The selection of relevant outcomes has been a contentious issue in previous evaluations of triage systems in primary care.27Most studies assessed primary care and hospital service use and workload. However,
these outcomes may not fully capture the aim of triage and more broadly the aim of primary care. We proposed that the aim of a primary care consultation management system is to provide an administrative framework for practices to facilitate (1) the safe, timely and definitive (‘first pass’) management of patients and (2) the timely and efficient management of primary care consulting time resource. We collected descriptive data on practices and patients, and for the following outcome domains: (1) total primary care workload [primary outcome measure (POM), including out-of-hours primary care, A&E and walk-in centre attendance]; (2) patient safety; (3) NHS resource use and cost, and non-attendance rates in primary care; (4) patient health status and experience of care; and (5) case complexity.
Describing practices and patients
Practice-level descriptive data (e.g. list size, location, rural or urban nature, staffing) were collected on trial entry via the Practice Profile Questionnaire completed by the practice manager. This questionnaire also captured information on the typical management of patients before the trial began, providing a description of‘UC’. Practice-level deprivation was collected from the APHO website.37
We collected patient-level descriptive data (age, gender, deprivation) from practice records. Patient self-reported ethnicity, presence of long-standing health conditions and ease of taking time away from work (where relevant) were derived from the postal questionnaire.
Primary outcome measure
The POM is the total number of NHS primary health-care contacts that took place in a 28-day period, commencing with the day of a patient’s index telephone request for a same-day consultation. This number includes the index consultation (initial health-care contact resulting from the index telephone call) and all subsequent NHS primary health-care contacts (as defined below) over the following 28 days, which may or may not be related to the nature of the index consultation. All POM data were collected via a case note review (seeData collection and management). The primary health-care contacts included in the POM were:
1. GP practice contacts:
i. GP face-to-face consultation (in surgery) ii. GP telephone consultation
iii. GP home visit (within surgery hours) iv. GP unspecified
v. nurse face-to-face consultation (in surgery) vi. nurse telephone consultation
vii. nurse home visit (within surgery hours) viii. nurse unspecified
2. out-of-hours primary care contacts:
i. GP face-to-face out-of-hours consultation ii. GP out-of-hours home visit
iii. GP telephone out-of-hours consultation iv. nurse face-to-face out-of-hours consultation
v. nurse out-of-hours home visit
vi. nurse out-of-hours telephone consultation vii. unspecified
3. walk-in centre contacts:
i. walk-in centre attendance (doctor) ii. walk-in centre attendance (nurse) iii. walk-in centre attendance (unspecified) 4. A&E contacts.
The focus of the trial is on primary care workload; however, it is recognised that changes in access to practice appointments may have a knock-on effect on A&E contacts and, therefore, these contacts were also included within the POM.
Secondary outcome measures
Patient safety
The number of deaths and unplanned‘emergency’hospital admissions (and associated number of bed-days) within 7 days, and A&E attendances within 28 days of the index consultation request were collected at case note review. An unplanned emergency hospital admission was defined when there was no evidence in the notes of advance planning, even on the day the admission occurred. The number of
‘planned’hospital admissions was also collected. An‘adverse events’reporting procedure (seeAppendix 10) was developed to monitor patient safety. The clinical lead(s) at each practice were contacted weekly by the trial researcher and asked to return a log sheet completed with any events arising during the intervention period, such as trial patient deaths, emergency hospital admissions or A&E attendances, as well as any problems with the triage system itself or patient complaints.
It became evident that the number of deaths recorded in the weekly log sheets of adverse events from practices did not always correspond to that identified at case note review. On discussion with the DMC, practices were asked to perform a search of their electronic records at the end of the trial to produce a report of all deaths occurring during the data collection period. This became the definitive source of data on patient deaths.
Patient management on the index day
A description of the management of patients on the index day of the same-day consultation request was based on patients’first two primary care contacts collected for our POM.
NHS resource use
The NHS resources that were combined into the POM were also reported separately as secondary outcomes. Non-attendance rates for allocated appointments in the 28 days following the index request were also collected by case note review. It was not possible to capture patients’contacts with NHS Direct from practice records. Patients’use of NHS Direct during the 28-day follow-up period was assessed through self-report by postal questionnaire.
We collected actual consultation length for the index triage and UC (face to face or telephone)
consultations on the Clinician Form (seeData collection and management). We also estimated the length of subsequent face-to-face consultations, for both‘same-day’and‘28-day follow-up’periods. The former was based on the recorded start and end times of a small sample of consultations captured over two randomly selected days in each practice during the intervention period. The latter was based on
consultation length used in published unit costs reported within the NHS Personal Social Services Research Unit (PSSRU38).
Patient-reported outcomes
All patient-reported outcomes were collected by the postal questionnaire.
Health status
Health status was assessed using the EuroQol Group European Quality of Life-5 Dimensions (EQ-5D39)
questionnaire, and a question on problem resolution28,29(five-point Likert scale). We had originally
intended to use the SF-36;40however, piloting emphasised the need to shorten the overall length of the
patient questionnaire for the main trial, and thus the shorter EQ-5D measure of health status was adopted (seeAppendix 1).
Patient experience of care
Patient experience in the context of this trial relates to an episode of care delivered following a same-day consultation request, potentially involving multiple health-care contacts during the index day. Survey instruments suitable for use in a UK setting ask individuals to evaluate a specific consultation41,42or
aggregate (practice-based) care. As no validated instruments assessing the patient’s experience of an overall episode of care were identified, we used relevant questions from the national GP Patient Survey instrument,43modifying the questions to focus on the patient’s recent experiences of care rather than over
the last 6 months. Items selected included the responsiveness of the consultation management system (e.g. how quickly care was provided, overall satisfaction) and patient evaluations (using a five-point Likert scale)44,45of the timeliness and convenience of the response46to the same-day consultation request.
Case complexity
To define patient case mix, the clinician conducting the index consultation captured the complexity of the case (after Howieet al.)47using an eight-point scoring schedule incorporated on the Clinician Form (see Data collection and management). Each consultation was scored as having either substantial (2 points), attributable (1 point) or no content (0 points) with respect to each of four domains: physical, social, psychological or‘other’(e.g. administrative) components to the consultation.