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Talevski J, Semciw AI, Boyd JH, Jessup RL, Miller SM, Hutton J, Lawrence J, Sher L. From concept to reality: A comprehensive exploration into the development and evolution of a virtual emergency department. J Am Coll Emerg Physicians Open 2024; 5:e13231. [PMID: 39056087 PMCID: PMC11269764 DOI: 10.1002/emp2.13231] [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: 05/03/2024] [Revised: 06/06/2024] [Accepted: 06/20/2024] [Indexed: 07/28/2024] Open
Abstract
Emergency department (ED) overcrowding remains a persistent challenge in global public health, leading to detrimental outcomes for patients and healthcare professionals. Traditional approaches to improve this issue have been insufficient, prompting exploration of novel strategies such as virtual care interventions. Our team developed the first comprehensive statewide virtual ED in Australia, the Victorian Virtual Emergency Department, offering an alternative to in-person care for non-life-threatening emergencies. Here, we present the development and ongoing refinement of this pioneering virtual care service, aiming to provide insights for hospital administrators and policymakers seeking to implement patient-centric care solutions worldwide. By sharing our model of care, we hope to guide further work toward addressing the global problem of over crowded EDs.
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Affiliation(s)
- Jason Talevski
- Victorian Virtual Emergency DepartmentThe Northern HospitalNorthern HealthMelbourneVictoriaAustralia
- School of Psychology and Public HealthLa Trobe UniversityMelbourneVictoriaAustralia
- Department of Medicine—Western HealthThe University of MelbourneMelbourneVictoriaAustralia
| | - Adam I. Semciw
- School of Allied HealthHuman Services and SportLa Trobe UniversityMelbourneVictoriaAustralia
- Allied HealthThe Northern HospitalNorthern HealthMelbourneVictoriaAustralia
| | - James H. Boyd
- School of Psychology and Public HealthLa Trobe UniversityMelbourneVictoriaAustralia
| | - Rebecca L. Jessup
- School of Allied HealthHuman Services and SportLa Trobe UniversityMelbourneVictoriaAustralia
- Allied HealthThe Northern HospitalNorthern HealthMelbourneVictoriaAustralia
| | - Suzanne M. Miller
- Victorian Virtual Emergency DepartmentThe Northern HospitalNorthern HealthMelbourneVictoriaAustralia
- Department of Critical CareMelbourne Medical SchoolThe University of MelbourneMelbourneVictoriaAustralia
| | - Jennie Hutton
- Victorian Virtual Emergency DepartmentThe Northern HospitalNorthern HealthMelbourneVictoriaAustralia
- School of Psychology and Public HealthLa Trobe UniversityMelbourneVictoriaAustralia
- Department of Critical CareMelbourne Medical SchoolThe University of MelbourneMelbourneVictoriaAustralia
| | - Joanna Lawrence
- Victorian Virtual Emergency DepartmentThe Northern HospitalNorthern HealthMelbourneVictoriaAustralia
- Virtual Health TeamRoyal Children's HospitalMelbourneVictoriaAustralia
- Health service and economic groupMelbourne Childrens Research InstituteMelbourneVictoriaAustralia
| | - Loren Sher
- Victorian Virtual Emergency DepartmentThe Northern HospitalNorthern HealthMelbourneVictoriaAustralia
- School of Psychology and Public HealthLa Trobe UniversityMelbourneVictoriaAustralia
- Department of PaediatricsMelbourne Medical SchoolThe University of MelbourneMelbourneVictoriaAustralia
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Caponnetto V, Dante A, El Aoufy K, Melis MR, Ottonello G, Napolitano F, Ferraiuolo F, Camero F, Cuoco A, Erba I, Rasero L, Sasso L, Bagnasco A, Alvaro R, Manara DF, Rocco G, Zega M, Cicolini G, Mazzoleni B, Lancia L. Community health services in European literature: A systematic review of their features, outcomes, and nursing contribution to care. Int Nurs Rev 2024. [PMID: 39073363 DOI: 10.1111/inr.13033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 07/12/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND To meet the population's needs, community care should be customized and continuous, adequately equipped, and monitored. INTRODUCTION Considering their fragmented and heterogeneous nature, a summary of community healthcare services described in European literature is needed. The aim of this study was to summarize their organizational models, outcomes, nursing contribution to care, and nursing-related determinants of outcomes. METHODS A systematic review was performed by searching PubMed, CINAHL, Scopus, and Embase in October 2022 and October 2023 (for updated results). Quantitative studies investigating the effects of community care, including nursing contribution, on patient outcomes were included and summarized. Reporting followed the PRISMA checklist. The review protocol was registered on PROSPERO (CRD42022383856). RESULTS Twenty-three studies describing six types of community care services were included, which are heterogeneous in terms of target population, country, interventions, organizational characteristics, and investigated outcomes. Heterogeneous services' effects were observed for access to emergency services, satisfaction, and compliance with treatment. Services revealed a potential to reduce rehospitalizations of people with long-term conditions, frail or older persons, children, and heart failure patients. Models are mainly multidisciplinary and, although staffing and workload may also have an impact on provided care, this was not enough investigated. DISCUSSION Community health services described in European literature in the last decade are in line with population needs and suggest different suitable models and settings according to different care needs. Community care should be strengthened in health systems, although the influence of staffing, workload, and work environment on nursing care should be investigated by developing new management models. CONCLUSIONS AND IMPLICATIONS FOR HEALTH POLICY Community care models are heterogeneous across Europe, and the optimum organizational structure is not clear yet. Future policies should consider the impact of community care on both health and economic outcomes and enhance nursing contributions to care.
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Affiliation(s)
- Valeria Caponnetto
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Angelo Dante
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Khadija El Aoufy
- Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Giulia Ottonello
- Department of Health Sciences, University of Genoa, Genova, Italy
- Ingram School of Nursing, McGill University, Montreal, Canada
- Direction of Health Professionals, "IRCCS Istituto Giannina Gaslini,", Genova, Italy
| | - Francesca Napolitano
- Department of Health Sciences, University of Genoa, Genova, Italy
- Department of Emergency and Admission, Policlinic Hospital "IRCSS San Martino,", Genova, Italy
| | - Fabio Ferraiuolo
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Francesco Camero
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Angela Cuoco
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
- Orthopedic and Traumatology Clinic, Orthopedic Institute "IRCSS Rizzoli,", Bologna, Italy
| | - Ilaria Erba
- Bachelor of Science in Nursing, Saint Camillus International University of Health and Medical Sciences, Rome, Italy
| | - Laura Rasero
- Department of Health Sciences, University of Florence, Florence, Italy
- Scientific Committee CERSI-FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
| | - Loredana Sasso
- Department of Health Sciences, University of Genoa, Genova, Italy
- Scientific Committee CERSI-FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
| | - Annamaria Bagnasco
- Department of Health Sciences, University of Genoa, Genova, Italy
- Scientific Committee CERSI-FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
| | - Rosaria Alvaro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
- Scientific Committee CERSI-FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
| | - Duilio Fiorenzo Manara
- Scientific Committee CERSI-FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
- Center for Nursing Research and Innovation, Vita-Salute San Raffaele University, Milan, Italy
| | - Gennaro Rocco
- Center of Excellence for Nursing Scholarship, Rome, Italy
- Faculty of Medicine, University "Our Lady of the Good Counsel", Tirana, Albania
| | - Maurizio Zega
- Center of Excellence for Nursing Scholarship, Rome, Italy
- FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
| | - Giancarlo Cicolini
- FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
- Section of Nursing and Midwifery, Department of Innovative Technologies in Medicine & Dentistry, University "G. d'Annunzio" Chieti - Pescara, Chieti, Italy
| | - Beatrice Mazzoleni
- FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Loreto Lancia
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
- Scientific Committee CERSI-FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
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Chair SY, Chien WT, Kendall S, Zang Y, Liu T, Choi KC. Effects of Telephone Consultation on Safety, Service Use, Patient Satisfaction, and Workload: Systematic Review and Meta-Analysis of Randomized Trials. Telemed J E Health 2024; 30:364-380. [PMID: 37624630 DOI: 10.1089/tmj.2023.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
Abstract
Objective: Telephone consultation (TC) is widely used for its easy access and convenience. This review aimed to assess the effects of TC including triage on safety, service use, patient satisfaction, and health professionals' workload to inform directions for future health service practice. Methods: CENTRAL, MEDLINE, Embase, CINAHL, ProQuest Dissertation & Theses (Health & Medicine), ClinincalTrials.gov, and International Clinical Trial Registry Platform were searched on April 7, 2022. The included were randomized controlled trials that compared TC with standard (face-to-face [F2F]) management or that by another group of call advisers. Cochrane methods were used to select eligible studies, assess the risk of bias, estimate summary effect measure, and grade evidence certainty. Meta-analysis was performed on important outcomes with moderate- or high-quality evidence. Results: Eight studies were included involving 40,002 participants. TC could increase call resolution-proportion of callers' concerns being addressed by telephone advice alone (two studies; high certainty) and reduce F2F contacts with doctors for the first consultation (two studies, moderate certainty) compared with standard management or TC by doctors. None of included studies reported increases in adverse events, including all-cause mortality, acute and emergency department visit, and hospitalization. There was inadequate evidence regarding the effects of TC on patient satisfaction and length of consultation. Conclusion: The findings support the benefits of TC on improving call resolution and reducing F2F contacts with doctors on the day of first management for regular day service; and TC by nurses can provide better effects than that by doctors for out-of-hours service.
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Affiliation(s)
- Sek Ying Chair
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Wai Tong Chien
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Sally Kendall
- Community Nursing and Public Health, Centre for Health Services Studies, University of Kent, Canterbury, United Kingdom
| | - Yuli Zang
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Ting Liu
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Kai Chow Choi
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
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Gellert GA, Rasławska-Socha J, Marcjasz N, Price T, Kuszczyński K, Młodawska A, Jędruch A, Orzechowski PM. How Virtual Triage Can Improve Patient Experience and Satisfaction: A Narrative Review and Look Forward. TELEMEDICINE REPORTS 2023; 4:292-306. [PMID: 37817871 PMCID: PMC10561746 DOI: 10.1089/tmr.2023.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 10/12/2023]
Abstract
Objective To complete a review of the literature on patient experience and satisfaction as relates to the potential for virtual triage (VT) or symptom checkers to enhance and enable improvements in these important health care delivery objectives. Methods Review and synthesis of the literature on patient experience and satisfaction as informed by emerging evidence, indicating potential for VT to favorably impact these clinical care objectives and outcomes. Results/Conclusions VT enhances potential clinical effectiveness through early detection and referral, can reduce avoidable care delivery due to late clinical presentation, and can divert primary care needs to more clinically appropriate outpatient settings rather than high-acuity emergency departments. Delivery of earlier and faster, more acuity level-appropriate care, as well as patient avoidance of excess care acuity (and associated cost), offer promise as contributors to improved patient experience and satisfaction. The application of digital triage as a front door to health care delivery organizations offers care engagement that can help reduce patient need to visit a medical facility for low-acuity conditions more suitable for self-care, thus avoiding unpleasant queues and reducing microbiological and other patient risks associated with visits to medical facilities. VT also offers an opportunity for providers to make patient health care experiences more personalized.
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Chaves ACC, Scherer MDDA, Conill EM. What contributes to Primary Health Care effectiveness? Integrative literature review, 2010-2020. CIENCIA & SAUDE COLETIVA 2023; 28:2537-2551. [PMID: 37672445 DOI: 10.1590/1413-81232023289.15342022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 01/11/2023] [Indexed: 09/08/2023] Open
Abstract
Primary Health Care (PHC) intends to rearrange services to make it more effective. Nevertheless, effectiveness in PHC is quite a challenge. This study reviews several articles regarding the effectiveness improvements in PHC between 2010 and 2020. Ninety out of 8,369 articles found in PubMed and the Virtual Health Library databases search were selected for thematic analysis using the Atlas.ti® 9.0 software. There were four categories identified: strategies for monitoring and evaluating health services, organizational arrangements, models and technologies applied to PHC. Studies concerning the sensitive conditions indicators were predominant. Institutional assessment programs, PHC as a structuring policy, appropriate workforce, measures to increase access and digital technologies showed positive effects. However, payment for performance is still controversial. The expressive number of Brazilian publications reveals the broad diffusion of PHC in the country and the concern on its performance. These findings reassure well-known aspects, but it also points to the need for a logical model to better define what is intended as effectiveness within primary health care as well as clarify the polysemy that surrounds the concept. We also suggest substituting the term "resolvability", commonly used in Brazil, for "effectiveness".
