Effectiveness of Acute Care Remote Triage Systems: a Systematic Review

Abstract

Background

Technology-based systems can facilitate remote decision-making to triage patients to the appropriate level of care. Despite technologic advances, the effects of implementation of these systems on patient and utilization outcomes are unclear. We evaluated the effects of remote triage systems on healthcare utilization, case resolution, and patient safety outcomes.

Methods

English-language searches of MEDLINE (via PubMed), EMBASE, and CINAHL were performed from inception until July 2018. Randomized and nonrandomized comparative studies of remote triage services that reported healthcare utilization, case resolution, and patient safety outcomes were included. Two reviewers assessed study and intervention characteristics independently for study quality, strength of evidence, and risk of bias.

Results

The literature search identified 5026 articles, of which eight met eligibility criteria. Five randomized, two controlled before-and-after, and one interrupted time series study assessed 3 categories of remote triage services: mode of delivery, triage professional type, and system organizational level. No study evaluated any other delivery mode other than telephone and in-person. Meta-analyses were unable to be performed because of study design and outcome heterogeneity; therefore, we narratively synthesized data. Overall, most studies did not demonstrate a decrease in primary care (PC) or emergency department (ED) utilization, with some studies showing a significant increase. Evidence suggested local, practice-based triage systems have greater case resolution and refer fewer patients to PC or ED services than regional/national systems. No study identified statistically significant differences in safety outcomes.

Conclusion

Our review found limited evidence that remote triage reduces the burden of PC or ED utilization. However, remote triage by telephone can produce a high rate of call resolution and appears to be safe. Further study of other remote triage modalities is needed to realize the promise of remote triage services in optimizing healthcare outcomes.

Protocol Registration

This study was registered and followed a published protocol (PROSPERO: CRD42019112262).

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References

  1. 1.

    Population Reference Bureau. Fact Sheet: Aging in the United States. Report. Available at: https://www.prb.org/aging-unitedstates-fact-sheet/. Accessed 6 Dec 2018.

  2. 2.

    Ailes EC, Gilboa SM, Honein MA, Oster ME. Estimated number of infants detected and missed by critical congenital heart defect screening. Pediatrics. 2015;135(6):1000–8.

    Article  Google Scholar 

  3. 3.

    Centers for Disease Control and Prevention (CDC). National Center for Chronic Disease Prevention and Health Promotion. Multiple Chronic Conditions. Available at: https://www.cdc.gov/chronicdisease/about/multiple-chronic.htm. Accessed 6 Dec 2018.

  4. 4.

    Agency for Healthcare Research and Quality. The Distribution of the U.S. Primary Care Workforce. Available at: https://www.ahrq.gov/research/findings/factsheets/primary/pcwork3/index.html. Accessed 6 Dec 2018.

  5. 5.

    Bodenheimer T, Pham HH. Primary care: current problems and proposed solutions. Health Aff (Millwood). 2010;29(5):799–805.

    Article  Google Scholar 

  6. 6.

    Kullgren JT, McLaughlin CG, Mitra N, Armstrong K. Nonfinancial barriers and access to care for U.S. adults. Health Serv Res. 2012;47(1 Pt 2):462–85.

    Article  Google Scholar 

  7. 7.

    Douthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some important barriers to health care access in the rural USA. Public Health. 2015;129(6):611–20.

    CAS  Article  Google Scholar 

  8. 8.

    Pitts SR, Carrier ER, Rich EC, Kellermann AL. Where Americans get acute care: increasingly, it's not at their doctor's office. Health Aff (Millwood). 2010;29(9):1620–9.

    Article  Google Scholar 

  9. 9.

    Gindi RM, Black LI, Cohen RA. Reasons for Emergency Room Use Among U.S. Adults Aged 18–64: National Health Interview Survey, 2013 and 2014. Natl Health Stat Report. 2016(90):1–16.

  10. 10.

    O'Malley AS. After-hours access to primary care practices linked with lower emergency department use and less unmet medical need. Health Affairs. 2013;32(1):175–183.

    Article  Google Scholar 

  11. 11.

    van Galen LS, Car J. Telephone consultations. BMJ. 2018;360k1047.

  12. 12.

    Mechanic OJ, Kimball AB. Telehealth Systems. StatPearls. Treasure Island (FL); 2018.

    Google Scholar 

  13. 13.

    Shih J, Portnoy J. Tips for Seeing Patients via Telemedicine. Curr Allergy Asthma Rep. 2018;18(10):50.

    Article  Google Scholar 

  14. 14.

    Saliba V, Legido-Quigley H, Hallik R, Aaviksoo A, Car J, McKee M. Telemedicine across borders: a systematic review of factors that hinder or support implementation. Int J Med Inform. 2012;81(12):793–809.

    Article  Google Scholar 

  15. 15.

    Bunn F, Byrne G, Kendall S. Telephone consultation and triage: effects on health care use and patient satisfaction. Cochrane Database Syst Rev. 2004(4):Cd004180.

  16. 16.

    Ismail SA, Gibbons DC, Gnani S. Reducing inappropriate accident and emergency department attendances: a systematic review of primary care service interventions. Br J Gen Pract. 2013;63(617):e813–20.

