Does a Previsit Phone Call from the Surgeon Reduce Decision Conflict?

Abstract

Background:

There is some evidence that previsit strategies can make in-person visits more productive and efficient. We compared between people who received a phone call before a musculoskeletal specialty visit and people who did not with respect to several factors: (1) decision conflict (difficulty deciding between two or more options), (2) perceived clinician empathy after an in-person visit, and (3) arrival for the scheduled in-person appointment. We also recorded the specialist's opinion that the phone call alone could adequately replace an in-person visit while maintaining quality, safety, and effectiveness.

Materials and Methods:

In this prospective randomized-controlled trial, 122 patients were enrolled and randomized to receive a previsit phone call by an orthopedic surgeon before a scheduled visit or not. After the in-person visit, patients completed a (1) demographic questionnaire including age, gender, race/ethnicity, marital status, level of education, work status, and comorbidities; (2) Decision Conflict Scale; and (3) Jefferson Scale of Patient Perceptions of Physician Empathy.

Results:

No significant difference was found between the two groups in decision conflict, perceived empathy, or not attending the scheduled visit. Of the 55 successful phone calls, the surgeon felt that 50 (91%) had the potential to safely and effectively replace an in-person visit.

Conclusion

: Although a previsit phone call did not reduce decision conflict or improve the patient experience as measured after one visit, there may be merit in studying an increased number of touch points, particularly with some subsets of illness featuring substantial stress or misconceptions. The identified potential for the application and transfer of specialty expertise through telephone alone also merits additional study.

Introduction

Decision conflict is a state of uncertainty about the best treatment option, especially when there are competing alternatives.^1
–3 Patient participation in decision making is associated with more favorable health outcomes.^3,4 Patient and family preferences, medical evidence, and clinical expertise enmeshed in the treatment plan can help optimize patient engagement.^3,5

To increase engagement and limit decision conflict, a patient first has to be aware that they have options. For instance, it might feel like a broken clavicle with obvious displacement on radiographs and crepitation with positioning of the arm can only be treated operatively. Next, a patient needs to have time to become aware of what matters most to them (their values). Continuing with the clavicle fracture example, most people prefer to avoid injury, including the controlled and strategic injury of surgery. Finally people can understand their options and their potential consequences to ensure their preferences are aligned with their values and not misdirected by common misconceptions.^6,7

In the clavicle example, there are several factors that might help people avoid surgery—at least initially—including knowing that natural healing can lead to satisfactory symptoms and function, that many patients adapt even if the fracture does not heal, and that surgery is an option later. At a minimum, a goal is to take steps to limit the possibility that their choice between surgery and natural healing is influenced by the type of misconceptions that can arise from automatic thoughts associated with the pain, deformity, radiographs, and crepitation with arm motion.

There is some evidence that previsit strategies can make visits more productive and efficient.⁸ For example, a study of people with diabetes found that proactive previsit preparation (e.g., previsit phone calls, identification of patient needs, and scheduling of a laboratory visit before the appointment) reduced no-show rates and improved compliance with recommended tests and screenings.⁸ In the setting of musculoskeletal expertise, building trust over time, and giving people time to reorient their thoughts about their symptoms and disease might facilitate engagement and decision making. Strategies for giving people an option to spread specialty care out in increments using alternative touch points made possible with technology (e.g., text, e-mail, voice, and video contact) might affect attendance at in-person visits as the regulatory and reimbursement climate transition to allow greater telehealth.

This study compared people who received a phone call before a musculoskeletal specialty visit with people who did not with respect to several factors: (1) decision conflict (difficulty deciding between two or more options), (2) perceived clinician empathy after an in-person visit, and (3) arrival for the scheduled in-person appointment. We also recorded the specialist's opinion that the phone call alone could adequately replace an in-person visit while maintaining quality, safety, and effectiveness.

Materials and Methods

Study Design

After institutional review board approval of this prospective randomized controlled trial (approval number 2018-12-0062), new patients seeing an orthopedic surgeon in the Upper Extremity integrated practice unit at University of Texas Health Austin were contacted 5 days before their visit, and asked for their help studying new methods of delivering care that involve randomization to different strategies. Patients were included between May 2019 and September 2019. Inclusion criteria were new patients scheduled to be seen, aged between 18 and 89 years old, and had English or Spanish fluency and literacy. Exclusion criteria were patients who were unable to provide informed consent. People were randomized 1:1 using a computer random number generator to receive a previsit phone call by an orthopedic surgeon before a scheduled visit or not.

