Does practice based nurse telephone triage using computerised decision support for same day patient requests

reduce practice costs and GP time required for these patients? A randomised trial. Authors: Mark Vorster BSc MB BS (Lon) FRCS (Eng) MRCGP General Practitioner Knebworth Hertfordshire David Stott BA D.Phil MSc Statistician Health Research and Development Support Unit University of Hertfordshire Address for correspondence: Dr Mark Vorster Address: Regal Chambers, 50 Bancroft, Hitchin, Herts SG5 1LL Tel 01462 453232 Fax 01462 631536 Email: mark.vorster@GP-E82075.nhs.uk Key Messages: What is already known on this topic: Telephone triage performed by nurses in primary care is effective with a high level of patient satisfaction It has not been shown to be cost effective for GPs to perform telephone triage for patients requesting same day attention What this study adds: Nurse telephone triage using computerised decision support for patients requesting same day attention reduces the amount of GP time needed for these patients and is cost effective for a UK general practice Word count (main article) = 1860 ABSTRACT Objectives To compare the effect of nurse telephone triage using computerised decision support versus usual receptionist handling of patient requests in terms of GP and nurse time and costs. Design Randomised trial with a cost analysis from the perspective of the practice. Patients requesting an appointment the same day were randomised to receive nurse telephone triage or usual care. Setting One mixed urban/semi-rural general practice in the South East of England Subjects 383 patients were eligible for randomisation, of which 374 agreed to be randomised. Interventions Nurse telephone triage involved a practice nurse carrying out a telephone consultation using decision support software. Usual care involved the receptionist granting the patient's request. Main outcome measures Number, length and costs of appointments with the general practitioner and practice nurse, prescription costs, number of appointments with other primary health care professionals over a 28 day period following first contact. Results There was a significant reduction in GP time per patient from a mean (S.D) of 13.03 (13.19) minutes in the control group to 7.36 (10.27) minutes in the triaged group. There were significantly reduced costs per patient in the triaged group compared to the usual care group of 8.70 per patient (95% C.I. -14.15 to -3.17). Conclusion

It was cost effective for this practice to have a nurse telephone triage service using computerised decision support for same day patient requests. Nurse telephone triage reduced the amount of GP time needed for these patients. INTRODUCTION: The availability of clinical time is an important quality and clinical governance issue. Methods to increase the clinical time available within present economic constraints need to be found (1,2). There is a recognised and increasing need for reassurance regarding health issues amongst the public (3), and nurses are known to be particularly effective at this, with high levels of patient satisfaction (4, 5, 6). However, there is a debate about whether nurses should compliment rather than substitute for GPs (GPs) (7), and. substituting nurses for doctors is not necessarily cheaper (8, 9, 10,11). Use of the telephone as a means of organising clinical workload is becoming increasingly widespread but where should telephone consultation take place? Patients prefer talking about their problems to professionals whom they know, and ready access to patients' medical records and local knowledge is probably advantageous (12, 13, 14, 15). It is probably not cost effective for GPs to provide an initial telephone 'sieve', (16, 17, 18). Nurses have been found to be effective at triaging out of hours (19), and in hours in primary care (20, 21). A study in three practices in York where nurses were supported by management protocols found that triage resulted in reduced GP time but did not reduce costs (11). Nurse telephone triage guided by computer decision support software (CDS) has been shown to be useful in primary care (22). It can also act as a medicolegal safeguard through the use of protocols and by facilitating call documentation and audit (23). We decided that a study to assess the cost effectiveness for a UK practice of nurse telephone triage using CDS 'in hours' to assess same day' requests would be a useful addition to the above debate. METHOD Subjects The study took place at one mixed urban/semi-rural general practice in Hertfordshire, (List size 12,700, 6 Partners, IDM deprivation score minimal at 6.5) Patients were recruited between August and November 1999. All consecutive patients phoning the surgery between the hours of 9 and 11am each Monday and Friday and requesting a same day appointment were asked to take part in the study by the receptionists. Interventions Receptionists recorded the patient request and obtained verbal consent. If consent was obtained, each patient was asked to wait on the telephone to receive the result of randomisation. Patients allocated to the triage nurse group were usually telephoned back by the nurse. Nurse telephone triage involved a practice nurse using TAS decision support software (24).This would assist the nurse in deciding what course of action should be followed and also provided a record of the encounter. Usual care involved the receptionist granting the patient's request. Objectives An analysis was conducted from the perspective of the practice to compare the costs per patient of nurse telephone triage with usual receptionist handling of patients requesting a same day appointment. As part of this analysis a comparison was also made of the amount of GP time taken. Outcomes Data were collected on timing of consultations with the GP and the practice nurse, which included the timing of the initial consultation and all contacts within the subsequent 28 days relating to the initial presenting problem. The software automatically logged nurse telephone consultation times. Doctors and nurses recorded times of all other contacts. Out of hours contacts were timed via the GP co-op reports. Contacts with services not directly funded by the practice were recorded but not costed. Prescription costs for each patient were totalled for the initial contact and for the subsequent 28 days. Sample Size Figures for consultation times were obtained from a pilot study in June 1999. We were looking for an effect size of 25%, a significance level of 5% with a power of 80%. The estimated N was 400 patients but we were only able to achieve a total of 374.