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Sarkodie SK, Wason JMS, Grayling MJ. A hybrid approach to comparing parallel-group and stepped-wedge cluster-randomized trials with a continuous primary outcome when there is uncertainty in the intra-cluster correlation. Clin Trials 2023; 20:59-70. [PMID: 36086822 PMCID: PMC9940131 DOI: 10.1177/17407745221123507] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIMS To evaluate how uncertainty in the intra-cluster correlation impacts whether a parallel-group or stepped-wedge cluster-randomized trial design is more efficient in terms of the required sample size, in the case of cross-sectional stepped-wedge cluster-randomized trials and continuous outcome data. METHODS We motivate our work by reviewing how the intra-cluster correlation and standard deviation were justified in 54 health technology assessment reports on cluster-randomized trials. To enable uncertainty at the design stage to be incorporated into the design specification, we then describe how sample size calculation can be performed for cluster- randomized trials in the 'hybrid' framework, which places priors on design parameters and controls the expected power in place of the conventional frequentist power. Comparison of the parallel-group and stepped-wedge cluster-randomized trial designs is conducted by placing Beta and truncated Normal priors on the intra-cluster correlation, and a Gamma prior on the standard deviation. RESULTS Many Health Technology Assessment reports did not adhere to the Consolidated Standards of Reporting Trials guideline of indicating the uncertainty around the assumed intra-cluster correlation, while others did not justify the assumed intra-cluster correlation or standard deviation. Even for a prior intra-cluster correlation distribution with a small mode, moderate prior densities on high intra-cluster correlation values can lead to a stepped-wedge cluster-randomized trial being more efficient because of the degree to which a stepped-wedge cluster-randomized trial is more efficient for high intra-cluster correlations. With careful specification of the priors, the designs in the hybrid framework can become more robust to, for example, an unexpectedly large value of the outcome variance. CONCLUSION When there is difficulty obtaining a reliable value for the intra-cluster correlation to assume at the design stage, the proposed methodology offers an appealing approach to sample size calculation. Often, uncertainty in the intra-cluster correlation will mean a stepped-wedge cluster-randomized trial is more efficient than a parallel-group cluster-randomized trial design.
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Affiliation(s)
- Samuel K Sarkodie
- Samuel K Sarkodie, Population Health
Sciences Institute, Newcastle University, 4th Floor Ridley Building 1, Queen
Victoria Road, Newcastle upon Tyne NE1 7RU, UK.
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Sher L, Semciw A, Jessup RL, Carrodus A, Boyd J. Structured evaluation of a virtual emergency department triage model of care: A study protocol. Emerg Med Australas 2022; 34:907-912. [PMID: 35570401 PMCID: PMC9790376 DOI: 10.1111/1742-6723.14010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 02/10/2022] [Accepted: 04/21/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE A new virtual ED service was introduced into a hospital network in the northern suburbs of Melbourne in response to changing needs during the COVID-19 pandemic. The 'virtual ED' utilises a telehealth model as a means of assessment for appropriately selected patients to facilitate either complete care or navigation into streamlined pathways for ongoing care, in some cases bypassing the ED entirely where appropriate. The proposed study aims to evaluate the implementation of the model and identify future improvement opportunities, assess the impact on traditional health service delivery processes and patient experience, and determine the acceptability of the 'virtual ED' model of care. METHODS The present study will consist of a pre-post- implementation evaluation using the RE-AIM framework. Routine health service data will be collected for 6 months post-implementation of the virtual ED model and compared to 24 months prior to implementation. Prospective data will be collected using routinely collected and survey data. Interviews and focus groups will be conducted to understand consumer and clinician perspectives on barriers and enablers to implementation and adoption of the virtual ED. RESULTS Descriptive statistics will be used to describe the study population and key outcomes, including changes in ED presentations and length of stay. Thematic analysis will be conducted on transcribed interviews and focus group data. This will be triangulated with data collected from patient feedback surveys. CONCLUSION This project will support the delivery of care to ED patients by evaluating the 'virtual ED' model of care.
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Affiliation(s)
- Loren Sher
- Emergency DepartmentNorthern Hospital EppingMelbourneVictoriaAustralia
- School of Psychology and Public HealthLa Trobe UniversityMelbourneVictoriaAustralia
| | - Adam Semciw
- School of Allied Health, Human Services and SportLa Trobe UniversityMelbourneVictoriaAustralia
- Allied Health Research, Northern Hospital EppingMelbourneVictoriaAustralia
| | - Rebecca L Jessup
- School of Allied Health, Human Services and SportLa Trobe UniversityMelbourneVictoriaAustralia
- Allied Health Research, Northern Hospital EppingMelbourneVictoriaAustralia
| | - Ariana Carrodus
- Project Management Office, Northern Hospital EppingMelbourneVictoriaAustralia
| | - James Boyd
- School of Psychology and Public HealthLa Trobe UniversityMelbourneVictoriaAustralia
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Kopka M, Schmieding ML, Rieger T, Roesler E, Balzer F, Feufel MA. Determinants of Laypersons' Trust in Medical Decision Aids: Randomized Controlled Trial. JMIR Hum Factors 2022; 9:e35219. [PMID: 35503248 PMCID: PMC9115664 DOI: 10.2196/35219] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/09/2022] [Accepted: 03/06/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Symptom checker apps are patient-facing decision support systems aimed at providing advice to laypersons on whether, where, and how to seek health care (disposition advice). Such advice can improve laypersons' self-assessment and ultimately improve medical outcomes. Past research has mainly focused on the accuracy of symptom checker apps' suggestions. To support decision-making, such apps need to provide not only accurate but also trustworthy advice. To date, only few studies have addressed the question of the extent to which laypersons trust symptom checker app advice or the factors that moderate their trust. Studies on general decision support systems have shown that framing automated systems (anthropomorphic or emphasizing expertise), for example, by using icons symbolizing artificial intelligence (AI), affects users' trust. OBJECTIVE This study aims to identify the factors influencing laypersons' trust in the advice provided by symptom checker apps. Primarily, we investigated whether designs using anthropomorphic framing or framing the app as an AI increases users' trust compared with no such framing. METHODS Through a web-based survey, we recruited 494 US residents with no professional medical training. The participants had to first appraise the urgency of a fictitious patient description (case vignette). Subsequently, a decision aid (mock symptom checker app) provided disposition advice contradicting the participants' appraisal, and they had to subsequently reappraise the vignette. Participants were randomized into 3 groups: 2 experimental groups using visual framing (anthropomorphic, 160/494, 32.4%, vs AI, 161/494, 32.6%) and a neutral group without such framing (173/494, 35%). RESULTS Most participants (384/494, 77.7%) followed the decision aid's advice, regardless of its urgency level. Neither anthropomorphic framing (odds ratio 1.120, 95% CI 0.664-1.897) nor framing as AI (odds ratio 0.942, 95% CI 0.565-1.570) increased behavioral or subjective trust (P=.99) compared with the no-frame condition. Even participants who were extremely certain in their own decisions (ie, 100% certain) commonly changed it in favor of the symptom checker's advice (19/34, 56%). Propensity to trust and eHealth literacy were associated with increased subjective trust in the symptom checker (propensity to trust b=0.25; eHealth literacy b=0.2), whereas sociodemographic variables showed no such link with either subjective or behavioral trust. CONCLUSIONS Contrary to our expectation, neither the anthropomorphic framing nor the emphasis on AI increased trust in symptom checker advice compared with that of a neutral control condition. However, independent of the interface, most participants trusted the mock app's advice, even when they were very certain of their own assessment. Thus, the question arises as to whether laypersons use such symptom checkers as substitutes rather than as aids in their own decision-making. With trust in symptom checkers already high at baseline, the benefit of symptom checkers depends on interface designs that enable users to adequately calibrate their trust levels during usage. TRIAL REGISTRATION Deutsches Register Klinischer Studien DRKS00028561; https://tinyurl.com/rv4utcfb (retrospectively registered).
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Affiliation(s)
- Marvin Kopka
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Cognitive Psychology and Ergonomics, Department of Psychology and Ergonomics (IPA), Technische Universität Berlin, Berlin, Germany
| | - Malte L Schmieding
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Tobias Rieger
- Work, Engineering and Organizational Psychology, Department of Psychology and Ergonomics (IPA), Technische Universität Berlin, Berlin, Germany
| | - Eileen Roesler
- Work, Engineering and Organizational Psychology, Department of Psychology and Ergonomics (IPA), Technische Universität Berlin, Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Markus A Feufel
- Division of Ergonomics, Department of Psychology and Ergonomics (IPA), Technische Universität Berlin, Berlin, Germany
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The effectiveness of the role of advanced nurse practitioners compared to physician-led or usual care: A systematic review. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2021. [DOI: 10.1016/j.ijnsa.2021.100034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Oncology Nursing Telephone Triage Workshop: Impact on Nurses' Knowledge, Confidence, and Skill. Cancer Nurs 2021; 45:E463-E470. [PMID: 34483280 DOI: 10.1097/ncc.0000000000000978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Outpatient oncology nurses are responsible for symptom assessment/management and care coordination during telephone triage. Nursing telephone triage interventions can improve patient outcomes and clinical efficiency. Therefore, the lack of education and training in telephone triage can greatly impact patient care. OBJECTIVE Using a prospective pretest/posttest design, we sought to determine if a telephone triage educational workshop would improve oncology nurses' knowledge, confidence, and skill over 12 weeks. INTERVENTION/METHODS The educational intervention incorporated an online didactic lecture, group case scenario, and feedback on a virtual triage simulation. Evaluation was conducted before and after the intervention through an online, 13-item survey (knowledge and confidence) and simulation utilizing a 56-item checklist (skills). RESULTS Thirteen oncology nurses were enrolled; 54% did not have telephone triage experience before this job. A total of 12 participants completed the workshop. From pretest to posttest, there was a median 1.0 out of 5.0 (interquartile range, 2.8) improvement in confidence (P = .008) and a 26.3% (interquartile range, 15.2) improvement in skills (P = .002). There was no difference in knowledge scores from pretest to posttest (P = .11). CONCLUSIONS This workshop was associated with an improvement in oncology nurse confidence and skill, using telephone triage models. It benefits an existing process within the outpatient center and it highlights a new educational strategy that may optimize nursing practice and improve patient care and experience. IMPLICATIONS FOR PRACTICE This workshop contributes to existing evidence of telephone triage models and nursing education. The findings can guide future research, nursing orientation, and educational activities within the field of nursing and telehealth.
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Wang B, Mehrotra A, Friedman AB. Urgent Care Centers Deter Some Emergency Department Visits But, On Net, Increase Spending. Health Aff (Millwood) 2021; 40:587-595. [PMID: 33819095 DOI: 10.1377/hlthaff.2020.01869] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There is substantial interest in using urgent care centers to decrease lower-acuity emergency department (ED) visits. Using 2008-19 insurance claims and enrollment data from a national managed care plan, we examined the association within ZIP codes between changes in rates of urgent care center visits and rates of lower-acuity ED visits. We found that although the entry of urgent care deterred lower-acuity ED visits, the impact was small. We estimate that thirty-seven additional urgent care center visits were associated with a reduction of a single lower-acuity ED visit. In addition, each $1,646 lower-acuity ED visit prevented was offset by a $6,327 increase in urgent care center costs. Therefore, despite a tenfold higher price per visit for EDs compared with urgent care centers, use of the centers increased net overall spending on lower-acuity care at EDs and urgent care centers.
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Affiliation(s)
- Bill Wang
- Bill Wang is a research assistant in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - Ateev Mehrotra
- Ateev Mehrotra is an associate professor of health care policy and medicine in the Department of Health Care Policy, Harvard Medical School
| | - Ari B Friedman
- Ari B. Friedman is an assistant professor of emergency medicine, medical ethics, and health policy in the Departments of Emergency Medicine and Medical Ethics and Health Policy and senior fellow of the Leonard Davis Institute, University of Pennsylvania, in Philadelphia, Pennsylvania
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Apiratwarakul K, Suzuki T, Celebi I, Tiamkao S, Bhudhisawasdi V, Gaysonsiri D, Ienghong K. Real Time Telephone Application Use for Consultation in Emergency Medical Services. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Emergency medical services (EMS) are an operation that requires speed and prompt decision-making to provide patients treatment and rescue them from crisis. A telephone application was created to be a communication channel. However, the effectiveness of EMS consulting via telephone application has not been well studied.
AIM: The aim of this study was to describe the use of real-time telephone application use for consultation in EMS.
METHODS: A cross-sectional, single EMS centered study at Srinagarind Hospital in Thailand. Data were gathered from LINE® Application under the name of “Current training EMKKU” and the EMS database throughout 2020-2021.
RESULTS: A total of 11550 messages with 6221 general text; messages were not involved in patients’ consultant (53.86%). The consultation mostly took place during the afternoon shifts (4PM to 0AM) accounted for 45.11%. We found that Thursday (19.63%) was the day with most frequent consulting services, followed by Tuesday (16.05%) and Friday (16.03%) regarding the consultation. There were 45 active users in the LINE® Application under the name of “Current training EMKKU”. The mean age of the participants was 32.10±5.60 years, and 51.11% (n = 23) of them was female.
CONCLUSIONS: The real-time telephone application is used for consultation related to patients' symptoms during EMS operations and ER patient care was most commonly in the afternoon and on Thursdays and Tuesdays.
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Revision of the Protocol of the Telephone Triage System in Tokyo, Japan. Emerg Med Int 2021; 2021:8832192. [PMID: 33996156 PMCID: PMC8081606 DOI: 10.1155/2021/8832192] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 03/30/2021] [Accepted: 04/09/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction The Emergency Telephone Consultation Center in Tokyo (#7119) was the first telephone triage system in Japan and has operated since 2007. This study examined the revision of the #7119 protocol by referring the linked data to each code of the triage protocol. Methods We selected candidates based on the medical codes targeted by the revision, linking data from the nurses' decisions in triage and the patients' condition severity when the ambulance arrived at the hospital, gathering data from June 1, 2016, to December 31, 2017. Then, several emergency physicians evaluated the cases and decided whether the code should be moved to the more or less urgent category or if new protocols and codes would be established. Results In this revision, 371 codes were moved to the less urgent category, 35 codes were moved to the more urgent category, and 128 codes were newly established. In all, 59 red codes (transfer to the ambulance dispatcher) were reduced, while 254 orange codes (attendance at hospital within 1 hour) and yellow codes (within 6 hours) were moved to less urgent, and 12 yellow and green codes (within 24 hours) were moved to more urgent. Conclusion We adjusted the triage codes for the revision by linking the call data with the case data. This revision should decrease the inappropriate use of ambulances and reduce the primary care workload. To achieve a more accurate revision, we need to refine the process of evaluating the validity of patients' acuity over the telephone during triage.