At the beginning of the call, people were asked whether they wanted to talk about their symptoms before the in-person visit with a specialist. They were informed that a legally binding doctor–patient relationship could not be established, meaning that the problem could not be diagnosed or treated over the phone. The call was likened to an online diagnosis guesser and accompanying information. Each person agreed to this arrangement before discussing his or her symptoms.

When people arrived for the in-person visit, a research assistant not involved in patient care asked patients to complete questionnaires after the visit. Questionnaires were available in both English and Spanish. If patients did not keep their scheduled appointment, the research assistant recorded the nonattendance. A few patients rescheduled and the research evaluation was eventually completed.

Measures

Patients were asked to complete a set of questionnaires in the following order: (1) a demographic questionnaire recording age, gender, race/ethnicity, marital status, level of education, work status, and comorbidities; (2) Decision Conflict Scale (DCS); and (3) Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE). All questionnaires were administrated on an encrypted tablet through a secure Health Insurance Portability and Accountability Act-compliant electronic platform: Research Electronic Data Capture, a secure web-based application for building and managing online surveys and databases.⁹

The DCS is a questionnaire assessing uncertainty in the face of options, modifiable factors contributing to uncertainty such as feeling uninformed, unclear about personal values, or unsupported in decision making, and effective decision making such as feeling the choice is informed, values based, likely to be implemented, and expressing satisfaction with the choice.^2,10,11 It is a 16-item questionnaire, measured on a 4-point Likert scale, with scores ranging from 0 (“strongly agree”) to 4 (“strongly disagree”).^2,10,11 The total score is the sum of all 16 items and will be between 0 and 64, where lower scores reflect a lower level of decisional conflict.^2,10

The JSPPPE is a questionnaire for measuring patient perception of empathic engagement with a physician.¹² It is a 5-item questionnaire with statements about the physician, measured on a 7-point Likert scale, with scores ranging from 1 (“strongly disagree”) to 7 (“strongly agree”).^12,13 The total score is the sum of all items of the JSPPPE and will be between 5 and 35, where a higher score indicates more empathic perception about the physician.^12,13 The JSPPPE is widely used and is translated into 10 languages.¹²

We also recorded the specialist's opinion that the phone call alone could adequately replace an in-person visit based on high confidence in the diagnosis, no need for diagnostic tests to confirm the diagnosis or measure the degree of pathology, and no need for in-person hands-on examination or treatment. By subsequently seeing the patients in person, we were able to confirm that this was true, thereby establishing the potential for safe high-quality care through phone call alone.

Study Population

Among 122 patients (62 patients in the intervention group and 60 patients in the control group) who fulfilled our eligibility criteria and were enrolled, 14 patients did not attend their scheduled in-person visit and 8 patients did attend their scheduled in-person visit but did not complete the questionnaires. The mean age (and standard deviation) of the remaining 100 patients was 47 ± 14 years old (range 18–86 years; Table 1). Twenty-seven (27%) patients were men.

Table 1.

Patient and Clinical Characteristics

VARIABLES	N = 100
	PERCENT^a
Patients	27
Men	73
Women, n (%)
Race/Ethnicity
Latino/Hispanic	49
White	35
Black/African American	11
Other	5
Marital status
Married/unmarried couple	51
Single	34
Divorced/separated	10
Widowed	5
Level of education
Elementary school	14
High school	43
2-year college	12
4-year college	19
Postgraduate degree	12
Work status
Full-time employed	39
Part-time employed	20
Homemaker	16
Retired	6
Disabled	6
Student	3
Other	10
Comorbidities
Diabetes	22
Other	11
None	67

	MEAN ± SD
Age in years	47 ± 14
JSPPPE	31 ± 7
DCS	9 ± 11

Percentage and number are the same since there were 100 participants.

DCS, Decision Conflict Scale; JSPPPE, Jefferson Scale of Patient Perceptions of Physician Empathy.

Data Analysis

A power analysis indicated that a sample of 98 patients (49 patients per group) would provide 90% statistical power, with alpha set to 0.05, to find a difference of 10 points on the Decisional Conflict Scale with SD set at 15. Aiming for 98 complete responses (49 per group) and accounting for 10% incomplete responses, we targeted enrollment at a minimum of 108 patients (54 per group).

We used intention-to-treat analysis. Of the 62 patients in the phone call group, we were unable to reach seven patients. These patients were retained in the phone call group.

Descriptive statistics are presented as the mean ± standard deviation (range) or median (interquartile range) for continuous variables and proportions for discrete variables.

All patients were included in the bivariate analyses to test the difference in no-show rate between patients who received a previsit phone call compared with patients who did not receive a previsit phone call. We used a Fisher exact test. We considered p < 0.05 as significant.

