title: Nurse telephone triage in out-of-hours GP practice: determinants of independent advice and return consultation.
abstract: BACKGROUND
  Nowadays, nurses play a central role in telephone triage in Dutch out-of-hours primary care. The percentage of calls that is handled through nurse telephone advice alone (NTAA) appears to vary substantially between GP cooperatives. This study aims to explore which determinants are associated with NTAA and with subsequent return consultations to the GP.
  
  
  METHODS
  For the ten most frequently presented problems, a two-week follow-up cohort study took place in one cooperative run by 25 GPs and 8 nurses, serving a population of 62,291 people. Random effects logistic regression analysis was used to study the determinants of NTAA and return consultation rates. The effect of NTAA on hospital referral rates was also studied as a proxy for severity of illness.
  
  
  RESULTS
  The mean NTAA rate was 27.5%--ranging from 15.5% to 39.4% for the eight nurses. It was higher during the night (RR 1.63, CI 1.48-1.76) and lower with increasing age (RR 0.96, CI 0.93-0.99, per ten years) or when the patient presented >2 problems (RR 0.65; CI 0.51-0.83). Using cough as reference category, NTAA was highest for earache (RR 1.49; CI 1.18-1.78) and lowest for chest pain (RR 0.18; CI 0.06-0.47). After correction for differences in case mix, significant variation in NTAA between nurses remained (p < 0.001). Return consultations after NTAA were higher after nightly calls (RR 1.23; CI 1.04-1.40). During first return consultations, the hospital referral rate after NTAA was 1.5% versus 3.8% for non-NTAA (difference -2.2%; CI -4.0 to -0.5).
  
  
  CONCLUSIONS
  Important inter-nurse variability may indicate differences in perception on tasks and/or differences in skill to handle telephone calls alone. Future research should focus more on modifiable determinants of NTAA rates.
authors.affiliation: Department of General Practice, Academic Medical Centre, University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands. e.p.mollvancharante@amc.uva.nl
authors.forename: Eric Peter
authors.initials: EP
authors.lastname: Moll van Charante
authors.forename: Gerben
authors.initials: G
authors.lastname: ter Riet
authors.forename: Sara
authors.initials: S
authors.lastname: Drost
authors.forename: Loes
authors.initials: L
authors.lastname: van der Linden
authors.forename: Niek S
authors.initials: NS
authors.lastname: Klazinga
authors.forename: Patrick J E
authors.initials: PJ
authors.lastname: Bindels
mesh_terms: D000328:Adult; D039602:After-Hours Care; D000368:Aged; D003266:Continuity of Patient Care / Q000706:statistics & numerical data*; D003953:Diagnosis-Related Groups; D005194:Family Practice / Q000458:organization & administration* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D009726:Nurses / Q000592:standards / Q000706:statistics & numerical data*; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D010865:Pilot Projects; D011787:Quality of Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012044:Regression Analysis; D013647:Task Performance and Analysis; D013689:Telephone; D014218:Triage