NHS Direct versus general practice based triage for same day appointments in primary care: cluster randomised controlled trial
http://www.100md.com
《英国医生杂志》
1 Department of Health Sciences, University of York, Heslington, York YO10 5DD, 2 Priory Medical Centre, Cornlands Road, Acomb, York YO24 3WX, 3 Tees East and North Yorkshire Ambulance Service, TENYAS NHS Direct, Willerby, Hull HU10 6HD
Correspondence to: D A Richards dr17@york.ac.uk
Abstract
Use of nurses to manage requests for same day appointments in primary care over the telephone is a popular system for managing general practitioners' workload.1 Triage has been shown to be safe in out of hours services2 and to reduce general practitioners' same day appointment workload by up to 49% in routine practice.3-6 Triage is not cheaper than standard appointment systems,6 and many general practices may be unable to employ the critical mass of nurses needed to deliver a comprehensive service. One solution may be for an external agency such as NHS Direct to provide triage services to practices.7
NHS Direct is a direct access health advice line. Nurse advisers use computerised decision support systems to advise callers. Having previously shown that telephone triage by practice nurses within general practice reduces same day appointments with general practitioners,6 we wanted to investigate the effectiveness and costs of delivering an off-site telephone triage service in order to determine if off-site triage is a feasible option for primary care. Our aim was to determine the relative effects on consultation workload and costs by conducting a randomised controlled trial of NHS Direct delivered telephone triage for patients requesting same day appointments compared with usual practice based triage.
Methods
A total of 4788 patients requested same day appointments during the trial period (fig). Seventy patients declined to participate, 68 in the NHS Direct arm and two in the usual care arm. Fifteen patients could not be contacted after their request for an appointment, leaving 4703 patients for whom we have data in the study, 2452 in the usual care group and 2251 in the NHS Direct group. The groups were equivalent in terms of age, sex, and number and type of presenting complaints, apart from more patients in the practice group with genitourinary complaints (table 1).
Flowchart of patients through study
In the NHS Direct weeks the mean number of patients was 173.8 (SD 26.2, minimum 119, maximum 220); in the practice weeks the mean was 189.0 (SD 32.1, minimum 140, maximum 250). A repeated measures analysis of variance gave a Greenhouse-Geisser corrected F of 7.1 (df = 2.7, 62.3; P = 0.001) for the interaction effect of group and final point of contact. Patients in the NHS Direct group were less likely to have their call resolved by a telephone contact or appointment with a nurse and were more likely to have an appointment with a general practitioner (table 2).
Table 2 Final point of contact for patients requesting same day appointments triaged by NHS Direct or practice. Values are numbers (percentages) unless stated otherwise
Time taken to manage same day requests
We found a significant difference in average nursing time between NHS Direct and practice triage; NHS Direct took 6.9 minutes longer to triage patients (table 3). When we controlled statistically for final destinations, the difference remained significant at 7.5 minutes. The average amount of general practitioner's time per patient was greater for NHS Direct patients (0.7 minutes), but when we controlled for final destinations the difference was no longer significant (0.2 minutes). The total time needed to manage patients' requests was dominated by nursing time, which is reflected in the average total time difference of 7.6 minutes, or 7.7 minutes when we controlled for final destination.
Table 3 Mean (SD) nursing time, general practitioners' time, and total time per patient after triage by NHS Direct or practice
Follow up care one month after same day appointment
We found no differences between the groups in the number of patients receiving further practice based care, out of hours care, or emergency services within one month of the index consultation (table 4).