Randomisation Randomisation was by means of envelopes containing a block randomisation (three triage and three usual care). An independent researcher at the University of Hertfordshire generated the random blocks and placed them in consecutively numbered sealed opaque envelopes. A member of practice staff physically separated from the reception area opened the next numbered, sealed envelope to allocate each patient to nurse triage or usual care. A computer search was made prior to randomisation to ensure that they were maintained in the same arm of the study if they had been previously recruited. Blinding The receptionists used a standard phrase to explain the nature of the study to each potential participant: We are studying different ways of handling urgent calls---this may include speaking to the nurse on the telephone and answering an anonymous questionnaire. Are you willing to take part? Patients were then randomised unless they declined to take part. The doctors or nurses seeing patients were not aware prior to a consultation into which arm of the study a patient had been entered, (but this may have become apparent during the consultation). Statistical methods The data was collected an Office 97 Excel spreadsheet. The data was transferred to SPSS for analysis. Cost effectiveness analysis was done using Unit Costs of Health and Social Care 1998 PSSRU (25). Given the non-normality of the cost and time data, additional calculation of bootstrap confidence limits for the difference in mean costs and mean total time was undertaken using STATA (26). Results: The diagram summarises participant flow through the study.

Assessed for eligibility (n = 383)

Excluded (n = 9) Refused to participate (n = 9)

Randomised (n = 374)

TRIAGED Allocated to intervention (n = 191) Provision recorded (n = 189) Attended (n = 189)

CONTROL Allocated to intervention (n = 183) Provision recorded (n = 182) Attended (n = 179)

Incomplete timing record (n = 54) Discontinued intervention (n = 0)

Incomplete timing record (n = 38) Discontinued intervention (n = 0)

Analysed (n = 135/189 for timings, 189/189 for re-contact) Incomplete timing record (n = 54)

Analysed (n = 141/179 for timings, 179/179 for re-contact) Incomplete timing record (n = 38)

There were no significant differences between triage and control group participants according to sex, age or initial request (Table 1). Requests were dominated by calls for a GP emergency appointment. Effectively 9 out of 10 requests in both groups were for either a GP emergency appointment or GP home visit.

The difference between triage and control groups in terms of primary outcomes are summarised in Tables 2 and 3. The differences between the two groups with respect to the provision that was made at initial contact are marked. While the pattern of provision among the control group is a close reflection of the requests, the triage group experienced a much greater involvement of practice nurse provision either in the form of telephone advice or nurse emergency appointment. The difference is particularly evident among the subset of patients who initially requested a GP emergency appointment. Only 49/152 (32.2%) of this subset received a GP emergency appointment among the triage group compared with 135/138 (97.7%) of the controls (see Table 4) Overall about a third of the patients had a re-contact during the 28-day follow-up period though the slightly higher rate among the triage group was not significant. Among the triage group 27.5% had a GP re-contact compared with 29.1% among the control. There were a small number of contacts with personnel or services not funded by the practice as shown in Table 5.

