Abstract
We investigated patients' adherence to recommendations after telephone triage at the Swiss Centre for Telemedicine. We studied cases where the medical problem was assessed as not requiring an immediate face-to-face consultation. Two weeks after teleconsultation, follow-up telephone interviews were conducted with 1129 self-care patients. The patients were asked if they had adhered to the telephone recommendations and whether they had had a subsequent face-to-face consultation. A total of 1003 patients (88%) were available for the follow-up telephone interview. Of those, 85% reported that they had adhered to all self-care recommendations and 86% had followed the advice about further use of the health-care system. Overall, 28% of patients had attended a face-to-face consultation. Half of them were referred by the teleconsultation centre, and half of them had decided themselves not to follow the centre's recommendation. Since acceptance of self-care recommendations after teleconsultation was high, teleconsultation may be an efficient alternative to face-to-face consultations for some conditions.
Introduction
Telephone consultation and triage have increasingly been used as a means for health-care delivery. 1,2 The patients' acceptance of recommendations received during teleconsultation is important to the success of this type of health-care delivery. 3 One important factor in patient satisfaction appears to be the reduced travel time and waiting times. Previous research has shown that patients' acceptance of medical recommendations given via the telephone is generally favourable. 4–6 However, several systematic reviews have concluded that there is insufficient information about patient satisfaction and acceptance of this type of health-care delivery, and have recommended further research. 2,7–11 One indicator of the acceptance of telephone triage is the level of adherence to the recommendations received. 3 We have investigated patients' adherence to recommendations after telephone triage at the Swiss Centre for Telemedicine. We studied cases where the medical problem was assessed as not requiring an immediate face-to-face consultation.
Swiss Centre
During the study period, the Swiss Centre for Telemedicine provided up to 400 teleconsultations per day, covering the whole spectrum of medical questions from acute health problems to health behaviour questions. In 2008, about 30% of the Swiss population had access to these teleconsultation services as part of their compulsory health insurance coverage. The telemedicine centre is paid directly by the health insurances on a per capita basis. 12 Within the Swiss health-care system, patients are generally free to choose a face-to-face health-care provider from their region. This also applied to persons who had access to teleconsultation services. In contrast to face-to-face consultations, there are no co-payments for a teleconsultation. In addition, the teleconsultation services were available 24 hours a day without significant waiting time and travel cost. Face-to-face primary or emergency care is accessible round the clock, whereas there are waiting times for weeks or even months for an appointment with a specialist. Patients (or the guardians if the patients were children) lived in communities spread throughout Switzerland and did not know the health personnel from the telemedicine centre.
When a patient telephones, an assistant records the medical problem, makes an assessment of its urgency (based on internal quality standards and under medical supervision), and assigns a time interval during which a physician trained in telemedicine will call the patient back for a detailed teleconsultation. In certain clinical situations, according to a careful assessment done by the doctors, no immediate face-to-face consultation is needed. Doctors recommend self-care measures such as bed rest, taking non-prescription medication or watchful waiting to the patient, and explain alarm symptoms indicating immediate need to contact the telemedicine centre again or turn to another health-care provider.
Methods
The patients selected for evaluation were those identified as not requiring face-to-face consultation in the electronic management system of the telemedicine centre. The evaluation was done for routine quality assessment and therefore did not require specific ethics approval.
Study design
All persons triaged to receive telephone advice only after a teleconsultation on a predefined number of evaluation days between July and December 2008 were eligible for the evaluation. Evaluation days included all weekdays including the weekend. There was an eight-day interval between consecutive evaluation days (e.g. Monday in week 1, Tuesday in week 2, etc.). Thus 16 days were needed to achieve the target sample size of 1000 persons. Eligible persons (n = 1129) were contacted about two weeks after teleconsultation for a follow-up telephone interview.
Measures
In the follow-up telephone interview, patients were asked whether they had adhered to the recommendations received from the doctor during the teleconsultation and whether they had contacted another health-care provider in the time interval between the initial teleconsultation and follow-up call. The follow-up interviews were carried out using a predefined list of open questions. Age, gender, language and reason for encounter were extracted from the clinical database of the telemedicine centre. The case files of those persons who reported a face-to-face consultation were reviewed to ascertain whether the recommendation of the telemedicine centre included the advice to have a face-to-face consultation after a specified time (e.g. if their condition did not improve), or whether the person called the telemedicine centre a second time and was then referred for a face-to-face consultation.
