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1.  Impact of telephone triage on emergency after hours GP Medicare usage: a time-series analysis 
Background
The Australian government sponsored trials aimed at addressing problems in after hours primary medical care service use in five different parts of the country with different after hours care problems. The study's objective was to determine in four of the five trials where telephone triage was the sole innovation, if there was a reduction in emergency GP after hours service utilization (GP first call-out) as measured in Medicare Benefits Schedule claim data. Monthly MBS claim data in both the pre-trial and trial periods was monitored over a 3-year period in each trial area as well as in a national sample outside the trial areas (National comparator). Poisson regression analysis was used in analysis.
Results
There was significant reduction in first call out MBS claims in three of the four study areas where stand-alone call centre services existed. These were the Statewide Call Centre in both its Metropolitan and Non-metropolitan areas in which it operated – Relative Risk (RR) = 0.87 (95% Confidence interval: 0.86 – 0.88) and 0.60 (95% CI: 0.54 – 0.68) respectively. There was also a reduction in the Regional Call Centre in the non-Metropolitan area in which it operated (RR = 0.46 (95% CI: 0.35 – 0.61) though a small increase in its Metropolitan area (RR = 1.11 (95% CI: 1.06 – 1.17). For the two telephone triage services embedded in existing organisations, there was also a significant reduction for the Deputising Service – RR = 0.62 (95% CI: 0.61 – 0.64) but no change in the Local Triage centre area.
Conclusion
The four telephone triage services were associated with reduced GP MBS claims for first callout after hours care in most study areas. It is possible that other factors could be responsible for some of this reduction, for example, MBS submitted claims for after hours GP services being reclassified from 'after hours' to 'in hours'. The goals of stand-alone call centres which are aimed principally at meeting population needs rather than managing demand may be being met only in part.
doi:10.1186/1743-8462-4-21
PMCID: PMC2151763  PMID: 17927836
2.  The effectiveness and cost-effectiveness of telephone triage of patients requesting same day consultations in general practice: study protocol for a cluster randomised controlled trial comparing nurse-led and GP-led management systems (ESTEEM) 
Trials  2013;14:4.
Background
Recent years have seen an increase in primary care workload, especially following the introduction of a new General Medical Services contract in 2004. Telephone triage and telephone consultation with patients seeking health care represent initiatives aimed at improving access to care. Some evidence suggests that such approaches may be feasible but conclusions regarding GP workload, cost, and patients’ experience of care, safety, and health status are equivocal. The ESTEEM trial aims to assess the clinical- and cost-effectiveness of nurse-led computer-supported telephone triage and GP-led telephone triage, compared to usual care, for patients requesting same-day consultations in general practice.
Methods/design
ESTEEM is a pragmatic, multi-centre cluster randomised clinical trial with patients randomised at practice level to usual care, computer decision-supported nurse triage, or GP-led triage. Following triage of 350–550 patients per practice we anticipate estimating and comparing total primary care workload (volume and time), the economic cost to the NHS, and patient experience of care, safety, and health status in the 4-week period following the index same-day consultation request across the three trial conditions.
We will recruit all patients seeking a non-emergency same-day appointment in primary care. Patients aged 12.0–15.9 years and temporary residents will be excluded from the study.
The primary outcome is the number of healthcare contacts taking place in the 4-week period following (and including) the index same-day consultation request. A range of secondary outcomes will be examined including patient flow, primary care NHS resource use, patients’ experience of care, safety, and health status.
The estimated sample size required is 3,751 patients (11,253 total) in each of the three trial conditions, to detect a mean difference of 0.36 consultations per patient in the four week follow-up period between either intervention group and usual care 90% power, 5% alpha, and an estimated intracluster correlation coefficient ICC of 0.05. The primary analysis will be based on the intention-to-treat principle and take the form of a random effects regression analysis taking account of the hierarchical nature of the study design. Statistical models will allow for adjustment for practice level minimisation variables and patient-level baseline covariates shown to differ at baseline.
Trial registration
Current Controlled Trials ISCRTN20687662
doi:10.1186/1745-6215-14-4
PMCID: PMC3574027  PMID: 23286331
Primary care; Telephone triage; Decision support; General practitioner; Nurse; Workload; Satisfaction; Cost-effectiveness; Cluster randomised controlled trial
