Call Center Remote Triage by Nurse Practitioners Was Associated With Fewer Subsequent Face-to-Face Healthcare Visits

Abstract

Background: In 2015, the Veterans Health Administration (VHA) incorporated nurse practitioners (NPs) into remote triage call centers to supplement registered nurse (RN)-handled calls.

Objective: To assess 7-day healthcare use following telephone triage by NPs compared to RNs. We hypothesized that NP clinical decision ability may reduce follow-up healthcare.

Design: Retrospective observational comparative effectiveness study of clinical and administrative databases. NP routed calls were matched to RN calls based on chief complaint with propensity score matching and multivariate count data models, adjusting for differences in call severity and patient comorbidity.

Participants: Callers to a VHA regional call center, April 2015 to March 2019.

Main measures: Primary care, specialty care, and emergency department (ED) visits plus hospitalizations within 7 days.

Key results: NP-handled calls (N = 1554) were matched to RN calls (N = 48,024) for the same chief complaint. NP-handled calls, compared to RNs, had lower comorbidities, fewer hospitalizations, and less urgent complaints. Seven-day healthcare use was lower for NP compared to RN calls for specialty care (0.15 vs. 0.20 visits per person [VPP]; p < 0.001), ED (0.11 vs. 0.27 VPP; p < 0.001), and hospitalizations (0.01 vs. 0.04 VPP; p < 0.001), but not primary care (0.43 vs. 0.42 VPP; p = 0.80). In adjusted analyses, estimated avoided in-person visits per 100 calls routed to NPs were 0.7 primary care visits (95% confidence interval [CI] 0.4, 1.0), 2.6 specialty care visits (95% CI 0.0, 5.1), 5.9 ED visits (95% CI 2.7, 9.1), and 1.4 hospital stays (95% CI 0.1, 2.6). Propensity score-matched models comparing NP (N = 1533) to RN (N = 2646) calls had adjusted odds ratios for 7-day healthcare use of 0.75 (primary care), 0.75 (specialty care), and 0.73 (ED) (all p < 0.003).

Conclusion: Incorporating NPs into a call center was associated with lower in-person healthcare use in the subsequent 7 days compared to routine RN-triaged calls.

Keywords: after-hours care; call center; telephone medicine; telephone triage.

Figure 1

Flow diagram of patient experience when contacting call center.

Fig. 2

Adjusted probability of healthcare use by day, type of use, and whether call was routed to an NP or RN. Calls to an NP were matched to RN routed calls based on the chief complaint of the call and whether the call was received during normal working hours. Estimates are adjusted for probability of visit from logistic regressions that controlled for patient socio-demographics, duration of the complaint, urgency of the condition as defined by the triage software, patient-reported pain score, and number of complicating factors the patients identified.

Figure 3

Propensity score–matched probability of healthcare use by day, type of use, and whether call was routed by an NP or RN. Propensity score model results do not include hospitalization due to small sample size and inability to adequately match.