An assessment of pediatric after-hours telephone care: a 1-year experience.

BACKGROUND: Pediatric after-hours telephone triage by call center nurses is an important part of pediatric health care provision. OBJECTIVES: To use a computerized database including the after-hours telephone calls for 90% of the pediatricians in Colorado to examine: (1) the epidemiology of after-hours calls during a 1-year period including the volume, seasonality, and timing of after-hours calls, the age of the patients, the presenting complaint, the triage dispositions, and mean rates of calls per pediatrician; (2) the process of care measures at the call center, including waiting times for nurse telephone call-backs, the length of triage calls, and how these factors varied by season; and (3) the frequency and content of calls requesting information but not requiring triage. DESIGN: Descriptive study. SETTING AND PARTICIPANTS: All telephone calls from the After-Hours Telephone Care Program, Denver, Colo, received between June 21, 1999, and June 20, 2000, were retrieved from a computerized database and categorized by age, season, triage disposition, and algorithm. MAIN OUTCOME MEASURES: The volume, seasonality, timing, age distribution, algorithms used, and triage dispositions of after-hours calls. The reasons for calls requesting information. RESULTS: During the 1-year period 141 922 calls were returned by the call center. Of the total calls, 88% were for a clinical illness; 5%, for information or advice; 5%, for calls in which the parent could not be recontacted; 1%, for duplicate calls, and 1%, for miscellaneous reasons. Listed in rank order for the year, the 10 most common algorithms used for illness calls were vomiting, colds, cough, earache, sore throat, fever, diarrhea, croup, head trauma, and eye infection. Of illness calls, 21% of callers were told to go in for urgent evaluation, 30% were told to contact their primary care physician either the next day or at a later time, 45% were given home care instructions, and 4% were referred to call the on-call physician. CONCLUSIONS: This study describes the epidemiology of after-hours telephone calls regarding children in 90% of the private practices in Colorado. Data provided are useful in guiding the planning of health care provision, providing staffing of after-hours facilities, and planning for the educational training of telephone care staff. They also highlight opportunities for patient education that might decrease unnecessary after-hours calls.

Consistency of triage decisions by call center nurses.

OBJECTIVES: To 1) assess consistency in triage disposition among pediatric telephone triage nurses using computer-based algorithms and 2) determine agreement between nurse dispositions and protocol dispositions. DESIGN/METHODS: Fifteen nurses from the After Hours Telephone Care Program in Denver were randomly selected to receive mock calls from standardized patients. Each nurse received the same 15 scenarios. Reliability in triage disposition was assessed using the kappa statistic. Audiotapes of cases were reviewed if an urgent referral was warranted by the protocol but not given 20% or more of the time. RESULTS: Mean agreement among nurses for individual cases was 83% (range, 64%-100%). Overall interrater reliability among nurses for triage disposition was 0.46 (95% confidence interval, 0.43-0.49). Mean agreement between nurses' dispositions and protocol dispositions was 81% (range, 33%-100%). Audio review revealed no differences in length of call or information elicited between cases receiving urgent and nonurgent dispositions. Reasons for incorrect dispositions were 1) information necessary to make the disposition directed by the protocol was given and ignored and 2) nurses did not elicit the necessary information prescribed by the protocol. CONCLUSIONS: Agreement regarding disposition decisions among call center nurses and between nurses and protocols was close to 80%. Disagreement with protocol dispositions occurred when nurses 1) did not follow protocols or 2) did not act on information provided by the parent. Our data suggest a need for additional attention to communication skills and to protocol adherence in training and ongoing quality improvement practices.

Disenrollment from a state child health insurance plan: are families jumping S(c)HIP?

BACKGROUND: Colorado's Child Health Plan Plus (CHP+) is a non-Medicaid state child health plan that began enrollment in April 1998. Families are disenrolled 12 months after enrollment if they fail to re-enroll. OBJECTIVE: To assess insurance coverage before and 1 year after initial enrollment in CHP+; reasons for disenrollment; and factors associated with re-enrollment. DESIGN/METHODS: We interviewed 480 randomly selected families 2 months after initial enrollment into CHP+ (September 1999 through January 2000) and 1 year later. RESULTS: Prior to CHP+, 38% of families had Medicaid (MK), 35% were privately insured (PI), 6% were uninsured (UI), and 20% had other/unknown insurance. After the 12 months, 34% were re-enrolled, 16% got other insurance (6% MK, 10% PI/other), 4% had children older than 18 years, and 46% were UI (9% had intentionally and 37% had unintentionally disenrolled from CHP+). All unintentionally disenrolled families were planning to re-enroll and 90% still appeared eligible. In multivariate analysis, having a primary care provider prior to enrollment was associated with re-enrollment (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1 to 2.6), but having problems with the application process impeded re-enrollment (OR 0.7, 95% CI 0.6 to 0.9). CONCLUSIONS: Only about a third of families eligible for State Children's Health Insurance Program successfully re-enrolled before their termination date. Institution of a passive renewal process would decrease unnecessary disenrollment in eligible families.

