Controversy exists regarding accessing after-hour telephone care by families unaccustomed to formal call systems. The Department of Pediatrics provides attending physician staffing for 5 ambulatory pediatric clinics and one private faculty practice site. All of these sites are located in the Bronx, New York. Almost all of the patients in the ambulatory clinic sites are enrolled in our hospital’s Medicaid Managed Care plan or have traditional Medicaid. The faculty practice serves patients with private insurance and Medicaid Managed Care.
The objective of this study was to examine the use of an after-hours telephone system by patients who receive care from any of the 5 ambulatory pediatric clinics compared with the faculty practice.
A review of all after-hours calls received by the pediatric on-call attending was conducted for the three-year period from July 1, 2001-June 30, 2004. The on-call attending physician receives telephone calls from five ambulatory pediatric clinics and one private faculty practice. This physician must complete a call sheet for each call, which includes the name of the caller’s primary care provider and clinic location. The total number of general pediatric visits to the five ambulatory clinics and faculty practice for the identical three-year period was also tabulated for comparison.
A total of 1,037 calls were received during the three-year period; 766 calls (73.9%) were from patients of the faculty practice and 271 calls (26.1%) were from the five ambulatory clinic sites. During the corresponding period, there were a total of 150,984 patient visits; 16,431 (10.9%) patient visits were to the faculty practice and 134,553 (89.1%) visits were to the ambulatory clinic sites. There was a significant difference between the calls/1000 visit ratio for the faculty practice (47.9±10.1) compared with the calls/1000 visit ratio for the clinic sites (2.0±0.8, p<.02).
Almost three times as many calls were received from faculty practice patients, yet the faculty practice accounted for only 10% of the total patient visits. Possible explanations for this dramatic difference may include (1) the protocol in the faculty practice is for patients to call the main office number and be connected to the answering service, whereas ambulatory clinic patients must call a separate 1-800 number that is listed on the back of their medicaid managed care insurance cards and (2) the more varied payor mix in the faculty practice – patients with private insurance may be more familiar with after-hours accessing of telephone care.
After-hour telephone triage systems – primarily staffed by nurses – are a fact of life in the United States in 2005. There are more than 50 pediatric call centers in the United States providing service to both adults and children. Recent data from the American Academy of Pediatrics Periodic Survey of Fellows provides an insight into the current popularity of such services. 1 Five hundred and forty Fellows of the Academy responded to the survey in 2000 (response rate 52%). Of those that provide telephone triage from their main practice during office hours, 63.9% of respondents indicated that nursing/office staff used written telephone triage protocols. Forty-six per-cent indicated that nursing/office staff used no written protocols and only 7.3% had a computerized/automated triage system for incoming calls. Of those whose triage was provided by the main practice after office hours, 64% used an answering service/hospital switchboard. Only 20.6% had a computerized triage service with trained staff nurses using written decision protocols, while 19.6% used a similar system with computerized protocols. Fourteen per-cent used voicemail with directions to call 911/ED or leave non-urgent recorded messages and 11.2% used a centralized triage service with trained staff.
No previous study has examined after-hours telephone consultation – specifically the difference between patients enrolled in Medicaid managed care plans and those enrolled in both Medicaid managed care and private insurance plans. 2 The objective of this study was to examine the use of an after-hours telephone system staffed by pediatric attending physicians comparing those patients who receive their care from 1 of 5 ambulatory pediatric clinics with those patients who receive their care from the faculty practice.
The After-Hours Telephone Consultation Service of the Department of Pediatrics provides after-hours telephone coverage for all children enrolled in either Partners in Health (PIH), the hospital’s Medicaid managed care plan, Medicaid, or any third party insurance provider. St. Barnabas Hospital serves an underserved area of the Mid-South Bronx. The population is ethnically diverse with primarily Hispanic and African American persons. The Department of Pediatrics at St. Barnabas Hospital consists of approximately 45 full and part-time faculty divided into the Divisions of Ambulatory Pediatrics, Pediatric Emergency Medicine, Inpatient Pediatrics, and Neonatology. Most of the faculty hold appointments at the Weill Medical College of Cornell University. The Hospital is affiliated with the New York Presbyterian Healthcare System.
