Cost-effectiveness of telephone or surgery asthma reviews: economic analysis of a randomised controlled trial

BACKGROUND: Only about a third of people with asthma attend an annual review. Clinicians need to identify cost-effective ways to improve access and ensure regular review. AIM: To compare the cost-effectiveness of nurse-led telephone with face-to-face asthma reviews. DESIGN OF STUDY: Cost-effectiveness analysis based on a 3-month randomised controlled trial. SETTING: Four general practices in England. METHOD: Adults due an asthma review were randomised to telephone or face-to-face consultations. Trial nurses recorded proportion reviewed, duration of consultation, and abortive calls/missed appointments. Data on use of healthcare resources were extracted from GP records. Cost-effectiveness was assessed from the health service perspective; sensitivity analyses were based on proportion reviewed and duration of consultation. RESULTS: A total of 278 people with asthma were randomised to surgery (n = 141) or telephone (n = 137) review. Onehundred-and-one (74%) of those with asthma in the telephone group were reviewed versus 68 (48%) in the surgery group (P <0.001). Telephone consultations were significantly shorter (mean duration telephone = 11.19 minutes [standard deviation {SD} = 4.79] versus surgery = 21.87 minutes [SD = 6.85], P <0.001). Total respiratory healthcare costs per patient over 3 months were similar (telephone = pounds sterling 64.49 [SD = 73.33] versus surgery = pounds sterling 59.48 [SD = 66.02], P = 0.55). Total costs of providing 101 telephone versus 68 face-to-face asthma reviews were also similar (telephone = pounds sterling 725.84 versus surgery = pounds sterling 755.70), but mean cost per consultation achieved was lower in the telephone arm (telephone = pounds sterling 7.19 [SD = 2.49] versus surgery = pounds sterling 11.11 [SD = 3.50]; mean difference = - pounds sterling 3.92 [95% confidence interval = - pounds sterling 4.84 to pounds sterling 3.01], P <0.001). CONCLUSIONS: Telephone consultations enable a greater proportion of asthma patients to be reviewed at no additional cost to the health service. This mode of delivering care improves access and reduces cost per consultation achieved.     

How well do nurse-run telephone consultations and consultations in the surgery agree? Experience in Swedish primary health care.

The telephone consultation service is an important part of Swedish primary health care. However, few studies have compared telephone consultations managed by nurses with surgery consultations managed by both doctors and nurses in terms of information obtained from the patient regarding his or her symptoms, and the management decisions made. In this study, the information obtained from a patient during a telephone consultation with a health centre nurse and the management decisions made, were compared with those obtained at a subsequent surgery consultation with the same nurse, and then with a doctor. Of 200 telephone consultations at a health centre (50 in each of the following four categories as defined by the management decision of the nurse: acute case, semi-acute case, referral case and self-care case), 193 patients were included in the study. The information given to the nurse during the telephone consultation was recorded. The patient was then asked to come for a surgery consultation on the same day, first with the same nurse and then with a general practitioner. A comparison was made between the information obtained and the decisions taken in these three situations. In 185 of the 193 cases (96%) the information led to the same management decision by the nurse, in both the telephone consultation and later in the surgery consultation. In all cases the same history was recorded by the nurse during the telephone and surgery consultations as by the general practitioner. This indicates that in most cases little or no information is missed in a telephone consultation with a nurse as compared with a surgery consultation with a nurse or doctor.(ABSTRACT TRUNCATED AT 250 WORDS)     

Patients evaluate accessibility and nurse telephone consultations in out-of-hours GP care: determinants of a negative evaluation