Among the patients who completed the questionnaires, bivariate analyses were conducted to test the difference of demographics, JSPPPE, and DCS between patients who received a previsit phone call compared with patients who did not receive a previsit phone call. We used a t-test and Mann–Whitney test for continuous variables and a Fisher's exact test for dichotomous and categorical variables. We considered p < 0.05 as significant. Variables with p < 0.10 were included in a multivariable linear regression model.

Results

There was no significant difference in decision conflict (DCS) or perceived empathy (JSPPPE) between patients who received a previsit phone call compared with patients who did not (Table 2). Marital status was the only variable with p < 0.10 (p = 0.073), so we did not create a multivariable linear regression model.

Table 2.

Bivariate Analyses of Difference in Other Variables (N = 100)

VARIABLES	RANDOMIZATION		p
VARIABLES	PHONE CALL (N = 45)	NO PHONE CALL (N = 55)	p
Age in years, n (%)	49 ± 2	45 ± 2	0.237
Men
Women, n (%)	38 (69)	35 (78)	0.372
Men, n (%)	17 (31)	10 (22)	0.372
Race/Ethnicity
Latino/Hispanic, n (%)	24 (44)	25 (56)	0.422
White, n (%)	23 (42)	12 (27)
Black/African American, n (%)	5 (9)	16 (13)
Other, n (%)	3 (5)	2 (4)
Marital status
Married/unmarried couple, n (%)	28 (51)	23 (51)	0.073
Single, n (%)	15 (27)	3 (7)
Divorced/separated/widowed, n (%)	12 (22)	19 (42)
Level of education
Elementary school, n (%)	7 (13)	7 (16)	0.697
High school, n (%)	23 (42)	20 (44)
2-year college, n (%)	9 (16)	3 (7)
4-year college, n (%)	10 (18)	9 (20)
Postgraduate degree, n (%)	6 (11)	6 (13)
Work status
Full-time employed, n (%)	19 (35)	20 (44)	0.700
Part-time employed, n (%)	12 (22)	8 (18)
Other, n (%)	24 (44)	17 (38)
Comorbidities
Diabetes, n (%)	12 (22)	10 (22)	0.502
Other, n (%)	8 (15)	3 (7)
None, n (%)	35 (64)	32 (71)
JSPPPE	33 [30–35]	34 [29–35]	0.419
DCS	6 [0–16]	5 [0–16]	0.458

There was no difference in the no-show rate between patients who were randomized to receive a previsit phone call (4 of 62 patients, 6% no-show) and patients who were not (10 of 60 patients, 17% no-show, p = 0.093, Table 3).

Table 3.

Bivariate Analysis of Difference in No-Shows (N = 122)

VARIABLES	RANDOMIZATION		p
VARIABLES	PHONE CALL	NO PHONE CALL	p
Present, n (%)	58 (94)	50 (83)	0.093
No-show, n (%)	4 (6)	10 (17)	0.093

Of the 55 successful phone calls, the surgeon believed that 50 (91%) had the potential to replace an in-person visit. A phone call would have been sufficient to establish the diagnosis and suggest treatment options, if permitted by law, and the safety of this approach can be confirmed. The remaining five (9%) needed in-person care: two with injuries that might benefit from surgery, two recovering from surgery (needing suture removal and new radiographs), and one patient with an injury and no available radiographs.

Among the 50 patients for whom initial care by phone was felt to be potentially adequate in an alternative regulatory environment and with confirmation of safety, the referral diagnosis changed in a single patient (arthritis to trigger thumb). Nine patients were diagnosed with carpal tunnel syndrome appropriate for surgery, and it would be possible to book surgery immediately if there were appropriate legal and insurance arrangements in place and the patient felt comfortable booking surgery after a phone call alone. Four had a trigger digit and would eventually come in for an injection or surgery. The other 41 patients had problems that could be managed entirely by phone, including most of the fractures and dislocations.

Discussion

Current access to specialty expertise is generally limited to relatively brief in-person visits. Most people with an upper limb problem see a specialist a single time.^14,15 This suggests that what most people get from a visit to a musculoskeletal specialist may be simply a better understanding of their problem. There may be more efficient, convenient, and cost-effective methods for reorienting common misconceptions about musculoskeletal symptoms than an in-person visit. Given that specialist advice is often counterintuitive and may not match a person's understanding of the problem or anticipated symptom course and management strategy,¹⁶ there are reasons to consider access to specialty expertise that has a greater number of touch points (more longitudinal) using various modes of communication. This study addressed some of the influences of a previsit phone call.