Outcomes associated with pediatric after-hours care by call centers: a multicenter study.

OBJECTIVES: To assess 1) parental opinion regarding appropriateness of triage, 2) utilization outcomes, and 3) the frequency of underreferral with subsequent hospitalization for children triaged by nurses at pediatric call centers. DESIGN/METHODS: From August 19 to October 1999, after-hours calls were randomly sampled from computerized records at 4 call centers at children's hospitals. Telephone surveys were conducted 3 to 7 days after the index calls. An expert panel to assess appropriateness of disposition reviewed audio recordings of calls given a nonurgent disposition and then hospitalized within 24 hours. RESULTS: Surveys were completed for 70.5% (N = 1561). Parental agreement with urgent or home care recommendations was >70% but with intermediary recommendations was <50%. Hospitalizations were more common among children urgently referred (4.6% vs 0.45%; P =.0003). Calls judged urgent by call center nurses and referred to a physician for secondary triage had lower rates of urgent visits (odds ratio [OR] 0.58; 95% confidence interval [CI] 0.53-0.65; P <.0001) and higher rates of never having a visit (OR 1.37; 95% CI 1.24-1.51; P <.0001) than those referred directly by nurses. The weighted rate of underreferral with hospitalization was 0.3% (95% CI 0.1-0.7%) or 1 in 481 calls (95% CI 1/152 to 1/1538). CONCLUSIONS: Our data demonstrate an underreferral rate with subsequent hospitalization of 1 in 500 calls and a significant reduction in visits when those cases judged urgent by call center nurses undergo secondary triage by physicians.

Changes in access, utilization, and quality of care after enrollment into a state child health insurance plan.

BACKGROUND: There currently are few published data evaluating the effect of State Children's Health Insurance Programs on health care outcome measures in children. Colorado's Child Health Plan Plus (CHP+) is a non-Medicaid State Children's Health Insurance Program that began enrollment in April 1998. The objectives of this study were to compare reported (1) access to care, (2) utilization of health care, and (3) quality of care during the year before and the first year after enrollment into CHP+. METHODS: We interviewed 480 randomly selected families by telephone 2 months after their first enrollment into CHP+ (September 1999 to January 2000) and, again, 1 year later. We used generalized linear models to examine the effect of enrollment on health care access, utilization, and quality while controlling for type of previous insurance, length of time uninsured before enrollment, race/ethnicity, and age. RESULTS: Regarding access to care, the percentage of families who reported a usual site of preventive care did not change significantly, but families reported more often being able to see providers as soon as desired for routine care (incidence ratio [IR]: 2.03; 95% confidence interval [CI]: 1.37-3.02]), for care when sick or injured (IR: 2.77; 95% CI: 1.85-4.16), for specialty care (IR: 1.96; 95% CI: 1.16-3.32), and for all health care (IR: 2.35; 95% CI: 1.81-3.07). Unmet medical needs decreased after versus before enrollment for prescription medications (IR: 0.38; 95% CI: 0.26-0.55), mental health care (IR: 0.63; 95% CI: 0.40-0.97), prescription glasses (IR: 0.44; 95% CI: 0.29-0.65), and dental care (IR: 0.59; 95% CI: 0.47-0.76). Regarding utilization, the proportion who saw a provider for routine care in the past year increased (IR: 1.39; 95% CI: 1.06-1.83), but reported visits for sick, specialty, and emergency department care and hospitalizations did not increase. Regarding quality of care, the proportion who rated their health care as "best" increased (RI: 1.31; 95% CI: 1.04-1.66) after versus before enrollment. CONCLUSIONS: Families who were newly enrolled into CHP+ perceived dramatic increases in access to all types of care and decreases in unmet medical needs, no increase in utilization of emergency department or hospitalization services, and improved overall quality of care in the year after enrollment into CHP+.