Follow-up After Telephone Consultations at Out-of-Hours Primary Care

Summary of Main Findings

In this sample, about 50% of the patients had a follow-up contact within the first weeks after the out-of-hours contact with the PCP cooperative. Patients were more likely to have a follow-up contact if they were older, received a home visit, or contacted a cooperative that had a higher percentage of telephone consultations. They were less likely to have a follow-up contact if they more positively evaluated the telephone nurse. Specific changes in the working style at PCP cooperatives, in particular in the use of telephone triage, may thus contribute to a lowered number of follow-up contacts because these are determined in part by patient experiences with the service rather than with medically defined need.

Comparison With Existing Literature

The rate of follow-up contacts after contact with the cooperative falls within the range found by other studies.^8⇓–10 Our results suggest that there are 3 factors related to the probability of a follow-up contact. First, older patients and patients who received a home visits are more likely to have a follow-up contact, which reflects the frequent occurrence of chronic illnesses, comorbidity, or urgent conditions in these groups.⁹ Consequently, follow-up in these cases probably is appropriate from a medical viewpoint.

Second, negative experiences with a telephone nurse increase the probability of a follow-up contact, as we expected.^9,11,14 This implies that not all follow-up contacts are necessary from a medical perspective. Patient dissatisfaction might be related in part to the lack of knowledge about telephone triage.²⁵ In addition, we found that that experiences with a telephone nurse were less relevant to a follow-up contact when a patient had a subsequent consultation at a center; in the case of a home visit, experience with a telephone nurse did not predict a follow-up contact. In part this may be because patients with a face-to-face contact with a PCP have more severe health problems and a follow-up contact is necessary, regardless of the experience with the nurse. Furthermore, experiences with a PCP might overrule experiences with a telephone nurse.

Third, PCP cooperatives with a high percentage of telephone consultations also had a higher probability of follow-up contacts. Although these cooperatives seem to perform efficient telephone triage, the subsequent follow-up contacts increase workload. A relatively high percentage of telephone consultations might lead to more patients with unmet expectations since they expected to see a PCP.^7,15⇓–17 Furthermore, at these cooperatives triage nurses might be more determined to end a contact by telephone and advise patients to contact their PCP later. In addition, the percentage of contacts that can be handled by nurse telephone consultation alone might be restricted because of the diagnostic scope presented.

Strengths and Limitations of the Study

We used a large dataset comprising patients from 16 different PCP cooperatives across the Netherlands. Patient characteristics of our sample seemed representative of the population contacting PCP cooperatives.¹⁹ Data collection was performed recently, so we were able to provide up-to-date information on patient experiences. Dutch PCP cooperatives have existed for more than a decade, so triage nurses are more experienced, patients are familiar with the service, and the organization is implemented well. The response rate was 50.4%, which is similar to response rates in other studies of patient surveys in this health care sector.^9,17,19 A nonresponse analysis was done for a previous study that used part of our data, and this did not reveal any important differences with respondents.²² Because our study is performed in a health care system with PCPs acting as gatekeepers, results should be interpreted and implemented with care when relating them to other health care systems.

Implications for Future Research and Clinical Practice

This study reemphasizes that patient contacts in PCP cooperatives are often part of a larger episode of care. A considerable number of patients had a follow-up contact subsequent to the cooperative contact. Although most follow-up contacts may be necessary,¹⁰ other contacts may be avoidable if PCP cooperatives would show better performance concerning patient-centered care, in particular with regard to patient satisfaction and the number of telephone consultations. Future training of triage nurses should focus on communication skills to address patients' expectations and worries and patient education. Specific changes in the working style at cooperatives may thus contribute to a lowered number of follow-up contacts because these are determined in part by patients' experiences with the service rather than with medically defined need.

Measures to enhance efficiency could focus on improving patient experience with nurse telephone consultations, in particular for patients receiving only a telephone contact, because experiences with a telephone nurse seem to be no longer relevant when a patient has a face-to-face contact with a PCP. In fact, PCP cooperatives with a high percentage of telephone consultations had an increased probability of a follow-up contact. This finding should be studied in more detail to find possible explanations (eg, patient dissatisfaction, under-triage by nurses, high workload, balance). Whereas for some patients the need for a face-to-face contact or telephone advice is evident, triage decisions are more difficult for other patients. This subgroup might have more follow-up contacts after a telephone contact. In addition, future research should further investigate the effect of the apparently efficient telephone triage on follow-up contacts and the potential shift of workload to daytime primary care. It might be more cost-efficient to handle contacts out-of-hours rather than referring patients to daytime care.