3.  Mystery shopping in health service evaluation. 
BACKGROUND: Over the last 5 years, primary care telephone triage systems have been introduced in the United Kingdom, United States, Australia, and most recently in New Zealand. Evaluation of the clinical safety of such systems poses a challenge for health planners and researchers. AIM: To evaluate the use of simulated patients in the assessment of aspects of clinical safety in a pilot New Zealand primary care telephone triage service. DESIGN OF STUDY: 'Mystery shopping', an evaluation strategy commonly used in market research, was adapted by using simulated patients for telephone triage service evaluation. SETTING: New Zealand. METHODS: Four scripted clinical scenarios were developed by academic general practitioners, validated in student teaching situations, and then used by simulated patients to make 101 telephone calls. The scenarios were designed to necessitate a referral to a medical practitioner for further investigation. The documentation kept by the callers was compared with the call records from the telephone triage company, and both were analysed for capture and handling of the clinical safety features of each scenario. In cases where the endpoint was not a medical assessment, possible reasons for this were explored. RESULTS: Records were retrieved for 85 telephone calls. Considerable triage variability was discovered. There were discrepancies between expected and actual triage outcomes with 51% of analysed calls resulting in a self-care recommendation. A number of reasons were identified both for the triage variability and the unpredicted outcomes. Audiotaping of consultations would have enhanced the credibility of the evaluation but it would have carried ethical constraints. CONCLUSION: Simulated patients can be used to evaluate the limitations of health services and to identify areas that could be addressed to improve patient safety. Evaluation of patient satisfaction with services is not sufficient alone to evaluate safety.
PMCID: PMC1314747  PMID: 14960218
4.  Computer assisted assessment and advice for "non-serious" 999 ambulance service callers: the potential impact on ambulance despatch 
Emergency Medicine Journal : EMJ  2003;20(2):178-183.
Design: Pragmatic controlled trial. Calls identified using priority dispatch protocols as non-serious were allocated to intervention and control groups according to time of call. Ambulance dispatch occurred according to existing procedures. During intervention sessions, nurses or paramedics within the control room used a computerised decision support system to provide telephone assessment, triage and, if appropriate, offer advice to permit estimation of the potential impact on ambulance dispatch.
Setting: Ambulance services in London and the West Midlands.
Subjects: Patients for whom emergency calls were made to the ambulance services between April 1998 and May 1999 during four hour sessions sampled across all days of the week between 0700 and 2300.
Main outcome measures: Triage decision, ambulance cancellation, attendance at an emergency department.
Results: In total, there were 635 intervention calls and 611 controls. Of those in the intervention group, 330 (52.0%) were triaged as not requiring an emergency ambulance, and 119 (36.6%) of these did not attend an emergency department. This compares with 55 (18.1%) of those triaged by a nurse or paramedic as requiring an ambulance (odds ratio 2.62; 95% CI 1.78 to 3.85). Patients triaged as not requiring an emergency ambulance were less likely to be admitted to an inpatient bed (odds ratio 0.55; 95% CI 0.33 to 0.93), but even so 30 (9.2%) were admitted. Nurses were more likely than paramedics to triage calls into the groups classified as not requiring an ambulance. After controlling for age, case mix, time of day, day of week, season, and ambulance service, the results of a logistic regression analysis revealed that this difference was significant with an odds ratio for nurses:paramedics of 1.28 (95% CI 1.12 to 1.47).
Conclusions: The findings indicate that telephone assessment of Category C calls identifies patients who are less likely to require emergency department care and that this could have a significant impact on emergency ambulance dispatch rates. Nurses were more likely than paramedics to assess calls as requiring an alternative response to emergency ambulance despatch, but the extent to which this relates to aspects of training and professional perspective is unclear. However, consideration should be given to the acceptability, reliability, and cost consequences of this intervention before it can be recommended for full evaluation.
doi:10.1136/emj.20.2.178
PMCID: PMC1726071  PMID: 12642540
5.  Impact of the urgent care telephone service NHS 111 pilot sites: a controlled before and after study 
BMJ Open  2013;3(11):e003451.
Objectives
To measure the impact of the urgent care telephone service NHS 111 on the emergency and urgent care system.
Design
Controlled before and after study using routine data.
Setting
Four pilot sites and three control sites covering a total population of 3.6 million in England, UK.
Participants and data
Routine data on 36 months of use of emergency ambulance service calls and incidents, emergency department attendances, urgent care contacts (general practice (GP) out of hours, walk in and urgent care centres) and calls to the telephone triage service NHS direct.
Intervention
NHS 111, a new 24 h 7 day a week telephone service for non-emergency health problems, operated by trained non-clinical call handlers with clinical support from nurse advisors, using NHS Pathways software to triage calls to different services and home care.
Main outcomes
Changes in use of emergency and urgent care services.
Results
NHS 111 triaged 277 163 calls in the first year of operation for a population of 1.8 million. There was no change overall in emergency ambulance calls, emergency department attendances or urgent care use. There was a 19.3% reduction in calls to NHS Direct (95% CI −24.6% to −14.0%) and a 2.9% increase in emergency ambulance incidents (95% CI 1.0% to 4.8%). There was an increase in activity overall in the emergency and urgent care system in each site ranging 4.7–12%/month and this remained when assuming that NHS 111 will eventually take all NHS Direct and GP out of hours calls.
