Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis
Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis
复制标题
DOI：
10.1016/s0140-6736(14)61058-8
复制
发表时间：
2014-11-22
期刊：
影响因子：
168.9
通讯作者：
Taylor, Rod S.
中科院分区：
文献类型：
--
作者：
Campbell, John L.;Fletcher, Emily;Taylor, Rod S.
背景电话分诊越来越多地用于管理初级保健的工作量;然而，这种方法的支持证据却很少。我们的目的是评估的有效性和成本后果的全科医生（GP）为主导的和护士为主导的电话分诊与平时的护理相比，为患者寻求同一天的协商在primary care.Methods我们做了一个务实的，集群随机对照试验和经济评估之间的2011年3月1日，2013年3月31日，在42个做法在英国的四个中心。实践被随机分配（1：1：1），通过计算机生成的随机序列最小化的地理位置，实践剥夺，和实践列表的大小，无论是GP领导的分流，护士领导的计算机支持的分流，或常规护理。我们纳入了打电话寻求当天与全科医生面对面咨询的患者。分配被隐藏的做法，直到他们同意参与和随机元素被包括在最小化算法，以保持隐藏。患者、临床医生和研究人员对分配不设盲，但实践分配对试验统计学家隐瞒。主要结果是在第一次同日请求后的28天内的初级保健工作量（患者接触者，包括参加事故和急诊科的患者）。按意向治疗和符合方案进行分析。本试验在ISRCTN注册，编号ISRCTN 20687662。结果我们随机将42名患者分为GP分诊组（n=13）、护士分诊组（n=15）和常规护理组（n=14），共20990名患者（n=6695 vs 7012 vs 7283），其中16 211例（77%）患者提供了主要结局数据（n=5171 vs 5468 vs 5572）。与常规护理相比，GP分诊与28天内每人平均接触次数增加33%有关（2.65 [SD 1.74] vs 1.91 [1.43];率比[RR] 1.33，95% CI 1.30-1.36），护士分诊增加48%（2.81 [SD 1.68]; RR 1.48，95% CI 1.44-1.52）。8例患者在索引请求后7天内死亡：GP分诊组5例，护士分诊组2例，常规护理组1例;然而，这些死亡与试验组或程序无关。虽然分诊干预与增加接触，估计费用超过28天之间的所有三个组（约75磅每名患者）。解释介绍电话分诊提供的家庭医生或护士与增加的初级保健接触的数量在28天后，病人的要求，同一天的家庭医生咨询，与那些通常的护理费用相似。电话分诊可能有助于提供初级保健。在考虑采用这种系统时，应评估整个系统的影响。
Background Telephone triage is increasingly used to manage workload in primary care; however, supporting evidence for this approach is scarce. We aimed to assess the effectiveness and cost consequences of general practitioner-(GP)-led and nurse-led telephone triage compared with usual care for patients seeking same-day consultations in primary care.Methods We did a pragmatic, cluster-randomised controlled trial and economic evaluation between March 1, 2011, and March 31, 2013, at 42 practices in four centres in the UK. Practices were randomly assigned (1: 1: 1), via a computer-generated randomisation sequence minimised for geographical location, practice deprivation, and practice list size, to either GP-led triage, nurse-led computer-supported triage, or usual care. We included patients who telephoned the practice seeking a same-day face-to-face consultation with a GP. Allocations were concealed from practices until after they had agreed to participate and a stochastic element was included within the minimisation algorithm to maintain concealment. Patients, clinicians, and researchers were not masked to allocation, but practice assignment was concealed from the trial statistician. The primary outcome was primary care workload (patient contacts, including those attending accident and emergency departments) in the 28 days after the first same-day request. Analyses were by intention to treat and per protocol. This trial was registered with the ISRCTN register, number ISRCTN20687662.Findings We randomly assigned 42 practices to GP triage (n=13), nurse triage (n=15), or usual care (n=14), and 20 990 patients (n=6695 vs 7012 vs 7283) were randomly assigned, of whom 16 211 (77%) patients provided primary outcome data (n=5171 vs 5468 vs 5572). GP triage was associated with a 33% increase in the mean number of contacts per person over 28 days compared with usual care (2.65 [SD 1.74] vs 1.91 [1.43]; rate ratio [RR] 1.33, 95% CI 1.30-1.36), and nurse triage with a 48% increase (2.81 [SD 1.68]; RR 1.48, 95% CI 1.44-1.52). Eight patients died within 7 days of the index request: five in the GP-triage group, two in the nurse-triage group, and one in the usual-care group; however, these deaths were not associated with the trial group or procedures. Although triage interventions were associated with increased contacts, estimated costs over 28 days were similar between all three groups (roughly 75 pound per patient).Interpretation Introduction of telephone triage delivered by a GP or nurse was associated with an increase in the number of primary care contacts in the 28 days after a patient's request for a same-day GP consultation, with similar costs to those of usual care. Telephone triage might be useful in aiding the delivery of primary care. The whole-system implications should be assessed when introduction of such a system is considered.