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Telephone triage not a time-saver

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GPs and nurses who assess patients by phone before seeing them in person end up spending far more of their time on the telephone rather that cutting down on their overall workload, a British investigation has found.

And it has warned that using receptionists as a barrier to ward off patients seeking same-day consultations might be inappropriate.

The report, Management of same-day appointments in primary care, by Justin Osborn and Matthew Thompson, published in The Lancet, drew on results from an earlier study by John Campbell and colleagues, entitled, the ESTEEM trial.

The ESTEEM trial compared three approaches to telephone triage of patients seeking same-day, but non-emergency, appointments in the United Kingdom: phone triage by GPs, phone triage by nurses using computer decision support, and usual care, such as a receptionist taking the call.

The study, which involved more than 16,000 patients across 42 medical practices, examined the practice workload in the 28 days after the same-day request, as well as costs and patient satisfaction.

It found that practices where doctors took the triage phone calls had a 33 per cent increase in the mean number of patient contacts per person over the 28-day period. Those who introduced nurse triage had a 48 per cent increase.

However, the increase in patient contact with the practice did not necessarily translate into face-to-face visits with the doctor.

The ESTEEM trial found the introduction of GP triage actually reduced the number of face-to-face contacts with GPs by about 40 per cent, while nurse triage reduced the number of GP face-to-face contacts by 20 per cent.

This reduction in face-to-face contact with doctors was offset though, by far more phone contacts. GPs experienced a 10-fold increase in phone calls, while for nurses there was a 100-fold increase.

“Therefore, to some extent, the differences in numbers and types of contacts between practices in the three groups represented redistribution of the workload,” the researchers said.

All three forms of screening involved similar costs, but patient satisfaction was lower in those practices using nurse triage than in those using GP triage or usual care.

“The fact that GP or nurse triage led to increased numbers of consultations, overall, suggests that the barrier imposed by receptionists or other non-clinical staff fielding requests for same-day consultations might be inappropriate,” The Lancet report says.

The authors said the findings of the ESTEEM trial echoed those of smaller trials of nurse triage for same-day appointments in general practice, one of which reported a reduction in same-day face-to-face GP contacts, but an increase in routine face-to-face visits to the GP and more phone contacts and face-to-face time with nurses.

“Many primary care practices struggle with ever-increasing demand from patients accustomed to round-the-clock services (and pressure from politicians and policy makers to satisfy this demand),” they said.

“Mere shifting of clinicians into triage roles is unlikely to free them from other duties.

“Another key message is that all triage systems offer trade-offs between different uses of staff in primary care, and none are necessarily better than others.

“Nevertheless, the ever-rising tide of demand for appointments means that we need to find ways to encourage greater patient self-management when appropriate, new forms of consultation or advice (with email or online consultations, or by expanding the work of pharmacists), and research to guide specific triage skills and clinical reasoning in primary care.”

Debra Vermeer