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ORIGINAL RESEARCH |
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Abstract |
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 Abstract Materials and MethodsResultsDiscussionReferences |
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Methods: In a prospective observational study, 12 resident and nine private physicians practicing obstetrics and gynecology completed data cards for after-hours telephone interactions with patients. Chief complaints were categorized as related to either women’s health or primary care and on whether women were pregnant, postpartum, or not pregnant. Triage dispositions (evaluate now, office follow-up, or home care) were compared between groups. Women also were asked what they would have done if they had been unable to contact their physicians by telephone.
Results: One hundred ninety-two of 276 calls evaluated (69.6%) were from pregnant women, 20 (7.2%) were from postpartum women, and 64 (23.3%) were from nonpregnant women. Calls were related to primary care health issues in 24.1% (n = 45) of pregnant women, 40% (n = 8) of postpartum women, and 28.1% (n = 18) of nonpregnant women. There were no differences between residents and private physicians in the proportion of women triaged to immediate evaluation for pregnancy (35.1% [n = 40] versus 41.9% [n = 31], P = .74) or postpartum (11.1% [n = 1] versus 10% [n = 1], P = .96) problems. Among 139 women triaged to office follow-up, 41% (n = 57) would have come to the hospital for emergency evaluation if they had been unable to reach their physicians.
Conclusion: Resident and private obstetrician-gynecologists provide primary care and women’s health care advice during after-hours telephone calls from patients. More than one third of after-hours telephone calls from pregnant women are triaged to immediate evaluation.
After-hours telephone calls from patients are a reality of medical practice, especially for obstetrician-gynecologists. To successfully manage calls requires an ability to assess medical acuity and to triage the case to the appropriate level of care, which is promoted by primary care specialties and managed care organizations.1,2 Residency programs in obstetrics and gynecology offer little training in telephone triage, so most obstetrician-gynecologists develop triage skills by experience and without formal guidance. Pediatric studies suggested that this is not an effective learning method and that skills might decrease over time without specific education.3 Studies on after-hours telephone interactions from other specialties have identified numerous problems with telephone triage, including incomplete medical history taking, noncompliance with dispositions, and poor communication.3–6 Many of those problems seem to be independent of physician experience or duration of practice.5,6
A MEDLINE review of the literature using the search terms "telephone," "triage," "office management," "outpatient," "after-hours," "women’s health," "obstetrics," and "gynecology" found no studies that examined the pattern, content, or management practices of after-hours telephone calls by obstetrician-gynecologists. Therefore, we designed this study to characterize the types of telephone interactions that patients have with obstetrician-gynecologists and to describe general management practices by physicians who receive the calls.
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Materials and Methods |
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AbstractMaterials and MethodsResultsDiscussionReferences |
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Participating physicians were given pocket-sized data cards to be filled out during after-hours calls. Information collected included physician group (private or resident), relationship of the person making the call to the patient, patient’s age, gestational age (if pregnant), chief complaint category (women’s health problems or primary care, ie, non–women’s health problems), disposition provided by physician (triage care level) and length of call (minutes). Physicians also were asked to ask callers about what patients would have done if they had been unable to reach their physicians. Physicians were instructed to record professional opinions about whether calls were appropriate based on call content and perceived acuity.
The data cards were returned to one of the investigators (ADR) and the information was reviewed and categorized. The gestational ages of pregnant women were separated by first trimester (less than 14 completed weeks), second trimester (14 through 26 completed weeks), and third trimester (more than 26 weeks). Women were classified as postpartum if they were no more than 6 weeks past delivery. Women who were neither pregnant nor postpartum were placed in the category "other."
Chief complaints of callers were classified as either primary care health questions (non–women’s health complaint) or women’s health questions. Calls that involved specific pregnancy issues were classified as women’s health related; however, pregnant women who called about issues other than pregnancy or women’s health were considered to have primary care complaints. There were many calls with chief complaints that were difficult to classify. Those specific complaints are shown in Table 1
and were assigned to primary care or women’s health categories based on adjunct information contained on data cards. Each call was given final classification independently by two of the investigators (ADR and JCS). Rare disagreements were resolved by consensus among authors.