The community served by the hospital is characterized by substantial poverty and is considered to be among the most economically depressed areas in New York State. In the year 2000, Bronx County consisted of 1,322,650 people or 17% of the population of New York City. The primary and secondary service areas of St. Barnabas Hospital and its affiliates encompass 17 zip codes located in Bronx County. The population of the primary service area is 425,445 and the secondary service area is 589,534 persons. The Bronx is racially diverse: 48.4% Hispanic, 31.2% African American, 14.5% White, and 5.9% “Other.” In 2000, 8.2% of all children living in New York City who were less than 5 years of age lived in the Bronx. This represented the highest percentage of this age group in the City. An overwhelming 61% of children in the service area are dependent on public assistance compared to 49% for Bronx County. 2
Those children covered by PIH or Medicaid are enrolled for their continuity of care in the primary care clinics of either the St. Barnabas Pediatric Primary Care Clinic or one of 4 satellite clinics located within a few miles of the main hospital setting (Union Community Health Center, Grand Concourse Health Center, Fordham Plaza Health Center and the Pediatric Clinic at 149th Street (formerly the HIP Clinic). There are a small number of patients with commercial insurance seen at any one of these 5 clinic sites. Patients receiving their continuity of care at any of these locations are defined as “clinic.” Those children who have third party commercial insurance or Medicaid managed care can be enrolled in the Faculty Practice at Bronx Park Medical Pavilion, located approximately 3 miles from the Hospital.
Beginning at 5pm each weeknight and all day Saturday and Sunday, the on-call attending physician, a member of the Division of Ambulatory Pediatrics is available to receive calls from both clinic and faculty practice patients. The attending physician must complete a call sheet for each patient contact, which includes the caller’s primary care provider and continuity clinic location.
We reviewed all calls to the on-call physician from July 1, 2001 to June 30, 2004. Data was abstracted from the call sheet. Comparisons were made between those calls made from any of the 5 ambulatory clinics and those calls from patients enrolled in the faculty practice. Chi-square was used to examine relationships between categorical variables and student’s t-test was used to examine relationships between dimensional variables. SPSS PC Ver. 10 was used as the statistical program.
A total of 1,037 calls were received during the three-year period; 766 calls (73.9%) were from patients enrolled in the faculty practice and 271 calls (26.1%) were from all five ambulatory clinic sites. During the same period of time, there were a total of 150,984 ambulatory pediatric patient visits: 16,431 (10.9%) patient visits were patient visits to the faculty practice and 134,553 (89.1%) were visits to all of the five ambulatory clinic sites. There was a significant difference between the calls/1000 visit ratio for patients enrolled in the faculty practice compared with the calls/1000 visit ratio for the clinic sites over the three-year period of study (Figure 1). This relationship was also found when we examined each individual year of study.
Our data showed that almost three times as many after-hour telephone calls were received from patient’s caregivers enrolled in the faculty practice, yet the faculty practice accounted for only 10% of the total patient visits during the study period. Possible explanations for this dramatic difference may include differences in how patient caregivers access the system. The protocol in the faculty practice is for patients to call the faculty practice main office number, which is answered by the answering service. The answering service then pages the pediatrician on call and connects them to the caregiver. Patients enrolled in one of the 5 ambulatory clinics must call a separate 1-800 number that is listed on the back of their Medicaid managed care insurance cards, which can be misplaced. Furthermore, the difference may also be explained by recognizing that there is a more varied payor mix in the faculty practice – some patients with private insurance may be more accustomed to after-hours medical access. These data suggest that 1) it may be helpful to use one system of access instead of two, and 2) a uniform policy of “when to call the after-hours physician on call” should be instituted through educational programs at both the Clinic and faculty practice locations.
There are some specific limitations of this study that may impact our findings. We did not collect data on the reason or chief complaint, level of urgency and disposition of each specific call, which could have contributed to the higher volume of calls from the faculty practice. Belman et al. recently published their experience in a 1 year study examining after-hours telephone calls to a computerized database which contained 90% of all calls made in the State of Colorado. 3 Of their total amount of calls (141,922) 88% were due to a clinical illness, 5% for information or advice, 5% where a parent could not be recontacted, 1% for duplicate calls and 1% for miscellaneous reasons. Twenty-one per-cent of this group were referred for urgent evaluation. Scarfone et al. recently published their findings from the receiving end of this process – the Pediatric Emergency Department. 4 5 Of the 8,265 telephone calls to the call center 1,473 (18%) children were referred to the Pediatric emergency yet only 931 (63%) were compliant and actually proceeded at the Emergency Department. The most common reasons cited by patients in Scarfone’s study for proceeding to the Emergency Department were related to the lower respiratory tract (50%) and gastrointestinal (14%) system.
In summary, this study demonstrates a wide disparity in the utilization of an after-hours pediatric telephone consultation service. Future studies should examine the impact of educational programs designed to provide improvements in the system as well as reasons and degree of urgency communicated by a patient’s caregiver and the eventual disposition of the problem.
American Academy of Pediatrics. Periodic Survey of Fellows No. 43. http://www.aap.org/research/periodicsurvey/ps43soci.htm#4a. Accessed December 3, 2005.
United States Census Year 2000. http://www.census.gov/. Accessed December 5, 2005.