Eficacia de un protocolo de asesoramiento médico telefónico formalizado para consultas por fiebre o gastroenteritis en centros de comunicación médica de emergencia. Ensayo clínico AMTF / Efficacy of emergency medical center use of a protocol during telephone calls to give medical advice related to fever or gastroenteritis: a cluster randomized controlled trial

Objetivos. Determinar la eficacia de un protocolo de asesoramiento médico telefónico formalizado (AMTF), realizado por un médico para consultas, para fiebre o gastroenteritis en centros de comunicación médica de emergencia. Método. Ensayo clínico por conglomerado, controlado. Los pacientes fueron aleatorizados al grupo AMTF o al grupo de atención habitual. Participaron 6 centros de comunicación médica de emergencia franceses. Se incluyeron pacientes que solicitaban asistencia telefónica por fiebre o gastroenteritis. El grupo ATMF realizó recomendaciones protocolizadas sobre el manejo terapéutico. Se valoró el número de consultas presenciales o ingreso hospitalario durante los 15 días siguientes a la consulta. También se evaluó la satisfacción del paciente y el coste económico. Resultados. Se incluyeron 2.498 llamadas. El grupo ATMF (n = 1.234) tuvo un riesgo relativo de 0,70 (CI 95% 0,58 a 0,85) de requerir un ingreso hospitalario o de realizar una consulta no programada durante el seguimiento. No hubo diferencias entre los dos grupos en cuanto al uso de ambulancia, el ingreso en cuidados intensivos, la mortalidad o morbilidad y la mejoría de los síntomas. La satisfacción de los pacientes fue del 90%. El coste total fue de 91 euros en el grupo de la ATMF y de 150 euros en el grupo de atención habitual (p < 0,01). Conclusiones. El grupo ATMF se asoció con una disminución de las consultas presenciales no programadas o del ingreso en el hospital. Este procedimiento es seguro y comporta un menor coste que la atención que se realiza habitualmente en la actualidad. (AU)

Objectives: To determine the efficacy of emergency medical center physicians' use of a protocol to guide their management of telephone consultations for fever and gastroenteritis. Material and methods: Cluster randomized controlled trial. Participating centers were randomized to use the telephone protocol or provide usual telephone assistance. Six emergency centers in France included calls from patients needing advice on fever or gastroenteritis. Centers assigned to the protocol followed specific guidelines on managing the call and giving advice on treatment. Primary endpoints were the number of in-person visits and hospital admissions required within 15 days of the call. Secondary endpoints were patient satisfaction and costs. Results: A total of 2498 calls were included. Use of the assigned protocol while attending 1234 calls was associated with a relative risk for hospitalization or an unscheduled in-person visit for care of 0.70 (95% CI, 0.58-0.85) versus usual practice. Ambulance use, admission to an intensive care unit, mortality, morbidity, and symptom improvement did not differ significantly between centers using the protocol and those following usual practice. Ninety percent of the patients were satisfied. The cost of care was €91 in centers applying the protocol and €150 in the other centers (P .01). Conclusion: Use of the protocol was associated with fewer unscheduled in-person visits for care and fewer hospital admissions. The protocol is safe and less costly than the centers' usual approaches to giving telephone advice. (AU)

Efficacy of emergency medical center use of a protocol during telephone calls to give medical advice related to fever or gastroenteritis: a cluster randomized controlled trial. / Eficacia de un protocolo de asesoramiento médico telefónico formalizado para consultas por fiebre o gastroenteritis en centros de comunicación médica de emergencia. Ensayo clínico AMTF.

OBJECTIVES: To determine the efficacy of emergency medical center physicians' use of a protocol to guide their management of telephone consultations for fever and gastroenteritis. MATERIAL AND METHODS: Cluster randomized controlled trial. Participating centers were randomized to use the telephone protocol or provide usual telephone assistance. Six emergency centers in France included calls from patients needing advice on fever or gastroenteritis. Centers assigned to the protocol followed specific guidelines on managing the call and giving advice on treatment. Primary endpoints were the number of in-person visits and hospital admissions required within 15 days of the call. Secondary endpoints were patient satisfaction and costs. RESULTS: A total of 2498 calls were included. Use of the assigned protocol while attending 1234 calls was associated with a relative risk for hospitalization or an unscheduled in-person visit for care of 0.70 (95% CI, 0.58-0.85) versus usual practice. Ambulance use, admission to an intensive care unit, mortality, morbidity, and symptom improvement did not differ significantly between centers using the protocol and those following usual practice. Ninety percent of the patients were satisfied. The cost of care was €91 in centers applying the protocol and €150 in the other centers (P .01). CONCLUSION: Use of the protocol was associated with fewer unscheduled in-person visits for care and fewer hospital admissions. The protocol is safe and less costly than the centers' usual approaches to giving telephone advice.