OBJECTIVE: The shift towards large-scale organization of out-of-hours primary healthcare in different western countries has created an important role for the nurse telephone consultation. We explored the association between negative patient evaluation of nurse telephone consultations and characteristics of patients and GP cooperatives. METHODS: A cross-sectional study using postal patient questionnaires sent to patients receiving a nurse telephone consultation from one of 26 GP cooperatives in the Netherlands. RESULTS: The total response was 49.3% (2583/5239). Negative evaluations were most frequently encountered for the general information received on the GP cooperative (35%). When patients expected a centre consultation or home visit, but only received a nurse telephone consultation, they were more negative about the accessibility (OR 1.7, CI 1.4-2.1) and nurse telephone consultation (OR 4.2, CI 3.2-5.6). In the presence of a special supervising telephone doctor at the cooperative's call centre, nurse telephone consultation was evaluated significantly less negative (OR 0.4, CI 0.2-0.8). CONCLUSION: Expectation of care mode was most strongly associated with a negative evaluation of nurse telephone consultation. The presence of a supervising telephone doctor may lead to a better evaluation of nurse telephone consultations. PRACTICE IMPLICATIONS: More attention should be paid to the provision of patient information on the GP cooperative and discrepancies between the care expected and the care offered.     

An assessment of the feasibility of telephone and email consultation in a chest clinic

One hundred and sixty-four consecutive patients attending a busy respiratory outpatient service were asked how acceptable was the concept of alternating face to face consultation with consultation by either telephone or email. The patients were then assessed as to their suitability for such non-traditional methods of consultation. Thirty patients (18.3%) were not agreeable to other forms of consultation and five could not speak English. One hundred and thirty-three (84%) had a suitable daytime telephone number for consultation purposes, but only 34 (21%) had email access, with this being commoner in the younger ages. One hundred and five patients were not thought to be suitable for alternative methods of consultation because of: the severity of their condition, the difficulty of assessing it over the telephone, or because they needed to attend the hospital for investigations. However, even in a clinic where the policy was already to return as many patients as possible to the care of their primary care physicians, and in a clinic where much work was already shared with respiratory nurse specialists, over one-third of patients were thought to be suitable for alternating face to face with telephone consultation. The diagnoses in those cases included asthma, suspected obstructive sleep apnoea, chronic obstructive pulmonary disease (COPD), unexplained cough, and some patients with respiratory malignancy being visited at home by the palliative medicine services. However, for those with asthma and for those awaiting results of investigations especially, use of telephone consultation appears to be an acceptable and convenient way of reducing the pressure upon time available for face to face consultations.     

Telerheumatology--diagnostic accuracy and acceptability to patient, specialist, and general practitioner.

This study examines the diagnostic accuracy and acceptability of telemedicine in the field of rheumatology. One hundred patients had a telephone and televisual consultation and the results were compared with a face-to-face consultation. While the telephone consultations were often unsatisfactory, the televisual consultations were highly accurate (97%) and acceptable to patients, general practitioners, and specialists.     

Frequency of microbiologically correct antibiotic therapy increased by infectious disease consultations and microbiological results

In a prospective observational study of bacteremic patients we ascertained the influence of different parts of culture results on the correctness of empirical antibiotic therapy. Ninety-three bacteremic patients requiring antibiotic treatment were included. Patients who had consultations with an infectious disease consultation service before they became bacteremic received microbiologically correct empirical antibiotic therapy more often than those who did not have such consultations (75% versus 53%; P = 0.03). As a direct result of Gram staining, 92% of all patients received microbiologically correct antibiotic therapy.     

The effects of telephone consultation and triage on healthcare use and patient satisfaction: a systematic review

