Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis.

BACKGROUND: Telephone triage is increasingly used to manage workload in primary care; however, supporting evidence for this approach is scarce. We aimed to assess the effectiveness 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. METHODS: We did a pragmatic, cluster-randomised controlled trial and economic evaluation between March 1, 2011, and March 31, 2013, at 42 practices in four centres in the UK. Practices were randomly assigned (1:1:1), via a computer-generated randomisation sequence minimised for geographical location, practice deprivation, and practice list size, to either GP-led triage, nurse-led computer-supported triage, or usual care. We included patients who telephoned the practice seeking a same-day face-to-face consultation with a GP. Allocations were concealed from practices until after they had agreed to participate and a stochastic element was included within the minimisation algorithm to maintain concealment. Patients, clinicians, and researchers were not masked to allocation, but practice assignment was concealed from the trial statistician. The primary outcome was primary care workload (patient contacts, including those attending accident and emergency departments) in the 28 days after the first same-day request. Analyses were by intention to treat and per protocol. This trial was registered with the ISRCTN register, number ISRCTN20687662. FINDINGS: We randomly assigned 42 practices to GP triage (n=13), nurse triage (n=15), or usual care (n=14), and 20,990 patients (n=6695 vs 7012 vs 7283) were randomly assigned, of whom 16,211 (77%) patients provided primary outcome data (n=5171 vs 5468 vs 5572). GP triage was associated with a 33% increase in the mean number of contacts per person over 28 days compared with usual care (2·65 [SD 1·74] vs 1·91 [1·43]; rate ratio [RR] 1·33, 95% CI 1·30-1·36), and nurse triage with a 48% increase (2·81 [SD 1·68]; RR 1·48, 95% CI 1·44-1·52). Eight patients died within 7 days of the index request: five in the GP-triage group, two in the nurse-triage group, and one in the usual-care group; however, these deaths were not associated with the trial group or procedures. Although triage interventions were associated with increased contacts, estimated costs over 28 days were similar between all three groups (roughly £75 per patient). INTERPRETATION: Introduction of telephone triage delivered by a GP or nurse was associated with an increase in the number of primary care contacts in the 28 days after a patient's request for a same-day GP consultation, with similar costs to those of usual care. Telephone triage might be useful in aiding the delivery of primary care. The whole-system implications should be assessed when introduction of such a system is considered. FUNDING: Health Technology Assessment Programme UK National Institute for Health Research.

Implementing telephone triage in general practice: a process evaluation of a cluster randomised controlled trial.

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.

Management of out-of-hours calls by a general practice cooperative: a geographical analysis of telephone access and consultation.

BACKGROUND: Centralization of urgent care services may reduce access for patients living further away from primary care centres (PCCs). Telephone-based access is often proposed to remedy this. OBJECTIVE: To examine the effect of distance and rurality on the doctor's decision to manage the call by telephone or face-to-face. METHODS: Geographical analysis of routine data on calls to an out-of-hours cooperative, including logistic regression to examine the effects of distance and rurality on triage decisions. RESULTS: For distances >6 km, the likelihood of receiving telephone advice only increased progressively with increasing distance from the PCC (Model 1). However, for those patients seen face-to-face, overall, there was increased likelihood of receiving a home visit (compared with PCC attendance) with increasing distance (Model 2). CONCLUSIONS: Patients experience differences in how their call to out-of-hours services is managed depending on where they live. Telephone access and consultation can be used to overcome geographical barriers but do not necessarily make access geographically equitable. Those who live furthest away are more likely to receive telephone advice rather than being seen face-to-face, but paradoxically, those who do get a home visit are more likely to live at a greater distance from the PCC. These findings present important challenges to proposals to integrate urgent care services and increase telephone-based provision and suggest that attention should be given to configuring services to ensure geographical equity of access, regardless of how far away people live from health services.

Nurses' use of computerised clinical decision support systems: a case site analysis.