The average total time per patient, when initial and any subsequent contacts were combined, was around 14 minutes for both groups. However the relative share of GP and nurse time is markedly different. Among the triage group the mean (S.D.) values were 7.36 (10.27) for GP time and 6.68 (3.35) for nurse time. Comparable figures for the control group were 13.03 (13.19) for GP time and 0.83 (2.99) for nurse time. The effect of this transfer of GP to nurse time among the triage group led to a significant reduction in time cost per patient of 7.39 (95% C.I. -12.47 to -2.93). Drugs costs were lower among the triage group though of borderline significance. The reduction in costs per patient of combined time and drugs costs was 8.70 (95% C.I. -14.15 to -3.17). The cost results are based on those patients for whom a fully recorded set of time data was available. There were no significant differences between those with a full time record and those with an incomplete record (Table 6). The slightly higher proportion of females among those with incomplete data is not likely to have biased the cost difference in favour of the triage group- the mean (S.D.) cost was higher among females (n = 162) at 24.45 (26.34) compared with males (n = 113) at 20.13 (17.65). Discussion:

Our results show that nurse telephone triage using CDS 'in hours' can operate cost effectively within a general practice. The ultimate management of the patients shows that triage had a significant effect in lessening the need for face to face contacts with a general practitioner. This produced the main effect in terms of reduction in cost per patient. The re-contact rates in the 28 days following the initial contact were not significantly different between the two arms of the study. One previous study showed a similar effect (21), but another study showed an increased rate of re-contact following nurse triage (11). Software costs were not included. If capital costs were included the actual cost effectiveness would depend on the number of patients triaged; increasing numbers would increase cost effectiveness. In our case the costs of the software had been reimbursed as part of a bid for a Health Authority quality initiative. Patient, doctor and nurse views of triage the service were obtained and will be reported elsewhere. What are the possible shortcomings of this study? It was conducted in a single centre in which the main author of the study was working. Only one nurse did the telephone triage. Due to organisational issues the triage could only operate for a restricted time during the week, (albeit the two busiest periods). Recordings of some times were made manually by the doctors and nurses. Timings of contacts analysed related to the initial presenting problem, and it is possible that some subsequent contacts could have been misinterpreted for inclusion or exclusion. However, these effects would have applied to both arms of the study. Patient costs were not taken into account, but it seems likely that if anything patient costs would be less in the triaged group, as they were less likely to have to attend the surgery. We have not included the costs for services (eg. Community nurses) not directly reimbursed by the practice (but this amounted to a minimal number of contacts). Various factors contributed to the delay in publication. Many of these reflect the difficulty of carrying out research at the coalface in primary care. Amongst these factors were time pressures on working GPs and nurses, changes in academic support provision , and some problems with tidying the data eg. excluding double counting. Conclusion: In this study we found it to be cost effective to operate a nurse telephone triage service for patients requesting same day management guided by decision support software within daytime UK general practice. Nurse telephone triage affected the ultimate management of patients towards less face to face contact with a general practitioner without affecting the rate of patient re-contact. The implications of this research are significant for primary care. With ever increasing demands, new models for practise will have to be found. In the real world of cost constraints, these systems will have to be effective but also economical. This may be particularly apt within the framework of any new GP contract. Any new systems should ideally be introduced to compliment the well established benefits of traditional, personal, general practice.

Contributors: General advice and support: Sue Le Masurier + Karin Friedli (Former Managers, HertNet), Shelley Hutton (Former Statistician, HertNet), Duncan Barron (Methodologist HertNet) Advice on economic evaluation: Gareth Harper (CRIPACC, University of Hertfordshire) Advice on statistical analysis: Julie Barber (see ref 26) Data inputting: Christine Vorster With thanks to: Carol Clapham (Practice Nurse) and the patients, staff and doctors at Knebworth Surgery Guarantor: Mark Vorster (Author) Ethical approval: Hertfordshire Ethics Committee Funding organisation: HertNet (Both authors declare independence from funder) Conflict of interest: Mark Vorster has been a Clinical Consultant for Plain Software (which markets TAS) since March 2000 David Stott declares that the answer to the questions on your competing interest statement are all No and nothing to declare References 1. Pereira Gray D. Forty seven minutes a year for the patient. Br J Gen Pract 1998; 48: 1816-1817 2. Paris J, McKeon K. Is there enough clinical time available in primary care? Br J Gen Pract 2000; 50; 236 3. O'Cathain A, Munro JF, Nicholl JP, Knowles E. How helpful is NHS Direct? Postal survey of callers BMJ 2000; 320: 1053 4. Brown SA, Grimes DE, A Meta analysis of nurse practitioners and nurse midwives in primary care. Nursing Research 1995 44 (6): pp 332-339 5. Shum C, Humphreys A, Wheeler D, Cochrane M, Skoda S, Clement S. Nurse management of patients with minor illnesses in general practice: multicentre randomised controlled trial BMJ 2000; 320: 1038-1043 6. Kinnersley P, Anderson A, Parry K, Clement J, Archard L, Turton P, Stainthorpe A, Fraser A, Butler C, Rogers C. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting 'same day' consultations in primary care BMJ 2000; 320: 1043-1048 7. Koperski M, Nurse practitioners in general practice-an inevitable progression? Br J Gen Pract 1997; 47: 696-698 8. NHS Executive South Thames. Evaluation of nurse practitioner pilot projects. SETRHA London: Touche Ross 1994