Conclusions
In its first year of operation in four pilot sites NHS 111 did not deliver the expected system benefits of reducing calls to the 999 ambulance service or shifting patients to urgent rather than emergency care. There is potential that this type of service increases overall demand for urgent care.
doi:10.1136/bmjopen-2013-003451
PMCID: PMC3831104  PMID: 24231457
ACCIDENT & EMERGENCY MEDICINE
6.  ParaMED Home: A protocol for a randomised controlled trial of paramedic assessment and referral to access medical care at home 
Abstract
Background
In Australia approximately 25% of Emergency Department (ED) attendances are via ambulance. ED overcrowding in Australia, as in many countries, is common. Measures to reduce overcrowding include the provision of enhanced timely primary care in the community for appropriate low risk injury and illness. Therefore paramedic assessment and referral to a community home hospital service, in preference to transfer to ED, may confer clinical and cost benefit.
Methods/Design
A randomised controlled trial. Consenting adult patients that call an ambulance and are assessed by paramedics as having an eligible low risk problem will be randomised to referral to ED via ambulance transfer or referral to a rapid response service that will assess and treat the patient in their own residence. The primary outcome measure is requirement for unplanned medical attention (in or out of hospital) in the first 48 hours. Secondary outcomes will include a number of other clinical endpoints. A cost effectiveness analysis will be conducted.
Discussion
If this trial demonstrates clinical non-inferiority and cost savings associated with the primary assessment service, it will provide one means to safely address ED overcrowding.
Trial Registration
Australian and New Zealand Clinical Trials Registry Number 12610001064099
doi:10.1186/1471-227X-11-7
PMCID: PMC3126720  PMID: 21649935
7.  Future provision of out of hours primary medical care: a survey with two general practitioner research networks. 
BMJ : British Medical Journal  1996;312(7027):352-356.
OBJECTIVE--To ascertain general practitioners' views about the future provision of out of hours primary medical care. DESIGN--Self completing postal questionnaire survey. SETTING--Wessex and north east England. SUBJECTS--116 general practitioners in the Wessex Primary Care Research Network and 83 in the Northern Primary Care Research Network. MAIN OUTCOME MEASURES--Intention to reduce or opt out of on call; plans for changing out of hours arrangements; the three most important changes needed to out of hours care; willingness to try, and perceived strengths and limitations of, three alternative out of hours care models--primary care emergency centres, telephone triage services, and cooperatives. RESULTS--The overall response rate was 74% (Wessex research network 77% (89/116), northern research network 71% (59/83)). Eighty three per cent of respondents (123/148) were willing to try at least one service model, primary care emergency centres being the most popular option. Key considerations were the potential for a model to reduce time on call and workload, to maintain continuity of care, and to fit the practice context. Sixty one per cent (91/148) hoped to reduce time on call and 25% (37/148) hoped to opt out completely. CONCLUSIONS--General practitioners were keen to try alternative arrangements for out of hours care delivery, despite the lack of formal trials. The increased flexibility in funding brought about by the recent agreement between the General Medical Services Committee and the Department of Health is likely to lead to a proliferation of different schemes. Careful monitoring will be necessary, and formal trials of new service models are needed urgently.
PMCID: PMC2350256  PMID: 8611835
8.  Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs 
BMJ : British Medical Journal  2002;325(7374):1214.
Objective
To compare the workloads of general practitioners and nurses and costs of patient care for nurse telephone triage and standard management of requests for same day appointments in routine primary care.
Design
Multiple interrupted time series using sequential introduction of experimental triage system in different sites with repeated measures taken one week in every month for 12 months.
Setting
Three primary care sites in York.
Participants
4685 patients: 1233 in standard management, 3452 in the triage system. All patients requesting same day appointments during study weeks were included in the trial.
Main outcome measures
Type of consultation (telephone, appointment, or visit), time taken for consultation, presenting complaints, use of services during the month after same day contact, and costs of drugs and same day, follow up, and emergency care.
Results
The triage system reduced appointments with general practitioner by 29-44%. Compared with standard management, the triage system had a relative risk (95% confidence interval) of 0.85 (0.72 to 1.00) for home visits, 2.41 (2.08 to 2.80) for telephone care, and 3.79 (3.21 to 4.48) for nurse care. Mean overall time in the triage system was 1.70 minutes longer, but mean general practitioner time was reduced by 2.45 minutes. Routine appointments and nursing time increased, as did out of hours and accident and emergency attendance. Costs did not differ significantly between standard management and triage: mean difference £1.48 more per patient for triage (95% confidence interval –0.19 to 3.15).
Conclusions
Triage reduced the number of same day appointments with general practitioners but resulted in busier routine surgeries, increased nursing time, and a small but significant increase in out of hours and accident and emergency attendance. Consequently, triage does not reduce overall costs per patient for managing same day appointments.