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Islam F, Sabbe M, Heeren P, Milisen K. Consistency of decision support software-integrated telephone triage and associated factors: a systematic review. BMC Med Inform Decis Mak 2021; 21:107. [PMID: 33743697 PMCID: PMC7981379 DOI: 10.1186/s12911-021-01472-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 03/14/2021] [Indexed: 11/12/2022] Open
Abstract
Background In the recent decades, the use of computerized decision support software (CDSS)-integrated telephone triage (TT) has become an important tool for managing rising healthcare demands and overcrowding in the emergency department. Though these services have generally been shown to be effective, large gaps in the literature exist with regards to the overall quality of these systems. In the current systematic review, we aim to document the consistency of decisions that are generated in CDSS-integrated TT. Furthermore, we also seek to map those factors in the literature that have been identified to have an impact on the consistency of generated triage decisions. Methods As part of the TRANS-SENIOR international training and research network, a systematic review of the literature was conducted in November 2019. PubMed, Web of Science, CENTRAL, and the CINAHL database were searched. Quantitative articles including a CDSS component and addressing consistency of triage decisions and/or factors associated with triage decisions were eligible for inclusion in the current review. Studies exploring the use of other types of digital support systems for triage (i.e. web chat, video conferencing) were excluded. Quality appraisal of included studies were performed independently by two authors using the Methodological Index for Non-Randomized Studies. Results From a total of 1551 records that were identified, 39 full-texts were assessed for eligibility and seven studies were included in the review. All of the studies (n = 7) identified as part of our search were observational and were based on nurse-led telephone triage. Scientific efforts investigating our first aim was very limited. In total, two articles were found to investigate the consistency of decisions that are generated in CDSS-integrated TT. Research efforts were targeted largely towards the second aim of our study—all of the included articles reported factors related to the operator- (n = 6), patient- (n = 1), and/or CDSS-integrated (n = 2) characteristics to have an influence on the consistency of CDSS-integrated TT decisions. Conclusion To date, some efforts have been made to better understand how the use of CDSS-integrated TT systems may vary across settings. In general, however, the evidence-base surrounding this field of literature is largely inconclusive. Further evaluations must be prompted to better understand this area of research. Protocol registration The protocol for this study is registered in the PROSPERO database (registration number: CRD42020146323). Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01472-3.
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Affiliation(s)
- Farah Islam
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, 3000, Leuven, Belgium
| | - Marc Sabbe
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, 3000, Leuven, Belgium.,Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter Heeren
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, 3000, Leuven, Belgium.,Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Research Foundation Flanders, Egmontstraat 5, 1000, Brussels, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, 3000, Leuven, Belgium. .,Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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15
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Björkman A, Engström M, Winblad U, Holmström IK. Malpractice claimed calls within the Swedish Healthcare Direct: a descriptive - comparative case study. BMC Nurs 2021; 20:21. [PMID: 33446213 PMCID: PMC7807404 DOI: 10.1186/s12912-021-00540-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 01/04/2021] [Indexed: 11/10/2022] Open
Abstract
Background Medical errors are reported as a malpractice claim, and it is of uttermost importance to learn from the errors to enhance patient safety. The Swedish national telephone helpline SHD is staffed by registered nurses; its aim is to provide qualified healthcare advice for all residents of Sweden; it handles normally about 5 million calls annually. The ongoing Covid-19 pandemic have increased call volume with approximate 30%. The aim of the present study was twofold: to describe all malpractice claims and healthcare providers’ reported measures regarding calls to Swedish Healthcare Direct (SHD) during the period January 2011–December 2018 and to compare these findings with results from a previous study covering the period January 2003–December 2010. Methods The study used a descriptive, retrospective and comparative design. A total sample of all reported malpractice claims regarding calls to SHD (n = 35) made during the period 2011–2018 was retrieved. Data were analysed and compared with all reported medical errors during the period 2003–2010 (n = 33). Results Telephone nurses’ failure to follow the computerized decision support system (CDSS) (n = 18) was identified as the main reason for error during the period 2011–2018, while failure to listen to the caller (n = 12) was the main reason during the period 2003–2010. Staff education (n = 21) and listening to one’s own calls (n = 16) were the most common measures taken within the organization during the period 2011–2018, compared to discussion in work groups (n = 13) during the period 2003–2010. Conclusion The proportion of malpractice claims in relation to all patient contacts to SHD is still very low; it seems that only the most severe patient injuries are reported. The fact that telephone nurses’ failure to follow the CDSS is the most common reason for error is notable, as SHD and healthcare organizations stress the importance of using the CDSS to enhance patient safety. The healthcare organizations seem to have adopted a more systematic approach to handling malpractice claims regarding calls, e.g., allowing telephone nurses to listen to their own calls instead of having discussions in work groups in response to events. This enables nurses to understand the latent factors contributing to error and provides a learning opportunity.
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Affiliation(s)
- Annica Björkman
- Faculty of Health and Occupational Studies, University of Gavle, Gävle, Sweden. .,Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
| | - Maria Engström
- Faculty of Health and Occupational Studies, University of Gavle, Gävle, Sweden
| | - Ulrika Winblad
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Inger K Holmström
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.,School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
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16
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Evaluation of a dental nurse-led triage system in a private dental practice during the COVID-19 pandemic. BDJ TEAM 2021. [PMCID: PMC7809541 DOI: 10.1038/s41407-020-0494-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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17
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A whole-team approach to triaging patients: is this the future? Br Dent J 2020; 229:598. [PMID: 33188339 PMCID: PMC7662725 DOI: 10.1038/s41415-020-2383-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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18
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Cowell A, Goodwin L, Hare K, Campbell C. Evaluation of a dental nurse-led triage system in a private dental practice during the COVID-19 pandemic. Br Dent J 2020:10.1038/s41415-020-2177-3. [PMID: 33082522 PMCID: PMC7574391 DOI: 10.1038/s41415-020-2177-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/08/2020] [Indexed: 11/10/2022]
Abstract
Objectives To evaluate a dental nurse-led triage system at a private dental practice in England after the cessation of face-to-face care during the COVID-19 pandemic; to assess types of presenting problems and their management upon practice reopening at alert level 4; and to explain the benefits of dental nurse-led triage and its relevance to other practices.Methods This retrospective service evaluation used anonymised data gathered for the purpose of assessing and triaging patients when they could not be seen face-to-face. Effectiveness of the triage system was assessed using predetermined criteria.Results Seventy patients were triaged during a 12-week period; 68.5% of patients were managed by the triaging dental nurse without escalation to a dentist and 77% of patients called only once. The most common presenting complaint was pain, followed by loose crown/bridge and fractured crown/tooth/bridge. Sixty-one percent of all patients accepted a face-to-face appointment upon reopening of the dental practice.Conclusions This study demonstrates the effectiveness of a dental nurse-led triage model where dental nurses have the skills and experience required to manage patients at first contact. This model would be applicable to other practices in the case of future emergency closures, as well as a routine out-of-hours service.
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Affiliation(s)
- Angela Cowell
- The Campbell Clinic (Private Dental Practice), Nottingham, UK
| | - Louise Goodwin
- The Campbell Clinic (Private Dental Practice), Nottingham, UK
| | - Katherine Hare
- The Campbell Clinic (Private Dental Practice), Nottingham, UK.
| | - Colin Campbell
- The Campbell Clinic (Private Dental Practice), Nottingham, UK
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19
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Salisbury C, Murphy M, Duncan P. The Impact of Digital-First Consultations on Workload in General Practice: Modeling Study. J Med Internet Res 2020; 22:e18203. [PMID: 32543441 PMCID: PMC7327596 DOI: 10.2196/18203] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/26/2020] [Accepted: 03/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background Health services in many countries are promoting digital-first models of access to general practice based on offering online, video, or telephone consultations before a face-to-face consultation. It is claimed that this will improve access for patients and moderate the workload of doctors. However, improved access could also potentially increase doctors’ workload. Objective The aim of this study was to explore whether and under what circumstances digital-first access to general practice is likely to decrease or increase general practice workload. Methods A process map to delineate primary care access pathways was developed and a model to estimate general practice workload constructed in Microsoft Excel (Microsoft Corp). The model was populated using estimates of key variables obtained from a systematic review of published studies. A MEDLINE search was conducted for studies published in English between January 1, 2000, and September 30, 2019. Included papers provided quantitative data about online, telephone, or video consultations for unselected patients requesting a general practice in-hours consultation for any problem. We excluded studies of general practitioners consulting specialists, consultations not conducted by doctors, and consultations conducted after hours, in secondary care, in specialist services, or for a specific health care problem. Data about the following variables were extracted from the included papers to form the model inputs: the proportion of consultations managed digitally, the proportion of digital consultations completed without a subsequent consultation, the proportion of subsequent consultations conducted by telephone rather than face-to-face, consultation duration, and the proportion of digital consultations that represent new demand. The outcome was general practice workload. The model was used to test the likely impact of different digital-first scenarios, based on the best available evidence and the plausible range of estimates from the published studies. The model allows others to test the impact on workload of varying assumptions about model inputs. Results Digital-first approaches are likely to increase general practice workload unless they are shorter, and a higher proportion of patients are managed without a subsequent consultation than observed in most published studies. In our base-case scenarios (based on the best available evidence), digital-first access models using online, telephone, or video consultations are likely to increase general practitioner workload by 25%, 3%, and 31%, respectively. An important determinant of workload is whether the availability of digital-first approaches changes the demand for general practice consultations, but there is little robust evidence to answer this question. Conclusions Digital-first approaches to primary care could increase general practice workload unless stringent conditions are met. Justification for these approaches should be based on evidence about the benefits in relation to the costs, rather than assumptions about reductions in workload. Given the potential increase in workload, which in due course could worsen problems of access, these initiatives should be implemented in a staged way alongside careful evaluation.
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Affiliation(s)
- Chris Salisbury
- Centre for Academic Primary Care, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Mairead Murphy
- Centre for Academic Primary Care, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Polly Duncan
- Centre for Academic Primary Care, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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20
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Graversen DS, Christensen MB, Pedersen AF, Carlsen AH, Bro F, Christensen HC, Vestergaard CH, Huibers L. Safety, efficiency and health-related quality of telephone triage conducted by general practitioners, nurses, or physicians in out-of-hours primary care: a quasi-experimental study using the Assessment of Quality in Telephone Triage (AQTT) to assess audio-recorded telephone calls. BMC FAMILY PRACTICE 2020; 21:84. [PMID: 32386511 PMCID: PMC7211335 DOI: 10.1186/s12875-020-01122-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 03/04/2020] [Indexed: 11/10/2022]
Abstract
Background To explore and compare safety, efficiency, and health-related quality of telephone triage in out-of-hours primary care (OOH-PC) services performed by general practitioners (GPs), nurses using a computerised decision support system (CDSS), or physicians with different medical specialities. Methods Natural quasi-experimental cross-sectional study conducted in November and December 2016. We randomly selected 1294 audio-recorded telephone triage calls from two Danish OOH-PC services triaged by GPs (n = 423), nurses using CDSS (n = 430), or physicians with different medical specialities (n = 441). An assessment panel of 24 physicians used a validated assessment tool (Assessment of Quality in Telephone Triage - AQTT) to assess all telephone triage calls and measured health-related quality, safety, and efficiency of triage. Results The relative risk (RR) of poor quality was significantly lower for nurses compared to GPs in four out of ten items regarding identifying and uncovering of problems. For most items, the quality tended to be lowest for physicians with different medical specialities. Compared to calls triaged by GPs (reference), the risk of clinically relevant undertriage was significantly lower for nurses, while physicians with different medical specialties had a similar risk (GP: 7.3%, nurse: 3.7%, physician: 6.1%). The risk of clinically relevant overtriage was significantly higher for nurses (9.1%) and physicians with different medical specialities (8.2%) compared to GPs (4.3%). GPs had significantly shorter calls (mean: 2 min 57 s, SD: 105 s) than nurses (mean: 4 min 44 s, SD: 168 s). Conclusions Our explorative study indicated that nurses using CDSS performed better than GPs in telephone triage on a large number of health-related items, had a lower level of clinically relevant undertriage, but were perceived less efficient. Calls triaged by physicians with different medical specialities were perceived less safe and less efficient compared to GPs. Differences in the organisation of telephone triage may influence the distribution of workload in primary and secondary OOH services. Future research could compare the long-term outcomes following a telephone call to OOH-PC related to safety and efficiency.