Table 4 Results of Poisson regression of number of practice based, emergency department, and out of hours consultations within one month for patients managed by NHS Direct or practice triage
Costs
Same day costs for general practitioners and nurses were greater in the NHS Direct group, leading to an overall mean cost difference of ￡2.88 ($5.16; 4.23) per patient triaged (table 5). We found no differences in other practice based costs (general practitioner and nurse follow up time, drugs, and tests), out of hours costs, or emergency department costs. When we controlled for final point of contact, the difference in nurse costs remained greater for NHS Direct but the total cost (￡1.50) was no longer significantly different. When we increased the unit costs of general practitioners' and nurses' salaries by including training costs as well as salary costs, the total costs remained different (mean difference ￡4.15, 95% confidence interval ￡2.00 to ￡6.36; P = 0.001), but this was not the case once we had controlled for final point of contact (￡2.71, - ￡0.66 to ￡6.08; P = 0.108). In a final sensitivity analysis, we reduced NHS Direct nurse time by half a standard deviation, which left nurse costs still significantly different (￡0.49, ￡0.35 to ￡0.63; P < 0.001) but reduced the overall cost difference to just under the 0.05 significance level (￡1.86, - ￡0.86 to ￡3.87; P = 0.07). Using these reduced figures and controlling for final point of contact resulted in nurse costs remaining greater for NHS Direct (￡0.61, ￡0.43 to ￡0.79; P < 0.001) but no difference in the total costs (￡0.44, - ￡2.66 to ￡3.54; P = 0.77).
Table 5 Difference in costs of care for NHS Direct and practice triage—costs on day plus total costs incurred one month after request for same day appointment
Discussion
Luthra M, Marshall MN. How do general practices manage requests from patients for `same day' appointments? A questionnaire survey. Br J Gen Pract 2001;51: 39-41.
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.
Gallagher M, Huddart T, Henderson B. Telephone triage of acute illness by a practice nurse in general practice: outcomes of care. Br J Gen Pract 1998;48: 1141-5.
Jones K, Gilbert P, Little J, Wilkinson K. Nurse triage for house call requests in a Tyneside general practice: patients' views and effect on doctor workload. Br J Gen Pract 1998;48: 1303-6.
Thompson F, George S, Lattimer V, Smith H, Moore M, Turnbull J, et al. Overnight calls in primary care: randomised controlled trial of management using nurse telephone consultation. BMJ 1999;319: 1408.
Richards DA, Meakins J, Tawfik J, Godfrey L, Dutton E, Richardson G, 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: 1214-7.
Munro J, Nicholl J, O'Caithain A, Knowles E. Impact of NHS Direct on demand for immediate care: observational study. BMJ 2000;321: 150-3.
Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic and statistical considerations. J Pers Soc Psychol 1986;51: 1173-82
Richards DA, Meakins J, Tawfik J, Godfrey L, Dutton E, Heywood P. Quality monitoring of nurse telephone triage: a pilot study. J Adv Nurs 2004; in press.(David A Richards, profess)
Correspondence to: D A Richards dr17@york.ac.uk
Abstract
Use of nurses to manage requests for same day appointments in primary care over the telephone is a popular system for managing general practitioners' workload.1 Triage has been shown to be safe in out of hours services2 and to reduce general practitioners' same day appointment workload by up to 49% in routine practice.3-6 Triage is not cheaper than standard appointment systems,6 and many general practices may be unable to employ the critical mass of nurses needed to deliver a comprehensive service. One solution may be for an external agency such as NHS Direct to provide triage services to practices.7
NHS Direct is a direct access health advice line. Nurse advisers use computerised decision support systems to advise callers. Having previously shown that telephone triage by practice nurses within general practice reduces same day appointments with general practitioners,6 we wanted to investigate the effectiveness and costs of delivering an off-site telephone triage service in order to determine if off-site triage is a feasible option for primary care. Our aim was to determine the relative effects on consultation workload and costs by conducting a randomised controlled trial of NHS Direct delivered telephone triage for patients requesting same day appointments compared with usual practice based triage.
Methods
A total of 4788 patients requested same day appointments during the trial period (fig). Seventy patients declined to participate, 68 in the NHS Direct arm and two in the usual care arm. Fifteen patients could not be contacted after their request for an appointment, leaving 4703 patients for whom we have data in the study, 2452 in the usual care group and 2251 in the NHS Direct group. The groups were equivalent in terms of age, sex, and number and type of presenting complaints, apart from more patients in the practice group with genitourinary complaints (table 1).
Flowchart of patients through study
In the NHS Direct weeks the mean number of patients was 173.8 (SD 26.2, minimum 119, maximum 220); in the practice weeks the mean was 189.0 (SD 32.1, minimum 140, maximum 250). A repeated measures analysis of variance gave a Greenhouse-Geisser corrected F of 7.1 (df = 2.7, 62.3; P = 0.001) for the interaction effect of group and final point of contact. Patients in the NHS Direct group were less likely to have their call resolved by a telephone contact or appointment with a nurse and were more likely to have an appointment with a general practitioner (table 2).