9. Richardson G, Maynard A. Fewer doctors? More nurses? A review of the knowledge base of doctor-nurse substitution Discussion paper 135 York: University of York 1995 10. Venning P, Durie A, Roland M, Roberts C, Leeses B. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care BMJ 2000; 320: 1048-53 11. Richards D, et al Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs BMJ 2002; 325: 1214 (23 November) 12. Glasper A. Telephone triage: a step forward for nursing practice? (Editorial) Br J Nurs. 1993; 2 (2): 108-9 13. Hallam L, Use of the telephone by practice nurses (Report to the Dept of Health) Manchester: Centre for Primary Care Research, University of Manchester 1992 14. Marsh GN, Dawes ML. Establishing a minor illness clinic in a busy general practice BMJ 1995; 310: 778-80 15. Florin D, Rosen R. (Editorial) Evaluating NHS Direct BMJ 319 3 July 1999 pp55-6 16. Stuart A, Rogers S, Modell M. Evaluation of a direct doctor-patient telephone advice line in general practice Br J Gen Pract 2000; 50: 305-306 17. Jiwa M, Mathers N, Campbell M. The effect of GP telephone triage on numbers seeking same day appointments Br J Gen Pract 2002; 52: 390-391 18 McKinstry B, Walker J, Campbell C. et al Telephone consultations to manage requests for same day appointments: a randomised controlled trial in two practices. Br J Gen Pract 2002, 52: 306-10 19. Lattimer V, George S, Thompson F, Thomas E, Mullee M, Turnbull J. et al Safety and effectiveness of nurse telephone consultation in out of hours primary care: Randomised controlled trial BMJ 1998; 317: 1054-9 20. Gallagher M. Telephone triage of acute illness in general practice: outcomes of care Br J Gen Pract 1998; 48: 1141-1145 21. Jones K, Gilbert P, Little J, Wilkinson K. Nurse triage for housecall requests in a Tyneside general practice: patients' views and effect on doctor workload. Br J Gen Pract 1998; 48: 1303-6 22. Crouch R, Dale J, Patel A. et al Ringing the changes: developing, piloting and evaluating a telephone advice system in Accident and Emergency and general practice settings. London: Dept of General Practice and Primary Care, King's College School of Medicine and Dentistry 1996

23. Coleman A. Where do I stand? Legal implications of telephone triage J Clin Nurs Vol 6 (3) May 1997 227-231 24. TAS (Telephone Advice System) Version 5.0--Plain Software company (http://www.plain.co.uk) 25. Netten A, Curtlis L. Unit costs of health and social care. Canterbury: University of Kent at Canterbury, Personal Social services Research Unit 1998 26. Barber JA, Thompson SG. Analysis of cost data in randomised controlled trials: An application of the non-parametric bootstrap. Statistics in Medicine 2000; 19: 3219-3236

PAPER SECTION And topic Item TITLE & ABSTRACT INTRODUCTION Background METHODS Participants Interventions Objectives 1