    Article  Google Scholar 

  17. 17.

    Lake R, Georgiou A, Li J, et al. The quality, safety and governance of telephone triage and advice services - an overview of evidence from systematic reviews. BMC Health Serv Res. 2017;17(1):614.

    Article  Google Scholar 

  18. 18.

    Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.

    Article  Google Scholar 

  19. 19.

    Evidence Partners Inc. DistillerAI website. Available at: https://www.evidencepartners.com/distiller-ai/. Accessed 12 Oct 2018.

  20. 20.

    Cochrane Effective Practice and Organisation of Care (EPOC). Suggested risk of bias criteria for EPOC reviews. EPOC Resources for review authors. 2017. Available at: http://epoc.cochrane.org/resources/epoc-resources-review-authors Accessed 17 May 2018.

  21. 21.

    Campbell JL, Fletcher E, Britten N, et al. Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis. Lancet. 2014;384(9957):1859–1868.

    Article  Google Scholar 

  22. 22.

    Turner J, O'Cathain A, Knowles E, Nicholl J. Impact of the urgent care telephone service NHS 111 pilot sites: a controlled before and after study. BMJ Open. 2013;3(11):e003451.

    CAS  Article  Google Scholar 

  23. 23.

    Richards DA, Godfrey L, Tawfik J, et al. NHS Direct versus general practice based triage for same day appointments in primary care: cluster randomised controlled trial. BMJ. 2004;329(7469):774.

    Article  Google Scholar 

  24. 24.

    Richards DA, Meakins J, Tawfik J, et al. Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs. BMJ. 2002;325(7374):1214.

    Article  Google Scholar 

  25. 25.

    McKinstry B, Walker J, Campbell C, Heaney D, Wyke S. Telephone consultations to manage requests for same-day appointments: a randomised controlled trial in two practices. Br J Gen Pract. 2002;52(477):306–10.

    PubMed  PubMed Central  Google Scholar 

  26. 26.

    Lattimer V, George S, Thompson F, et al. Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial. The South Wiltshire Out of Hours Project (SWOOP) Group. BMJ. 1998;317(7165):1054–9.

    CAS  Article  Google Scholar 

  27. 27.

    Cragg DK, McKinley RK, Roland MO, et al. Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. I: The process of care. BMJ. 1997;314(7075):187–9.

    CAS  Article  Google Scholar 

  28. 28.

    Munro J, Nicholl J, O'Cathain A, Knowles E. Impact of NHS Direct on demand for immediate care: Observational study. BMJ. 2000;321(7254):150–153.

    CAS  Article  Google Scholar 

  29. 29.

    Friedman BW, Mulvey L, Davitt M, et al. Predicting 7-day and 3-month functional outcomes after an ED visit for acute nontraumatic low back pain. Am J Emerg Med. 2012;30(9):1852–1859.

    Article  Google Scholar 

  30. 30.

    Downes MJ, Mervin MC, Byrnes JM, Scuffham PA. Telephone consultations for general practice: a systematic review. Syst Rev. 2017;6(1):128.

    Article  Google Scholar 

  31. 31.

    Blank L, Coster J, O'Cathain A, et al. The appropriateness of, and compliance with, telephone triage decisions: a systematic review and narrative synthesis. J Adv Nurs. 2012;68(12):2610–21.

    Article  Google Scholar 

  32. 32.

    Bunn F, Byrne G, Kendall S. The effects of telephone consultation and triage on healthcare use and patient satisfaction: a systematic review. Br J Gen Pract. 2005;55(521):956–61.

    PubMed  PubMed Central  Google Scholar 

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Funding

This project was funded by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative (ESP 09-010). This work was also supported by the Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) (CIN 13-410) at the Durham VA Health Care System. The views expressed are those of the authors and do not reflect the official views or policy of the Department of Defense or its Components. Dr. Goldstein’s effort is supported by VA HSR&D CDA award no. 13-263. Dr. Van Voorhees’s effort is supported by VA Rehabilitation Research and Development CDA (1K2RX001298). Dr. Whited is supported by VA HSR&D Award SDR 16-192. Dr. Lewinski is supported by a VA OAA HSR&D PhD Fellowship TPH 21-000.

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Contributions

The authors gratefully acknowledge Chad Kessler for his help with topic scoping, Eric Monson for his help with data visualization, Belinda Ear for help with project administration, and Liz Wing for editorial assistance. Additionally, we would like to thank the following key stakeholders and technical expert panel members for their feedback during the development and execution of this project: Jennifer MacDonald, Elizabeth Yano, Peter Kaboli, and Danielle Rose.

Corresponding author

Correspondence to Joel C. Boggan MD, MPH.

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Boggan, J.C., Shoup, J.P., Whited, J.D. et al. Effectiveness of Acute Care Remote Triage Systems: a Systematic Review. J GEN INTERN MED 35, 2136–2145 (2020). https://doi.org/10.1007/s11606-019-05585-4

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KEY WORDS

  • remote triage
  • telephone triage
  • healthcare utilization
  • patient safety
  • systematic review