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Data were analyzed using SAS (SAS Institute, Cary, NC) and summarized using descriptive statistics. Proportions are reported as percentages with 95% confidence intervals (CIs). Data are reported separately for calls that were from pregnant women, postpartum women, and women who were neither. Call characteristics were compared between private physicians and residents using two-tailed unpaired t test for normally distributed continuous data and contingency tables with 
2 test for categoric data. Contingency tables with 2 test were used to compare physician dispositions with actions patients would have taken if they had been unable to contact physicians and call characteristics by trimester for pregnant women. P < .05 was considered statistically significant. Because each physician contributed multiple subjects to the study there was a potential that the subjective variables of triage disposition and judgement of call appropriateness were dependent on the practice patterns of the particular physician. Therefore, to account for potential clustering effects due to nonindependence of individual observations, those variables were analyzed using methods for survey data analysis.7
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Results |
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Postpartum
Triage dispositions of physicians and information about what callers would have done if they had been unable to contact on-call physicians were available for 15 postpartum calls. Six (40%, 95% CI 15.2, 64.8) women would have come directly to the hospital for evaluation, seven (46.7%, 95% CI 21.5, 71.9) would have called the office in the morning, and two (13.3%, 95% CI 0, 30.5) would have taken other unspecified actions. Five of 13 (38.5%, 95% CI 12.0, 65.0) women given physician dispositions of either office or home care would have come to the hospital for immediate evaluation. Physicians judged calls appropriate in 15 of 17 cases (88.2%, 95% CI 79.2, 100). The proportion of calls considered appropriate was not significantly different (P = .93) when divided by chief complaint categories of primary care (seven of eight [87.5%], 95% CI 64.6, 100) and women’s health (eight of nine [88.9%], 95% CI 68.4, 100).
Other
Triage dispositions of physicians and information about what action callers would have taken if they had been unable to contact on-call physicians were available in 53 calls. Ten (18.9%, 95% CI 8.4, 29.4) women would have come directly to the hospital for evaluation, 28 (52.8%, 95% CI 39.4, 66.2) would have called the office in the morning, and 15 (28.3%, 95% CI 16.2, 40.4) would have taken other unspecified actions. Four of 27 (14.8%, 95% CI 1.4, 28.2) women who were given physician dispositions of either office or home care would have come to the hospital for immediate evaluation. Physicians judged the call as appropriate in 38 of 59 (64.4%, 95% CI 52.2, 76.6) cases. The proportion of calls considered appropriate was significantly different (P = .002) when divided by the chief complaint categories of primary care (16 of 17 [94.1%, 95% CI 82.9, 100]) and women’s health (22 of 42 [52.4%, 95% CI 37.3, 67.5]).
For each type of call, data were compared between private physicians and residents to determine whether the type of physician had an influence on call assessments and results. There was no difference in the number of private (38 of 131 [29.0%], 95% CI 21.2, 36.8) and resident (41 of 140 [29.3%], 95% CI 21.8, 36.8) physicians who gave dispositions of "evaluate now" (P = .96). Among pregnant women, private physicians had older callers, shorter calls, more calls in the first trimester, and were less likely to judge the calls appropriate (Table 3). Among postpartum women, the only significant difference was that callers to private physicians were older (Table 4). Among calls from nonpregnant, nonpostpartum patients, private physicians had older callers, shorter calls, and triaged more to immediate evaluations (Table 5).
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Discussion |
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AbstractMaterials and MethodsResultsDiscussionReferences |
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Differences in practice demographics might account for the few observed differences between private and resident after-hours telephone calls (Tables 3
, 4, and 5). Private practices generally are more likely to have long-established relationships with women beyond pregnancy and, therefore, might have a higher proportion of older gynecologic patients. The greater number of first-trimester pregnancy calls to private physicians also might indicate a tendency for private patients to seek earlier prenatal care with established health care providers. Calls to private physicians were slightly shorter, which might indicate increased experience with patient telephone calls, consistent with pediatric studies.3,5 It is not known whether shorter calls equated with better triage practice.
