Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a clusterrandomised controlled trial and cost-consequence analysis John L Campbell, Emily Fletcher, Nicky Britten, Colin Green, Tim A Holt, Valerie Lattimer, David A Richards, Suzanne H Richards, Chris Salisbury, Raff Calitri, Vicky Bowyer, Katherine Chaplin, Rebecca Kandiyali, Jamie Murdoch, Julia Roscoe, Anna Varley, Fiona C Warren, Rod S Taylor SummaryBackground Telephone triage is increasingly used to manage workload in primary care; however, supporting evidence for this approach is scarce. We aimed to assess the eff ectiveness and cost consequences of general practitioner-(GP)-led and nurse-led telephone triage compared with usual care for patients seeking same-day consultations in primary care.

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BackgroundTelephone triage is proposed as a method of managing increasing demand for primary care. Previous studies have involved small samples in limited settings, and focused on nurse roles. Evidence is limited regarding the impact on primary care workload, costs, and patient safety and experience when triage is used to manage patients requesting same-day consultations in general practice.ObjectivesIn comparison with usual care (UC), to assess the impact of GP-led telephone triage (GPT) and nurse-led computer-supported telephone triage (NT) on primary care workload and cost, patient experience of care, and patient safety and health status for patients requesting same-day consultations in general practice.DesignPragmatic cluster randomised controlled trial, incorporating economic evaluation and qualitative process evaluation.SettingGeneral practices (n = 42) in four regions of England, UK (Devon, Bristol/Somerset, Warwickshire/Coventry, Norfolk/Suffolk).ParticipantsPatients requesting same-day consultations.InterventionsPractices were randomised to GPT, NT or UC. Data collection was not blinded; however, analysis was conducted by a statistician blinded to practice allocation.Main outcome measuresPrimary – primary care contacts [general practice, out-of-hours primary care, accident and emergency (A&E) and walk-in centre attendances] in the 28 days following the index consultation request. Secondary – resource use and costs, patient safety (deaths and emergency hospital admissions within 7 days of index request, and A&E attendance within 28 days), health status and experience of care.ResultsOf 20,990 eligible randomised patients (UCn = 7283; GPTn = 6695; NTn = 7012), primary outcome data were analysed for 16,211 patients (UCn = 5572; GPTn = 5171; NTn = 5468). Compared with UC, GPT and NT increased primary outcome contacts (over 28-day follow-up) by 33% [rate ratio (RR) 1.33, 95% confidence interval (CI) 1.30 to 1.36] and 48% (RR 1.48, 95% CI 1.44 to 1.52), respectively. Compared with GPT, NT was associated with a marginal increase in primary outcome contacts by 4% (RR 1.04, 95% CI 1.01 to 1.08). Triage was associated with a redistribution of primary care contacts. Although GPT, compared with UC, increased the rate of overall GP contacts (face to face and telephone) over the 28 days by 38% (RR 1.38, 95% CI 1.28 to 1.50), GP face-to-face contacts were reduced by 39% (RR 0.61, 95% CI 0.54 to 0.69). NT reduced the rate of overall GP contacts by 16% (RR 0.84, 95% CI 0.78 to 0.91) and GP face-to-face contacts by 20% (RR 0.80, 95% CI 0.71 to 0.90), whereas nurse contacts increased. The increased rate of primary care contacts in triage arms is largely attributable to increased telephone contacts. Estimated overall patient–clinician contact time on the index day increased in triage (GPT = 10.3 minutes; NT = 14.8 minutes; UC = 9.6 minutes), although patterns of clinician use varied between arms. Taking account of both the pattern and duration of primary outcome contacts, overall costs over the 28-day follow-up were similar in all three arms (approximately £75 per patient). Triage appeared safe, and no differences in patient health status were observed. NT was somewhat less acceptable to patients than GPT or UC. The process evaluation identified the complexity associated with introducing triage but found no consistency across practices about what works and what does not work when implementing it.ConclusionsIntroducing GPT or NT was associated with a redistribution of primary care workload for patients requesting same-day consultations, and at similar cost to UC. Although triage seemed to be safe, investigation of the circumstances of a larger number of deaths or admissions after triage might be warranted, and monitoring of these events is necessary as triage is implemented.Trial registrationCurrent Controlled Trials ISRCTN20687662.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 19, No. 13. See the NIHR Journals Library website for further project information.