AIMS AND OBJECTIVES: To explore how nurses use computerised clinical decision support systems in clinical practice and the factors that influence use. BACKGROUND: There is limited evidence for the benefits of computerised clinical decision support systems in nursing, with the majority of existing research focusing on nurses' use of decision support for telephone triage. Research has suggested that several factors including nurses' experience, features of the technology system and organisational factors may influence how decision support is used in practice. DESIGN: A multiple case site study. METHODS: Four case sites were purposively selected to provide variation in staff experience, technology used and decisions supported by the technology. Data were collected in each case site using non-participant observation of nurse/patient consultations (n = 115) and interviews with nurses (n = 55). Data were analysed using thematic content analysis. RESULTS: Computerised decision support systems were used in a variety of ways by nurses, including recording information, monitoring patients' progress and confirming decisions that had already been made. Nurses' experience with the decision and the technology affected how they used a decision support system and whether or not they over-rode recommendations made by the system. The ability of nurses to adapt the technology also affected its use. CONCLUSIONS: How nurses use computerised decision support appears to be the result of an interaction between a nurses' experience and their ability to adapt the technology to 'fit' with local clinical practice. RELEVANCE TO CLINICAL PRACTICE: One of the stated aims of introducing computerised decision support systems to assist nursing practice is to reduce variation and/or the number of errors associated with clinical practice. The study found unanticipated uses in such systems such as the routine over-riding of recommendations which could lead to an increase rather than a decrease in variation or errors.

A national survey of computerized decision support systems available to nurses in England.

AIM: To examine the characteristics of computerized decision support systems (CDSS) currently available to nurses working in the National Health Service (NHS) in England. METHOD: A questionnaire survey sent to a stratified random sample of 50% of all NHS care providers (Trusts) in England, asking respondents to provide information on CDSS currently used by nurses. RESULTS: Responses were received from 108 of the 277 Trusts included in the sample. Electronic patient record systems were the most common type of CDSS reported by Trusts (n = 61) but they were least likely to have features that have been associated with improved clinical outcomes. CONCLUSIONS: The availability of CDSS with features that have been associated with improved patient outcomes for nurses in the NHS in England is limited. There is some evidence that the nature of the Trust affects whether or not nurses have access to CDSS to assist their decision making. IMPLICATIONS FOR NURSING MANAGEMENT: The implementation of CDSS is increasing throughout the NHS. Many CDSS are introduced without adequate evidence to support its introduction and there is little evaluation of the benefits once they are implemented. Policy makers and nursing management should consider whether the introduction of CDSS aids nurse decision making and benefits patient outcomes.

Experience and nurses use of computerised decision support systems.

Computerised clinical decision support systems (CDSS) are increasingly being used by nurses to support their clinical practice. One of the factors which may affect how nurses use technology such as CDSS may be their clinical experience. This paper uses data from a wider study examining how nurses use CDSS to examine the role of experience in nurses' use of CDSS. Data was drawn from two sources; a secondary analysis of interviews from a study examining nurses' use of CDSS in telephone triage and the analysis of observations and interviews of nurses using CDSS in two case sites. Two themes arose from the analysis of the data; the integration of knowledge from CDSS and how experience affects CDSS use. The implications of these results are discussed in relation to our knowledge of the characteristics of the development of expertise in nursing.

What happens to patient experience when you want to see a doctor and you get to speak to a nurse? Observational study using data from the English General Practice Patient Survey.