Description How participants were allocated to interventions (e.g., "random allocation", "randomized", or "randomly assigned"). Scientific background and explanation of rationale. Eligibility criteria for participants and the settings and locations where the data were collected. Precise details of the interventions intended for each group and how and when they were actually administered. Specific objectives and hypotheses. Clearly defined primary and secondary outcome measures and, when applicable, any methods used to enhance the quality of measurements (e.g., multiple observations, training of assessors). How sample size was determined and, when applicable, explanation of any interim analyses and stopping rules. Method used to generate the random allocation sequence, including details of any restriction (e.g., blocking, stratification). Method used to implement the random allocation sequence (e.g., numbered containers or central telephone), clarifying whether the sequence was concealed until interventions were assigned. Who generated the allocation sequence, who enrolled participants, and who assigned participants to their groups. Whether or not participants, those administering the interventions, and those assessing the outcomes were blinded to group assignment. When relevant, how the success of blinding was evaluated. Statistical methods used to compare groups for primary outcome(s); Methods for additional analyses, such as subgroup analyses and adjusted analyses. Flow of participants through each stage (a diagram is strongly recommended). Specifically, for each group report the numbers of participants randomly assigned, receiving intended treatment, completing the study protocol, and analyzed for the primary outcome. Describe protocol deviations from study as planned, together with reasons. Dates defining the periods of recruitment and follow-

Reported on page # 1

2 3

2 2

4 5

Outcomes

Sample size Randomization -Sequence generation Randomization -Allocation concealment Randomization -Implementation

10

Blinding (masking)

11

Statistical methods RESULTS Participant flow

12

13

Recruitment

14

10

up. Baseline data 15 Baseline demographic and clinical characteristics of each group. Number of participants (denominator) in each group included in each analysis and whether the analysis was by "intention-to-treat" . State the results in absolute numbers when feasible (e.g., 10/20, not 50%). For each primary and secondary outcome, a summary of results for each group, and the estimated effect size and its precision (e.g., 95% confidence interval). Address multiplicity by reporting any other analyses performed, including subgroup analyses and adjusted analyses, indicating those pre-specified and those exploratory. All important adverse events or side effects in each intervention group. Interpretation of the results, taking into account study hypotheses, sources of potential bias or imprecision and the dangers associated with multiplicity of analyses and outcomes. Generalizability (external validity) of the trial findings. General interpretation of the results in the context of current evidence. Table 1

Numbers analyzed

16

Outcomes and estimation

17

Table 2+3

Ancillary analyses

18

Tables 46

Adverse events DISCUSSION Interpretation

19

20

Generalizability Overall evidence

21 22

6 6

2P nevig era deniatbo erew snoitaulav mohw morf stcejbus eht fo sliateD )31( A/N detats era stifeneb rehto dna setats htlaeh eulav ot sdohteM )21( 2P detats ylraelc era noitaulave cimonoce eht rof )s(erusaem emoctuo yramirp ehT )11( A/N )seiduts ssenevitceffe fo rebmun a fo weivrevo na no desab fi( nevig era setamitse fo sisylana-atem ro sisehtnys fo dohtem eht fo sliateD )01( 5-2P )yduts elgnis a no desab fi( nevig era yduts ssenevitceffe fo stluser dna ngised eht fo sliateD )9( 2P detats era desu setamitse ssenevitceffe fo )s(ecruos ehT )8(

2P desserdda snoitseuq eht ot noitaler ni deifitsuj si noitaulave cimonoce fo mrof fo eciohc ehT )7( 2P detats si desu noitaulave cimonoce fo mrof ehT )6( 2P debircsed ylraelc era derapmoc gnieb sevitanretla ehT )5( 2P detats si derapmoc snoitnevretni ro semmargorp evitanretla eht gnisoohc rof elanoitar ehT )4( 2P deifitsuj dna detats ylraelc era sisylana eht fo )s(tniopweiv ehT )3( 2P detats si noitseuq hcraeser eht fo ecnatropmi cimonoce ehT )2( 1P detats si noitseuq hcraeser ehT )1(
noitcelloc ataD
11