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Affiliation(s)
- D S Graversen
- Research Unit for General Practice, Aarhus, Bartholins Allé 2, 8000, Aarhus C, Denmark. .,Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - M B Christensen
- Research Unit for General Practice, Aarhus, Bartholins Allé 2, 8000, Aarhus C, Denmark.,Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - A F Pedersen
- Research Unit for General Practice, Aarhus, Bartholins Allé 2, 8000, Aarhus C, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - A H Carlsen
- Research Unit for General Practice, Aarhus, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - F Bro
- Research Unit for General Practice, Aarhus, Bartholins Allé 2, 8000, Aarhus C, Denmark.,Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - H C Christensen
- Emergency Medical Services, Copenhagen, Denmark.,The National Clinical Databases (RKKP), Copenhagen, Denmark
| | - C H Vestergaard
- Research Unit for General Practice, Aarhus, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - L Huibers
- Research Unit for General Practice, Aarhus, Bartholins Allé 2, 8000, Aarhus C, Denmark
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21
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Jimènez Torres M, Beitl K, Hummel Jimènez J, Mayer H, Zehetmayer S, Umek W, Veit-Rubin N. Benefit of a nurse-led telephone-based intervention prior to the first urogynecology outpatient visit: a randomized-controlled trial. Int Urogynecol J 2020; 32:1489-1495. [PMID: 32388632 PMCID: PMC8203547 DOI: 10.1007/s00192-020-04318-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/13/2020] [Indexed: 11/28/2022]
Abstract
Introduction and hypothesis Triage has become a valid tool to reduce workload during the first consultation in a specialized clinic. A nurse-led telephone intervention prior to the first urogynecologic visit reduces visit duration and increases patients’ and physicians’ satisfaction. Methods All patients scheduled for their very first visit were recruited. They were randomized into an intervention group (prior contact by a specialized urogynecology nurse) and a control group (no contact). The intervention included a questionnaire about history and symptoms. Patients were prompted to complete a bladder diary. Primary outcome was duration of the consultation; secondary outcomes were patients’ and physicians’ satisfaction with the intervention. Results Fifty-five patients were allocated to the intervention group and 53 to the control group with no difference regarding age, BMI, parity, menopausal status and primary diagnosis. Mean duration of the telephone call was 10.8 min (SD 4.4). The consultation was significantly shorter in the intervention group than in the control group (mean difference: 4 min and 8 s, p = 0.017). In the intervention group, 79% of the patients found the consultation quality “excellent,” 86% would return, and 77% would recommend our clinic to a relative or friend compared with 68%, 67% and 66%, respectively, in the control group. Physicians were “very satisfied” or “satisfied” with the patient preparation. Conclusions A nurse-led intervention reduces the duration of the first uroynecologic consultation and is associated with high patient and physician satisfaction. Further research should evaluate whether it also decreases the number of follow-up visits and further referrals. Electronic supplementary material The online version of this article (10.1007/s00192-020-04318-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maria Jimènez Torres
- Department of Obstetrics and Gynecology, Medical University of Vienna, Waehringer Guertel 18, 1090, Wien, Austria
| | - Klara Beitl
- Department of Obstetrics and Gynecology, Medical University of Vienna, Waehringer Guertel 18, 1090, Wien, Austria
| | - Julia Hummel Jimènez
- Department of Obstetrics and Gynecology, Medical University of Vienna, Waehringer Guertel 18, 1090, Wien, Austria
| | - Hanna Mayer
- Department of Nursing Sciences, University of Vienna, Alser Straße 23, 1080, Wien, Austria
| | - Sonja Zehetmayer
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090, Wien, Austria
| | - Wolfgang Umek
- Department of Obstetrics and Gynecology, Medical University of Vienna, Waehringer Guertel 18, 1090, Wien, Austria. .,Karl Landsteiner Institute of Special Obstetrics and Gynecology, Silbergasse 18, 1190, Wien, Austria.
| | - Nikolaus Veit-Rubin
- Department of Obstetrics and Gynecology, Medical University of Vienna, Waehringer Guertel 18, 1090, Wien, Austria.,Karl Landsteiner Institute of Special Obstetrics and Gynecology, Silbergasse 18, 1190, Wien, Austria
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Fenech ME, Buston O. AI in Cardiac Imaging: A UK-Based Perspective on Addressing the Ethical, Social, and Political Challenges. Front Cardiovasc Med 2020; 7:54. [PMID: 32351974 PMCID: PMC7174604 DOI: 10.3389/fcvm.2020.00054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/20/2020] [Indexed: 12/12/2022] Open
Abstract
Imaging and cardiology are the healthcare domains which have seen the greatest number of FDA approvals for novel data-driven technologies, such as artificial intelligence, in recent years. The increasing use of such data-driven technologies in healthcare is presenting a series of important challenges to healthcare practitioners, policymakers, and patients. In this paper, we review ten ethical, social, and political challenges raised by these technologies. These range from relatively pragmatic concerns about data acquisition to potentially more abstract issues around how these technologies will impact the relationships between practitioners and their patients, and between healthcare providers themselves. We describe what is being done in the United Kingdom to identify the principles that should guide AI development for health applications, as well as more recent efforts to convert adherence to these principles into more practical policy. We also consider the approaches being taken by healthcare organizations and regulators in the European Union, the United States, and other countries. Finally, we discuss ways by which researchers and frontline clinicians, in cardiac imaging and more broadly, can ensure that these technologies are acceptable to their patients.
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23
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Haddad RN, Sakr C, Khabbaz L, Azouri H, Eid B. Telephone Consultation and Prescription in Pediatrics: Contributing Factors and Impact on Clinical Outcomes. Front Pediatr 2020; 7:515. [PMID: 32010647 PMCID: PMC6974533 DOI: 10.3389/fped.2019.00515] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 11/27/2019] [Indexed: 12/20/2022] Open
Abstract
Objectives: To evaluate phone-based consultation practices and drug prescription profiles in pediatrics and to highlight their possible uses, contributing factors, and effects on clinical outcomes. Background: The ownership and everyday use of cell phones are increasing worldwide. Telehealth is gaining the support of health professionals for the delivery of simple healthcare measures to more complex management decisions. Despite this, in our country, doctors have been advised by concerned authorities to avoid any phone-based medical activity as the safety of such practices is still not well-established, especially among vulnerable pediatric patients. Patients and Methods: This cross-sectional study was conducted on a national level over 5 months. Phone consultations and prescription behaviors data were collected through a self-administrated questionnaire. The target population consisted of pediatric-trained physicians with at least 1 year of experience. Factors influencing telephone prescriptions were assessed using bivariate analysis. Results: Of among 120 included physicians (75.0% male), 64.2% were general pediatricians, 77.5% practiced in private clinics, and 27.5% had more than 20 years of work experience. All participants gave medical advice over the phone; 61.7% considered that they should be reimbursed for these activities and 29.2% of them reviewed 50% of their patients for the same complaint. A total of 109 participants (90.8%) prescribed drugs using a direct phone call (80.7%), SMS (27.5%), or WhatsApp application (61.5%). Antipyretics (97.2%) and cough suppressants (48.1%) were the most frequently prescribed drugs. Pharmacists' corrective interventions were seen in 40.4% of prescriptions. Fever was the only symptom that was statistically associated with phone prescriptions. Prescribers seemed to be less experienced and were more likely to consider phone-based practices as reimbursable activities. Conclusions: Consultations and prescriptions through mobile phones are extremely frequent in pediatric practices, even when restricted by responsible authorities. Our results highlight the frequency of medical prescription errors and the need for corrective interventions by pharmacists. The current practice of telemedicine may not ensure the patient's safety but exists rather as a convenience. There is a need for proper oversight with a regulatory framework and input from all stakeholders, including pediatricians and pharmacists.
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Affiliation(s)
- Raymond N. Haddad
- Department of Pediatrics, Hotel Dieu de France University Medical Center, Saint Joseph University, Beirut, Lebanon
| | - Celine Sakr
- Faculty of Pharmacy, Saint-Joseph University, Medical Sciences Campus, Beirut, Lebanon
| | - Lydia Khabbaz
- Faculty of Pharmacy, Saint-Joseph University, Medical Sciences Campus, Beirut, Lebanon
| | - Hayat Azouri
- Faculty of Pharmacy, Saint-Joseph University, Medical Sciences Campus, Beirut, Lebanon
| | - Bassam Eid
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Hotel Dieu de France University Medical Center, Saint Joseph University, Beirut, Lebanon
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Siddiqui N, Greenfield D, Lawler A. Calling for confirmation, reassurance, and direction: Investigating patient compliance after accessing a telephone triage advice service. Int J Health Plann Manage 2019; 35:735-745. [PMID: 31803956 DOI: 10.1002/hpm.2934] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/24/2019] [Accepted: 10/10/2019] [Indexed: 11/06/2022] Open
Abstract
Understanding the influence of a telephone triage advice service (TTAS) on patients seeking care is critical to realize enhancements in patient care, functioning of emergency departments (EDs), and effectiveness of the health system. This study addresses the question: what influence does a TTAS have on a patient's attendance at an ED and the wider health system? Records from 2016 to 2017 of 12,741 calls from a national TTAS were linked to 72,577 ED presentations to a hospital in regional Australia, retrospectively. Matching criteria included patient within the hospital's statistical local area code, age, gender, and ED attendance within 8 hours of TTAS call. Five statistical analyses of the data were conducted. There were 2857 matches. TTAS patients accessing the ED had a slightly higher proportion of women and a greater proportion of children under 4 years than usual. When TTAS confirmed callers' inclination for ED care, however only up to 69% subsequently attended the ED. When TTAS redirected others initially less inclined to more urgent care, up to 62% attended the ED. TTAS empowers vulnerable patients to access appropriate and timely services and promotes clinical and functional integration of care. Improvements of TTAS can come through investigation of callers' compliance factors.
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Affiliation(s)
- Nazlee Siddiqui
- Australian Institute of Health Service Management, Tasmanian School of Business and Economics, University of Tasmania, Hobart, Australia
| | - David Greenfield
- Australian Institute of Health Service Management, Tasmanian School of Business and Economics, University of Tasmania, Hobart, Australia
| | - Anthony Lawler
- Department of Health Tasmania, University of Tasmania, Hobart, Australia
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Patient-Reported Access in the Patient-Centered Medical Home and Avoidable Hospitalizations: an Observational Analysis of the Veterans Health Administration. J Gen Intern Med 2019; 34:1546-1553. [PMID: 31161568 PMCID: PMC6667567 DOI: 10.1007/s11606-019-05060-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/27/2018] [Accepted: 03/27/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The Patient-Centered Medical Home (PCMH) has emphasized timely access to primary care, often by using non-traditional modes of delivery, such as care in person after-hours or by phone during or after normal hours. Limited data exists on whether improving patient-reported access with these service types reduces hospitalization. OBJECTIVE To examine the association of patient-reported access to primary care within the Veteran Health Administration (VHA) via five service types and hospitalizations for ambulatory care sensitive conditions (ACSCs). DESIGN Retrospective cohort study, using multivariable logistic regression adjusting for patient demographics, comorbidity, characteristics of patients' area of residence, and clinic-level random effects. PARTICIPANTS A total of 69,710 VHA primary care patients who responded to the 2012 Survey of Healthcare Experiences of Patients (SHEP), PCMH module. MAIN MEASURES Survey questions captured patients' ability to obtain care from VHA for five service types: routine care, immediate care, after-hours care, care by phone during regular office hours, and care by phone after normal hours. Outcomes included binary measures of hospitalization for overall, acute, and chronic ACSCs in 2013, identified in VHA administrative data and Medicare fee-for-service claims. KEY RESULTS Patients who reported "always" able to obtain after-hours care compared to "never" were less likely to be hospitalized for chronic ACSCs (OR 0.62, 95% CI 0.44-0.89, p = 0.009). Patients reporting "usually" getting care by phone during regular hours were more likely have a hospitalization for chronic ACSC (OR 1.49, 95% CI 1.03-2.17, p = 0.034). Experiences with routine care, immediate care, and care by phone after-hours demonstrated no significant association with hospitalization for ACSCs. CONCLUSIONS Improving patients' ability to obtain after-hours care was associated with fewer hospitalizations for chronic ACSCs, while access to care by phone during regular hours was associated with more hospitalizations. Health systems should consider the benefits, including reduced hospitalizations for chronic ACSCs, against the costs of implementing each of these PCMH services.
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Vilstrup E, Graversen DS, Huibers L, Christensen MB, Pedersen AF. Communicative characteristics of general practitioner-led and nurse-led telephone triage at two Danish out-of-hours services: an observational study of 200 recorded calls. BMJ Open 2019; 9:e028434. [PMID: 31230024 PMCID: PMC6596995 DOI: 10.1136/bmjopen-2018-028434] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Out-of-hours (OOH) telephone triage is used to manage patient flow, but knowledge of the communicative skills of telephone triagists is limited. The aims of this study were to compare communicative parameters in general practitioner (GP)-led and nurse-led OOH telephone triage and to discuss differences in relation to patient-centred communication and safety issues. DESIGN Observational study. SETTING Two Danish OOH settings: a large-scale general practitioner cooperative in the Central Denmark Region (n=100 GP-led triage conversations) and Medical Helpline 1813 in the Capital Region of Denmark (n=100 nurse-led triage conversations with use of a clinical decision support system). PARTICIPANTS 200 audio-recorded telephone triage conversations randomly selected. PRIMARY AND SECONDARY OUTCOME MEASURES Conversations were compared with regard to length of call, distribution of speaking time, question types, callers' expression of negative affect, and nurses' and GPs' responses to callers' negative affectivity using the Mann-Whitney U test and the Student's t-test. RESULTS Compared with GPs, nurses had longer telephone contacts (137s vs 264 s, p=0.001) and asked significantly more questions (5 vs 9 questions, p=0.001). In 36% of nurse-led triage conversations, triage nurses either transferred the call to a physician or had to confer the call with a physician. Nurses gave the callers significantly more spontaneous talking time than GPs (23.4s vs 17.9 s, p=0.01). Compared with nurses, GPs seemed more likely to give an emphatic response when a caller spontaneously expressed concern; however, this difference was not statistically significant (36% vs 29%, p=0.6). CONCLUSIONS When comparing communicative parameters in GP-led and nurse-led triage, several differences were observed. However, the impact of these differences in the perspective of patient-centred communication and safety needs further research. More knowledge is needed to determine what characterises good quality in telephone triage communication.