OBJECTIVES: To examine patient consultation preferences for seeing or speaking to a general practitioner (GP) or nurse; to estimate associations between patient-reported experiences and the type of consultation patients actually received (phone or face-to-face, GP or nurse). DESIGN: Secondary analysis of data from the 2013 to 2014 General Practice Patient Survey. SETTING AND PARTICIPANTS: 870 085 patients from 8005 English general practices. OUTCOMES: Patient ratings of communication and 'trust and confidence' with the clinician they saw. RESULTS: 77.7% of patients reported wanting to see or speak to a GP, while 14.5% reported asking to see or speak to a nurse the last time they tried to make an appointment (weighted percentages). Being unable to see or speak to the practitioner type of the patients' choice was associated with lower ratings of trust and confidence and patient-rated communication. Smaller differences were found if patients wanted a face-to-face consultation and received a phone consultation instead. The greatest difference was for patients who asked to see a GP and instead spoke to a nurse for whom the adjusted mean difference in confidence and trust compared with those who wanted to see a nurse and did see a nurse was -15.8 points (95% CI -17.6 to -14.0) for confidence and trust in the practitioner and -10.5 points (95% CI -11.7 to -9.3) for net communication score, both on a 0-100 scale. CONCLUSIONS: Patients' evaluation of their care is worse if they do not receive the type of consultation they expect, especially if they prefer a doctor but are unable to see one. New models of care should consider the potential unintended consequences for patient experience of the widespread introduction of multidisciplinary teams in general practice.

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.

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.

Professional perspectives on systemic barriers to admission avoidance: learning from a system dynamics study of older people's admission pathways.

BACKGROUND: There is debate worldwide about the best way to manage increased healthcare demand within ageing populations, particularly rising rates of unplanned and avoidable hospital admissions. OBJECTIVES: To understand health and social care professionals' perspectives on barriers to admission avoidance throughout the admissions journey, in particular: the causes of avoidable admissions in older people; drivers of admission and barriers to use of admission avoidance strategies; and improvements to reduce unnecessary admissions. DESIGN: A qualitative framework analysis of interview data from a System dynamics (SD) modelling study. METHODS: Semi-structured interviews were conducted with twenty health and social care professionals with experience of older people's admissions. The interviews were used to build understanding of factors facilitating or hindering admission avoidance across the admissions system. Data were analysed using framework analysis. RESULTS: Three overarching themes emerged: understanding the needs of the patient group; understanding the whole system; and systemwide access to expertise in care of older people. There were diverse views on the underlying reasons for avoidable admissions and recognition of the need for whole-system approaches to service redesign. CONCLUSIONS: Participants recommended system redesign that recognises the specific needs of older people, but there was no consensus on underlying patient needs or specific service developments. Access to expertise in management of older and frailer patients was seen as a barrier to admission avoidance throughout the system. IMPLICATIONS FOR PRACTICE: Providing access to expertise and leadership in care of frail older people across the admissions system presents a challenge for service managers and nurse educators but is seen as a prerequisite for effective admission avoidance. System redesign to meet the needs of frail older people requires agreement on causes of avoidable admission and underlying patient needs.

The impact of using computer decision-support software in primary care nurse-led telephone triage: interactional dilemmas and conversational consequences.

Telephone triage represents one strategy to manage demand for face-to-face GP appointments in primary care. Although computer decision-support software (CDSS) is increasingly used by nurses to triage patients, little is understood about how interaction is organized in this setting. Specifically any interactional dilemmas this computer-mediated setting invokes; and how these may be consequential for communication with patients. Using conversation analytic methods we undertook a multi-modal analysis of 22 audio-recorded telephone triage nurse-caller interactions from one GP practice in England, including 10 video-recordings of nurses' use of CDSS during triage. We draw on Goffman's theoretical notion of participation frameworks to make sense of these interactions, presenting 'telling cases' of interactional dilemmas nurses faced in meeting patient's needs and accurately documenting the patient's condition within the CDSS. Our findings highlight troubles in the 'interactional workability' of telephone triage exposing difficulties faced in aligning the proximal and wider distal context that structures CDSS-mediated interactions. Patients present with diverse symptoms, understanding of triage consultations, and communication skills which nurses need to negotiate turn-by-turn with CDSS requirements. Nurses therefore need to have sophisticated communication, technological and clinical skills to ensure patients' presenting problems are accurately captured within the CDSS to determine safe triage outcomes. Dilemmas around how nurses manage and record information, and the issues of professional accountability that may ensue, raise questions about the impact of CDSS and its use in supporting nurses to deliver safe and effective patient care.

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.

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.

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).