OBJETIVO: Determinar la eficacia de un protocolo de asesoramiento médico telefónico formalizado (AMTF), realizado por un médico para consultas, para fiebre o gastroenteritis en centros de comunicación médica de emergencia. METODO: Ensayo clínico por conglomerado, controlado. Los pacientes fueron aleatorizados al grupo AMTF o al grupo de atención habitual. Participaron 6 centros de comunicación médica de emergencia franceses. Se incluyeron pacientes que solicitaban asistencia telefónica por fiebre o gastroenteritis. El grupo ATMF realizó recomendaciones protocolizadas sobre el manejo terapéutico. Se valoró el número de consultas presenciales o ingreso hospitalario durante los 15 días siguientes a la consulta. También se evaluó la satisfacción del paciente y el coste económico. RESULTADOS: Se incluyeron 2.498 llamadas. El grupo ATMF (n = 1.234) tuvo un riesgo relativo de 0,70 (CI 95% 0,58 a 0,85) de requerir un ingreso hospitalario o de realizar una consulta no programada durante el seguimiento. No hubo diferencias entre los dos grupos en cuanto al uso de ambulancia, el ingreso en cuidados intensivos, la mortalidad o morbilidad y la mejoría de los síntomas. La satisfacción de los pacientes fue del 90%. El coste total fue de 91 euros en el grupo de la ATMF y de 150 euros en el grupo de atención habitual (p 0,01). CONCLUSIONES: El grupo ATMF se asoció con una disminución de las consultas presenciales no programadas o del ingreso en el hospital. Este procedimiento es seguro y comporta un menor coste que la atención que se realiza habitualmente en la actualidad.

Effectiveness and cost-effectiveness of telephone consultations for fever or gastroenteritis using a formalised procedure in general practice: study protocol of a cluster randomised controlled trial.

BACKGROUND: Telephone consultations in general practice are on the increase. However, data on their efficiency in terms of out-of-hours general practitioner (GP) workload, visits to hospital emergency departments (ED), cost, patient safety and satisfaction are relatively scant. The aim of this trial is to assess the effectiveness of telephone consultations provided by French emergency call centres in patients presenting with isolated fever or symptoms of gastroenteritis, mainly encountered diseases. METHODS/DESIGN: This is a prospective, open-label, multicentre, pragmatic, cluster randomised clinical trial of an estimated 2880 patients making an out-of-hours call to one of six French emergency call centres for assistance with either fever or symptoms of gastroenteritis without seriousness criteria. Each call is handled by a call centre physician. Out-of-hours is 8 p.m. to 7.59 a.m. on weekdays, 1 p.m. to 7.59 a.m. on Saturdays and round-the-clock on Sundays and school holidays. Patients will be enrolled over 1 year. In the intervention arm, a telephone consultation based on a protocol, the formal Telephone Medical Advice (fTMA), is offered to each patient calling. This protocol aims to overcome a physical consultation during out-of-hours periods. It offers reassurance and explanations, advice on therapeutic management which may include, in addition to hygiene and diet measures, a telephone prescription of antipyretic, analgesic, rehydration medication or others, and recommendations on surveillance of the patient and any action to be taken. The patient is invited to call again if the condition worsens or new symptoms develop and to make an appointment with their family GP during office hours. In the control arm, the call centre physician handles calls as usual. This physician can carry out a telephone consultation with or without a telephone prescription, dispatch an on-duty GP, the fire brigade or an ambulance to the patient, or refer the patient to an on-duty physician or to the ED. Each patient will receive a follow-up call on day 15. The primary endpoint is the frequency of out-of-hours, face-to-face GP consultations or visits to the ED during the 15 days following the index call. The secondary endpoints measured on day 15 are the number of stays in intensive care, the number of hospital admissions, the number of interventions by the fire brigade, emergency medical and ambulance services, the number and length of prescribed sick-leave episodes, all-cause mortality, morbidity, clinical outcome, patient compliance, patient satisfaction, the number of renewed calls to the call centre, the number of patients receiving multiple face-to-face GP consultations and costs incurred. DISCUSSION: This trial will assess the effectiveness and the cost-effectiveness of a formalised response to calls for assistance with fever or symptoms of gastroenteritis without seriousness criteria. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02286245 , registered on 9 September 2014.

[Criteria of the patient's decision concerning vaccination against influenza AH1N1, in Belgium and France]. / Critères de décision du patient concernant la vaccination contre la grippe AH1N1, en Belgique et en France.

INTRODUCTION: We have analyzed the reasons evoked by the patients to decide or not to be vaccinated against AH1N1 influenza, in France and Belgium. METHODS: Semi-structured interviews were performed, recorded and transcribed for analysis. Fifty-eight interviews were performed with patient living in the region of Midi-Pyrénées, France (21 interviews) and in the province of Liège, Belgium (37 interviews). The patients were recruited by general practitioners. Within the sample, some patients were vaccinated against AH1N1 influenza and others were not. RESULTS: Five criteria influenced the decision to be vaccinated or not: how people understand the epidemic and the threats it represents; their representation about the vaccine (and its harmlessness); their beliefs and representations about vaccination; the influence of the health professionals' opinion; the discussions between the patient and his acquaintances; and how the patient seeks for information. CONCLUSION: These elements can be considered as criteria influencing the decision about any vaccination. They reflect the patient's subjectivity, the patient's perception of vaccination. Investigating these dimensions in the patient's mind can help the practitioner to positively influence the reluctant patients. Identifying threats and received ideas should allow the doctor to correct them and accept vaccination.