What is already known on this topicNurse telephone triage is used to manage the increasing demand for same day appointments in general practiceEvidence that nurse telephone triage is effective is limitedWhat this study addsTriage resulted in 29-44% fewer same day appointments with general practitioners than standard managementNursing and overall time increased in the triage group as 40% of patients were managed by nursesTriage was not less costly than standard management because of increased costs for nursing, follow up, out of hours, and accident and emergency care
PMCID: PMC135495  PMID: 12446539
9.  From Doctor to Nurse Triage in the Danish Out-of-Hours Primary Care Service: Simulated Effects on Costs 
Introduction. General practitioners (GP) answer calls to the Danish out-of-hours primary care service (OOH) in Denmark, and this is a subject of discussions about quality and cost-effectiveness. The aim of this study was to estimate changes in fee costs if nurses substituted the GPs. Methods. We applied experiences from The Netherlands on nurse performance in the OOH triage concerning the number of calls per hour. Using the 2011 number of calls in one region, we examined three hypothetical scenarios with nurse triage and calculated the differences in fee costs. Results. A new organisation with 97 employed nurses would be needed. Fewer telephone consultations may result in an increase of face-to-face contacts, resulting in an increase of 23.6% in costs fees. Under optimal circumstances (e.g., a lower demand for OOH services, a high telephone termination rate, and unchanged GP fees) the costs could be reduced by 26.2% though excluding administrative costs of a new organisation. Conclusion. Substituting GPs with nurses in OOH primary care may increase the cost in fees compared to a model with only GPs. Further research is needed involving more influencing factors, such as costs due to nurse training and running the organisation.
doi:10.1155/2013/987834
PMCID: PMC3806230  PMID: 24194984
10.  Exploring users' experiences of accessing out‐of‐hours primary medical care services 
Quality & Safety in Health Care  2007;16(6):469-477.
Background
Since 2000, out‐of‐hours primary medical care services in the UK have undergone major changes in the organisation and delivery of services in response to recommendations by the Carson Review and more recently, through the new General Medical Services Contract (GMS2). People calling their general practice in the evening or at weekends are redirected to the out‐of‐hours service which may offer telephone advice, a home visit or a visit to a treatment centre. Little is known about users' experiences under the new arrangements.
Aim
To explore users' experiences of out‐of‐hours primary medical care.
Design of study
A qualitative study employing focus groups and telephone interviews.
Setting
Three out‐of‐hours primary medical care service providers in England.
Methods
Focus groups and telephone interviews were conducted with 27 recent users of out‐of‐hours services.
Results
Key areas of concern included the urgency with which cases are handled, and delays when waiting for a call back or home visit. Users felt that providers were reluctant to do home visits. The service was regarded as under‐resourced and frequently misused. Many expressed anxiety about calling, feeling unsure about how appropriate their call was and many were uncertain about how the service operated.
Conclusions
Service users need clear information on how current out‐of‐hours services operate and how it should be used. Problems with triaging need to be addressed, users should be kept informed of any delays, and care needs to be taken to ensure that the new arrangements do not alienate older people or individuals with complex health needs.
doi:10.1136/qshc.2006.021501
PMCID: PMC2653185  PMID: 18055893
11.  Safety of telephone triage in out-of-hours care: A systematic review 
Objective
Telephone triage in patients requesting help may compromise patient safety, particularly if urgency is underestimated and the patient is not seen by a physician. The aim was to assess the research evidence on safety of telephone triage in out-of-hours primary care.
Methods
A systematic review was performed of published research on telephone triage in out-of-hours care, searching in PubMed and EMBASE up to March 2010. Studies were included if they concerned out-of-hours medical care and focused on telephone triage in patients with a first request for help. Study inclusion and data extraction were performed by two researchers independently. Post-hoc two types of studies were distinguished: observational studies in contacts with real patients (unselected and highly urgent contacts), and prospective observational studies using high-risk simulated patients (with a highly urgent health problem).
Results
Thirteen observational studies showed that on average triage was safe in 97% (95% CI 96.5–97.4%) of all patients contacting out-of-hours care and in 89% (95% CI 86.7–90.2%) of patients with high urgency. Ten studies that used high-risk simulated patients showed that on average 46% (95% CI 42.7–49.8%) were safe. Adverse events described in the studies included mortality (n = 6 studies), hospitalisations (n = 5), attendance at emergency department (n=1), and medical errors (n = 6).
Conclusions
There is room for improvement in safety of telephone triage in patients who present symptoms that are high risk. As these have a low incidence, recognition of these calls poses a challenge to health care providers in daily practice.
doi:10.3109/02813432.2011.629150
PMCID: PMC3308461  PMID: 22126218
After-hours care; emergency medical services; primary health care; safety; telephone; triage
12.  NHS Direct versus general practice based triage for same day appointments in primary care: cluster randomised controlled trial 
BMJ : British Medical Journal  2004;329(7469):774.
Objective To assess the relative effects on consultation workload and costs of off-site triage by NHS Direct for patients requesting same day appointments compared with usual on-site nurse telephone triage in general practice.
Design Cluster randomised controlled trial.
Setting Three primary care sites in York, England.
Participants 4703 patients: 2452 with practice based triage, 2251 with NHS Direct triage. All consecutive patients making requests for same day appointments during study weeks were eligible for the trial.
Main outcome measures Type of consultation after request for same day appointment (telephone, appointment, or visit); time taken for consultation; service use during the month after same day contact; costs of same day, follow up, and emergency care.
