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

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

A Description of Midlife Women Experiencing Intimate Partner Violence Using Electronic Medical Record Information.

BACKGROUND: Intimate partner violence (IPV) is an important health problem affecting women of all ages, but is often not addressed during healthcare visits. PURPOSE: To use electronic records of diagnoses and telephone advice calls to describe the clinical patterns of midlife women experiencing IPV. MATERIALS AND METHODS: Using case-control methodology, women with an ICD9 diagnosis of IPV were chosen from those enrolled in 2005-2006 in Kaiser Permanente Northern California (KPNC) and matched on visit date, age, and facility with women without such a diagnosis. The study population was divided into subsets: ages 45-53 years (318 cases, 1588 controls); ages 54-64 years (200 cases, 1000 controls). Diagnoses and symptoms reported by phone that were significantly related to the cases compared with the controls were identified using multivariate logistic regression. RESULTS: Among women aged 45-53 years, diagnoses of anxiety (odds ratio [OR] = 2.05) and of psychiatric problems (OR = 1.65) and calls for head injury (OR = 3.17), mental health problems (OR = 2.46), and sexually transmitted diseases (OR = 2.40) were associated with IPV. Among women aged 54-64 years, diagnoses of anxiety (OR = 1.74) and other psychiatric problems (OR = 1.76), injuries (other than head and neck) (OR = 1.57), urinary tract infection (UTI; OR = 2.31), headache (OR = 2.06), and calls for mental health problems (OR = 4.16) were associated with IPV. Among all women aged 45-64 years, history of prior IPV was strongly associated with subsequent diagnosis of IPV. CONCLUSIONS: Information available in the electronic health record of women who have been identified as experiencing IPV can be used to identify patterns of symptoms and diagnosis among midlife women. These patterns can potentially be used to improve identification of IPV in this age group. In addition to screening of all women for IPV, the presence of psychiatric problems, injuries, headache, and UTI and prior experience of IPV should prompt additional focused clinical inquiry about IPV in midlife women.

Optimizing the use of telephone nursing advice for upper respiratory infection symptoms.

OBJECTIVES: To describe efforts to optimize telephone self-care advice for upper respiratory infection (URI) symptoms by registered nurses in Kaiser Permanente Northern California's Appointment and Advice Call Center, and to assess the sufficiency of this advice. STUDY DESIGN: Retrospective observational study. METHODS: The study sample included 279,625 calls from adults 18 years and older that resulted in self-care advice for URI symptoms in 2009. Utilizing electronic medical records of these calls and follow-ups, we determined the rate of return calls within 7 days and the clinical outcomes associated with these. Advice for self-care at home was considered sufficient if no return calls received within 7 days of the original call were associated with the need for a "higher" level of care, such as an appointment. RESULTS: Self-care advice was sufficient for 88% of index advice calls, with either no follow-up calls within 7 days associated with a higher level of care, or follow-up calls only for additional advice or nonmedical information. CONCLUSIONS: Telephone advice for self-care by registered nurses can effectively manage URI symptoms for most otherwise healthy adults.

A predictive model to help identify intimate partner violence based on diagnoses and phone calls.

BACKGROUND: Intimate partner violence (IPV) is a significant health problem but goes largely undiagnosed, undisclosed, and clinically undocumented. PURPOSE: To use historical data on diagnoses and telephone advice calls to develop a predictive model that identifies clinical profiles of women at high risk for undisclosed IPV. METHODS: A case-control study was conducted in women aged 18-44 years enrolled at Kaiser Permanente Northern California (KPNC) in 2005-2006 using symptoms reported by telephone and clinical diagnosis from electronic medical records. Analysis was conducted in 2007-2010. Overall, 1276 cases were identified using ICD-9 codes for IPV and were matched with 5 controls each. A full multivariate model was developed to identify those with IPV, as well as a reduced model and a summed-score model whose performance characteristics were assessed. RESULTS: Predictors most highly associated with IPV were history of remote IPV (OR=7.8); calls or diagnoses for psychiatric problems (OR=2.4); calls for HIV concerns (OR=2.4); and clinical diagnoses of prenatal complications (OR=2.1). Using the summed-score model for a population with IPV prevalence of 7%, and using a threshold score of 3 for predicting IPV with a sensitivity of 75%, 9.7 women would need to be assessed to diagnose one case of IPV. CONCLUSIONS: Diagnosed IPV was associated with a clinical profile based on both telephone call data and clinical diagnoses. The simple predictive model can prompt focused clinical inquiry and improve diagnosis of IPV in any clinical setting.