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Affiliation(s)
- Emil Vilstrup
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Dennis Schou Graversen
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Linda Huibers
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Morten Bondo Christensen
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Anette Fischer Pedersen
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Newbould J, Ball S, Abel G, Barclay M, Brown T, Corbett J, Doble B, Elliott M, Exley J, Knack A, Martin A, Pitchforth E, Saunders C, Wilson ECF, Winpenny E, Yang M, Roland M. A ‘telephone first’ approach to demand management in English general practice: a multimethod evaluation. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07170] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
The increasing difficulty experienced by general practices in meeting patient demand is leading to new approaches being tried, including greater use of telephone consulting.
Objectives
To evaluate a ‘telephone first’ approach, in which all patients requesting a general practitioner (GP) appointment are asked to speak to a GP on the telephone first.
Methods
The study used a controlled before-and-after (time-series) approach using national reference data sets; it also incorporated economic and qualitative elements. There was a comparison between 146 practices using the ‘telephone first’ approach and control practices in England with regard to GP Patient Survey scores and secondary care utilisation (Hospital Episode Statistics). A practice manager survey was used in the ‘telephone first’ practices. There was an analysis of practice data and the patient surveys conducted in 20 practices using the ‘telephone first’ approach. Interviews were conducted with 43 patients and 49 primary care staff. The study also included an analysis of costs.
Results
Following the introduction of the ‘telephone first’ approach, the average number of face-to-face consultations in practices decreased by 38% [95% confidence interval (CI) 29% to 45%; p < 0.0001], whereas there was a 12-fold increase in telephone consultations (95% CI 6.3-fold to 22.9-fold; p < 0.0001). The average durations of consultations decreased, which, when combined with the increased number of consultations, we estimate led to an overall increase of 8% in the mean time spent consulting by GPs, although there was a large amount of uncertainty (95% CI –1% to 17%; p = 0.0883). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload. Comparing ‘telephone first’ practices with control practices in England in terms of scores in the national GP Patient Survey, there was an improvement of 20 percentage points in responses to the survey question on length of time to get to see or speak to a doctor or nurse. Other responses were slightly negative. The introduction of the ‘telephone first’ approach was followed by a small (2%) increase in hospital admissions; there was no initial change in accident and emergency (A&E) department attendance, but there was a subsequent small (2%) decrease in the rate of increase in A&E attendances. We found no evidence that the ‘telephone first’ approach would produce net reductions in secondary care costs. Patients and staff expressed a wide range of both positive and negative views in interviews.
Conclusions
The ‘telephone first’ approach shows that many problems in general practice can be dealt with on the telephone. However, the approach does not suit all patients and is not a panacea for meeting demand for care, and it is unlikely to reduce secondary care costs. Future research could include identifying how telephone consulting best meets the needs of different patient groups and practices in varying circumstances and how resources can be tailored to predictable patterns of demand.
Limitations
We acknowledge a number of limitations to our approach. We did not conduct a systematic review of the literature, data collected from clinical administrative records were not originally designed for research purposes and for one element of the study we had no control data. In the economic analysis, we relied on practice managers’ perceptions of staff changes attributed to the ‘telephone first’ approach. In our qualitative work and patient survey, we have some evidence that the practices that participated in that element of the study had a more positive patient experience than those that did not.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Jennifer Newbould
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UK
| | - Sarah Ball
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UK
| | - Gary Abel
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Matthew Barclay
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Tray Brown
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jennie Corbett
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UK
| | - Brett Doble
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Josephine Exley
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UK
| | | | - Adam Martin
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UK
| | - Emma Pitchforth
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UK
| | - Catherine Saunders
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Edward CF Wilson
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Eleanor Winpenny
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UK
| | - Miaoqing Yang
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UK
| | - Martin Roland
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Graversen DS, Pedersen AF, Carlsen AH, Bro F, Huibers L, Christensen MB. Quality of out-of-hours telephone triage by general practitioners and nurses: development and testing of the AQTT - an assessment tool measuring communication, patient safety and efficiency. Scand J Prim Health Care 2019; 37:18-29. [PMID: 30689490 PMCID: PMC6454404 DOI: 10.1080/02813432.2019.1568712] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To develop a valid and reliable assessment tool able to measure quality of communication, patient safety and efficiency in out-of-hours (OOH) telephone triage conducted by both general practitioners (GP) and nurses. DESIGN The Dutch KERNset tool was translated into Danish and supplemented with items from other existing tools. Face validity, content validity and applicability in OOH telephone triage (OOH-TT) were secured through a two-round Delphi process involving relevant stakeholders. Forty-eight OOH patient contacts were assessed by 24 assessors in test-retest and inter-rater designs. SETTING OOH-TT services in Denmark conducted by GPs, nurses or doctors with varying medical specialisation. PATIENTS Audio-recorded OOH patient contacts. MAIN OUTCOME MEASURES Test-retest and inter-rater reliability were analysed using ICCagreement, Fleiss' kappa and percent agreement. RESULTS Major adaptations during the Delphi process were made. The 24-item assessment tool (Assessment of Quality in Telephone Triage - AQTT) measured communicative quality, health-related quality and four overall quality aspects. The test-retest ICCagreement reliability was good for the overall quality of communication (0.85), health-related quality (0.83), patient safety (0.81) and efficiency (0.77) and satisfactory when assessing specific aspects. Inter-rater reliability revealed reduced reliability in ICCagreement and in Fleiss' kappa. Percent agreement revealed satisfactory agreements when differentiating between 'poor' and 'sufficient' quality). CONCLUSION The AQTT demonstrated high face, content and construct validity, satisfactory test-retest reliability, reduced inter-rater reliability, but satisfactory percent agreement when differentiating between 'poor' and 'sufficient' quality. The AQTT was found feasible and clinically relevant for assessing the quality of GP- and nurse-led OOH-TT. KEYPOINTS Comparative knowledge is sparse regarding quality of out-of-hours telephone triage conducted by general practitioners and nurses. The assessment tool (AQTT) enables assessment of quality in OOH telephone triage conducted by nurses and general practitioners AQTT is feasible and clinically relevant for assessment of communication, patient safety and efficiency. AQTT can be used to identify areas for improvement in telephone triage.
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Affiliation(s)
- D. S. Graversen
- Research Unit for General Practice, Aarhus, Denmark & Department of Public Health, Aarhus University, Aarhus C, Denmark
- CONTACT Dennis Schou Graversen Research Unit for General Practice, Aarhus, Denmark & Department of Public Health, Aarhus University, Bartholins Allé 2, 8000Aarhus C, Denmark
| | - A. F. Pedersen
- Research Unit for General Practice, Aarhus, Denmark & Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - A. H. Carlsen
- Research Unit for General Practice, Aarhus, Denmark & Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - F. Bro
- Research Unit for General Practice, Aarhus, Denmark & Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - L. Huibers
- Research Unit for General Practice, Aarhus, Denmark & Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - M. B. Christensen
- Research Unit for General Practice, Aarhus, Denmark & Department of Public Health, Aarhus University, Aarhus C, Denmark
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Laurant M, van der Biezen M, Wijers N, Watananirun K, Kontopantelis E, van Vught AJAH. Nurses as substitutes for doctors in primary care. Cochrane Database Syst Rev 2018; 7:CD001271. [PMID: 30011347 PMCID: PMC6367893 DOI: 10.1002/14651858.cd001271.pub3] [Citation(s) in RCA: 180] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Current and expected problems such as ageing, increased prevalence of chronic conditions and multi-morbidity, increased emphasis on healthy lifestyle and prevention, and substitution for care from hospitals by care provided in the community encourage countries worldwide to develop new models of primary care delivery. Owing to the fact that many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing. Substitution of nurses for doctors is one strategy used to improve access, efficiency, and quality of care. This is the first update of the Cochrane review published in 2005. OBJECTIVES Our aim was to investigate the impact of nurses working as substitutes for primary care doctors on:• patient outcomes;• processes of care; and• utilisation, including volume and cost. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), part of the Cochrane Library (www.cochranelibrary.com), as well as MEDLINE, Ovid, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EbscoHost (searched 20.01.2015). We searched for grey literature in the Grey Literature Report and OpenGrey (21.02.2017), and we searched the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov trial registries (21.02.2017). We did a cited reference search for relevant studies (searched 27.01 2015) and checked reference lists of all included studies. We reran slightly revised strategies, limited to publication years between 2015 and 2017, for CENTRAL, MEDLINE, and CINAHL, in March 2017, and we have added one trial to 'Studies awaiting classification'. SELECTION CRITERIA Randomised trials evaluating the outcomes of nurses working as substitutes for doctors. The review is limited to primary healthcare services that provide first contact and ongoing care for patients with all types of health problems, excluding mental health problems. Studies which evaluated nurses supplementing the work of primary care doctors were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently carried out data extraction and assessment of risk of bias of included studies. When feasible, we combined study results and determined an overall estimate of the effect. We evaluated other outcomes by completing a structured synthesis. MAIN RESULTS For this review, we identified 18 randomised trials evaluating the impact of nurses working as substitutes for doctors. One study was conducted in a middle-income country, and all other studies in high-income countries. The nursing level was often unclear or varied between and even within studies. The studies looked at nurses involved in first contact care (including urgent care), ongoing care for physical complaints, and follow-up of patients with a particular chronic conditions such as diabetes. In many of the studies, nurses could get additional support or advice from a doctor. Nurse-doctor substitution for preventive services and health education in primary care has been less well studied.Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low- or moderate-certainty evidence):• Nurse-led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor-led care. However, the results vary and it is possible that nurse-led primary care makes little or no difference to the number of deaths (low-certainty evidence).• Blood pressure outcomes are probably slightly improved in nurse-led primary care. Other clinical or health status outcomes are probably similar (moderate-certainty evidence).• Patient satisfaction is probably slightly higher in nurse-led primary care (moderate-certainty evidence). Quality of life may be slightly higher (low-certainty evidence).We are uncertain of the effects of nurse-led care on process of care because the certainty of this evidence was assessed as very low.The effect of nurse-led care on utilisation of care is mixed and depends on the type of outcome. Consultations are probably longer in nurse-led primary care (moderate-certainty evidence), and numbers of attended return visits are slightly higher for nurses than for doctors (high-certainty evidence). We found little or no difference between nurses and doctors in the number of prescriptions and attendance at accident and emergency units (high-certainty evidence). There may be little or no difference in the number of tests and investigations, hospital referrals and hospital admissions between nurses and doctors (low-certainty evidence).We are uncertain of the effects of nurse-led care on the costs of care because the certainty of this evidence was assessed as very low. AUTHORS' CONCLUSIONS This review shows that for some ongoing and urgent physical complaints and for chronic conditions, trained nurses, such as nurse practitioners, practice nurses, and registered nurses, probably provide equal or possibly even better quality of care compared to primary care doctors, and probably achieve equal or better health outcomes for patients. Nurses probably achieve higher levels of patient satisfaction, compared to primary care doctors. Furthermore, consultation length is probably longer when nurses deliver care and the frequency of attended return visits is probably slightly higher for nurses, compared to doctors. Other utilisation outcomes are probably the same. The effects of nurse-led care on process of care and the costs of care are uncertain, and we also cannot ascertain what level of nursing education leads to the best outcomes when nurses are substituted for doctors.