BACKGROUND: Telephone 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. OBJECTIVES: In 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. DESIGN: Pragmatic cluster randomised controlled trial, incorporating economic evaluation and qualitative process evaluation. SETTING: General practices (n = 42) in four regions of England, UK (Devon, Bristol/Somerset, Warwickshire/Coventry, Norfolk/Suffolk). PARTICIPANTS: Patients requesting same-day consultations. INTERVENTIONS: Practices 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 MEASURES: Primary - 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. RESULTS: Of 20,990 eligible randomised patients (UC n = 7283; GPT n = 6695; NT n = 7012), primary outcome data were analysed for 16,211 patients (UC n = 5572; GPT n = 5171; NT n = 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. CONCLUSIONS: Introducing 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 REGISTRATION: Current Controlled Trials ISRCTN20687662. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 13. See the NIHR Journals Library website for further project information.

The effectiveness and cost-effectiveness of telephone triage of patients requesting same day consultations in general practice: study protocol for a cluster randomised controlled trial comparing nurse-led and GP-led management systems (ESTEEM).

BACKGROUND: Recent years have seen an increase in primary care workload, especially following the introduction of a new General Medical Services contract in 2004. Telephone triage and telephone consultation with patients seeking health care represent initiatives aimed at improving access to care. Some evidence suggests that such approaches may be feasible but conclusions regarding GP workload, cost, and patients' experience of care, safety, and health status are equivocal. The ESTEEM trial aims to assess the clinical- and cost-effectiveness of nurse-led computer-supported telephone triage and GP-led telephone triage, compared to usual care, for patients requesting same-day consultations in general practice. METHODS/DESIGN: ESTEEM is a pragmatic, multi-centre cluster randomised clinical trial with patients randomised at practice level to usual care, computer decision-supported nurse triage, or GP-led triage. Following triage of 350-550 patients per practice we anticipate estimating and comparing total primary care workload (volume and time), the economic cost to the NHS, and patient experience of care, safety, and health status in the 4-week period following the index same-day consultation request across the three trial conditions.We will recruit all patients seeking a non-emergency same-day appointment in primary care. Patients aged 12.0-15.9 years and temporary residents will be excluded from the study.The primary outcome is the number of healthcare contacts taking place in the 4-week period following (and including) the index same-day consultation request. A range of secondary outcomes will be examined including patient flow, primary care NHS resource use, patients' experience of care, safety, and health status.The estimated sample size required is 3,751 patients (11,253 total) in each of the three trial conditions, to detect a mean difference of 0.36 consultations per patient in the four week follow-up period between either intervention group and usual care 90% power, 5% alpha, and an estimated intracluster correlation coefficient ICC of 0.05. The primary analysis will be based on the intention-to-treat principle and take the form of a random effects regression analysis taking account of the hierarchical nature of the study design. Statistical models will allow for adjustment for practice level minimisation variables and patient-level baseline covariates shown to differ at baseline. TRIAL REGISTRATION: Current Controlled Trials ISCRTN20687662.

Do telephones overcome geographical barriers to general practice out-of-hours services? Mixed-methods study of parents with young children.

OBJECTIVE: To examine if telephones overcome geographical barriers to accessing primary care out-of-hours by parents of young children. METHODS: Mixed methods including quantitative analysis of 5697 calls about children aged 0-4 years, 30 hours of observation at primary care centres, eight interviews with parents and a review of 80 telephone call recordings. RESULTS: Call rates for children (0-4 years) decreased with increasing distance: the 20% of people who lived furthest from a primary care centre made fewer calls, 570 per 1000 patients/year (95% CI 558 to 582) than the 20% living closest, 652 (95% CI 644 to 661). Overall, call rates decreased with increasing rurality. Qualitative analysis suggested that this geographical variation was linked to familiarity with the system (notably previous contact with health services) and the availability of services, legitimacy of demand (particularly for children) and negotiation about mode of care. CONCLUSIONS: People already disadvantaged by their distance from facilities or socioeconomic circumstances may continue to be at a disadvantage when services are provided by telephone.