Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial. The South Wiltshire Out of Hours Project (SWOOP) Group. Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. Effectiveness of an ambulatory care telephone service in reducing drop-in visits and improving satisfaction with care. The effect of GP telephone triage on numbers seeking same-day appointments. A randomized controlled study of a home health care team. Changing remuneration systems: effects on activity in general practice. Combining specialist and primary health care teams for HIV positive patients: retrospective and prospective studies.
To determine the safety and effectiveness of nurse telephone consultation in out of hours primary care by investigating adverse events and the management of calls.
                Block randomised controlled trial over a year of 156 matched pairs of days and weekends in 26 blocks. One of each matched pair was randomised to receive the intervention.
                One 55 member general practice cooperative serving 97 000 registered patients in Wiltshire.
                All patients contacting the out of hours service or about whom contact was made during specified times over the trial year.
                A nurse telephone consultation service integrated within a general practice cooperative. The out of hours period was 615 pm to 1115 pm from Monday to Friday, 1100 am to 1115 pm on Saturday, and 800 am to 1115 pm on Sunday. Experienced and specially trained nurses received, assessed, and managed calls from patients or their carers. Management options included telephone advice; referral to the general practitioner on duty (for telephone advice, an appointment at a primary care centre, or a home visit); referral to the emergency service or advice to attend accident and emergency. Calls were managed with the help of decision support software.
                Deaths within seven days of a contact with the out of hours service; emergency hospital admissions within 24 hours and within three days of contact; attendance at accident and emergency within three days of a contact; number and management of calls in each arm of the trial.
                14 492 calls were received during the specified times in the trial year (7308 in the control arm and 7184 in the intervention arm) concerning 10 134 patients (10.4% of the registered population). There were no substantial differences in the age and sex of patients in the intervention and control groups, though male patients were underrepresented overall. Reasons for calling the service were consistent with previous studies. Nurses managed 49.8% of calls during intervention periods without referral to a general practitioner. A 69% reduction in telephone advice from a general practitioner, together with a 38% reduction in patient attendance at primary care centres and a 23% reduction in home visits was observed during intervention periods. Statistical equivalence was observed in the number of deaths within seven days, in the number of emergency hospital admissions, and in the number of attendances at accident and emergency departments. Conclusions Nurse telephone consultation produced substantial changes in call management, reducing overall workload of general practitioners by 50% while allowing callers faster access to health information and advice. It was not associated with an increase in the number of adverse events. This model of out of hours primary care is safe and effective. 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.
                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.
                Three primary care sites in York.
                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.
                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.
                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 pound 1.48 more per patient for triage (95% confidence interval -0.19 to 3.15).
                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. To compare the cost effectiveness of general practitioners and nurse practitioners as first point of contact in primary care.
                Multicentre randomised controlled trial of patients requesting an appointment the same day.
                20 general practices in England and Wales.
                1716 patients were eligible for randomisation, of whom 1316 agreed to randomisation and 1303 subsequently attended the clinic. Data were available for analysis on 1292 patients (651 general practitioner consultations and 641 nurse practitioner consultations).
                Consultation process (length of consultation, examinations, prescriptions, referrals), patient satisfaction, health status, return clinic visits over two weeks, and costs.
                Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4. 20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37. 2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner 18.ll pound sterling v general practitioner 20.70 pound sterling adjusted difference 2.33 pound sterling - 1.62 pound sterling to 6.28 pound sterling).
                The clinical care an health service costs of nurse practitioners and general practitioners were similar. If nurse practitioners were able to maintain the benefits while reducing their return consultation rate or shortening consultation times, they could be more cost effective than general practitioners. To assess the acceptability and safety of a minor illness service led by practice nurses in general practice.
                Multicentre, randomised controlled trial.
                5 general practices in south east London and Kent representing semi-rural, suburban, and urban settings.
                1815 patients requesting and offered same day appointments by receptionists.
                Patients were assigned to treatment by either a specially trained nurse or a general practitioner. Patients seen by a nurse were referred to a general practitioner when appropriate.
                The general satisfaction of the patients as measured by the consultation satisfaction questionnaire. Other outcome measures included the length of the consultation, number of prescriptions written, rates of referral to general practitioners, patient's reported health status, patient's anticipated behaviour in seeking health care in future, and number of patients who returned to the surgery, visits to accident and emergency, and out of hours calls to doctors.
                Patients were very satisfied with both nurses and doctors, but they were significantly more satisfied with their consultations with nurses (mean (SD) score of satisfaction 78.6 (16. 0) of 100 points for nurses v 76.4 (17.8) for doctors; 95% confidence interval for difference between means -4.07 to -0.38). Consultations with nurses took about 10 minutes compared with about 8 minutes for consultations with doctors. Nurses and doctors wrote prescriptions for a similar proportion of patients (nurses 481/736 (65.4%) v doctors 518/816 (63.5%)). 577/790 (73%) patients seen by nurses were managed without any input from doctors.