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Affiliation(s)
- Miranda Laurant
- Radboud Institute for Health Sciences, IQ healthcareRadboud University Medical CenterPO Box 9101NijmegenNetherlands6500 HB
- HAN University of Applied SciencesFaculty of Health and Social StudiesNijmegenNetherlands
| | - Mieke van der Biezen
- Radboud Institute for Health Sciences, IQ healthcareRadboud University Medical CenterPO Box 9101NijmegenNetherlands6500 HB
| | | | - Kanokwaroon Watananirun
- Faculty of Medicine, Siriraj Hospital, Mahidol UniversityDepartment of Obstetrics and GynaecologyMahidolThailand
| | - Evangelos Kontopantelis
- The University of ManchesterCentre for Health Informatics, Institute of Population HealthWilliamson Building, 5th FloorOxford RoadManchesterGreater ManchesterUKM13 9PL
| | - Anneke JAH van Vught
- HAN University of Applied SciencesFaculty of Health and Social StudiesNijmegenNetherlands
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Shaw S, Wherton J, Vijayaraghavan S, Morris J, Bhattacharya S, Hanson P, Campbell-Richards D, Ramoutar S, Collard A, Hodkinson I, Greenhalgh T. Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06210] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BackgroundThere is much enthusiasm from clinicians, industry and the government to utilise digital technologies and introduce alternatives to face-to-face consultations.Objective(s)To define good practice and inform digital technology implementation in relation to remote consultations via Skype™ (Microsoft Corporation, Redmond, WA, USA) and similar technologies.DesignMultilevel mixed-methods study of remote video consultations (micro level) embedded in an organisational case study (meso level), taking account of the national context and wider influences (macro level).SettingThree contrasting clinical settings (Diabetes, Antenatal Diabetes and Cancer Surgery) in a NHS acute trust.Data collection and analysisMacro level – interviews with 12 national-level stakeholders combined with document analysis. Meso level – longitudinal organisational ethnography comprising over 300 hours of observations, 24 staff interviews and analysis of 16 documents. Micro level – 30 video-recorded remote consultations; 17 matched audio-recorded face-to-face consultations. Interview and ethnographic data were analysed thematically and theorised using strong structuration theory. Consultations were transcribed verbatim and analysed using the Roter interaction analysis system (RIAS), producing descriptive statistics on different kinds of talk and interaction.ResultsPolicy-makers viewed remote video consultations as a way of delivering health care efficiently in the context of rising rates of chronic illness and growing demand for services. However, the reality of establishing such services in a busy and financially stretched NHS acute trust proved to be far more complex and expensive than anticipated. Embedding new models of care took much time and many resources, and required multiple workarounds. Considerable ongoing effort was needed to adapt and align structures, processes and people within clinics and across the organisation. For practical and safety reasons, virtual consultations were not appropriate for every patient or every consultation. By the end of this study, between 2% and 20% of all consultations were being undertaken remotely in participating clinics. Technical challenges in setting up such consultations were typically minor, but potentially prohibitive. When clinical, technical and practical preconditions were met, virtual consultations appeared to be safe and were popular with both patients and staff. Compared with face-to-face consultations, virtual consultations were very slightly shorter, patients did slightly more talking and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Virtual consultations appeared to work better when the clinician and the patient knew and trusted each other. Some clinicians used Skype adaptively to support ad hoc clinician-initiated and spontaneous patient-initiated encounters. Other clinicians chose not to use the new service model at all.ConclusionsVirtual consultations appear to be safe, effective and convenient for patients who are preselected by their clinicians as ‘suitable’, but such patients represent a small fraction of clinic workloads. There are complex challenges to embedding virtual consultation services within routine practice in the NHS. Roll-out (across the organisation) and scale-up (to other organisations) are likely to require considerable support.LimitationsThe focus on a single NHS organisation raises questions about the transferability of findings, especially quantitative data on likely uptake rates.Future researchFurther studies on the micro-analysis of virtual consultations and on the spread and scale-up of virtual consulting services are planned.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sara Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Joseph Wherton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | | | | | | | | | | | | | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Schmitz CAA, Rodrigues Gonçalves M, Nunes Umpierre R, Da Silva Siqueira AC, Pereira D'Ávila O, Goulart Molina Bastos C, Dal Moro RG, Katz N, Harzheim E. Teleconsulta: nova fronteira da interação entre médicos e pacientes. REVISTA BRASILEIRA DE MEDICINA DE FAMÍLIA E COMUNIDADE 2017. [DOI: 10.5712/rbmfc12(39)1540] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
A teleconsulta, uma ação de telessaúde, apesar de ser regulamentada em vários países, ainda não é permitida no Brasil. O presente texto explora a situação da teleconsulta na América do Norte, na Europa e em outros países, fazendo um paralelo com a situação nacional dentro da medicina e de outras profissões da saúde. Ao final, por meio do referencial utilizado, é construída uma argumentação de forma a assumir um posicionamento favorável à regulamentação da teleconsulta no país.
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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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Storhaug HC, Mead SB, Steinsbekk A. A qualitative study of employees' opinions on establishing a generic call-centre. BMC FAMILY PRACTICE 2017; 18:90. [PMID: 29041908 PMCID: PMC5646114 DOI: 10.1186/s12875-017-0661-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 10/09/2017] [Indexed: 11/23/2022]
Abstract
Background To investigate opinions among employees at an Out-of-Hours general practitioner (OOH-GP) service and a safety alarm service about the establishment of a generic call-centre. Methods Qualitative study using individual and group interviews with 14 employees and managers involved in preparation of a merge into a new generic call-centre. They were asked about their opinions towards establishing a generic call-centre where all contact about unplanned health inquiries from the public had to be done by telephone and how to solve more requests on the phone. Data was analysed thematically. Results Participants who alternate between call handling and direct patient contact (personnel at the OOH-GP) believed that just handling calls would be monotonous, less challenging and provide poorer quality. This was not supported by those working at the safety alarm service. There were different opinions about introducing mandatory use of decision support system for all inquiries, but it was a common understanding that it would lead to more patients in need of face-to-face consultations due to over triage. To solve more requests on the phone participants believed a public information campaign was required, that GPs received more of the emergency requests within their ordinary working hours and having salaried doctors in the OOH-GP service. Conclusion In the participants’ opinion, successful establishment of a generic call-centre depends on the employees’ possibility of direct patient contact, clarifications on the use of decision support system and good information to the population.
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Affiliation(s)
| | - Sara Bjune Mead
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
| | - Aslak Steinsbekk
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway.
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Newbould J, Abel G, Ball S, Corbett J, Elliott M, Exley J, Martin A, Saunders C, Wilson E, Winpenny E, Yang M, Roland M. Evaluation of telephone first approach to demand management in English general practice: observational study. BMJ 2017; 358:j4197. [PMID: 28954741 PMCID: PMC5615264 DOI: 10.1136/bmj.j4197] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective To evaluate a "telephone first" approach, in which all patients wanting to see a general practitioner (GP) are asked to speak to a GP on the phone before being given an appointment for a face to face consultation.Design Time series and cross sectional analysis of routine healthcare data, data from national surveys, and primary survey data.Participants 147 general practices adopting the telephone first approach compared with a 10% random sample of other practices in England.Intervention Management support for workload planning and introduction of the telephone first approach provided by two commercial companies.Main outcome measures Number of consultations, total time consulting (59 telephone first practices, no controls). Patient experience (GP Patient Survey, telephone first practices plus controls). Use and costs of secondary care (hospital episode statistics, telephone first practices plus controls). The main analysis was intention to treat, with sensitivity analyses restricted to practices thought to be closely following the companies' protocols.Results After the introduction of the telephone first approach, face to face consultations decreased considerably (adjusted change within practices -38%, 95% confidence interval -45% to -29%; P<0.001). An average practice experienced a 12-fold increase in telephone consultations (1204%, 633% to 2290%; P<0.001). The average duration of both telephone and face to face consultations decreased, but there was an overall increase of 8% in the mean time spent consulting by GPs, albeit with large uncertainty on this estimate (95% confidence interval -1% to 17%; P=0.088). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase. Compared with other English practices in the national GP Patient Survey, in practices using the telephone first approach there was a large (20.0 percentage points, 95% confidence interval 18.2 to 21.9; P<0.001) improvement in length of time to be seen. In contrast, other scores on the GP Patient Survey were slightly more negative. Introduction of the telephone first approach was followed by a small (2.0%) increase in hospital admissions (95% confidence interval 1% to 3%; P=0.006), no initial change in emergency department attendance, but a small (2% per year) decrease in the subsequent rate of rise of emergency department attendance (1% to 3%; P=0.005). There was a small net increase in secondary care costs.Conclusions The telephone first approach shows that many problems in general practice can be dealt with over the phone. The approach does not suit all patients or practices and is not a panacea for meeting demand. There was no evidence to support claims that the approach would, on average, save costs or reduce use of secondary care.
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Affiliation(s)
- Jennifer Newbould
- Cambridge Centre for Health Services Research, RAND Europe, Westbrook Centre, Cambridge CB4 1YG, UK
| | - Gary Abel
- University of Exeter Medical School, Smeall Building, St Luke's Campus, Exeter EX1 2LU, UK
| | - Sarah Ball
- Cambridge Centre for Health Services Research, RAND Europe, Westbrook Centre, Cambridge CB4 1YG, UK
| | - Jennie Corbett
- Cambridge Centre for Health Services Research, RAND Europe, Westbrook Centre, Cambridge CB4 1YG, UK
| | - Marc Elliott
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90401-3208, USA
| | - Josephine Exley
- Cambridge Centre for Health Services Research, RAND Europe, Westbrook Centre, Cambridge CB4 1YG, UK
| | - Adam Martin
- Cambridge Centre for Health Services Research, RAND Europe, Westbrook Centre, Cambridge CB4 1YG, UK
| | - Catherine Saunders
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Forvie Site, Cambridge CB2 0SR, UK
| | - Edward Wilson
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Forvie Site, Cambridge CB2 0SR, UK
| | - Eleanor Winpenny
- Cambridge Centre for Health Services Research, RAND Europe, Westbrook Centre, Cambridge CB4 1YG, UK
| | - Miaoqing Yang
- Cambridge Centre for Health Services Research, RAND Europe, Westbrook Centre, Cambridge CB4 1YG, UK
| | - Martin Roland
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Forvie Site, Cambridge CB2 0SR, UK
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Tran DT, Gibson A, Randall D, Havard A, Byrne M, Robinson M, Lawler A, Jorm LR. Compliance with telephone triage advice among adults aged 45 years and older: an Australian data linkage study. BMC Health Serv Res 2017; 17:512. [PMID: 28764695 PMCID: PMC5539620 DOI: 10.1186/s12913-017-2458-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/18/2017] [Indexed: 11/25/2022] Open
Abstract
Background Middle-aged and older patients are prominent users of telephone triage services for timely access to health information and appropriate referrals. Non-compliance with advice to seek appropriate care could potentially lead to poorer health outcomes among those patients. It is imperative to assess the extent to which middle-aged and older patients follow triage advice and how this varies according to their socio-demographic, lifestyle and health characteristics as well as features of the call. Methods Records of calls to the Australian healthdirect helpline (July 2008–December 2011) were linked to baseline questionnaire data from the 45 and Up Study (participants age ≥ 45 years), records of emergency department (ED) presentations, hospital admissions, and medical consultation claims. Outcomes of the call included compliance with the advice “Attend ED immediately”; “See a doctor (immediately, within 4 hours, or within 24 hours)”; “Self-care”; and self-referral to ED or hospital within 24 h when given a self-care or low-urgency care advice. Multivariable logistic regression was used to investigate associations between call outcomes and patient and call characteristics. Results This study included 8406 adults (age ≥ 45 years) who were subjects of 11,088 calls to the healthdirect helpline. Rates of compliance with the advices “Attend ED immediately”, “See a doctor” and “Self-care” were 68.6%, 64.6% and 77.5% respectively, while self-referral to ED within 24 h followed 7.0% of calls. Compliance with the advice “Attend ED immediately” was higher among patients who had three or more positive lifestyle behaviours, called after-hours, or stated that their original intention was to attend ED, while it was lower among those who lived in rural and remote areas or reported high or very high levels of psychological distress. Compliance with the advice “See a doctor” was higher in patients who were aged ≥65 years, worked full-time, or lived in socio-economically advantaged areas, when another person made the call on the patient’s behalf, and when the original intention was to seek care from an ED or a doctor. It was lower among patients in rural and remote areas and those taking five medications or more. Patients aged ≥65 years were less likely to comply with the advice “Self-care”. The rates of self-referral to ED within 24 h were greater in patients from disadvantaged areas, among calls made after-hours or by another person, and when the original intention was to attend ED. Patients who were given a self-care or low-urgency care advice, whose calls concerned bleeding, cardiac, gastrointestinal, head and facial injury symptoms, were more likely to self-refer to ED. Conclusions Compliance with telephone triage advice among middle-age and older patients varied substantially according to both patient- and call-related factors. Knowledge about the patients who are less likely to comply with telephone triage advice, and about characteristics of calls that may influence compliance, will assist in refining patient triage protocols and referral pathways, training staff and tailoring service design and delivery to achieve optimal patient compliance. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2458-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Duong Thuy Tran
- Centre for Big Data Research in Health-Faculty of Medicine, UNSW Sydney (The University of New South Wales), Sydney, NSW, 2052, Australia.
