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document
The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice : a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care ( the ESTEEM trial ) . BACKGROUND Telephone triage is proposed as a method of managing increasing demand for primary care . Previous studies have involved small samples in limited settings , and focused on nurse roles . Evidence is limited regarding the impact on primary care workload , costs , and patient safety and experience when triage is used to manage patients requesting same-day consultations in general practice . OBJECTIVES In comparison with usual care ( UC ) , to assess the impact of GP-led telephone triage ( GPT ) and nurse-led computer-supported telephone triage ( NT ) on primary care workload and cost , patient experience of care , and patient safety and health status for patients requesting same-day consultations in general practice . DESIGN Pragmatic cluster randomised controlled trial , incorporating economic evaluation and qualitative process evaluation . SETTING General practices ( n = 42 ) in four regions of England , UK ( Devon , Bristol/Somerset , Warwickshire/Coventry , Norfolk/Suffolk ) . PARTICIPANTS Patients requesting same-day consultations . INTERVENTIONS Practices were randomised to GPT , NT or UC . Data collection was not blinded ; however , analysis was conducted by a statistician blinded to practice allocation . MAIN OUTCOME MEASURES Primary - primary care contacts [ general practice , out-of-hours primary care , accident and emergency ( A & E ) and walk-in centre attendances ] in the 28 days following the index consultation request . Secondary - resource use and costs , patient safety ( deaths and emergency hospital admissions within 7 days of index request , and A & E attendance within 28 days ) , health status and experience of care . RESULTS Of 20,990 eligible randomised patients ( UC n = 7283 ; GPT n = 6695 ; NT n = 7012 ) , primary outcome data were analysed for 16,211 patients ( UC n = 5572 ; GPT n = 5171 ; NT n = 5468 ) . Compared with UC , GPT and NT increased primary outcome contacts ( over 28-day follow-up ) by 33 % [ rate ratio ( RR ) 1.33 , 95 % confidence interval ( CI ) 1.30 to 1.36 ] and 48 % ( RR 1.48 , 95 % CI 1.44 to 1.52 ) , respectively . Compared with GPT , NT was associated with a marginal increase in primary outcome contacts by 4 % ( RR 1.04 , 95 % CI 1.01 to 1.08 ) . Triage was associated with a redistribution of primary care contacts . Although GPT , compared with UC , increased the rate of overall GP contacts ( face to face and telephone ) over the 28 days by 38 % ( RR 1.38 , 95 % CI 1.28 to 1.50 ) , GP face-to-face contacts were reduced by 39 % ( RR 0.61 , 95 % CI 0.54 to 0.69 ) . NT reduced the rate of overall GP contacts by 16 % ( RR 0.84 , 95 % CI 0.78 to 0.91 ) and GP face-to-face contacts by 20 % ( RR 0.80 , 95 % CI 0.71 to 0.90 ) , whereas nurse contacts increased . The increased rate of primary care contacts in triage arms is largely attributable to increased telephone contacts . Estimated overall patient-clinician contact time on the index day increased in triage ( GPT = 10.3 minutes ; NT = 14.8 minutes ; UC = 9.6 minutes ) , although patterns of clinician use varied between arms . Taking account of both the pattern and duration of primary outcome contacts , overall costs over the 28-day follow-up were similar in all three arms ( approximately £75 per patient ) . Triage appeared safe , and no differences in patient health status were observed . NT was somewhat less acceptable to patients than GPT or UC . The process evaluation identified the complexity associated with introducing triage but found no consistency across practices about what works and what does not work when implementing it . CONCLUSIONS Introducing GPT or NT was associated with a redistribution of primary care workload for patients requesting same-day consultations , and at similar cost to UC . Although triage seemed to be safe , investigation of the circumstances of a larger number of deaths or admissions after triage might be warranted , and monitoring of these events is necessary as triage is implemented . TRIAL REGISTRATION Current Controlled Trials ISRCTN20687662 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 19 , No . 13 . See the NIHR Journals Library website for further project information .
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Intervention_Educational
telephone triage
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Intervention_Educational
general practitioner-led and nurse-led management systems
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Intervention_Educational
Telephone triage
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Intervention_Educational
triage
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Intervention_Educational
usual care ( UC )
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Intervention_Educational
GP-led telephone triage ( GPT )
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Intervention_Educational
nurse-led computer-supported telephone triage ( NT )
70298
Participant_Condition
GP-led telephone triage ( GPT )
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Participant_Condition
nurse-led computer-supported telephone triage ( NT
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Participant_Sample-size
20,990
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Participant_Sample-size
n = 7012