The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial)

Abstract

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.

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

“…136 Given the largely social nature of such interventions and the risk of outcome-based evaluation determining the net effect to be minimal, formative theory-driven evaluation options should be considered. 141,142 Activate the patient role in safety Cultivating conditions in which patients, parents and carers feel comfortable challenging HCPs is needed and could prevent safety incidents.…”

“…In 2015, a randomised controlled trial by Campbell et al 136 was not sufficiently powered to detect differences in safety outcomes (in terms of patient mortality, emergency hospital admissions, and accident and emergency attendance rates) between same-day consultations with GPs/telephone calls, nurse-led computer-supported services and usual care. However, the accompanying process evaluation recognised the importance of culture, capacity and involvement of all practice staff when introducing such major changes to access.…”

Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study

“…Telephone contact is used variably for assessment and triage of acute problems; [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] general practice consultations; [34][35][36][37][38][39][40] to offer health education; 41,42 and to offer support for those with chronic illness 43,44 or those in need of palliative care. 45 The literature on telephone consultations consists largely of small and heterogeneous primary studies, most of which had practical challenges or methodological flaws.…”

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans

“…In addition, clinic support staff may need to be trained to manage an increased volume of telephone contact, triage patient complaints, and address minor issues to the extent that these activities replace face-to-face visits. Expanding the registered nurse role might be a cost-effective approach for between-visit monitoring and might include nurse-run disease management programs (Herbert et al, 2008), which could be telephone-based (Dunagan et al, 2005), or nurse triage and consultation by phone (Campbell et al, 2015). Use of a patient portal (for example, MyHealtheVet) for secure messaging with providers might also be utilized to support extended follow-up visit intervals.…”