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Background Patients at risk of severe exacerbations contribute disproportionally to asthma mortality, morbidity and costs. We evaluated the effectiveness and costs of using 'asthma risk registers' for these patients in primary care. Methods In a cluster-randomised trial, 29 primary care practices identified 911 at-risk asthma patients using British asthma guideline criteria (severe asthma plus adverse psychosocial characteristics). Intervention practices added electronic alerts to identified patients' records to flag their at-risk status and received practicebased training about using the alerts to improve patient access and opportunistic management. Control practices continued routine care. Numbers of patients experiencing the primary outcome of a moderate-severe exacerbation (resulting in death, hospitalisation, accident and emergency attendance, out-of-hours contact, or a course/boost in oral prednisolone for asthma), other healthcare and medication usage, and costs over 1 year were derived from practice-based records. Results There was no significant effect on exacerbations (control: 46.5%; intervention: 53.6%, OR, 95% CI 1.30, 0.93 to 1.80). However, this composite outcome masked relative reductions in intervention patients experiencing hospitalisations (OR 0.50, 95% CI 0.26 to 0.94), accident and emergency (OR 0.74, 95% CI 0.42 to 1.31) and out-of-hours contacts (OR 0.79, 95% CI 0.45 to 1.37); and a relative increase in prednisolone prescription for exacerbations (OR 1.31, 95% CI 0.92 to 1.85). Furthermore, prescription of nebulised short-acting b-agonists reduced and long-acting b-agonists increased for intervention relative to control patients. The adjusted mean per patient healthcare cost was £138.21 lower (p¼0.837) among intervention practices. Conclusion Using asthma risk registers in primary care did not reduce treated exacerbations, but reduced hospitalisations and increased prescriptions of recommended preventative therapies without increasing costs.

BackgroundProcess 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.MethodsIn 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).ResultsImplementation 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.ConclusionsThe 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 materialThe online version of this article (doi:10.1186/s12913-016-1651-8) contains supplementary material, which is available to authorized users.

BackgroundEstablishing patient goals is widely recommended as a way to deliver care that matters to the individual patient with multimorbidity, who may not be well served by single-disease guidelines. Though multimorbidity is now normal in general practice, little is known about how doctors and patients should set goals together.AimTo determine the key components of the goal-setting process in general practice.Design and settingIn-depth qualitative analysis of goal-setting consultations in three UK general practices, as part of a larger feasibility trial. Focus groups with participating GPs and patients. The study took place between November 2016 and July 2018.MethodActivity analysis was applied to 10 hours of video-recorded doctor–patient interactions to explore key themes relating to how goal setting was attempted and achieved. Core challenges were identified and focus groups were analysed using thematic analysis.ResultsA total of 22 patients and five GPs participated. Four main themes emerged around the goal-setting process: patient preparedness and engagement; eliciting and legitimising goals; collaborative action planning; and GP engagement. GPs were unanimously positive about their experience of goal setting and viewed it as a collaborative process. Patients liked having time to talk about what was most important to them. Challenges included eliciting goals from unprepared patients, and GPs taking control of the goal rather than working through it with the patient.ConclusionGoal setting required time and energy from both parties. GPs had an important role in listening and bearing witness to their patients’ goals. Goal setting worked best when both GP and patient were prepared in advance.

Background There is a growing need for methods that acknowledge and successfully capture the dynamic interaction between context and implementation of complex interventions. Case study research has the potential to provide such understanding, enabling in-depth investigation of the particularities of phenomena. However, there is limited guidance on how and when to best use different case study research approaches when evaluating complex interventions. This study aimed to review and synthesise the literature on case study research across relevant disciplines, and determine relevance to the study of contextual influences on complex interventions in health systems and public health research. Methods Systematic meta-narrative review of the literature comprising (i) a scoping review of seminal texts (n = 60) on case study methodology and on context, complexity and interventions, (ii) detailed review of empirical literature on case study, context and complex interventions (n = 71), and (iii) identifying and reviewing ‘hybrid papers’ (n = 8) focused on the merits and challenges of case study in the evaluation of complex interventions. Results We identified four broad (and to some extent overlapping) research traditions, all using case study in a slightly different way and with different goals: 1) developing and testing complex interventions in healthcare; 2) analysing change in organisations; 3) undertaking realist evaluations; 4) studying complex change naturalistically. Each tradition conceptualised context differently—respectively as the backdrop to, or factors impacting on, the intervention; sets of interacting conditions and relationships; circumstances triggering intervention mechanisms; and socially structured practices. Overall, these traditions drew on a small number of case study methodologists and disciplines. Few studies problematised the nature and boundaries of ‘the case’ and ‘context’ or considered the implications of such conceptualisations for methods and knowledge production. Conclusions Case study research on complex interventions in healthcare draws on a number of different research traditions, each with different epistemological and methodological preferences. The approach used and consequences for knowledge produced often remains implicit. This has implications for how researchers, practitioners and decision makers understand, implement and evaluate complex interventions in different settings. Deeper engagement with case study research as a methodology is strongly recommended.