Research ArticleOriginal Research

Improving Acute Respiratory Infection Care Through Nurse Phone Care and Academic Detailing of Physicians

Kim Pittenger, Barbara L. Williams, Robert S. Mecklenburg and C. Craig Blackmore
The Journal of the American Board of Family Medicine March 2015, 28 (2) 195-204; DOI: https://doi.org/10.3122/jabfm.2015.02.140197

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    Traditional and improved care pathways for acute respiratory infection (ARI). PCP, primary care provider; Rx, prescription; RN, registered nurse.

  • Figure 2.
    Figure 2.

    Statistical process control P-chart for antibiotic rate by month, January 2010 to November 2013, including both provider visits and nurse provided phone care.

  • Figure 3.
    Figure 3.

    Proportion of antibiotics for visits for acute respiratory illness (ARI) by established patients before and after the ARI value stream intervention, for 10 providers with the highest volume (N = 12,083 visits). All differences were significant (P < .001) except provider G (P = .30).

Tables

  • Table 1. Description of Cohorts, Inclusive of All Patients Seeking Care for ARI
    VariableTotalBefore Intervention (January 1, 2010 to February 28, 2012)After Intervention (March 1, 2012 to November 30, 2013)P Value
    Number (total)56,26632,49723,769
    Number per month1,1551,2501,132.25
    Age, mean years (SD)*52.1 (16.4)51.4 (16.1)53.2 (16.7)< .001
    Gender (% female)*34,678 (64)20,845 (64)13,833 (63).12
    Diagnosis code (%)*< .001
        Sinusitis16,932 (31)11,102 (34)5830 (27)< .001
        Cough9,344 (17)4,567 (14)4,777 (22)< .001
        Acute bronchitis6,649 (12)5,217 (16)1,432 (7)< .001
        Other ARI21,358 (39)11,611 (36)9,747 (45)< .001

    • ↵* In the 54,283 with provider visits.

    • ARI, acute respiratory illness; SD, standard deviation.

  • Table 2. Cost analysis for nursing phone care and academic detailing
    Cost AreaCost Detail‖Cost Estimate Calculations
    Cost savings for nursing phone care per year*
        ARI-related clinic visitsVisits avoided (21 months)‡1983
    Visits avoided per year (95% CI for sensitivity analysis)1,133 (1,101, 1,159)
    Avoided visit average cost$133
    Estimate avoided clinic visit costs per year (range in sensitivity analysis from 95% CI of visits avoided)$150,708 ($146,433, $154,147)
        AntibioticsAntibiotics avoided per year through nursing phone care1133 × 0.56§ = 635
    Average cost of antibiotic$9.61
    Estimate avoided cost per year (range from 95% CI of visits avoided above)$6,098 ($5,925, $6,237)
        Total (range in sensitivity analysis)Costs avoided$156,806 ($152,358, $160,384)
    Cost savings for academic detailing per year*
        AntibioticsAntibiotics avoided per year through academic detailing (number of ARI visits × difference in antibiotic rate before and after intervention)13,584 × 16.5%=2,241
    Sensitivity analysis on antibiotics avoided from 95% CI for difference in antibiotic rate (from text)13,584 × 12.5%=1,698
    13,584 × 20.5%=2,785
    Average cost of antibiotic$9.61
        Total (range in sensitivity analysis)Antibiotic costs avoided$21,539 ($16,317, $26,763)
    Cost for academic detailing†
        Start-up costsTraining (2-day course on academic detailing, including tuition, lodging, salary, and travel for physician and pharmacist one-time cost, amortized)$4,391
        Annual costsBenchmark data computer program development (8 hours per year)$438
    Preparation and presentation of academic detailing to providers (yearly cost: 32 hours for physician, 50 hours for pharmacist)$13,265
    Provider cost to receive detailing per year (2 hours per provider (70 ± 9 providers) with 24 receiving an additional hour)$17,098 ($15,220, $18,975)
        Total per year (including amortized start-up costs)$35,192 ($33,315, $37,069)
    Cost expenditures for nursing phone care per year†
        Nurse-provided phone careTwo nurse salaries per year$161,680
    Percent of phone care for ARI (95% CI)46.8% (45.7%, 47.8%)
    Total (range in sensitivity analysis)Estimate added cost per year$75,666 ($73,888, $77,283)
    Total savings to health care payers per year*
    Cost savings from visits avoided (from above)$156,806 ($152,358, $160,384)
    Antibiotic costs avoided (from above)$21,539 ($16,317, $26,763)
    Overall annual savings at Virginia Mason (range in sensitivity analysis)$178,345 ($168,675, $187,147)
    Annual savings per 1,000 episodes of ARI at Virginia Mason (range in sensitivity analysis)$13,129 ($12,417, $13,777))
    Total cost to delivery system per year
    Nursing phone care costs (from above)$75,666 ($73,888, $77,283)
    Academic detailing costs (from above)$35,192 ($33,315, $37,069)
    Total costs$110,858 ($107,203, $114,352)
    Total savings to health care payers per year if nurse care and academic detailing were reimbursed$67,487 ($54,323, $79,944)

    • ↵* Cost analysis from the payer perspective.

    • ↵† Cost analysis from the healthcare delivery perspective.

    • ↵‡ Number of patients with nurse phone care without subsequent provider visit.

    • ↵§ Baseline rate of antibiotic use.

    • ↵‖ Values represent estimated cost savings and expenditures.

    • ARI, acute respiratory illness; CI, confidence interval.

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