BACKGROUND: In recent years there has been a growth in the use of the telephone consultation for healthcare problems. This has developed, in part, as a response to increased demand for GP and accident and emergency department care. AIM: To assess the effects of telephone consultation and triage on safety, service use, and patient satisfaction. DESIGN OF STUDY: We looked at randomised controlled trials, controlled studies, controlled before/after studies, and interrupted time series of telephone consultation or triage in a general healthcare setting. SETTING: All healthcare settings were included but the majority of studies were in primary care. METHOD: We searched the Cochrane Central Register of Controlled Trials, EPOC specialised register, PubMed, EMBASE, CINAHL, SIGLE, and the National Research Register and checked reference lists of identified studies and review articles. Two reviewers independently screened studies for inclusion, extracted data, and assessed study quality. RESULTS: Nine studies met our inclusion criteria: five randomised controlled trials; one controlled trial; and three interrupted time series. Six studies compared telephone consultation with normal care; four by a doctor, one by a nurse, and one by a clinic clerk. Three of five studies found a significant decrease in visits to GPs but two found an increase in return consultations. In general at least 50% (range = 25.5-72.2%) of calls were handled by telephone consultation alone. Of seven studies reporting accident and emergency department visits, six showed no difference between the groups and one--of nurse telephone consultation--found an increase. Two studies reported deaths and found no difference between nurse telephone consultation and normal care. CONCLUSIONS: Although telephone consultation appears to have the potential to reduce GP workload, questions remain about its effect on service use. Further rigorous evaluation is needed with emphasis on service use, safety, cost, and patient satisfaction.     

Experiences from the epicenter: Professional impact of the COVID‐19 pandemic on genetic counselors in New York

The COVID‐19 pandemic disrupted the delivery of healthcare services, including genetic counseling. This study assessed the professional impact of the pandemic on genetic counselors (GCs) and evaluated how genetics service delivery models changed in New York State (NYS). One hundred sixty‐five NYS GCs participated in an anonymous survey. Clinic structure, telegenetics (video and/or telephone consultations) use and acceptability, and professional practices before and during the pandemic were compared. The most frequently reported consultation type shifted from in‐person only (49%) before the pandemic to telegenetics only (39%) during. Most were satisfied with video (93.1%) and telephone (81.4%) telegenetics. Additionally, 93.5% of participants expressed a desire to continue using telegenetics after the pandemic resolves. Common obstacles included difficulties coordinating sample collection (60.2%) and obtaining written consent for testing (57.6%). Billing methods for consultations during the pandemic did not change significantly. Participants were asked about NYS's lack of licensure, which restricts billing options. Most felt that genetic counseling licensure would benefit the profession (92.6%), the public (88.5%), and their institution/company (74.5%). This study provides insight into the effects of the rapid adoption of telegenetics and can guide future discussions about best practices for its use even after the health crisis resolves.     

Informal consultations in infectious diseases and clinical microbiology practice

Informed consultation between physicians is an important part of medical practice. The aim of the study was to evaluate the nature and frequency of such consultations in infectious diseases and clinical microbiology practice. This study was done in five university hospitals. Twenty-one infectious diseases and clinical microbiology specialists participated in informal ('curbside') consultations. In a written questionnaire, physicians were asked to report the number and nature of the informal consultations (ICs) they were asked to provide. A total three hundred and sixty-two such consultations were carried out during a three-month period. The ICs occurred most frequently in the hospital (82.3%). Most of the ICs from outside the hospital were by telephone. Most of the ICs (54.4%) were requested by fellows of specialists. 78.7% of the ICs were requested during working hours. 58.8% of consultations took less than 5 min, 18.8% took 6–10 min, 15.2% took 11–20 min, and 7.2% took over 20 min. The four most common reasons for obtaining ICs were to: help to select an appropriate treatment plan (41.4%), help to select an appropriate prophylaxis (19.3%), interpret laboratory data (10.2%), and provide information about antibiotics (10.2%). 30.1% of ICs resulted in subsequent formal consultation and only four patients (1.1%) were transferred to the consultants' clinics. Informal consultations are a frequent occurrence in the practice of infectious diseases and clinical microbiology (ID&CM). Physicians use this sort of consultation to select an appropriate treatment plan and obtain medical information. This study confirms the importance of the ID&CM specialists as a resource for medical personnel.     

