title: Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis.
abstract: BACKGROUND
  Telephone triage is increasingly used to manage workload in primary care; however, supporting evidence for this approach is scarce. We aimed to assess the effectiveness and cost consequences of general practitioner-(GP)-led and nurse-led telephone triage compared with usual care for patients seeking same-day consultations in primary care.
  
  
  METHODS
  We did a pragmatic, cluster-randomised controlled trial and economic evaluation between March 1, 2011, and March 31, 2013, at 42 practices in four centres in the UK. Practices were randomly assigned (1:1:1), via a computer-generated randomisation sequence minimised for geographical location, practice deprivation, and practice list size, to either GP-led triage, nurse-led computer-supported triage, or usual care. We included patients who telephoned the practice seeking a same-day face-to-face consultation with a GP. Allocations were concealed from practices until after they had agreed to participate and a stochastic element was included within the minimisation algorithm to maintain concealment. Patients, clinicians, and researchers were not masked to allocation, but practice assignment was concealed from the trial statistician. The primary outcome was primary care workload (patient contacts, including those attending accident and emergency departments) in the 28 days after the first same-day request. Analyses were by intention to treat and per protocol. This trial was registered with the ISRCTN register, number ISRCTN20687662.
  
  
  RESULTS
  We randomly assigned 42 practices to GP triage (n=13), nurse triage (n=15), or usual care (n=14), and 20,990 patients (n=6695 vs 7012 vs 7283) were randomly assigned, of whom 16,211 (77%) patients provided primary outcome data (n=5171 vs 5468 vs 5572). GP triage was associated with a 33% increase in the mean number of contacts per person over 28 days compared with usual care (2·65 [SD 1·74] vs 1·91 [1·43]; rate ratio [RR] 1·33, 95% CI 1·30-1·36), and nurse triage with a 48% increase (2·81 [SD 1·68]; RR 1·48, 95% CI 1·44-1·52). Eight patients died within 7 days of the index request: five in the GP-triage group, two in the nurse-triage group, and one in the usual-care group; however, these deaths were not associated with the trial group or procedures. Although triage interventions were associated with increased contacts, estimated costs over 28 days were similar between all three groups (roughly £75 per patient).
  
  
  CONCLUSIONS
  Introduction of telephone triage delivered by a GP or nurse was associated with an increase in the number of primary care contacts in the 28 days after a patient's request for a same-day GP consultation, with similar costs to those of usual care. Telephone triage might be useful in aiding the delivery of primary care. The whole-system implications should be assessed when introduction of such a system is considered.
  
  
  BACKGROUND
  Health Technology Assessment Programme UK National Institute for Health Research.
authors.affiliation: Primary Care Research Group, University of Exeter Medical School, Exeter, UK. Electronic address: john.campbell@exeter.ac.uk.
authors.forename: John L
authors.initials: JL
authors.lastname: Campbell
authors.affiliation: Primary Care Research Group, University of Exeter Medical School, Exeter, UK.
authors.forename: Emily
authors.initials: E
authors.lastname: Fletcher
authors.affiliation: Institute of Health Service Research, University of Exeter Medical School, Exeter, UK.
authors.forename: Nicky
authors.initials: N
authors.lastname: Britten
authors.affiliation: Institute of Health Service Research, University of Exeter Medical School, Exeter, UK.
authors.forename: Colin
authors.initials: C
authors.lastname: Green
authors.affiliation: Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
authors.forename: Tim A
authors.initials: TA
authors.lastname: Holt
authors.affiliation: School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK.
authors.forename: Valerie
authors.initials: V
authors.lastname: Lattimer
authors.affiliation: Institute of Health Service Research, University of Exeter Medical School, Exeter, UK.
authors.forename: David A
authors.initials: DA
authors.lastname: Richards
authors.affiliation: Primary Care Research Group, University of Exeter Medical School, Exeter, UK.
authors.forename: Suzanne H
authors.initials: SH
authors.lastname: Richards
authors.affiliation: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: Chris
authors.initials: C
authors.lastname: Salisbury
authors.affiliation: Primary Care Research Group, University of Exeter Medical School, Exeter, UK.
authors.forename: Raff
authors.initials: R
authors.lastname: Calitri
authors.affiliation: Department of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK.
authors.forename: Vicky
authors.initials: V
authors.lastname: Bowyer
authors.affiliation: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: Katherine
authors.initials: K
authors.lastname: Chaplin
authors.affiliation: Institute of Health Service Research, University of Exeter Medical School, Exeter, UK.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Kandiyali
authors.affiliation: School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK.
authors.forename: Jamie
authors.initials: J
authors.lastname: Murdoch
authors.affiliation: Department of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK.
authors.forename: Julia
authors.initials: J
authors.lastname: Roscoe
authors.affiliation: School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK.
authors.forename: Anna
authors.initials: A
authors.lastname: Varley
authors.affiliation: Primary Care Research Group, University of Exeter Medical School, Exeter, UK.
authors.forename: Fiona C
authors.initials: FC
authors.lastname: Warren
authors.affiliation: Primary Care Research Group, University of Exeter Medical School, Exeter, UK.
authors.forename: Rod S
authors.initials: RS
authors.lastname: Taylor
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D016000:Cluster Analysis; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D005260:Female; D058006:General Practice / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012016:Reference Values; D012017:Referral and Consultation / Q000191:economics* / Q000706:statistics & numerical data; D013222:State Medicine / Q000191:economics; D013689:Telephone / Q000191:economics / Q000706:statistics & numerical data*; D013997:Time Factors; D014218:Triage / Q000191:economics / Q000379:methods*; D006113:United Kingdom; D016526:Workload; D055815:Young Adult