Results Patients in the NHS Direct group were less likely to have their call resolved by a nurse and were more likely to have an appointment with a general practitioner. Mean total time per patient in the NHS Direct group was 7.62 minutes longer than in the practice based group. Costs were greater in the NHS Direct group—£2.88 (£0.88 to £4.87) per patient triaged—as a result of the difference between the groups in proportions of patients at each final point contact after triage.
Conclusions External management of requests for same day appointments by nurse telephone triage through NHS Direct is possible but comes at a higher cost than practice nurse delivered triage in primary care. If NHS Direct could achieve the same proportions of consultation types as practice based triage, costs would be comparable.
doi:10.1136/bmj.38226.605995.55
PMCID: PMC520999  PMID: 15377574
13.  Safety of telephone consultation for "non-serious" emergency ambulance service patients 
Quality & safety in health care  2004;13(5):363-373.
Objective: To assess the safety of nurses and paramedics offering telephone assessment, triage, and advice as an alternative to immediate ambulance despatch for emergency ambulance service callers classified by lay call takers as presenting with "non-serious" problems (category C calls).
Design: Data for this study were collected as part of a pragmatic randomised controlled trial reported elsewhere. The intervention arm of the trial comprised nurse or paramedic telephone consultation using a computerised decision support system to assess, triage, and advise patients whose calls to the emergency ambulance service had been classified as "non-serious" by call takers applying standard priority despatch criteria. A multidisciplinary expert clinical panel reviewed data from ambulance service, accident and emergency department, hospital inpatient and general practice records, and call transcripts for patients triaged by nurses and paramedics into categories that indicated that despatch of an emergency ambulance was unnecessary. All cases for which one or more members of the panel rated that an emergency ambulance should have been despatched were re-reviewed by the entire panel for an assessment of the "life risk" that might have resulted.
Setting: Ambulance services in London and the West Midlands, UK.
Study population: Of 635 category C patients assessed by nurses and paramedics, 330 (52%) cases that had been triaged as not requiring an emergency ambulance were identified.
Main outcome measures: Assessment of safety of triage decisions.
Results: Sufficient data were available from the routine clinical records of 239 (72%) subjects to allow review by the specialist panel. For 231 (96.7%) sets of case notes reviewed, the majority of the panel concurred with the nurses' or paramedics' triage decision. Following secondary review of the records of the remaining eight patients, only two were rated by the majority as having required an emergency ambulance within 14 minutes. For neither of these did a majority of the panel consider that the patient would have been at "life risk" without an emergency ambulance being immediately despatched. However, the transcripts of these two calls indicated that the correct triage decision had been communicated to the patient, which suggests that the triage decision had been incorrectly entered into the decision support system.
Conclusions: Telephone advice may be a safe method of managing many category C callers to 999 ambulance services. A clinical trial of the full implementation of this intervention is needed, large enough to exclude the possibility of rare adverse events.
doi:10.1136/qshc.2003.008003
PMCID: PMC1743899  PMID: 15465940
14.  Patient And phaRmacist Telephonic Encounters (PARTE) in an underserved rural population with asthma: methods and rationale 
Innovations in pharmacy  2011;2(3):49-.
Purpose
Methods used to deliver and test a pharmacy-based asthma care telephonic service for an underserved, rural patient population are described.
Summary
In a randomized controlled trial (RCT), the Patient And phaRmacist Telephonic Encounters (PARTE) project is assessing the feasibility, acceptability, and preliminary impact of providing pharmacy-based asthma care service telephonically. The target audience is a low income patient population across a large geographic area served by a federally qualified community health center. Ninety-eight participants have been randomized to either standard care or the intervention group who received consultation and direct feedback from pharmacists via telephone regarding their asthma self-management and medication use. Pharmacists used a counseling framework that incorporates the Indian Health Services 3 Prime Questions and the RIM Technique (Recognition, Identification, and Management) for managing medication use problems. Pharmacists encouraged patients to be active partners in the decision-making process to identify and address the underlying cause of medication use problems. Uniquely, this trial collected process and summative data using qualitative and quantitative approaches. Pharmacists’ training, the fidelity and quality of pharmacists’ service delivery, and short term patient outcomes are being evaluated. This evaluation will improve our ability to address research challenges and intervention barriers, refine staff training, explore patient perspectives, and evaluate measures’ power to provide preliminary patient outcome findings.
Conclusion
A mixed method evaluation of a structured pharmacist intervention has the potential to offer insights regarding staff training, service fidelity and short term outcomes using quantitative and qualitative data in an RCT. Results will provide evidence regarding the feasibility and quality of carrying out the study and service delivery from the multiple perspectives of participants, clinicians, and researchers.
PMCID: PMC3711922  PMID: 23864987
patient-pharmacist communication; asthma; telepharmacy
15.  Creating a shared vision of out of hours care: using rapid appraisal methods to create an interagency, community oriented, approach to service development. 
BMJ : British Medical Journal  1996;312(7040):1206-1210.
