Primary care

Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs

David A Richards, senior lecturer ^a, Joan Meakins, general practitioner ^b, Jane Tawfik, nursing team leader ^b, Lesley Godfrey, general practitioner ^b, Evelyn Dutton, research administrator ^b, Gerald Richardson, research fellow ^c, Daphne Russell, lecturer ^d. 

^a School of Nursing, Midwifery and Health Visiting, University of Manchester, Manchester M13 9PL, ^b Priory Medical Group, Rawcliffe Surgery, York YO30 6ND, ^c Centre for Health Economics, University of York, York YO1 5DD, ^d Department of Health Sciences, University of York

Correspondence to: D A Richards David.Richards{at}man.ac.uk

	Abstract

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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 topic Nurse telephone triage is used to manage the increasing demand for same day appointments in general practice Evidence that nurse telephone triage is effective is limited What this study adds Triage resulted in 29-44% fewer same day appointments with general practitioners than standard management Nursing and overall time increased in the triage group as 40% of patients were managed by nurses Triage was not less costly than standard management because of increased costs for nursing, follow up, out of hours, and accident and emergency care

	Introduction

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Changes in the delivery of primary care¹ have led to an increase in workload.² Much of this workload is accounted for by requests for same day appointments (urgent appointments),³ home visits,⁴ and out of hours calls. ^{5 6} Studies of the effect of triage on workload have been small and had a restricted focus (for example, calls in the morning only,³ out of hours,⁷ and home visit requests received before 10 30 am⁴). Triage has been reported to reduce general practitioners' same day activity by between 25% and 49%, ^{3 4 7} but only one small study examined use of services after triage. This study found an increased rate of return to the practice within the first week after triage.³

We are not aware of any studies of comprehensive nurse telephone triage systems for patients requesting same day appointments during working hours or of any studies examining the costs of such services in routine practice. We investigated the effect on general practitioner and nurse workloads and cost of patient care of nurse telephone triage and standard appointment management systemsboth operating routinely in primary care.

	Participants and methods

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The study took place in a large general practice in York. The practice had five surgery sites in inner city York, a list size of 25 000, 16 general practitioners (nine full time, four part time, two retainers, and one registrar), and a nursing team consisting of one full time nurse team leader and seven practice nurses (whole time equivalents 3.3). The practice population had a slightly poorer standardised mortality ratio, higher unemployment, and more pensionable residents than the regional average. Three of the practice's surgery sites participated in the study, giving a total study population of 20 800.

Design
We entered all consecutive patients requesting same day appointments into the trial using the broadest possible inclusion criteria. At each study site for one week in each of three consecutive months, all patients requesting same day appointments entered the trial and were managed by the standard management system. The triage system was then introduced, data being collected on patients for one week in each of the next nine months. Surgery sites entered the study sequentially at three monthly intervals. All patients requesting same day contact between 8 30 am and 5 pm during data collection weeks were eligible. There is more about our trial's design on bmj.com.

	Interventions

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In both systems, patients requesting a same day appointment were offered a routine appointment by receptionists, who were instructed not to attempt any triage. If patients continued to request a same day appointment the following procedures applied:

Standard managementPatients requesting same day appointments were fitted into extra general practitioner appointments at the end of each surgery by receptionists. Occasionally, general practitioners took telephone calls and practice nurses saw some patients on an ad hoc basis.

Triage systemReceptionists passed on requests for same day appointments to six experienced practice nurses who had received 30 hours of minor illness management training and were supported by computerised management protocols developed by the practice. Nurses assessed and managed the call through telephone advice only, a same day nurse appointment, a same day general practitioner appointment, a home visit, or a routine nurse or general practitioner appointment.

Measures
We collected data on all requests for same day appointments for one week in every month. The information recorded included the type of consultation (telephone, appointment, or visit), the time taken for the consultation, up to three presenting complaints per patient (chosen from 10 categories), and up to three clinical decisions made during the consultation (chosen from 13 categoriesfor example, prescription, advice, or type of onward referral). We checked and validated recorded data against clinical notes in the electronic patient record. We also used the electronic patient record to determine demographic details, final point of same day contact, and use of services during the month after contact.

All costs for same day appointment activity and one month follow up care were calculated at the level of the individual patient. We calculated costs of general practitioner and nurse time using salary and earning scales current at the time of the study. Prescription costs were taken from the British National Formulary, and the costs of tests and emergency care were obtained from local provider units. Because follow up consultations were not timed, we used the average time for telephone consultations, appointments, or home visits recorded in the standard management or triage conditions to calculate follow up general practitioner and nurse costs.

Analysis
We analysed the data on an intention to treat basis. The only patients for whom data were not analysed were those who had no further contact with a general practitioner or nurse after their request and so had no data recorded.