| | - Amy Gibson
- Centre for Big Data Research in Health-Faculty of Medicine, UNSW Sydney (The University of New South Wales), Sydney, NSW, 2052, Australia
| | - Deborah Randall
- Centre for Big Data Research in Health-Faculty of Medicine, UNSW Sydney (The University of New South Wales), Sydney, NSW, 2052, Australia
| | - Alys Havard
- Centre for Big Data Research in Health-Faculty of Medicine, UNSW Sydney (The University of New South Wales), Sydney, NSW, 2052, Australia
| | - Mary Byrne
- Healthdirect Australia, 133 Castlereagh Street, Sydney, NSW, 2000, Australia
| | - Maureen Robinson
- Healthdirect Australia, 133 Castlereagh Street, Sydney, NSW, 2000, Australia
| | - Anthony Lawler
- School of Medicine, University of Tasmania and Healthdirect Australia, Department of Health and Human Services, Level 2, 22 Elizabeth Street, Hobart, TAS, 7000, Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health-Faculty of Medicine, UNSW Sydney (The University of New South Wales), Sydney, NSW, 2052, Australia
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Vaona A, Pappas Y, Grewal RS, Ajaz M, Majeed A, Car J. Training interventions for improving telephone consultation skills in clinicians. Cochrane Database Syst Rev 2017; 1:CD010034. [PMID: 28052316 PMCID: PMC6464130 DOI: 10.1002/14651858.cd010034.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Since 1879, the year of the first documented medical telephone consultation, the ability to consult by telephone has become an integral part of modern patient-centred healthcare systems. Nowadays, upwards of a quarter of all care consultations are conducted by telephone. Studies have quantified the impact of medical telephone consultation on clinicians' workload and detected the need for quality improvement. While doctors routinely receive training in communication and consultation skills, this does not necessarily include the specificities of telephone communication and consultation. Several studies assessed the short-term effect of interventions aimed at improving clinicians' telephone consultation skills, but there is no systematic review reporting patient-oriented outcomes or outcomes of interest to clinicians. OBJECTIVES To assess the effects of training interventions for clinicians' telephone consultation skills and patient outcomes. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, five other electronic databases and two trial registers up to 19 May 2016, and we handsearched references, checked citations and contacted study authors to identify additional studies and data. SELECTION CRITERIA We considered randomised controlled trials, non-randomised controlled trials, controlled before-after studies and interrupted time series studies evaluating training interventions compared with any control intervention, including no intervention, for improving clinicians' telephone consultation skills with patients and their impact on patient outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data and assessed the risk of bias of eligible studies using standard Cochrane and EPOC guidance and the certainty of evidence using GRADE. We contacted study authors where additional information was needed. We used standard methodological procedures expected by Cochrane for data analysis. MAIN RESULTS We identified one very small controlled before-after study performed in 1989: this study used a validated tool to assess the effects of a training intervention on paediatric residents' history-taking and case management skills. It reported no difference compared to no intervention, but authors did not report any quantitative analyses and could not supply additional data. We rated this study as being at high risk of bias. Based on GRADE, we assessed the certainty of the evidence as very low, and consequently it is uncertain whether this intervention improves clinicians' telephone skills.We did not find any study assessing the effect of training interventions for improving clinicians' telephone communication skills on patient primary outcomes (health outcomes measured by validated tools or biomedical markers or patient behaviours, patient morbidity or mortality, patient satisfaction, urgency assessment accuracy or adverse events). AUTHORS' CONCLUSIONS Telephone consultation skills are part of a wider set of remote consulting skills whose importance is growing as more and more medical care is delivered from a distance with the support of information technology. Nevertheless, no evidence specifically coming from telephone consultation studies is available, and the training of clinicians at the moment has to be guided by studies and models based on face-to-face communication, which do not consider the differences between these two communicative dimensions. There is an urgent need for more research assessing the effect of different training interventions on clinicians' telephone consultation skills and their effect on patient outcomes.
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Affiliation(s)
- Alberto Vaona
- Azienda ULSS 20 ‐ VeronaPrimary CareOspedale di MarzanaPiazzale Ruggero Lambranzi 1VeronaItaly37142
| | - Yannis Pappas
- University of BedfordshireInstitute for Health ResearchPark SquareLutonBedfordUKLU1 3JU
| | - Rumant S Grewal
- Imperial College LondonGlobal eHealth Unit, Department of Primary Care and Public Health, School of Public HealthThe Reynolds Building, Charing Cross CampusSt Dunstans RoadLondonLondonUKW6 8RP
| | - Mubasshir Ajaz
- University of BedfordshireInstitute for Health ResearchPark SquareLutonBedfordUKLU1 3JU
| | - Azeem Majeed
- Imperial College LondonDepartment of Primary Care and Public HealthThe Reynolds Building, Charing Cross CampusSt Dunstan's RoadLondonUKW6 8RP
| | - Josip Car
- Lee Kong Chian School of Medicine, Nanyang Technological UniversityCentre for Population Health Sciences (CePHaS)3 Fusionopolis Link, #03‐08Nexus@one‐northSingaporeSingapore138543
- University of LjubljanaDepartment of Family Medicine, Faculty of MedicineLjubljanaSlovenia
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Atherton H, Ziebland S. What do we need to consider when planning, implementing and researching the use of alternatives to face-to-face consultations in primary healthcare? Digit Health 2016; 2:2055207616675559. [PMID: 29942570 PMCID: PMC6001190 DOI: 10.1177/2055207616675559] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 09/23/2016] [Indexed: 11/26/2022] Open
Abstract
Objectives Communications technologies are variably utilised in healthcare. Policymakers globally have espoused the potential benefits of alternatives to face-to-face consultations, but research is in its infancy. The aim of this essay is to provide thinking tools for policymakers, practitioners and researchers who are involved in planning, implementing and evaluating alternative forms of consultation in primary care. Methods We draw on preparations for a focussed ethnographic study being conducted in eight general practice settings in the UK, knowledge of the literature, qualitative social science and Cochrane reviews. In this essay we consider different types of patients, and also reflect on how the work, practice and professional identities of different members of staff in primary care might be affected. Results Elements of practice are inevitably lost when consultations are no longer face-to-face, and we know little about the impact on core aspects of the primary care relationship. Resistance to change is normal and concerns about the introduction of alternative methods of consultation are often expressed using proxy reasons; for example, concerns about patient safety. Any planning or research in the field of new technologies should be attuned to the potential for unintended consequences. Conclusions Implementation of alternatives to the face-to-face consultation is more likely to succeed if approached as co-designed initiatives that start with the least controversial and most promising changes for the practice. Researchers and evaluators should explore actual experiences of the different consultation types amongst patients and the primary care team rather than hypothetical perspectives.
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Affiliation(s)
- Helen Atherton
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford Radcliffe Observatory Quarter, Oxford, UK
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Reuter PG, Desmettre T, Guinemer S, Ducros O, Begey S, Ricard-Hibon A, Billier L, Grignon O, Megy-Michoux I, Latouff JN, Sourbes A, Latier J, Durand-Zaleski I, Lapostolle F, Vicaut E, Adnet F. Effectiveness and cost-effectiveness of telephone consultations for fever or gastroenteritis using a formalised procedure in general practice: study protocol of a cluster randomised controlled trial. Trials 2016; 17:461. [PMID: 27659897 PMCID: PMC5034584 DOI: 10.1186/s13063-016-1585-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 09/05/2016] [Indexed: 11/30/2022] Open
Abstract
Background Telephone consultations in general practice are on the increase. However, data on their efficiency in terms of out-of-hours general practitioner (GP) workload, visits to hospital emergency departments (ED), cost, patient safety and satisfaction are relatively scant. The aim of this trial is to assess the effectiveness of telephone consultations provided by French emergency call centres in patients presenting with isolated fever or symptoms of gastroenteritis, mainly encountered diseases. Methods/design This is a prospective, open-label, multicentre, pragmatic, cluster randomised clinical trial of an estimated 2880 patients making an out-of-hours call to one of six French emergency call centres for assistance with either fever or symptoms of gastroenteritis without seriousness criteria. Each call is handled by a call centre physician. Out-of-hours is 8 p.m. to 7.59 a.m. on weekdays, 1 p.m. to 7.59 a.m. on Saturdays and round-the-clock on Sundays and school holidays. Patients will be enrolled over 1 year. In the intervention arm, a telephone consultation based on a protocol, the formal Telephone Medical Advice (fTMA), is offered to each patient calling. This protocol aims to overcome a physical consultation during out-of-hours periods. It offers reassurance and explanations, advice on therapeutic management which may include, in addition to hygiene and diet measures, a telephone prescription of antipyretic, analgesic, rehydration medication or others, and recommendations on surveillance of the patient and any action to be taken. The patient is invited to call again if the condition worsens or new symptoms develop and to make an appointment with their family GP during office hours. In the control arm, the call centre physician handles calls as usual. This physician can carry out a telephone consultation with or without a telephone prescription, dispatch an on-duty GP, the fire brigade or an ambulance to the patient, or refer the patient to an on-duty physician or to the ED. Each patient will receive a follow-up call on day 15. The primary endpoint is the frequency of out-of-hours, face-to-face GP consultations or visits to the ED during the 15 days following the index call. The secondary endpoints measured on day 15 are the number of stays in intensive care, the number of hospital admissions, the number of interventions by the fire brigade, emergency medical and ambulance services, the number and length of prescribed sick-leave episodes, all-cause mortality, morbidity, clinical outcome, patient compliance, patient satisfaction, the number of renewed calls to the call centre, the number of patients receiving multiple face-to-face GP consultations and costs incurred. Discussion This trial will assess the effectiveness and the cost-effectiveness of a formalised response to calls for assistance with fever or symptoms of gastroenteritis without seriousness criteria. Trial registration ClinicalTrials.gov Identifier: NCT02286245, registered on 9 September 2014.
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Affiliation(s)
- Paul-Georges Reuter
- Service des Urgences et Service d'Aide Médicale Urgente, Centre Hospitalier Universitaire Avicenne, Assistance Publique-Hôpitaux de Paris, 125 rue de Stalingrad, 93009, Bobigny Cedex, France. .,Université Paris 13, Sorbonne Paris Cité, EA 3509, Bobigny, France.
| | - Thibaut Desmettre
- Urgences et SAMU 25 - Centre Hospitalier Régional Universitaire de Besançon, 1 Bd Fleming, 25030, Besançon Cedex, France.,Université de Franche Comté-Bourgogne, UMR 6249 CNRS/UFC, 1 Bd Fleming, 25030, Besançon Cedex, France
| | - Sabine Guinemer
- Service des Urgences et Service d'Aide Médicale Urgente, Centre Hospitalier Universitaire Avicenne, Assistance Publique-Hôpitaux de Paris, 125 rue de Stalingrad, 93009, Bobigny Cedex, France.,Université Paris 13, Sorbonne Paris Cité, EA 3509, Bobigny, France
| | - Olivier Ducros
- SAMU-SMUR 95, Centre Hospitalier René Dubos, 6 Avenue de l'Île de France, 95300, Pontoise, France
| | - Stéphane Begey
- Association COmtoise de REgulation Libérale, CHRU de Besançon, 1 Bd Fleming, 25030, Besançon Cedex, France
| | - Agnès Ricard-Hibon
- SAMU-SMUR 95, Centre Hospitalier René Dubos, 6 Avenue de l'Île de France, 95300, Pontoise, France
| | - Laurianne Billier
- SAMU 44, PHU Urgences - Médecines - Soins Critiques, Centre Hospitalo-Universitaire de Nantes, 1 quai Moncousu, 44 093, Nantes Cedex, France
| | - Océane Grignon
- SAMU 44, PHU Urgences - Médecines - Soins Critiques, Centre Hospitalo-Universitaire de Nantes, 1 quai Moncousu, 44 093, Nantes Cedex, France
| | - Isabelle Megy-Michoux
- SAMU SMUR Urgences, Centre Hospitalier Châteauroux, 216 avenue de Verdun, 36000, Châteauroux, France
| | - Jean-Noël Latouff
- SAMU SMUR Urgences, Centre Hospitalier Châteauroux, 216 avenue de Verdun, 36000, Châteauroux, France
| | - Adeline Sourbes
- SAMU 82, Centre Hospitalier de Montauban, 100 rue Léon Vladel, 82000, Montauban, France
| | - Julien Latier
- SAMU 82, Centre Hospitalier de Montauban, 100 rue Léon Vladel, 82000, Montauban, France
| | - Isabelle Durand-Zaleski
- Assistance Publique-Hôpitaux de Paris, URC Eco, Paris, France.,Inserm, ECEVE, U1123, Paris, France
| | - Frédéric Lapostolle
- Service des Urgences et Service d'Aide Médicale Urgente, Centre Hospitalier Universitaire Avicenne, Assistance Publique-Hôpitaux de Paris, 125 rue de Stalingrad, 93009, Bobigny Cedex, France.,Université Paris 13, Sorbonne Paris Cité, EA 3509, Bobigny, France
| | - Eric Vicaut
- Unité de Recherche Clinique, Saint Louis - Lariboisière - Fernand Widal University Hospital, AP-HP, Paris, France
| | - Frédéric Adnet
- Service des Urgences et Service d'Aide Médicale Urgente, Centre Hospitalier Universitaire Avicenne, Assistance Publique-Hôpitaux de Paris, 125 rue de Stalingrad, 93009, Bobigny Cedex, France.,Université Paris 13, Sorbonne Paris Cité, EA 3509, Bobigny, France
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Carson-Stevens A, Hibbert P, Williams H, Evans HP, Cooper A, Rees P, Deakin A, Shiels E, Gibson R, Butlin A, Carter B, Luff D, Parry G, Makeham M, McEnhill P, Ward HO, Samuriwo R, Avery A, Chuter A, Donaldson L, Mayor S, Panesar S, Sheikh A, Wood F, Edwards A. Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04270] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundThere is an emerging interest in the inadvertent harm caused to patients by the provision of primary health-care services. To date (up to 2015), there has been limited research interest and few policy directives focused on patient safety in primary care. In 2003, a major investment was made in the National Reporting and Learning System to better understand patient safety incidents occurring in England and Wales. This is now the largest repository of patient safety incidents in the world. Over 40,000 safety incident reports have arisen from general practice. These have never been systematically analysed, and a key challenge to exploiting these data has been the largely unstructured, free-text data.AimsTo characterise the nature and range of incidents reported from general practice in England and Wales (2005–13) in order to identify the most frequent and most harmful patient safety incidents, and relevant contributory issues, to inform recommendations for improving the safety of primary care provision in key strategic areas.MethodsWe undertook a cross-sectional mixed-methods evaluation of general practice patient safety incident reports. We developed our own classification (coding) system using an iterative approach to describe the incident, contributory factors and incident outcomes. Exploratory data analysis methods with subsequent thematic analysis was undertaken to identify the most harmful and most frequent incident types, and the underlying contributory themes. The study team discussed quantitative and qualitative analyses, and vignette examples, to propose recommendations for practice.Main findingsWe have identified considerable variation in reporting culture across England and Wales between organisations. Two-thirds of all reports did not describe explicit reasons about why an incident occurred. Diagnosis- and assessment-related incidents described the highest proportion of harm to patients; over three-quarters of these reports (79%) described a harmful outcome, and half of the total reports described serious harm or death (n = 366, 50%). Nine hundred and ninety-six reports described serious harm or death of a patient. Four main contributory themes underpinned serious harm- and death-related incidents: (1) communication errors in the referral and discharge of patients; (2) physician decision-making; (3) unfamiliar symptom presentation and inadequate administration delaying cancer diagnoses; and (4) delayed management or mismanagement following failures to recognise signs of clinical (medical, surgical and mental health) deterioration.ConclusionsAlthough there are recognised limitations of safety-reporting system data, this study has generated hypotheses, through an inductive process, that now require development and testing through future research and improvement efforts in clinical practice. Cross-cutting priority recommendations include maximising opportunities to learn from patient safety incidents; building information technology infrastructure to enable details of all health-care encounters to be recorded in one system; developing and testing methods to identify and manage vulnerable patients at risk of deterioration, unscheduled hospital admission or readmission following discharge from hospital; and identifying ways patients, parents and carers can help prevent safety incidents. Further work must now involve a wider characterisation of reports contributed by the rest of the primary care disciplines (pharmacy, midwifery, health visiting, nursing and dentistry), include scoping reviews to identify interventions and improvement initiatives that address priority recommendations, and continue to advance the methods used to generate learning from safety reports.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Andrew Carson-Stevens