Qualitative analysis of cancer telephone consultations: Differences in the counseling needs of Japanese men and women

ObjectiveTo analyze large-scale data obtained from telephone cancer consultations and clarify sex differences in the information sought by callers to guide future cancer survivor support.MethodsWe qualitatively analyzed 10,534 cases of telephone consultations with cancer patients. The relationships between callers’ words and sex were visualized through a correspondence analysis, and the keywords extracted were visualized with a dependency relationship to the words “worry” and “anxiety,” which had a high prevalence in the text data.ResultsMost of the male callers sought consultation about stomach cancer (11.8%), the consultations were predominantly about “suspicion of having cancer” (25.2%), and males indicated that the goal was to gather accurate information. Female callers mostly sought consultation about breast cancer (18.4%) were mainly interested in learning about “treatment” (31.0%), and mostly used the keywords "worry" and "anxiety." The total number of callers without a definitive diagnosis accounted for 20% of all consultations.ConclusionsHealthcare providers need to understand unique sex-based coping styles and perform regular follow-ups. There is also a need for online platforms that provide information from the patient’s perspective.Practical implicationsProviding a cancer consultation support system and easy-to-understand medical information will improve communication between survivors, their families, and medical staff.     

Utilization and cost savings of a wide-area computer network for neurosurgical consultation.

BACKGROUND AND OBJECTIVE: Telemedicine systems offer many potential advantages for health care delivery. Most reports have centered on the delivery of primary and medical subspecialty care rather than on its impact on patient care and the potential for cost savings. In 1993, we implemented NeuroLink, a wide-area teleradiology network for delivery of specialty care in neurologic surgery at Allegheny General Hospital (AGH). This study was designed to determine the potential cost savings of such a network. METHODS: We prospectively reviewed 100 consecutive telemedicine neurosurgical consultations from 20 western Pennsylvania community hospitals participating in the NeuroLink network. Data related to referring hospital, diagnosis, disposition of the patient, and mode of transportation were reviewed. To determine the potential cost savings, the differential of hospital-based charges between AGH and western Pennsylvania primary hospitals was calculated based on an average length of stay (LOS), patient bed costs, and transportation charges. RESULTS: Of the 100 patients, 33 did not require transfer to a tertiary facility but were instead managed at the community hospital as a direct result of the remote diagnosis and image review disclosing that neurosurgical procedures or intensive care were not required. Cost analysis, comparing the average LOS at AGH with that of the average community hospital, including transportation, showed savings of $502,638. CONCLUSION: Our neurosurgical wide-area computer network has led to more appropriate transfer of patients to a tertiary facility and significant estimated cost savings.     

Quantifying implicit uncertainty in primary care consultations: A systematic comparison of communication about medically explained versus unexplained symptoms

ObjectiveGeneral practitioners (GPs) disclose more uncertainty (e.g. “I don’t know”) in consultations with patients presenting medically unexplained symptoms (MUS) versus medically explained symptoms (MES), which could negatively affect patient outcomes. This study assessed if this pattern also holds for more subtle, implicit uncertainty expressions (e.g. “maybe”, “might”) during different consultation phases, and assessed their relation to patient pre-post consultation anxiety.MethodsWe quantified implicit markers of uncertainty of 18 GPs in 82 consultations about MUS or MES during different consultation phases. Relative frequencies of implicit uncertainty per consultation were regressed on differences in momentary anxiety pre and post consultation.ResultsWe coded 2590 GP utterances. Uncertainty expressions were more frequent in MUS versus MES consultations (OR = 1.54, p = .004), especially during diagnosis and treatment recommendations compared to physical examinations (OR =0 .45, p = .001). Implicit uncertainty was not related to patients’ changes in anxiety (b = ?0.11, p = .817).ConclusionsGPs express more uncertainty during MUS (versus MES) consultations, especially during the diagnostic phase and treatment recommendations. This does not necessarily affect patient anxiety.Practice implicationsImplicit uncertainty expressions reflect the mere complexity of communicating a medically unexplained diagnosis, which does not affect patient anxiety.     

The quality of record keeping in primary care: a comparison of computerised, paper and hybrid systems.