To determine if triage influenced the time taken to manage same day requests, we did time series analyses of the mean total, general practitioner, and nurse times per patient. We used these analyses to predict the time taken to manage requests by general practitioners, nurses, or both. We calculated relative risks and associated confidence intervals for the final point of contact after standard management or triage and for the impact of different types of triage outcome on subsequent use of services. We summated cost data for each individual patient, calculating sample means and standard deviations for each cost variable. We compared the average (mean) costs between the groups using independent t tests. See bmj.com for more details of our analysis.

	Results

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We included 4685 patients, 1233 in standard management and 3452 in the triage system. The triage group had more presenting complaints per patient, a higher proportion of respiratory and dermatological complaints, and fewer mental health complaints.

At all surgery sites, triage resulted in fewer patients receiving a general practitioner appointment than standard management (table 1). More patients in the triage group received telephone consultations (relative risk 2.41, 95% confidence interval 2.08 to 2.80) or nurse care (3.79, 3.21 to 4.48), and there was a small reduction in home visits (0.85, 0.72 to 1.00).

Time taken to manage same day requests
Management time in the triage system was higher, but both the total amount of general practitioner time and the proportion per patient was reduced (table 2). The extra time required for triage and some of the existing general practitioner management time was taken up by nurses.

*P<0.05, **P<0.01, ***P<0.001 for difference between standard and triage.

Triage took a mean 1.7 minutes longer per patient than standard management (P<0.001), with nursing time 4.15 minutes longer (P<0.001). However fewer general practitioner appointments, general practitioner telephone consultations, and home visits in the triage system resulted in general practitioners spending a mean 2.45 minutes less per patient for the total population of triaged patients (P<0.05).

Follow up care
More patients in the triage system returned for further practice based care within one month of the initial appointment request than in standard care (relative risk 1.11, 95% confidence interval 1.01 to 1.22). The mean number of return consultations was greater in triaged patients, and more patients used out of hours and accident and emergency services (table 3). Patients were more likely to have contact with the practice after same day telephone care than after appointments (1.32, 1.23 to 1.41) and after nurse care than general practitioner care (1.15, 1.08 to 1.23).

Costs of providing a triage service
General practitioner same day costs and drug costs were significantly less for the triage patients, but these savings were offset by significant increases in costs for nurses (both for same day appointments and at follow up) and for out of hours and accident and emergency care . Overall triage costs were higher than those for standard management, but the difference did not reach significance. There was a mean difference of £1.48 more per patient for triage (95% confidence interval -0.19 to 3.15), the largest component of which was out of hours and accident and emergency care. See bmj.com for a detailed break down of costs and our sensitivity analysis.

	Discussion

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Our triage system resulted in general practitioners having 29-44% fewer same day appointments than standard management, with 40% of requests being managed by nurses alone. However, although general practitioner time was 2.45 minutes less per patient in the triage system, the total time to manage same day requests was 1.70 minutes more per patient. Triage was no cheaper than standard management.

Robustness of results
The type of presenting problems differed between the standard and triage groups. This cannot be because receptionists selected certain patients for triage because we included data from every patient requesting a same day appointment during data collection periods. These differences do not account for cost differences between standard management and triage. In both groups, respiratory and dermatological disorders were cheaper to treat than other conditions. The increased numbers of respiratory and dermatological disorders in the triage group, therefore, do not account for the increase in costs. The larger number of patients with multiple diagnoses in the triage group is not explained by nurses eliciting more complaints or categorising problems under multiple headingsgeneral practitioners made more diagnoses in triage than in standard management. Furthermore, although the difference between costs of one and multiple diagnoses was highly significant (P<0.001), the larger number of multiple diagnoses in the triage group accounted for only £0.69 of the cost difference between the groups.

Effect of triage
During triage, patients were more than twice as likely to receive telephone advice only and almost four times as likely to be managed by a nurse. The triage system affected general practitioner time by reducing the proportion of patients managed by general practitioners not by reducing individual consultation times during general practitioner appointments or home visits.

In line with previous findings,³ more patients returned to surgery within one month after triage than standard management. However, more patients also required accident and emergency or out of hours care. This observation is at odds with the findings of the South Wiltshire Out of Hours Project (SWOOP) trial, which reported no difference in the number of accident and emergency attendances between triage and standard care.⁸ However, that trial measured attendance only three days after triage whereas we measured it after 28 days. Furthermore, the number attending accident and emergency is relatively small. The effect on emergency care needs further investigation since additional use of out of hours and accident and emergency services may be a consequence of patients not having their needs met in the triage system. Other measures of patient outcomes are also required in future studies to investigate the clinical effectiveness and quality of triage for individual patients.

	Acknowledgments

We thank the patients, nurses, doctors, and receptionists who took part in this study and Phil Heywood, who provided advice at the later design stage and during data collection and made helpful comments on an earlier draft of this paper.

Contributors: see bmj.com.

	Footnotes

Funding: The research was supported by a grant from the NHS Executive Northern and Yorkshire Regional Office Responsive Funding Programme.

Competing interests: None declared.

This is an abridged version; the full version is on bmj.com

	References

Top Abstract Introduction Participants and methods Interventions Results Discussion References

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(Accepted 15 August 2002)