OBJECTIVES--To undertake a district wide review of out of hours primary health care services and identify the views of users and providers about current arrangements and options for development. DESIGN--A range of qualitative and quantitative survey methods based on rapid appraisal methods, modified to apply to an inner city district. SETTING--Socially deprived, multiethnic district in south east London with a population of over 700,000. MAIN OUTCOME MEASURES--Strengths and weaknesses of current out of hours services and suggestions for developments. RESULTS--Widespread dissatisfaction with current arrangements was identified, with specific problems relating to access, availability, demand for services, and interagency communication. Several areas for development were identified, including the establishment of an out of hours cooperative, multiagency primary care emergency centres, and telephone advice-triage. Many of these are now being planned or piloted. CONCLUSIONS--Rapid appraisal provided a helpful method, enabling partnerships to be established between local agencies and users in relation to service development. The shared understanding and commitment to improving services that resulted is now having a major impact on out of hours care in the district.
Images
PMCID: PMC2350982  PMID: 8634567
16.  Availability and utilisation of physician-based pre-hospital critical care support to the NHS ambulance service in England, Wales and Northern Ireland 
Emergency Medicine Journal : EMJ  2011;29(3):177-181.
Background
Every day throughout the UK, ambulance services seek medical assistance in providing critically ill or injured patients with pre-hospital care.
Objective
To identify the current availability and utilisation of physician-based pre-hospital critical care capability across England, Wales and Northern Ireland.
Design
A postal and telephone survey was undertaken between April and December 2009 of all 13 regional NHS ambulance services, 17 air ambulance charities, 34 organisations affiliated to the British Association for Immediate Care and 215 type 1 emergency departments in England, Wales and Northern Ireland. The survey focused on the availability and use of physician-based pre-hospital critical care support.
Results
The response rate was 100%. Although nine NHS ambulance services recorded physician attendance at 6155 incidents, few could quantify doctor availability and utilisation. All but one of the British Association for Immediate Care organisations deployed ‘only when available’ and only 45% of active doctors could provide critical care support. Eleven air ambulance services (65%) operated with a doctor but only 5 (29%) operated 7 days a week. Fifty-nine EDs (27%) had a pre-hospital team but only 5 (2%) had 24 h deployable critical care capability and none were used regularly.
Conclusion
There is wide geographical and diurnal variability in availability and utilisation of physician-based pre-hospital critical care support. Only London ambulance service has access to NHS-commissioned 24 h physician-based pre-hospital critical care support. Throughout the rest of the UK, extensive use is made of volunteer doctors and charity sector providers of varying availability and capability.
doi:10.1136/emj.2010.106963
PMCID: PMC3282040  PMID: 21427108
Major incidents; prehospital care; prehospital care; critical care transport, prehospital care, doctors in PHC
17.  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.
PMCID: PMC1570504  PMID: 16378566
consultation; hotlines; review, systematic; telephone; triage
18.  Referrals to chiropractors and osteopaths: a survey of general practitioners in rural and regional New South Wales, Australia 
Background
Chiropractic and osteopathy form a significant part of the healthcare setting in rural and regional Australia, with national registration of practitioners, public subsidies for services and high utilisation by the Australian public. However, despite their significant role in rural and regional Australia, there has been little exploration of the interface between chiropractic and osteopathy and conventional primary health care practitioners in this area. The study aim was to examine the referral practices and factors that underlie referral to chiropractors and osteopaths by rural and regional Australian general practitioners (GPs), by drawing on a sample of GPs in rural and regional New South Wales.
Methods
A 27-item questionnaire was sent to all 1486 GPs currently practising in rural and regional Divisions of General Practice in New South Wales, Australia.
Results
A total of 585 GPs responded to the questionnaire, with 49 questionnaires returned as “no longer at this address” (response rate: 40.7%). The majority of GPs (64.1%) referred to a chiropractor or osteopath at least a few times per year while 21.7% stated that they would not refer to a chiropractor or osteopath under any circumstances. Patients asking the GP about CAM (OR=3.59; CI: 1.12, 11.55), GP’s use of CAM practitioners as a major source of information (OR=4.39; 95% CI: 2.04, 9.41), lack of other treatment options (OR=2.41; 95% CI: 1.18, 5.12), access to a wide variety of medical specialists (OR=12.5; 95% CI: 2.4, 50.0), GP’s belief in the efficacy of chiropractic and osteopathy services (OR=3.39; 95% CI: 2.19, 5.25) and experiencing positive results from patients using these services previously (OR=1.67; CI: 1.02, 2.75) were all independently predictive of increased referral to chiropractic and osteopathy services amongst the rural GPs.
