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.     

The comparative impact of video-consultation on neurosurgical health services

This study evaluated the impact of telemedicine technology on the provision of neurosurgical health services. We focused on the differences between the use of real time audio-visual teleconferencing and teleradiology versus conventional telephone consultations in the referral of neurosurgical patients from a large district general hospital. All patients requiring emergency neurosurgical consultation were included for randomization into telephone consultation only (Mode A), teleradiology and telephone consultation (Mode B) and video-consultation (Mode C). Measures of effectiveness included diagnostic accuracy and adverse events during the transfer and Glasgow Outcome Score. In a 10-month period, 327 patients were recruited and randomized into the study: the male/female ratio was 2:1 and the number of patients required to be transferred to the neurosurgical unit was 125 (38%). There was a trend towards a more favourable outcome in the video-consultation mode (44%, Mode C), versus teleradiology (31%, Mode B), versus telephone consultation (38%, Mode A). The interim data of this prospective randomized trial suggests that video-consultation may have a favourable impact on emergency neurosurgical consultations.     

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.     

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.     

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.     

Work,knowledge and argument in specialist consultations: Incorporating tacit knowledge into system design and development

To understand how video telephone technology could support consultations between pathologists and surgeons, this study looked at what constitutes ‘work’ in clinical consultations. Using several methods (participant observation, video and interviews), we found pathologists and surgeons both share and do not share similar understandings of what a consultation is, what one should achieve in a consultation, and what in fact constitutes a ‘successful’ consultation. Furthermore, the same objects of consultation (the products of ‘offstage’ work) can be used and defined quite differently depending on how a consultation is framed. Differences and disjunctions like these have to be better understood if computer-supported cooperative healthcare work (CSCHW) applications are to be adopted and accepted.     

Consultation length, patient-estimated consultation length, and satisfaction with the consultation.

Lack of time is a frequently expressed patient concern, but actual measured consultation length is often not associated with patient satisfaction. Correlational analysis of patients from nine GP practices was used to test the hypothesis that patients' perceptions of consultation length are influenced not just by actual consultation length, but by other aspects of their experience of consultations. The consultations of 160 patients were timed, and patients in subsequent interviews gave estimates of consultation duration and completed a satisfaction questionnaire. Consultations where patients were more satisfied appeared to patients to have lasted longer (partial correlation r = 0.26), but were not actually longer. Patient concerns about time may be as much about quality time as about actual time.     

Telephone change agentry in the diffusion of a program for the elderly

This study examined whether telephone consultation subsequent to a five-day workshop on a geriatric program, called milieu therapy, affected the degree to which the adoption of the program took place in nursing homes and hospitals. The nursing homes and hospitals were randomly assigned to three conditions: 1) no person receiving telephone consultation, 2) one person receiving consultation, and 3) three persons receiving consultation. Following the workshop, five consultations were conducted, one every two weeks. Three months after the last consultation a follow-up questionnaire was used to examine the extent of the program adoption. Results of the study indicated that telephone consultation did not create more information dissemination. However, the consultation with three persons 1) enhanced the inclusion of more staff in the planning groups, 2) supported low social status staff in taking leadership roles, and 3) included more staff from various work areas into the planning group. No significant difference could be found for the degree of actual program adoption that took place within the organizations.     

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.     

Deprivation, psychological distress, and consultation length in general practice.

BACKGROUND: Recent research has shown the benefits of longer consultations in general practice. Approximately 40% of patients presenting to general practitioners (GPs) are psychologically distressed. Studies have shown that psychological morbidity increases with increasing socioeconomic deprivation. The combined effects of psychological morbidity and socioeconomic deprivation on consultation length are unknown. In addition, though it is known that doctors correctly identify half their distressed patients as such, the effect of consultation length on identification is unknown. AIM: To examine factors associated with presentation and recognition of psychological distress in GPs' surgeries and the interaction of these factors with consultation length. DESIGN OF STUDY: A cross-sectional study. SETTING: Nine general practices in the West of Scotland, involving 1075 consultations of 21 full-time GPs. METHOD: The main outcome measures were patient psychological distress (measured by General Health Questionnaire-12), doctors' identification of psychological distress, consultation length, and Carstairs deprivation category scores. RESULTS: The mean consultation length was 8.71 minutes (SD = 4.40) and the prevalence of positive GHQ scores was 44.7%. Increasing GHQ (greater psychological distress) and lower deprivation category scores (greater affluence) were associated with longer consultations. Positive GHQ scoring increased with greater socioeconomic deprivation and also peaked in the 30 to 39 years age group. Recognition of psychological distress was greater in longer consultations (50% increase in consultation length associated with 32% increase in recognition). CONCLUSION: Increasing socioeconomic deprivation is associated with higher prevalence of psychological distress and shorter consultations. This provides further evidence to support Tudor Hart's 'inverse care law' and has implications for the resourcing of primary care in deprived areas.     

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.     

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.     

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.     

Exploring patient experiences in the student outpatient clinic - A contribution to learning

ObjectiveTo understand how patients experience participation in student encounters.MethodsQualitative semi-structured telephone interviews with ten cardiac surgery patients who had attended voluntary postoperative consultations in a student outpatient clinic. The interview guide included questions about reasons for and experiences of being part of a teaching situation. Interviews were analysed through inductive thematic analysis where pieces of text in each interview were assigned different codes and condensed into themes.ResultsThe patients expressed a duality in their reasons for participating in student consultations: (1) a personal need for assurance (safety) and (2) a wish to help students (altruism). Students were perceived as professional and sometimes insecure. Being part of an educational situation was meaningful to the patients because they did not feel objectified. Knowing that there was a backup supervisor made the patients feel safe even though the supervisor was not present during all parts of the consultation.ConclusionsPatients experienced safety, understood their role in all parts of the consultation, and shared a wish to help students learn.Practice implicationsA sequential consultation model alternating between student- and supervisor-driven supervision can balance student autonomy and patient safety. This knowledge could guide future patient-centred medical education in student clinics.     

Consultation rates in English general practice.

Methods of estimating the annual consulting rate per patient are reviewed. Methodological problems include the definition of consultations as opposed to problems encountered, the definition of population at risk, the reliability of data about home visits and the limitations of extrapolating data collected over a short period. Estimates of consultation rate are usually obtained from surveys which have other primary objectives. The annual consultation rate in 1981, excluding telephone contacts, was estimated at 3.5 consultations per patient. In spite of its limited sample size, the general household survey provides a reliable estimate of the national consulting rate. There is, however, a need to validate it against a survey covering a longer period in which consultation rates are measured and not just estimated from memory. The total workload of the 'average' doctor changed little between 1970 and 1981 in spite of reducing list size. Home visits accounted for approximately 15% of all consultations in 1981 and this value has been consistent over the period 1980-83.