Limitations of this study include that neither the phone calls nor the visits were timed. The participating surgeon had the impression that in-person visits were easier and more efficient after a phone call to start establishing a relationship, but this was not measured. Our primary outcome was decision conflict, and the overall level of decision conflict was low, making it difficult to demonstrate a difference with alternative strategies for relationship building and expertise transfer. The results might be different in a study of specific problems associated with greater decision conflict or with a measure that can discern differences in the lower levels of decision conflict. Another limitation is the substantial ceiling effect of current patient experience measures such as perceived empathy. A measurement has a ceiling effect when the top score is over-represented and a floor effect when the lowest score is over-represented. Experience measures have such strong ceiling effects (nearly half the subjects give the top rating) that they are typically dichotomized for analysis, which loses information about the variation in experience and makes it difficult to learn about interventions to improve patient experience.^17
–19 This study was done in one clinic with one surgeon, and it is possible that the findings do not generalize. Nevertheless, this initial exploration of some modifications to specialty care might stimulate additional research, particularly in regions with different financial incentives and regulatory strategies. This study was analyzed using strict intention to treat and not all people randomized to a previsit phone call were contacted. These data represent a strategy of attempting phone contact before the visit. The findings are best applied to patients with an orthopedic upper extremity disease and may not generalize to patients with other pathology. It is not clear why there was a relative imbalance of men and women. Since there was no effect of gender in the analyses, it probably did not influence the findings.

The observation of no significant difference in decision conflict between patients who received a phone call and patients who did not receive a phone call is not consistent with the study of previsit coordination in patients with diabetes that noted improved adherence after 24 months among patients who received a phone call.⁸ It may be that it takes longer for the incremental care to influence decision conflict, satisfaction, and outcomes and that longer longitudinal studies would have different results. It may also be the case that most people are already planning to adapt and manage many problems on their own, limiting the potential effect of specialty care.¹⁴ Future studies can address a phone call or web-based information as an alternative to specialty care.

The observation of no difference in nonattendance is interesting as it might be that some patients are more likely to attend after a call (improved relationship and feeling that one matters) and some may be less likely to attend (satisfied with general understanding rather than specific diagnosis and treatment). Given the observed differences (6% nonattendance with phone call vs. 17% without), a larger study might detect a small but relevant difference that might inform evolutions in care with the potential to reduce costs, increase clinician productivity, and improve outcomes.²⁰ For example, in the aforementioned study with 7,491 patients with diabetes, there was 6.7% less nonattendance in a 24-month period when patients had previsit phone calls.⁸

The participating surgeon felt that an in-person visit could be exchanged for a phone call for the vast majority of people. This shows the potential impact of alternative forms of specialty care such as self-care websites,²¹ text chats, electronic mail, audio only, and audio and video telehealth. It can be convenient for many patients for whom mobility, transportation, and schedule flexibility are an issue. At the time of this study, we did not have the infrastructure for a formal video, so video visits were not an option. If necessary or preferred, patients can still be invited for an in-person visit. Also, we did not ask the patients whether they had the same feeling if the in-person visit could have exchanged for a phone call. This could be a goal for a future study. Also, deciding to replace an in-person visit with an audio or video visit will always have to be a shared decision.

It was also the participating surgeon's observation (not measured) that visits with patients who received a phone call started at a more advanced stage, building on the relationship initiated by phone and getting into next level questions given that people had a chance to consider some initial expertise transferred to them by phone. It is possible that a phone call further in advance—one that allowed diagnosis and treatment by phone, in particular—might lead to more cancelled appointments and self-management. Perhaps a series of calls or various text, audio, and video synchronous and asynchronous touch points would provide equivalent or better treatment than one or more in-person visits. The key element may be a gradual gentle correction of common misconceptions. This is a hypothesis worth addressing.

Conclusion

Although a phone call did not reduce decision conflict or improve the patient experience as measured after one visit, there may be merit in studying an increased number of touch points, particularly with some subsets of illness featuring substantial stress or misconceptions. The identified potential for the application and transfer of specialty expertise using telehealth also merits additional study.

Footnotes

Authors' Contributions

Y.V., L.E.B., and D.R. certify that they all fulfill all the criteria for authorship.

Acknowledgments

We thank Joost Kortlever for helping with the IRB submission and Drew Saltzman for helping us with enrolling.

Disclosure Statement

All authors certify that they have no commercial associations (e.g., consultancies, stock ownership, equity interest, and patent/licensing arrangements) that might pose a conflict of interest in connection with the submitted article.

Funding Information

No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

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