Conclusions
There is a significant interface between chiropractic and osteopathy and Australian rural and regional general practice in New South Wales. Although there is generally high support for chiropractic and osteopathy among Australian GPs, this was not absolute and the heterogeneity of responses suggests that there remain tensions between the professions. The significant interface between chiropractic and osteopathy may be due in part to the inclusion of these professions in the publicly subsidised national healthcare delivery scheme. The significant impact of chiropractic and osteopathy and general practice in rural and regional Australian healthcare delivery should serve as an impetus for increased research into chiropractic and osteopathy practice, policy and regulation in these areas.
doi:10.1186/2045-709X-21-5
PMCID: PMC3599860  PMID: 23369205
Chiropractic; Osteopathy; General practice; Rural healthcare; Health services; Referral; Interdisciplinary care; Primary care
19.  Out-of-hours palliative care: a qualitative study of cancer patients, carers and professionals 
Background
New out-of-hours healthcare services in the UK are intended to offer simple, convenient access and effective triage. They may be unsatisfactory for patients with complex needs, where continuity of care is important.
Aim
To explore the experiences and perceptions of out-of-hours care of patients with advanced cancer, and with their informal and professional carers.
Design of study
Qualitative, community-based study using in-depth interviews, focus groups and telephone interviews.
Setting
Urban, semi-urban and rural communities in three areas of Scotland.
Method
Interviews with 36 patients with advanced cancer who had recently used out-of-hours services, and/or their carers, with eight focus groups with patients and carers and 50 telephone interviews with the patient's GP and other key professionals.
Results
Patients and carers had difficulty deciding whether to call out-of-hours services, due to anxiety about the legitimacy of need, reluctance to bother the doctor, and perceptions of triage as blocking access to care and out-of-hours care as impersonal. Positive experiences related to effective planning, particularly transfer of information, and empathic responses from staff. Professionals expressed concern about delivering good palliative care within the constraints of a generic acute service, and problems accessing other health and social care services.
Conclusions
Service configuration and access to care is based predominantly on acute illness situations and biomedical criteria. These do not take account of the complex needs associated with palliative and end-of-life care. Specific arrangements are needed to ensure that appropriately resourced and integrated out-of-hours care is made accessible to such patient groups.
PMCID: PMC1821404  PMID: 16438809
palliative care; cancer care; out-of-hours medical care; qualitative research; primary health care
20.  Death of an infant after contacting a telephone triage call centre: is telephone triage really safe? 
BMJ Case Reports  2010;2010:bcr0820092144.
The death of a previously well 13-month-old infant approximately 5 h after his mother contacted the Queensland Nurse led telephone triage call centre ‘13Health’ for advice is the first Australian casualty of telephone triage. Experience from this case and another ‘near miss’ incident Australia highlight the potential of this model of care to harm patients using the service when it attempts to provide health advice compared with health information.
doi:10.1136/bcr.08.2009.2144
PMCID: PMC3027892  PMID: 22802265
21.  Use of health services by remote dwelling Aboriginal infants in tropical northern Australia: a retrospective cohort study 
BMC Pediatrics  2012;12:19.
Background
Australia is a wealthy developed country. However, there are significant disparities in health outcomes for Aboriginal infants compared with other Australian infants. Health outcomes tend to be worse for those living in remote areas. Little is known about the health service utilisation patterns of remote dwelling Aboriginal infants. This study describes health service utilisation patterns at the primary and referral level by remote dwelling Aboriginal infants from northern Australia.
Results
Data on 413 infants were analysed. Following birth, one third of infants were admitted to the regional hospital neonatal nursery, primarily for preterm birth. Once home, most (98%) health service utilisation occurred at the remote primary health centre, infants presented to the centre about once a fortnight (mean 28 presentations per year, 95%CI 26.4-30.0). Half of the presentations were for new problems, most commonly for respiratory, skin and gastrointestinal symptoms. Remaining presentations were for reviews or routine health service provision. By one year of age 59% of infants were admitted to hospital at least once, the rate of hospitalisation per infant year was 1.1 (95%CI 0.9-1.2).
Conclusions
The hospitalisation rate is high and admissions commence early in life, visits to the remote primary health centre are frequent. Half of all presentations are for new problems. These findings have important implications for health service planning and delivery to remote dwelling Aboriginal families.
doi:10.1186/1471-2431-12-19
PMCID: PMC3384247  PMID: 22373262
22.  The impact of population-based disease management services for selected chronic conditions: the Costs to Australian Private Insurance - Coaching Health (CAPICHe) study protocol 
BMC Public Health  2012;12:114.
Background
Recent evidence from a large scale trial conducted in the United States indicates that enhancing shared decision-making and improving knowledge, self-management, and provider communication skills to at-risk patients can reduce health costs and utilisation of healthcare resources. Although this trial has provided a significant advancement in the evidence base for disease management programs it is still left for such results to be replicated and/or generalised for populations in other countries and other healthcare environments. This trial responds to the limited analyses on the effectiveness of providing chronic disease management services through telephone health coaching in Australia. The size of this trial and it's assessment of cost utility with respect to potentially preventable hospitalisations adds significantly to the body of knowledge to support policy and investment decisions in Australia as well as to the international debate regarding the effect of disease management programs on financial outcomes.
