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

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