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
- Wales Primary and Emergency Care (PRIME) Research Centre, Cardiff University, Cardiff, UK
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Peter Hibbert
- Australian Institute for Health Innovation (AIHI), Macquarie University, Sydney, NSW, Australia
| | - Huw Williams
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Huw Prosser Evans
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Alison Cooper
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Philippa Rees
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Anita Deakin
- Australian Patient Safety Foundation, University of South Australia, Adelaide, SA, Australia
| | - Emma Shiels
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Russell Gibson
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Amy Butlin
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Ben Carter
- Centre for Medical Education, Cardiff University, Cardiff, UK
| | - Donna Luff
- Harvard Medical School, Harvard University, Boston, MA, USA
| | - Gareth Parry
- Harvard Medical School, Harvard University, Boston, MA, USA
- Institute for Healthcare Improvement (IHI), Cambridge, MA, USA
| | - Meredith Makeham
- Australian Institute for Health Innovation (AIHI), Macquarie University, Sydney, NSW, Australia
| | - Paul McEnhill
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Hope Olivia Ward
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Raymond Samuriwo
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Anthony Avery
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | | | - Liam Donaldson
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sharon Mayor
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Sukhmeet Panesar
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Aziz Sheikh
- Harvard Medical School, Harvard University, Boston, MA, USA
- Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - Fiona Wood
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Adrian Edwards
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
- Wales Primary and Emergency Care (PRIME) Research Centre, Cardiff University, Cardiff, UK
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Murdoch J. Process evaluation for complex interventions in health services research: analysing context, text trajectories and disruptions. BMC Health Serv Res 2016; 16:407. [PMID: 27538946 PMCID: PMC4990981 DOI: 10.1186/s12913-016-1651-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 08/10/2016] [Indexed: 11/10/2022] Open
Abstract
Background Process evaluations assess the implementation and sustainability of complex healthcare interventions within clinical trials, with well-established theoretical models available for evaluating intervention delivery within specific contexts. However, there is a need to translate conceptualisations of context into analytical tools which enable the dynamic relationship between context and intervention implementation to be captured and understood. Methods In this paper I propose an alternative approach to the design, implementation and analysis of process evaluations for complex health interventions through a consideration of trial protocols as textual documents, distributed and enacted at multiple contextual levels. As an example, I conduct retrospective analysis of a sample of field notes and transcripts collected during the ESTEEM study - a cluster randomised controlled trial of primary care telephone triage. I draw on theoretical perspectives associated with Linguistic Ethnography to examine the delivery of ESTEEM through staff orientation to different texts. In doing so I consider what can be learned from examining the flow and enactment of protocols for notions of implementation and theoretical fidelity (i.e. intervention delivered as intended and whether congruent with the intervention theory). Results Implementation of the triage intervention required staff to integrate essential elements of the protocol within everyday practice, seen through the adoption and use of different texts that were distributed across staff and within specific events. Staff were observed deploying texts in diverse ways (e.g. reinterpreting scripts, deviating from standard operating procedures, difficulty completing decision support software), providing numerous instances of disruption to maintaining intervention fidelity. Such observations exposed tensions between different contextual features in which the trial was implemented, offering theoretical explanations for the main trial findings. Conclusions The value of following how trial protocols produce new texts is that we can observe the flow of ‘the intervention as intended’ across a series of events which are enacted to meet specific demands of intervention delivery. Such observations are not solely premised on identifying routines or practices of implementation, but where ‘protocols as intended’ breaks down. In doing so, I discuss whether it is here where we might expose the ‘active ingredients’ of interventions in action. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1651-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jamie Murdoch
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK.
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The effect of nurses' preparedness and nurse practitioner status on triage call management in primary care: A secondary analysis of cross-sectional data from the ESTEEM trial. Int J Nurs Stud 2016; 58:12-20. [PMID: 27087294 PMCID: PMC4845697 DOI: 10.1016/j.ijnurstu.2016.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 02/03/2016] [Accepted: 02/03/2016] [Indexed: 11/30/2022]
Abstract
Background Nurse-led telephone triage is increasingly used to manage demand for general practitioner consultations in UK general practice. Previous studies are equivocal about the relationship between clinical experience and the call outcomes of nurse triage. Most research is limited to investigating nurse telephone triage in out-of-hours settings. Objective To investigate whether the professional characteristics of primary care nurses undertaking computer decision supported software telephone triage are related to call disposition. Design Questionnaire survey of nurses delivering the nurse intervention arm of the ESTEEM trial, to capture role type (practice nurse or nurse practitioner), prescriber status, number of years’ nursing experience, graduate status, previous experience of triage, and perceived preparedness for triage. Our main outcome was the proportion of triaged patients recommended for follow-up within the practice (call disposition), including all contact types (face-to-face, telephone or home visit), by a general practitioner or nurse. Settings 15 general practices and 7012 patients receiving the nurse triage intervention in four regions of the UK. Participants 45 nurse practitioners and practice nurse trained in the use of clinical decision support software. Methods We investigated the associations between nursing characteristics and triage call disposition for patient ‘same-day’ appointment requests in general practice using multivariable logistic regression modelling. Results Valid responses from 35 nurses (78%) from 14 practices: 31/35 (89%) had ≥10 years’ experience with 24/35 (69%) having ≥20 years. Most patient contacts (3842/4605; 86%) were recommended for follow-up within the practice. Nurse practitioners were less likely to recommend patients for follow-up odds ratio 0.19, 95% confidence interval 0.07; 0.49 than practice nurses. Nurses who reported that their previous experience had prepared them less well for triage were more likely to recommend patients for follow-up (OR 3.17, 95% CI 1.18–5.55). Conclusion Nurse characteristics were associated with disposition of triage calls to within practice follow-up. Nurse practitioners or those who reported feeling ‘more prepared’ for the role were more likely to manage the call definitively. Practices considering nurse triage should ensure that nurses transitioning into new roles feel adequately prepared. While standardised training is necessary, it may not be sufficient to ensure successful implementation.
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Calitri R, Warren FC, Wheeler B, Chaplin K, Fletcher E, Murdoch J, Richards S, Taylor RS, Varley A, Campbell J. Distance from practice moderates the relationship between patient management involving nurse telephone triage consulting and patient satisfaction with care. Health Place 2015; 34:92-6. [DOI: 10.1016/j.healthplace.2015.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 04/15/2015] [Accepted: 04/17/2015] [Indexed: 11/28/2022]
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Warren FC, Calitri R, Fletcher E, Varley A, Holt TA, Lattimer V, Richards D, Richards S, Salisbury C, Taylor RS, Campbell JL. Exploring demographic and lifestyle associations with patient experience following telephone triage by a primary care doctor or nurse: secondary analyses from a cluster randomised controlled trial. BMJ Qual Saf 2015; 24:572-82. [PMID: 25986572 PMCID: PMC4552919 DOI: 10.1136/bmjqs-2015-003937] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 04/21/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND The ESTEEM trial was a cluster randomised controlled trial that compared two telephone triage management systems (general practitioner (GP) or a nurse supported by computer decision support software) with usual care, in response to a request for same-day consultation in general practice. AIM To investigate associations between trial patients' demographic, health, and lifestyle characteristics, and their reported experiences of care. SETTING Recruitment of 20 990 patients occurred between May 2011 and December 2012 in 42 GP practices in England (13 GP triage, 15 nurse triage, 14 usual care). METHOD Patients reported their experiences via a postal questionnaire issued 4 weeks after their initial request for a same-day consultation. Overall satisfaction, ease of accessing medical help/advice, and convenience of care were analysed using linear hierarchical modelling. RESULTS Questionnaires were returned by 12 132 patients (58%). Older patients reported increased overall satisfaction compared with patients aged 25-59 years, but patients aged 16-24 years reported lower satisfaction. Compared with white patients, patients from ethnic minorities reported lower satisfaction in all three arms, although to a lesser degree in the GP triage arm. Patients from ethnic minorities reported higher satisfaction in the GP triage than in usual care, whereas white patients reported higher satisfaction with usual care. Patients unable to take time away from work or who could only do so with difficulty reported lower satisfaction across all three trial arms. CONCLUSIONS Patient characteristics, such as age, ethnicity and ability to attend their practice during work hours, were associated with their experiences of care following a same-day consultation request in general practice. Telephone triage did not increase satisfaction among patients who were unable to attend their practice during working hours. TRIAL REGISTRATION NUMBER ISCRTN20687662.
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Affiliation(s)
- Fiona C Warren
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Raff Calitri
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Emily Fletcher
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Anna Varley
- School of Nursing Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Tim A Holt
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Valerie Lattimer
- School of Nursing Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - David Richards
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Suzanne Richards
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Rod S Taylor
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - John L Campbell
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
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Murdoch J, Varley A, Fletcher E, Britten N, Price L, Calitri R, Green C, Lattimer V, Richards SH, Richards DA, Salisbury C, Taylor RS, Campbell JL. Implementing telephone triage in general practice: a process evaluation of a cluster randomised controlled trial. BMC FAMILY PRACTICE 2015; 16:47. [PMID: 25887747 PMCID: PMC4395901 DOI: 10.1186/s12875-015-0263-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 03/30/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Telephone triage represents one strategy to manage demand for face-to-face GP appointments in primary care. However, limited evidence exists of the challenges GP practices face in implementing telephone triage. We conducted a qualitative process evaluation alongside a UK-based cluster randomised trial (ESTEEM) which compared the impact of GP-led and nurse-led telephone triage with usual care on primary care workload, cost, patient experience, and safety for patients requesting a same-day GP consultation. The aim of the process study was to provide insights into the observed effects of the ESTEEM trial from the perspectives of staff and patients, and to specify the circumstances under which triage is likely to be successfully implemented. Here we report perspectives of staff. METHODS The intervention comprised implementation of either GP-led or nurse-led telephone triage for a period of 2-3 months. A qualitative evaluation was conducted using staff interviews recruited from eight general practices (4 GP triage, 4 Nurse triage) in the UK, implementing triage as part of the ESTEEM trial. Qualitative interviews were undertaken with 44 staff members in GP triage and nurse triage practices (16 GPs, 8 nurses, 7 practice managers, 13 administrative staff). RESULTS Staff reported diverse experiences and perceptions regarding the implementation of telephone triage, its effects on workload, and on the benefits of triage. Such diversity were explained by the different ways triage was organised, the staffing models used to support triage, how the introduction of triage was communicated across practice staff, and by how staff roles were reconfigured as a result of implementing triage. CONCLUSION The findings from the process evaluation offer insight into the range of ways GP practices participating in ESTEEM implemented telephone triage, and the circumstances under which telephone triage can be successfully implemented beyond the context of a clinical trial. Staff experiences and perceptions of telephone triage are shaped by the way practices communicate with staff, prepare for and sustain the changes required to implement triage effectively, as well as by existing practice culture, and staff and patient behaviour arising in response to the changes made. TRIAL REGISTRATION Current Controlled Trials ISRCTN20687662. Registered 28 May 2009.
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Affiliation(s)
- Jamie Murdoch
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK.
| | - Anna Varley
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK.
| | - Emily Fletcher
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK.
| | - Nicky Britten
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK.
| | - Linnie Price
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK.
| | - Raff Calitri
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK.
| | - Colin Green
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK.
| | - Valerie Lattimer
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK.
| | - Suzanne H Richards
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK.
| | - David A Richards
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK.
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - Rod S Taylor
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK.
| | - John L Campbell
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK.
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