Statistical analysis
In the statistical analysis we excluded missing responses. Thus the proportions shown below represent the percentages of the total number of people who responded to the relevant question. Demographic and clinical characteristics of the participants (n = 1003) and of those persons who were not available for the telephone interview (n = 126) were compared.
Results
A total of 1003 patients (88%) were interviewed. The age range of the patients who responded was 1 month to 95 years. The mean age was 30 years. Slightly more than half of the patients (578 of 1003, 58%) were female. Most patients were German speaking (87%), 11% spoke French, and 2% spoke another language. The most frequent reason for encounter was musculoskeletal problems (23%), followed by digestive (17%), respiratory (13%) and skin (13%) problems, see Table 1.
Demographic and clinical characteristics of the study sample (n = 1003)
*International Classification of Primary Care 2nd edition; 49 missing values
Adherence to recommendations
Most patients reported that they had adhered to all the recommendations given by the doctor at the telemedicine centre (n = 847, 85%). An additional 86 persons (9%) reported that they had been partly adherent, i.e. that they had applied some but not all of the recommendations. A few patients (n = 60, 6%) had not been adherent to recommendations (Table 2).
Self-reported follow-up characteristics of callers who received telephone advice only
*10 missing values
†6 missing values
Health-care system usage
A total of 713 patients (72%) reported that they had not used any other health-care provider after the teleconsultation, whereas 284 (28%) had had an immediate face-to-face consultation (Table 2). Of those who reported a face-to-face consultation, 122 patients (12%) had been advised in the teleconsultation to commence with self-care measures, but to have a face-to-face consultation if there was no improvement within a specified time, or if their condition deteriorated. Twenty-three patients (2%) contacted the telemedicine centre a second time for a teleconsultation within this period and were then referred for a face-to-face consultation by the telemedicine centre. A total of 139 patients (14%) reported a face-to-face consultation without having been advised to do so by the telemedicine centre. Overall, 858 patients (86%) were adherent with respect to recommendations about other health-care providers, either because they had been advised to have no face-to-face consultation and reported not having been to the doctor, or because they had been referred to a face-to-face consultation by the telemedicine centre.
Non-responders
There was no significant difference in age between patients who were not available for telephone interview (n = 126) and patients participating in the evaluation (n = 1003). Nor were there significant differences in gender, language and reason for encounter between the two groups.
Discussion
The adherence rates to the recommendations of more than 85% observed in the present study show that the acceptance of telemedical recommendations is very high in the Swiss population. Furthermore, the majority of the patients had adhered to the recommended usage (86%) of other health-care providers, which may be relevant to the implementation of managed care in Switzerland. A substantial number of face-to-face consultations might be saved if patients receive telephone triage as their first contact with the health-care system for most of the common medical conditions.
Previous reviews have found few studies evaluating patient satisfaction after teleconsultation and teletriage, and few which assessed adherence to recommendations. 8,9,11 One study investigated patients' self-reported compliance with nurse recommendations in an after-hours call centre and found an overall compliance rate of 88%, which is similar to our results (85% adherence to self-care recommendations, 86% adherence to recommendations regarding immediate face-to-face consultations). 13 Another self-report study evaluating a voluntary nurse triage system found that of all callers who were recommended to follow self-care instructions while monitoring the condition for change, 12% scheduled an office visit and 2% used hospital emergency room services for further care. 14 The overall proportion of face-to-face consultations in our study was 28%, with about half of them being referred by the telemedicine centre, and half of them choosing to go for a face-to-face consultation despite telephone recommendations given by the telemedical doctor. The exact reasons underlying these consultations were not further investigated in this study, but they could be due to a long lasting relationship with a specific general practitioner who may clearly provide more than just a specific medical answer to a given problem. 13,15 In addition, in Switzerland, in principle, reimbursement of face-to-face consultations is guaranteed by the Swiss Federal Law on Compulsory Health Insurance. 16 So, the proportion of persons in need of a face-to-face consultation after telephone triage in our study may be roughly the same size as reported by O'Connell et al. 17
The present study had several limitations. First, it focused on adherence to telephone recommendations and did not investigate referrals to emergency departments, general practitioners or other physicians. The latter would need a different study design, including a thorough evaluation of the appropriateness and outcome of the visit to the other health-care providers, and this was not possible in the context of the present study. In addition, we did not assess the reasons why callers decided to visit a physician against the recommendation of the telemedicine centre. So, we do not know whether their condition worsened, whether they did not trust the advice, whether they bowed to family pressures, or even whether they went to their physician for an unrelated problem. However, previous user surveys at our centre have revealed that callers are generally reluctant to disclose their reasons for non-adherence, especially if the survey is performed by the centre from which they had received the recommendation. Therefore, it may be better to use qualitative research methods applied by study personnel from an independent centre to evaluate patients' adherence and reasons for non-adherence, both for telephone recommendations and for referral to other health-care providers.
