Current issues of ACP Journal Club are published in Annals of Internal Medicine


Quality Improvement

Clinician-initiated telephone calls substituted for clinic visits reduced costs and health care use

ACP J Club. 1992 July-Aug;117:30. doi:10.7326/ACPJC-1992-117-1-030


Source Citation

Wasson J, Gaudette C, Whaley F, et al. Telephone care as a substitute for routine clinic follow-up. JAMA. 1992 Apr 1;267:1788-93.


Abstract

Objective

To examine the effect of substituting clinician-initiated telephone calls for some clinic visits on medical care usage and patient health.

Design

Randomized trial with 2-year follow-up.

Setting

A Veterans Affairs primary care clinic.

Patients

497 men ≥ 54 years, who were ambulatory and lived within 168 km of the clinic, were included. Patients who had not used the clinic for 6 months, could not read or use the telephone, had only psychiatric or alcohol abuse problems, or required regular injections or blood tests were excluded. Clinicians were 6 board-certified internists, 5 physicians' assistants, and 3 nurse practitioners.

Intervention

After an initial visit clinicians recommended a date for the next visit. For control patients (usual care) an appointment was made. For patients in the telephone-care group, a clinic appointment was made with twice the recommended time interval, and 3 intervening clinician-initiated telephone calls were scheduled. Clinicians were given 60 minutes per week to make a maximum of 4 telephone calls and were provided with patient charts and prescription lists. At subsequent appointments clinicians were encouraged to lengthen the interval between visits for telephone-care patients.

Main outcome measures

Data on prescribed medications, tests, procedures, and hospitalizations were extracted from computerized records. Patient satisfaction and functional status were measured at baseline and at study end.

Main results

Clinicians made an average of 8 calls per patient and 83% of these were ≤ 10 minutes. Both groups were equally satisfied with their care provider, quality of care, and health care access. By year 2, 10 of 249 telephone-care and 18 of 248 usual-care patients had died (P = 0.12). Telephone-care costs were 28% less ($1656 saved per patient for 2 years, P = 0.004). Patients in the telephone-care group had 19% fewer clinic visits (P < 0.001); took 14% fewer medications (P = 0.006); and had fewer hospitalizations per patient (1.74 vs 2.24, P = 0.01), shorter hospital stays (28% fewer days, P = 0.005), and 41% fewer intensive care unit days (P = 0.03). For patients starting with fair or poor health, telephone care resulted in lower care charges ($1292 saved per patient for 2 years, P = 0.01) and a possible reduction in mortality (P = 0.06) and improved activity (P = 0.02).

Conclusion

Physician-initiated telephone calls substituted for some clinic visits lowered costs and health care usage without harming patient health.

Source of funding: Veterans Affairs Health Services Research and Development Program.

Address for reprint: Dr. J. Wasson, Center for the Aging, Dartmouth Medical School, 7265 Strasenburgh Hall, Hanover, NH 03755-3862,USA.


Commentary

The article by Wasson and colleagues addresses 1 aspect of telephone-based patient care: the pre-emptive phone call. This study shows that telephone contact initiated by a primary care provider can substitute for direct face-to-face contact, without a decline in satisfaction or health outcome. Cost reduction was substantial (28%). There was some indication that regular telephone contact might actually improve mortality for patients who perceived their health to be fair or poor at the start of the study. On the other hand, an increase occurred in the number of patients with 1 poor blood pressure measurement among the telephone-care compared with the usual-care groups after 24 months (4.5% vs 1.2%, P = 0.02).

The authors appropriately comment on the limited generalizability of this report (compliant, male veterans from rural Vermont) and the implications (patients are satisfied and expenditures are reduced without compromising outcomes). They correctly conclude that telephone care is unlikely to be widely adopted despite its potential benefits unless current reimbursement policies are changed. They propose a reimbursement rate for a telephone contact equivalent to an outpatient visit (Current Procedural Terminology [CPT] code value of 1.0). Although this suggestion is reasonable, it remains to be tested whether this would be adequate incentive for physicians to change their practice, whether similar benefits would be obtained in other settings where the providers may be less motivated and receive less encouragement to lengthen the interval between office visits, and whether providers in other settings would find telephone care equally satisfying.

Other unresolved issues include 1) What would the effect be on patients if they had to pay for telephone contact? 2) How much telephone contact should be "bundled" with a given office visit? 3) What are the liability limits to "telephone medicine"? 4) How are patients to be educated about the best way to use telephone contact? The telephone has become an essential tool in patient management. Wasson and colleagues have begun the process to determine what value society will assign to this aspect of medical practice.

John D. Goodson, MD
Massachusetts General HospitalBoston, Massachusetts, USA