srepap scimonoce htlaeh rof stsilkcehC

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6P staevac etairporppa eht yb deinapmocca era snoisulcnoC )53( 6P detroper atad eht morf wollof snoisulcnoC )43( 6P nevig si noitseuq yduts eht ot rewsna ehT )33( 3 elbaT mrof detagergga sa llew sa detagerggasid a ni detneserp era semoctuo rojaM )23( A/N detroper si sisylana latnemercnI )13( 2P derapmoc era sevitanretla tnaveleR )03( A/N detats era deirav era selbairav eht hcihw revo segnar ehT )92( A/N deifitsuj si sisylana ytivitisnes rof selbairav fo eciohc ehT )82( A/N nevig si sisylana ytivitisnes ot hcaorppa ehT )72( 3 elbaT + 3P atad citsahcots rof nevig era slavretni ecnedifnoc dna stset lacitsitats fo sliateD )62( A/N detnuocsid ton era stifeneb ro stsoc fi nevig si noitanalpxe nA )52( 3P deifitsuj si )s(etar fo eciohc ehT )42( A/N detats si )s(etar tnuocsid ehT )32( 3P detats si stifeneb dna stsoc fo noziroh emiT )22(
stluser fo noitaterpretni dna sisylanA

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12

Table 1 Baseline Characteristics Characteristics Age and Gender Female Age 65 and over Age: mean (S.D.)
1

Triage (n = 189) n (%) 112 (59.30 %) 41 (21.9) 39.15 (27.43)

Control (n = 182) n (%) 115 (63.2%) 39 (21.4%) 39.97 (27.65)

sign. 0.503* >0.999* 0.774**

Request at first contact GP emergency appointment 152 (80.4%) 138 (75.8 %) GP home visit 25 (13.2%) 25 (13.7%) Other 12 (6.3% 19 (10.4%) 1. Data on age for triage group based on n = 187. * Yates chi-square test; ** unpaired t test Table 2 Provision and re-contact. Triage (n = 189) n (%) Control (n = 182) n (%) 139 (76.4%) 24 (13.2%) 5 (2.7%) 3 (1.6%) 5 (2.7%) 6 (3.3%) Control (n = 179) 52 (29.1%) 12 (6.7%) 60 (33.5%)

) ) 0.343* )

Provision and re-contact Provision GP emergency appointment GP home visit GP routine appointment Nurse emergency appointment Nurse telephone advice Other

sign. * ) ) ) ) <0.001 ) ) sign. ** 0.833 0.057 0.483

54 (28.6%) 9 (4.8%) 22 (11.6%) 36 (19.0%) 56 (29.6%) 12 (6.3%) Triage Total attenders (n = 189) Re-contact with GP 52 (27.5%) Re-contact with nurse 25 (13.2%) Re-contact with either GP or nurse 71 (37.6%) * chi-square test; ** Yates chi-square test. Table 3 Time and costs per patient.

Triage Control Triage - control (n = 135) ( n = 141) Mean (SD) Mean (SD) Difference in means (95% C.I.)* Total time (mins) 14.04 (11.40) 13.86 (13.37) 0.18 (-2.99 to 2.94) Time cost () 16.00 (18.49) 23.39 (23.27) -7.39 (-12.47 to -2.93) Drug cost () 2.21 (5.15) 3.52 (5.62) -1.32 (-2.65 to -0.04) Time + drug cost () 18.21 (20.29) 26.91 (25.00) -8.70 (-14.15 to -3.17) * bias corrected and accelerated bootstrap confidence limits. Time and Cost

Table 4 Provision according to initial request Triage Requests Provision GP emergency appt GP home visit GP routine appointment Nurse emergency appt. Nurse telephone advice Other provision Total GP emergency appt 49 2 19 32 46 4 152 GP home visit 4 7 2 1 4 7 25 1 3 6 1 12 138 1 1 25 Other requests 1 GP emergency appt 135 1 1 Control Requests GP home visit 2 22 Other requests 2 1 4 3 4 5 19

Table 5 Contacts with other services (all contacts within 28 days) Triage Other Service Contacts Midwife/Health Visitor Community Nurse Accident and Emergency Hospital Admission Total (n = 189) 5 5 5 1 16 Control (n = 182) 0 1 0 2 3

Table 6 Baseline characteristics of participants according to completeness of time record Baseline characteristics Complete record Gender: female 162/275 (58.9%) Age group 65 and over 212/274 (77.4%) Age: mean (S.D.) 39.23 (27.56) Requested GP emergency app. 213/275 (77.5%) * Yates chi-square test; ** unpaired t test Incomplete record 63/93 (67.7%) 74/92 (80.4%) 40.50 (27.48) 76/93 (81.7%) sign. 0.165* 0.639* 0.703** 0.471*