                Practice nurses seem to offer an effective service for patients with minor illnesses who request same day appointments. The purpose of this research was to determine whether a specialized telephone service could cut down on unscheduled visits to ambulatory care and improve satisfaction with care. Patients who were to receive care (N = 561) were assigned randomly to a specialized telephone service or a control group. They were measured with regard to satisfaction with care before being assigned and 6 months later. The number of scheduled and unscheduled visits also were monitored for a 1-year follow-up period. The telephone service, which provided a triage system for referrals as well as a source of central contact for scheduling or for complaints, helped to improve satisfaction and reduce the number of unscheduled visits within 6 months. Such a service also may have application in other problem areas in the delivery of quality ambulatory care. Telephone consultations with general practitioners (GPs) have not been shown to be an effective way to reduce the demandfor face-to face appointments during the surgery hours. This study aims to determine if GP telephone triage can effectively reduce the demandforface-to -face consultations for patients seeking same-day appointments in general practice. We report an interrupted time series, twoyears before and one year after introduction of GP-led telephone triage. Demand for face-to face appointments with a GPwas reduced by 39% (95% CI = 29 to 51%, P < 0.001). more than 92% of the telephone calls lasted less thanfive minutes. The telephone bill increased by 26%. For a substantial proportion of patients seeking same-day appointments telephone consultations were an acceptable alternative service. This report describes the findings of a randomized study of a new team approach to home care for homebound chronically or terminally ill elderly. The team includes a physician, nurse practitioner, and social worker delivering primary health care in the patient's home, including physician house calls. Weekly team conferences assure coordination of patient care. The team is available for emergency consultation through a 24-hour telephone service. The team physician attends to the patient during necessary hospitalizations. This approach was evaluated in a randomized experimental design study measuring its impact on health care utilization, functional changes in patients, and patient and caretaker satisfaction. The team patients had fewer hospitalizations, nursing home admissions, and outpatient visits than the controls. They were more often able to die at home, if this was their wish. As expected, they used more in-home services, measured in weighted cost figures; their overall cost was lower than their controls, but the difference was not statistically significant. Their functional abilities did not change differently from the controls, but they, and especially their informal caretakers in the home, expressed significantly higher satisfaction with the care received. To investigate the effects on general practitioners' activities of a change in their remuneration from a capitation based system to a mixed fee per item and capitation based system.
                Follow up study with data collected from contact sheets completed by general practitioners in one period before (March 1987) a change in their remuneration system and two periods after (March 1988, November 1988), with a control group of general practitioners with a mixed fee per item and capitation based system throughout.
                General practices in Copenhagen city (index group) and Copenhagen county (control group).
                265 General practitioners in Copenhagen city, of whom 100 were selected randomly from the 130 who agreed to participate (10 exclusions) and 326 general practitioners in Copenhagen county.
                Number of consultations (face to face and by telephone) and renewals of prescriptions, diagnostic and curative services, and specialist and hospital referrals per 1000 enlisted patients in one week.
                Of the 75 general practitioners who completed all three sheets, four were excluded for incomplete data. Total contact rates per 1000 patients listed rose significantly compared with the rates before the change index in the city (100.0 before the change v 111.7 (95% confidence interval 106.4 to 117.4 after the change) and over the same time in the control group (100.0 v 106.0), but within a year these rates fell (to 104.2(99.1 to 109.6) and 104.0 respectively). There was an increase in consultations by telephone initially but not thereafter. Rates of examinations and treatments that attracted specific additional remuneration after the change rose significantly compared with those before (diagnostic services, 138.1 (118.7 to 160.5) and 159.5 (137.8 to 184.7) and curative services 194.6 (152.2 to 248.9) and 194.8(152.3 to 249.2) for second and third data collections respectively) and with the control group (diagnostic services 105.3, 107.6 and curative services 106.0, 115.0) whereas referral rates to secondary care fell (specialist referrals 90.1 (80.7 to 100.6) and 77.0 (68.6 to 86.4) and hospital referrals 87.4 (71.1 to 107.5) and 68.4 (54.7 to 85.4] in doctors in the city.
                Introducing a partial fee for service system seemed to stimulate the provision of services by general practitioners, resulting in reduced referral rates. The concept of a "target income" which doctors aim at, rather than maximising their income seemed to play a part in adjustment to changing the system of remuneration. To develop and evaluate a model of health care for HIV positive patients involving specialist, hospital based teams and primary health care teams.
                One year retrospective and a 2 1/2 year prospective study.
                Two hospitals in West London and 88 general practitioners in 72 general hospitals.
                209 adults with HIV infection.
                General practitioners enrolled in the project were faxed structured outpatient clinic summaries. When hospital inpatients were discharged, a brief discharge summary was faxed. General practitioners had access to consultant physicians skilled in HIV medicine through a 24 hour mobile telephone service. An HIV/AIDS management and treatment guide containing relevant local information was produced. Quarterly discussion forums for general practitioners were held, and a regular newsletter was produced.
                Hospital attendance and general practitioner consultations; perceived benefits and problems of patients and general practitioners.
                The average length of a hospital inpatient stay was halved for those patients who had participated in the project for two years, and the average number of visits to the outpatient clinic per month fell for patients with AIDS. There was a substantial increase in the number of visits to general practitioners by patients with AIDS and symptomatic HIV infection. Patients and general practitioners both felt that the standard of health care provided had improved.
                This model of health care efficiently and effectively utilised existing teams of hospital and primary health care professionals to provide care for HIV positive patients. Simple, prompt, and regular communication systems which provided information relevant to the needs of general practitioners were central to its success.
Telephone consultation appears to reduce the number of surgery contacts and out-of-hours visits by general practitioners. However, questions remain about its affect on service use and further rigorous evaluation is needed with emphasis on service use, safety, cost and patient satisfaction.