Table 2 Final point of contact for patients requesting same day appointments triaged by NHS Direct or practice. Values are numbers (percentages) unless stated otherwise
Time taken to manage same day requests
We found a significant difference in average nursing time between NHS Direct and practice triage; NHS Direct took 6.9 minutes longer to triage patients (table 3). When we controlled statistically for final destinations, the difference remained significant at 7.5 minutes. The average amount of general practitioner's time per patient was greater for NHS Direct patients (0.7 minutes), but when we controlled for final destinations the difference was no longer significant (0.2 minutes). The total time needed to manage patients' requests was dominated by nursing time, which is reflected in the average total time difference of 7.6 minutes, or 7.7 minutes when we controlled for final destination.
Table 3 Mean (SD) nursing time, general practitioners' time, and total time per patient after triage by NHS Direct or practice
Follow up care one month after same day appointment
We found no differences between the groups in the number of patients receiving further practice based care, out of hours care, or emergency services within one month of the index consultation (table 4).
Table 4 Results of Poisson regression of number of practice based, emergency department, and out of hours consultations within one month for patients managed by NHS Direct or practice triage
Costs
Same day costs for general practitioners and nurses were greater in the NHS Direct group, leading to an overall mean cost difference of ￡2.88 ($5.16; 4.23) per patient triaged (table 5). We found no differences in other practice based costs (general practitioner and nurse follow up time, drugs, and tests), out of hours costs, or emergency department costs. When we controlled for final point of contact, the difference in nurse costs remained greater for NHS Direct but the total cost (￡1.50) was no longer significantly different. When we increased the unit costs of general practitioners' and nurses' salaries by including training costs as well as salary costs, the total costs remained different (mean difference ￡4.15, 95% confidence interval ￡2.00 to ￡6.36; P = 0.001), but this was not the case once we had controlled for final point of contact (￡2.71, - ￡0.66 to ￡6.08; P = 0.108). In a final sensitivity analysis, we reduced NHS Direct nurse time by half a standard deviation, which left nurse costs still significantly different (￡0.49, ￡0.35 to ￡0.63; P < 0.001) but reduced the overall cost difference to just under the 0.05 significance level (￡1.86, - ￡0.86 to ￡3.87; P = 0.07). Using these reduced figures and controlling for final point of contact resulted in nurse costs remaining greater for NHS Direct (￡0.61, ￡0.43 to ￡0.79; P < 0.001) but no difference in the total costs (￡0.44, - ￡2.66 to ￡3.54; P = 0.77).
Table 5 Difference in costs of care for NHS Direct and practice triage—costs on day plus total costs incurred one month after request for same day appointment
Discussion
Luthra M, Marshall MN. How do general practices manage requests from patients for `same day' appointments? A questionnaire survey. Br J Gen Pract 2001;51: 39-41.
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.
Gallagher M, Huddart T, Henderson B. Telephone triage of acute illness by a practice nurse in general practice: outcomes of care. Br J Gen Pract 1998;48: 1141-5.
Jones K, Gilbert P, Little J, Wilkinson K. Nurse triage for house call requests in a Tyneside general practice: patients' views and effect on doctor workload. Br J Gen Pract 1998;48: 1303-6.
Thompson F, George S, Lattimer V, Smith H, Moore M, Turnbull J, et al. Overnight calls in primary care: randomised controlled trial of management using nurse telephone consultation. BMJ 1999;319: 1408.
Richards DA, Meakins J, Tawfik J, Godfrey L, Dutton E, Richardson G, 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: 1214-7.
Munro J, Nicholl J, O'Caithain A, Knowles E. Impact of NHS Direct on demand for immediate care: observational study. BMJ 2000;321: 150-3.
Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic and statistical considerations. J Pers Soc Psychol 1986;51: 1173-82
Richards DA, Meakins J, Tawfik J, Godfrey L, Dutton E, Heywood P. Quality monitoring of nurse telephone triage: a pilot study. J Adv Nurs 2004; in press.(David A Richards, profess)