In addition, the adherence measures of the present study were based on the callers' self-reporting and may therefore be subject to response or recall bias. This would result in overestimation of acceptance rates. For example, O'Connell and colleagues linked nurse triage call data with face-to-face medical encounter data from HMO practices who used the triage service, and found a rate of adherence to self-care advice of 66%, 17 and other research also consistently found that administrative data showed lower adherence than survey data. 4–6 Since there are inherent limitations in both types of data, the true adherence rate may lie between the two values. 17 Future studies should take into account both self-reporting and objective information, such as face-to-face encounter data.
Furthermore, patients were interviewed two weeks after teleconsultation, and may have accessed the health-care system after the follow-up telephone interview. However, the medical conditions assessed during teleconsultation or triage are usually settled within two weeks or at least show a clear trend. A previous randomized controlled trial reported that the overall workload of general practitioners was decreased if a telephone consultation system was in place. This indicates that teleconsultation and teletriage may not lead merely to a delay, but they effectively reduce the number of face-to-face consultations. 15
In addition, data were collected in a single centre in Switzerland. This may limit the generalizability of the results to other geographical regions or health-care systems. This centre is the largest in Europe after the NHS Direct Service in the UK. A large proportion of people from the four culturally different regions in Switzerland had access to services of the Swiss Centre for Telemedicine, and the participants in this study represent a diverse sample of callers from newborns to elderly persons with a broad range of clinical questions from general practice to specialist care problems.
Teleconsultation and teletriage could save money by reducing indirect costs such as travel time, waiting time, and lowering direct costs from inappropriate or unnecessary face-to-face visits. Several studies have shown the cost-saving effects of such telemedical services. 2,3,15,18 In the absence of a coherent reimbursement system for teleconsultations and face-to-face consultations in Switzerland, direct costs for medical consultations in both settings are not comparable. However, even under the assumption that direct costs of a teleconsultation are similar to that of a face-to-face consultation, telemedicine is likely to decrease direct costs for patients who can be treated by telephone because additional diagnostic procedures such as laboratory tests that may be done routinely in the face-to-face setting are not needed in telephone-only situations. Costs and adequacy of care need to be investigated further to obtain objective data.
Given the high acceptance of teleconsultation and teletriage, it is time to develop and evaluate such models of health-care delivery. Even in health-care settings such as Switzerland without a general obligation to use telemedicine services, it appears likely that a substantial number of immediate face-to-face consultations may be replaced by teleonsultation and teletriage, as seen for example in uncomplicated urinary tract infections. 19 Telemedicine models may therefore help to optimise the use of the available health resources and foster reasonable access to health professionals and services. 2,20 The underlying rationale is that patients with uncomplicated problems can be managed by telephone, whereas in more complex situations or when additional examinations are needed patients can be referred to the appropriate health-care provider at the appropriate time.
The results of our evaluation underline patients' high acceptance of telephone recommendations and referral advice given after teleconsultation. These results increase trust in the applicability of such telemedicine models in various health-care settings.
Footnotes
Acknowledgements
The study was funded by the Swiss Centre for Telemedicine. The results were presented at the Med-e-Tel conference 2010 in Luxembourg. The first two authors contributed equally to the work.