Methods
Intention to treat study applying a prospective randomised design comparing usual care with extensive outreach to encourage use of telephone health coaching for those people identified from a risk scoring algorithm as having a higher likelihood of future health costs. The trial population has been limited to people with one or more of the following selected chronic conditions: namely, low back pain, diabetes, coronary artery disease, heart failure, and chronic obstructive pulmonary disease. This trial will enrol at least 64,835 sourced from the approximately 3 million Bupa Australia private health insured members located across Australia. The primary outcome will be the total (non-maternity) cost per member as reported to the private health insurer (i.e. charged to the insurer) 12 months following entry into the trial for each person. Study recruitment will be completed in early 2012 and the results will be available in late 2013.
Discussion
If positive, CAPICHe will represent a potentially cost-effective strategy to improve health outcomes in higher risk individuals with a chronic condition, in a private health insurance setting.
Trial Registration
Australian New Zealand Clinical Trials Registry reference: ACTRN12611000580976
doi:10.1186/1471-2458-12-114
PMCID: PMC3306732  PMID: 22325668
23.  Predictors of podiatry utilisation in Australia: the North West Adelaide Health Study 
Background
Foot problems are highly prevalent in the community; however no large population-based studies have examined the characteristics of those who do and do not access podiatry services in Australia. The aim of this study was to explore patterns of podiatry utilisation in a population-based sample of people aged 18 years and over living in the northwest region of Adelaide, South Australia.
Methods
The North West Adelaide Health Study is a representative longitudinal cohort study of 4,060 people randomly selected and recruited by telephone interview. The interview included questions regarding healthcare service utilisation in the past year. Data were also collected on education, income and major medical conditions.
Results
Overall, 9.5% of the total sample and 17.7% of those who reported foot pain had attended a podiatrist in the past year. Participants who had accessed podiatry treatment were more likely to be female, be aged over 45 years, be obese, and have major chronic medical conditions (osteoporosis, osteoarthritis, diabetes, cardiovascular disease and high blood pressure). Those who reported foot pain but had not accessed a podiatrist were more likely to be male and be aged 20 to 34 years.
Conclusion
Only a small proportion of people who report foot pain have accessed podiatry services in the past year. There is a need to further promote podiatry services to the general community, particularly to men and younger people.
doi:10.1186/1757-1146-1-8
PMCID: PMC2553780  PMID: 18822163
24.  Access to general practitioner services amongst underserved Australians: a microsimulation study 
Background
One group often identified as having low socioeconomic status, those living in remote or rural areas, are often recognised as bearing an unequal burden of illness in society. This paper aims to examine equity of utilisation of general practitioner services in Australia.
Methods
Using the 2005 National Health Survey undertaken by the Australian Bureau of Statistics, a microsimulation model was developed to determine the distribution of GP services that would occur if all Australians had equal utilisation of health services relative to need.
Results
It was estimated that those who are unemployed would experience a 19% increase in GP services. Persons residing in regional areas would receive about 5.7 million additional GP visits per year if they had the same access to care as Australians residing in major cities. This would be a 18% increase. There would be a 20% increase for inner regional residents and a 14% increase for residents of more remote regional areas. Overall there would be a 5% increase in GP visits nationally if those in regional areas had the same access to care as those in major cities.
Conclusion
Parity is an insufficient goal and disadvantaged persons and underserved areas require greater access to health services than the well served metropolitan areas due to their greater poverty and poorer health status. Currently underserved Australians suffer a double disadvantage: poorer health and poorer access to health services.
doi:10.1186/1478-4491-10-1
PMCID: PMC3292913  PMID: 22264385
25.  Streamline triage and manage user expectations: lessons from a qualitative study of GP out-of-hours services 
Background
Several models of GP out-of-hours provision exist in the UK but there is little detail about their effectiveness to meet users' needs and expectations.
Aim
To explore users' needs, expectations, and experiences of out-of-hours care, and to identify proposals for service redesign.
Setting
Service providers in urban (GP cooperative), mixed (hospital based), rural (private) locations in Wales.
Participants
Sixty recent service users or carers (20 in each location).
Method
Semi-structured telephone interviews; thematic analysis.
Results
Users' concerns were generally consistent across the three different services. Efficiency was a major concern, with repetitive triage procedures and long time delays at various stages in the process being problematic. Access to a doctor when required was also important to users, who perceived an obstructive gatekeeping function of preliminary contacts. Expectations moderated the relationship between user concerns and satisfaction. Where expectations of outcome were unfulfilled, participants reported greater likelihood of reconsulting with the same or alternative services for the same illness episode. Accurate expectations concerning contacts with the next administrative, nursing, or medical staff professional were managed by appropriate information provision.
Conclusion
Users require more streamlined and flexible triage systems. Their expectations need to be understood and incorporated into how services advise and provide services for users, and actively managed to meet the aims of both enhancing satisfaction and enabling users to cope with their condition. Better information and education about services are needed if users are to derive the greatest benefit and satisfaction. This may influence choices about using the most appropriate forms of care.
doi:10.3399/bjgp10X483490
PMCID: PMC2828862  PMID: 20202350
out-of-hours medical care; family medicine; qualitative evaluation

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