Patients evaluate accessibility and nurse telephone consultations in out-of-hours GP care: Determinants of a negative evaluation
Introduction
In some western countries a tendency can be observed away from GP practices collaborating in local rotas during out-of-out-hours primary health care, towards large-scaled GP cooperatives with use of telephone triage and consultation [1], [2]. This reorganization resulted in a sharp decrease of GP workload [3] and was also associated with higher levels of job satisfaction by GPs [4], [5], [6], [7].
These changes may have had important consequences for patients as well. Formerly, patients were most likely to speak to a GP on the phone and receive GP care from a small and local rota group, whereas currently their call is being answered by a telephone nurse who decides what action should take place. In many GP cooperatives, there has been a sharp decrease in the number of home visits, while up to 50% of all contacts is now handled by telephone alone [3]. Although nurse telephone triage appears to be effective and safe [8], patients who received a nurse telephone consultation showed lower satisfaction levels than those who contacted a GP [9], [10], [11], [12], [13].
In Denmark GPs decided to take on the telephone triage themselves [2], while the UK introduced telephone nurses [3]. Also, the UK and Switzerland introduced national telephone help lines which are freely accessible to all residents and provide telephone triage and advice by trained nurses [14], [15]. The Netherlands has a hybrid model: a GP is available in the background for consultation and supervision, but the triage nurse handles the large majority of the telephone calls by herself [16]. Some cooperatives in the Netherlands prefer a more prominent role for the GP in telephone triage and advice. They created a special function of ‘telephone doctor’ who is present at all times at the cooperatives’ call centre, giving advice and feed-back to triage nurses and taking over in complex cases [17].
Based on literature we hypothesized that a mismatch in expectation of care mode (telephone nurse advice only, instead of contact with a doctor) [18], age (younger respondents) [9], [12] and nationality (non-Dutch) [9] would be associated with a more negative evaluation.
Based on our own impressions, we also expected a more positive patient evaluation in large cooperatives, having more staff to guarantee the quality of telephone triage and financial capacity to arrange for one or more fully equipped satellite locations to increase the proximity to the population served. Likewise, we expected that patients would favour a model with a more prominent role for the GP in telephone triage and advice [17].
To test such hypotheses we performed a multi-centred study in 26 GP cooperatives. We focused on the negative patient evaluation to find incentives for improving the quality of care, using the following questions:
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Which aspects of the GP cooperative's accessibility and nurse telephone consultation were more negatively evaluated?
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To what extent are patient- or GP cooperative-related determinants associated with a negative patient evaluation on accessibility and nurse telephone consultation?
Section snippets
Design and population
A cross-sectional study was performed by means of postal patient questionnaires, sent to patients who only received a telephone consultation from a GP cooperative. This study was conducted from March 2003 to May 2005 within 28 GP cooperatives across the Netherlands serving around 4 million patients, a quarter of the total Dutch population. These GP cooperatives have most of the following features in common listed in Box 1.
All participating GP cooperatives followed a standard research protocol.
Population
In total 28 GP cooperatives participated in this study. Two cooperatives that were not able to follow the research protocol were excluded. Altogether, 5239 questionnaires were posted to patients who had received a telephone consultation, and 2583 patients responded (49.3%).
Patient evaluation
Overall, average scores for both scales were satisfactory, ranging from 7.2 for accessibility to 7.6 for nurse telephone consultation, respectively. Nevertheless, a substantial percentage of the respondents gave negative
Discussion
Although the overall evaluation of accessibility and nurse telephone consultation appears to be satisfactory, considerable differences were found between the highest and lowest percentages of negative evaluations by respondents from the 26 participating GP cooperatives. Overall, the lowest evaluation was given for the general information received on the GP cooperative, followed by various aspects of nurse telephone consultation, like effectiveness of the advice or reassurance.
Patients who
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