BACKGROUND: Computerised record keeping in primary care is increasing. However, no study has systematically examined the completeness of computer records in practices using different forms of record keeping. AIM: To compare computer-only record keeping to paper-only and hybrid systems, by measuring the number of consultations and symptoms recorded within individual consultations. DESIGN OF STUDY: Retrospective cohort study. SETTING: Eighteen general practices in the Exeter Primary Care Trust. METHOD: This study was part of a retrospective case control study of cancer patients aged over 40 years. All recorded consultations for a 2-year period were identified and coded for 1396 patients. Records were classified as paper, computer, or hybrid, depending on which medium stored the clinical information from consultations. RESULTS: More consultations were recorded in hybrid systems (median in 2 years = 11, interquartile range [IQR] = 6-18) than computer systems (median in 2 years = 9, IQR = 4-16.5) or paper systems (median in 2 years = 8, IQR = 5-14,): P <0.001. In a Poisson regression analysis, which included age, sex, and future cancer diagnosis, the rates of consultations recorded in paper and computer systems were 16% and 11% lower, respectively, than in hybrid systems. Fewer telephone consultations were recorded in paper systems, and fewer home visits in computer systems. Fewer symptoms were recorded in individual consultations on computer systems. Recording of absent symptoms and severity of symptoms was highest in paper systems. CONCLUSION: Hybrid systems of primary care record keeping document higher numbers of consultations than computer-only or paper-only systems. The quality of individual consultation recording is highest in paper-only systems. This has medicolegal implications and may impact upon continuity of care.     

Telephone and face-to-face consultation in breast cancer diagnosis: a comparative study

OBJECTIVE: This study compares telephone consultations with the results of clinical examinations to assess the value and accuracy of telephone consultations for the future planning in a breast cancer clinic in Tehran, Iran. METHODS: In 2500 telephone calls, 800 Symptomatic patients were identified and asked to visit the center for the further investigations by the specialists. The agreement between two observers data were compared by the kappa statistic. RESULTS: Totally 174 patients complied with the recommendation and included in the study. The most common chief complaints of visitors were: breast mass (42%) and breast pain (35%). Kappa statistic showed a very good agreement (K=0.62, P<0.001) between consultants' diagnosis and the specialists findings. This agreement for breast cancer diagnosis, although lower, was also good (K=0.55, P<0.001). CONCLUSION: The study findings indicate that consultants may diagnose and manage some common conditions via telephone, usually following the established protocols. More studies are needed to determine the economic and logistic advantages of telephone consultations. PRACTICE IMPLICATIONS: By assessment of strength and weakness of this service, it is possible to develop an easy to use information system for women who need breast care.     

A follow-up study of psychiatric consultations in the general hospital: What happens to patients after discharge?

BACKGROUND: An appropriate follow-up is considered essential in the consultation-liaison psychiatry setting, but it is often neglected. This study evaluated the effectiveness of the psychiatric consultation process in the general hospital, by investigating what occurred to patients 3-5 months after discharge. METHODS: We used a three-part questionnaire: (1) the results of the consultation process; (2) a telephone interview with patients, and (3) a telephone interview with the patients' primary care physician, to whom the patients were referred after discharge from hospital. We contacted all consecutive, unselected patients referred to psychiatric consultation from January to July 1999. Complete data were available for 119 patients from an initial group of 318. RESULTS: The consultation process was well accepted by patients and useful to general hospital physicians to complete the final diagnosis of the patient when discharged from hospital. In most cases (78.9%), the psychiatric letter was attached to the discharge letter. The second part of the questionnaire indicated that most patients were satisfied with the consultation process. They thought it helped focus their problems and 60% asserted that they felt better after following their psychiatrists' instructions or therapy. The primary care physicians agreed with the diagnostic results of the psychiatric consultation, mainly followed the psychiatrists' advice, and generally expressed positive comments about the consultation-liaison service. CONCLUSIONS: Compliance of hospital physicians, patients, and primary care physicians was good. Follow-up studies on outcome of psychiatric consultations are few and further analysis is strongly recommended.     

