCLUSIONS

The pilot project had a high level of satisfaction and resolution, demonstrating cost savings by reducing 55% of face to face visits, with a saving of 35.2 euros per telephone consultation. A teleconsultation model for dealing with emergencies in primary care by telephone would be comparable to a practice staffed by trained paediatric nurses.

Determinants of nonurgent use of the emergency department for pediatric patients in 12 hospitals in Belgium

INTRODUCTION

The nonurgent use of the emergency department (ED) for pediatric patients is an increasing problem facing healthcare systems worldwide. To evaluate the magnitude of the phenomenon and to identify associated factors, an observational prospective survey was performed including all patients (<15 years) attending the ED in 12 Belgian hospitals during 2 weeks in autumn 2010. Use of ED was considered appropriate if at least one of the following criteria was met: child referred by doctor or police, brought by ambulance, in need for short stay, technical examination or orthopedic treatment, in-patient admission, or death. Among the 3,117 children, attending ED, 39.9 % (1,244) of visits were considered inappropriate. Five factors were significantly associated with inappropriate use: age of child, distance to ED, having a registered family doctor, out-of-hours visit, and geographic region. The adjusted odds ratio and 95 % confidence intervals are respectively-1.7 (1.3-2.0), 1.7 (1.3-2.2), 1.5 (1.1-2.2), 1.5 (1.2-1.9), and 0.6 (0.5-0.8).

CONCLUSIONS

Almost 40 % of all paediatric ED attendances did not require hospital expertise. The risk of an inappropriate use of ED by pediatrician patients is predominantly associated with organizational and cultural factors. Access, equity, quality of care, and medical human resources availability have to be taken into account to design financially sustainable model of care for those patients. Furthermore, future research is needed to explain reasons why parents visit ED rather than using of primary-care services.

Telehealth nurse practitioner student clinical experiences: an essential educational component for today's health care setting

In order to meet the continuous changes and innovations within the health care system, nurse practitioner faculty must look to the future and prepare nurse practitioner graduates who deliver safe, quality patient care addressing the realities of a global society with a fast-paced expansion of technologies. Preparing nurse practitioner students for practice must include more than information technology knowledge in graduate nursing programs. Formal clinical experiences using various telehealth applications must be integrated into nurse practitioner training. Innovative strategies must be explored by nurse practitioner faculty to assure that graduates can meet the demanding technological demands of our current health care society.

The value of telephone triage for patients with appendicitis

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.

Are e-health web users looking for different symptom information than callers to triage centers?

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.

Differences between surrogate telephone triage calls in an adult population and self calls

We reviewed surrogate calls (i.e. those made on behalf of the patient) to a national triage call centre to determine whether there were differences between calls made by surrogates and self calls. During a three-year period there were 14,646 calls (14% of the total) made by a surrogate on behalf of the patient. Surrogate calls, as a percentage of total calls, increased with the age of the patient from 12% in the 18-34 year age group to 43% in the 80 and over age group (P < 0.0001). The symptoms of vomiting or nausea and dizziness or light-headedness were significantly more likely to be reported by surrogate callers than self callers. Surrogates reported a higher original intention of taking patients to the hospital emergency department (ED) compared with self callers across all adult age groups (OR 1.64; 95% CI 1.57 to 1.71). A higher proportion (38%) of surrogate calls ended with the nurse recommending an ED visit compared with only 26% of self calls (OR 1.72; 95% CI 1.66 to 1.79). Calls about men accounted for 54% of surrogate calls but only 26% of self calls (OR 3.3; 95% CI 3.2 to 3.4), suggesting that surrogate calls may be a way of increasing medical access for men.

Paediatric health calls to Swedish telenurses: a descriptive study of content and outcome

We collected data about telephone triage calls concerning children in Sweden. A sample of 110 paediatric calls were recorded. The transcribed data were analysed regarding word count, reasons for calling, results of calls, ages and gender of children, and gender of parents. The median call length was 4.4 min and the median child's age was 3.5 years. Mothers made 73% of calls, but mothers and fathers called to the same extent about daughters and sons, and regardless of age. The most common reasons for calls were ear problems, rash/wound or fever. In nearly half the calls, the telenurses provided self-care advice. Call length, word count or caller's part of word count did not differ according to gender of parents or children. However, mothers were more likely to receive self-care advice while fathers were more often referred to other health services by the telenurses. Telenurses might need to improve their gender competence, and more male telenurses in the service would potentially be beneficial to callers.

Follow-through after calling a nurse telephone advice line: a population-based study

BACKGROUND

Nurse telephone advice (NTA) lines, a major initiative in primary health care reform, provide symptom triage and health information. Compliance studies utilizing database analysis are frequently limited to a defined population, such as children or Emergency Department (ED) users.

OBJECTIVES

To explore caller characteristics associated with following NTA advice to go to the ED, see a health care professional or self-care for Calgary, Canada (population 1 million).

METHODS

NTA data were linked with utilization data to assess ED and physician visits following a call. Four nurse advice categories were defined: go to ED, health care provider in 24 hours, health care provider in 72 hours if symptoms persist and self-care. Follow-through was defined based on health care utilization within specified time periods following the call. Logistic regression identified characteristics associated with follow-through of NTA nurse advice; characteristics included age, sex, neighbourhood income, health status, time of call and type of care protocol.

RESULTS

Follow-through was highest for self-care advice (83.7%), followed by ED advice (52.3%) and then 24-hour advice (43.2%). Lower follow-through on ED or 24-hour advice was associated with age <4 years, and having lower income, and the opposite was true for self-care advice. Patients with a cardiac complaint had the highest odds of following ED advice. Patients with a gastrointestinal or obstetrics/gynaecology/genitourinary complaint were less likely to follow 24-hour advice. Patients with fever were less likely to follow self-care advice.

CONCLUSIONS

Understanding characteristics associated with lower follow-through may help the NTA service to refine its approaches to clients.

Health literacy and child health promotion: implications for research, clinical care, and public policy

The nation's leading sources of morbidity and health disparities (eg, preterm birth, obesity, chronic lung disease, cardiovascular disease, type 2 diabetes, mental health disorders, and cancer) require an evidence-based approach to the delivery of effective preventive care across the life course (eg, prenatal care, primary preventive care, immunizations, physical activity, nutrition, smoking cessation, and early diagnostic screening). Health literacy may be a critical and modifiable factor for improving preventive care and reducing health disparities. Recent studies among adults have established an independent association between lower health literacy and poorer understanding of preventive care information and poor access to preventive care services. Children of parents with higher literacy skills are more likely to have better outcomes in child health promotion and disease prevention. Adult studies in disease prevention have suggested that addressing health literacy would be an efficacious strategy for reducing health disparities. Future initiatives to reduce child health inequities should include health-promotion strategies that meet the health literacy needs of children, adolescents, and their caregivers.