The overall duration of calls (mean 4.7 minutes) for obstetrician-gynecologists was similar to call durations reported by pediatricians.1,3 The rate of physician dispositions for immediate evaluations of pregnant women (37.8%) was much higher than for other primary care specialties, in which reported rates were 10–24% for pediatrics9,10 and 12% for general medical practice.11 For nonpregnant women, our evaluate-immediately disposition rate of 9.4% was similar to that of other specialties,9–11 which suggests that obstetrician-gynecologists modify triage management on the basis of pregnancy status. That practice is appropriate because there is an increased risk of high acuity problems in pregnancy. This study had a greater than 80% power (
of .05) to detect a difference in the proportion of calls triaged to evaluate now between private and resident physicians, assuming rates of 15% and 30%, respectively.
The effect of after-hours telephone triage on overall medical resource use is best shown by comparison of physician triage decisions to actions callers would have taken had there been no telephone encounter. Among 139 calls in which physicians recommended office or home management, 57 callers (41%) stated that they would have visited the hospital. That is a high discordance in perception of urgency and shows the importance of telephone management in directing callers to the level of care appropriate for the problem. Although we did not study compliance with triage recommendations, Baker et al6 reported that 56% of pediatric patients referred for emergency or urgent care and 34% of those referred for follow-up office care did not comply with after-hours triage recommendations. We did not evaluate the accuracy of acuity assessments, but no adverse outcomes were reported to the investigators.
Our data suggest that obstetrician-gynecologists provide advice for primary care and women’s health care during after-hours telephone encounters. That mix highlights the difficulty of categorizing the exact nature of typical obstetric-gynecology practice and emphasizes the importance of adequate training for correct after-hours triage. Residency and postgraduate education programs should consider how to educate physicians about after-hours telephone skills. Surveys of chief complaints can be used to identify target areas for education programs. The medical and economic effects of good triage practice are potentially enormous.
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Footnotes |
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Received September 22, 1999. Received in revised form March 15, 2000. Accepted April 13, 2000.
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References |
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2. Katz HP. Quality telephone medicine: Training and triage. HMO Pract 1990;137–41.
3. Greitzer L, Stapleton FB, Wright L, Wedgwood RJ. Telephone assessment of illness by practicing pediatricians. J Pediatr 1976;88: 880–2.[Medline]
4. Bradley-Brown S, Eberle BJ. Use of the telephone by pediatric house staff: A technique for pediatric care not taught. J Pediatr 1974;84:117–9.[Medline]
5. Perrin EC, Goodman HC. Telephone management of acute pediatric illnesses. N Engl J Med 1978;298:130–5.[Abstract]
6. Baker RC, Schubert CJ, Kirwan KA, Lenkauskas SM, Spaeth JT. After-hours telephone triage and advice in private and non-private pediatric populations. Arch Pediatr Adolesc Med 1999;153:292–6.
7. Levy PS, Lemeshow S. Sampling of populations, methods and applications. 3rd ed. New York: Wiley-Liss, John Wiley & Sons, Inc, 1999.
8. Kelley M, Mashburn J. Telephone triage in the office setting. J Nurse-Midwifery 1990;35:245–51.
9. Poole SR, Schmitt BD, Curruth T, Peterson-Smith A, Slusarski M. After-hours telephone coverage: The application of an area-wide telephone triage and advice system for pediatric practices. Pediatrics 1993;92:670–9.
10. Benjamin JT. Pediatrics residents’ telephone triage experience. Arch Pediatr Adolesc Med 1997;151:1254–7.[Abstract]
11. Delichatsios H, Callahan M, Charlson M. Outcomes of telephone medical care. J Gen Intern Med 1998;13:579–85.[Medline]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