The patient, the doctor and the emergency department: a cross-sectional study of patient-centredness in 1990 and 2005

OBJECTIVE: To compare and contrast the duration and content of physician-patient interaction for patients presenting to an emergency department with problems of low acuity in 1990 and 2005 treated by different grades of physician. METHODS: Observational study with data collection in May-July 1990 and May-July 2005. Patients identified at nurse triage as presenting with 'primary care' problems were allocated by time of arrival to senior house officers (1990, n=7; 2005, n=10), specialist registrars/staff grades (1990, n=4; 2005, n=7) or sessionally employed general practitioners (1990, n=8; 2005, n=12) randomly rostered to work in a consulting room that had a wall-mounted video camera. A stratified sample of 430 video-taped consultations (180 (42%) from 1990 and 250 (58%) from 2005) was analysed using the Roter Interaction Analysis System. Main outcome measures -- length of consultation; numbers of utterances of physician and patient talk related to building a relationship, data gathering, activating/partnering (i.e. actively encouraging the patient's involvement in decision-making), and patient education/counselling. RESULTS: On average consultation length was 251s (95% CI for difference: 185-316) longer in 2005 than in 1990. The difference was especially marked for senior house officers (mean duration 385s in 1990 and 778s in 2005; 95% CI of difference: 286-518). All groups of physician showed increased communication related to activating and partnering and building a therapeutic relationship with the patient. While senior house officers demonstrated a greatly increased focus on data gathering, only general practitioners substantially increased the amount of talk centred on patient education and counselling; compared to senior house officers, the odds ratio for the number of such utterances included in consultations was 2.8 (95% CI: 1.4, 5.3). CONCLUSION: Although patient-centredness together with consultation length increased for all three physician groups over the duration of this study, senior house officers and specialist registrars/staff grades continued to place less emphasis on advice-giving and counselling than did general practitioners. The extent to which these observed changes in practice were determined by policy, management and training initiatives, and their impact on patient outcome, needs further study. PRACTICE IMPLICATIONS: Video-recording consultations is feasible in an acute hospital setting, and could be used to support training and workforce development. General practitioners can make a distinctive contribution to the workforce of emergency departments. Their consulting style differs from that of hospital physicians and may benefit patient care through a greater focus on patient education and counselling.     

Effects of a short text message reminder system on emergency department length of stay

PurposeSpecialty consultations and waiting for admission to a hospital bed are major contributors to increased length of stay and overcrowding in the emergency department. We implemented a computerized short messaging service to inform care providers of patient delay in order to reduce length of stay. The purpose of this study was to evaluate the effects of this strategy on length of stay in the emergency department.MethodsThis was a before-and-after observational study. Prior to this study, we registered the mobile phone numbers of all board certified specialists into a computerized physician order entry database and developed an auto-sending short messaging program linked to consultation orders. The short message was transmitted at 2 and 4 h after consultation, when a disposition was not yet established, and at 8 h after the admission order if the patient was still waiting. The length of stay of consulted patients and intervals such as consultation time (registration–consultation), disposition time (consultation–admission decision), and boarding time (admission decision–hospitalization) of admitted patients were compared between the pre-implementation (September 2009) and post-implementation period (November 2009). Subgroup analyses of disposition time were performed according to time of consultation and the number of consultations.ResultsA total of 7518 patients visited the emergency department during the pre-periods and post-periods. Among them, 3335 patients required specialty consultations. The median length of stay of consulted patients decreased significantly after implementation of the messaging system (pre-207 min vs. post-193 min, p < 0.001). Among admitted patients, the median length of stay decreased by 36 min from 294 min to 258 min (p < 0.001). In the subgroup analysis, times for establishing patient dispositions decreased significantly when the consultation was performed at night and when there was only one department consulted. The numbers of patients with disposition times within 2 and 4 h and boarding times within 8 h were all increased after implementation of the short message service program.ConclusionsThis study suggested that the computerized physician order entry-based short messaging service program, used to inform decision-makers of patient delay, could reduce the length of stay for consulted patients in the emergency department.