David E. Hildebrandt, PhD

We found recently that about 10% of after-hours calls from patients were not forwarded by the answering service to the physician on call because the patient did not think the problem was an emergency.¹ In reviewing these calls, it became evident that many were indeed serious enough to require immediate contact with a medical professional.

The purpose of this study was to evaluate the management of after-hours phone calls made to primary care physicians’ offices and their answering services in a large metropolitan area. General descriptions of after-hours calls have been reported,^2,3,4 and the management of these calls by professional and nurse triage services have been studied.^5,6 However, the management of telephone triage by answering services has not been examined. No published data exist on the number of after-hours phone calls to US physicians.

Methods

This study had 2 components. In part 1, we surveyed 91 primary care offices (in family practice, internal medicine, obstetrics, and pediatrics) to determine how they handle after-hours phone calls. In part 2, we analyzed all calls from our previous study¹ that were not identified by the patient as an emergency and, hence, not forwarded to the on-call physician.

Survey of primary care physicians’ answering services

The physicians in each specialty were identified in their respective section of the telephone book,⁷ and, by using a systematic sampling technique, every fifth name was selected and surveyed. All surveys were completed in October and November 2001 after regular office hours, generally between 10:00 PM and 1:00 AM.

Using a structured survey interview form, the principal investigator indicated during each call that this was an anonymous research survey and asked if the answering service personnel could answer several questions. The information collected in each 3- to 5-minute interview included: whether there was a recorded message, whether the patient was instructed to call 911, who answered the call after the recorded message, what information was requested, who made the decision to initiate contact with the on-call physician, and what happened to calls that were not forwarded.

If the patient was instructed to choose an “option” from the medical office telephone system, this option was selected if it would lead to an answering service. If it offered to call or page the physician directly, then that survey was terminated. The name of the answering service was recorded to determine how many different services were used in this metropolitan area. We did not survey offices on how they managed the phone call reports received the next day or how they managed clinical calls during regular office hours.

Analysis of phone calls classified by patients as nonemergent

In our previous study,¹ we entered the chief complaint of all after-hours telephone calls made to our community-based family practice training program between April 2000 and March 2001 into an Access database program (Microsoft Access 97, Microsoft Corporation, Redmond, WA). These after-hours calls were routed to an answering service when the office was closed. Patients were asked by the answering service: “Is this an emergency?” Patients who were not certain were asked if they needed to speak directly with the physician. The calls were sent to the physician on call only if the patient stated to the answering service operator that the problem was an “emergency” or if they were uncertain and requested to speak directly with the physician.

For this study, we analyzed only the nonemergency calls that were not forwarded to a physician. We chose 4 local family physicians who were unaware of the purpose of the study to review these calls. We asked them to: “Indicate which of these complaints you want your after-hours answering service to forward to the physician on call and which can wait to be faxed to the office the following morning.” We analyzed their responses with descriptive statistics (SAS 8.0, SAS Institute, Cary, NC) and an overall multirater statistic (Magree macro 1.0, SAS Institute). The HealthOne Institutional Review Board approved this study.

Results

Survey of primary care physicians’ answering services

Table 1 presents the results of our survey of primary care physicians. Most physicians had a recorded message instructing the patient how to reach the physician after hours. In 4 cases, the message implied that the patient should not call unless that person had a “true emergency.”

After calling 5 pediatricians, it became clear that the pediatricians used a single, well-described nurse triage service for managing after-hours calls,⁵ and the pediatric offices were not included in further analysis. We have only partial data for 2 physicians because their answering service was too busy to complete the survey.

Fifty-six percent of the offices had recorded messages that instructed the caller to hang up and dial 911 if the problem was a “life-threatening” emergency. After the initial recorded message, 67% of the calls were answered by an answering service.

A full 93% of the answering services required the patient to decide whether to initiate contact with the on-call physician. Only those calls reported by the caller to be an “emergency” were forwarded to the on-call physician. In 2 cases, the answering service operator suggested to us that they were instructed to “use their judgment” in forwarding calls to the on-call physician. Five of the answering services commented that about 90% of the calls are forwarded to the physician and 10% are not forwarded, closely matching our previous findings.¹

Ninety-five percent of the answering services faxed reports on all calls, including those not forwarded during the night, to the offices the following business day. Twelve answering services were used by the 91 practices in our study: 2 handled only family practice offices, 1 handled only internal medicine offices, 1 handled only obstetric offices, and 8 handled calls for multiple specialties.

Analysis of phone calls classified by patients as nonemergent

Over 1 year, 2835 clinical calls (eg, not administrative or appointment cancellations) were made to the office after hours, and 90% were considered to be an emergency and forwarded to the oncall physician. The remaining 10% (288 calls) were faxed to the office the next day. Table 2 shows examples of those calls that were not forwarded. Our 4 physician reviewers of the nonemergency calls wanted to speak to the patient immediately at a mean of 50% of the calls rather than wait until the following business day (range, 22%%–77%, κ=.45).

TABLE 1
Telephone triage summary by specialty

TABLE 2
Sample of calls classified as nonemergent by patients

Discussion

In studying after-hours phone calls, we found several systematic barriers between patients and physicians: wrong numbers, messages necessitating a second phone call, and requirements that the patient decide whether the medical complaint was serious enough to initiate contact with the oncall physician. These barriers may negatively affect patient health due to unnecessary delays in evaluation and treatment.

Most patients asked to speak with the physician immediately about important clinical matters: medications, chest pain, contractions, or fever. However, some patients appeared unable to make appropriate triage decisions or persevere long enough to overcome the systematic barriers that prevented them from talking to a physician.

Our physician panel would have wanted to talk to the “no emergency” patients immediately in approximately half the cases. If 10% of 50 million to 100 million after-hours phone calls each year in the United States are not forwarded to the physician because the caller feels the complaint is not emergent, and if half those calls are potentially serious, there may be as many as 2.5 million to 5 million potentially dangerous delays in care each year.

We cannot expect an answering service operator or a parent to know how to triage an infant with a fever when physicians disagree on appropriate disposition.⁸ New parents with a sick infant, an older patient with chest pain, or a woman having preterm contractions during her first pregnancy might be uncertain as to what constitutes an “emergency.”

Solutions

Several solutions to this problem exist. We made a change in our office and now have all clinical calls forwarded to the on-call physician. No triage decisions are made by the patient or the answering service. This has led to an average increase of only 1 to 2 more patient calls per night. Offices also could become part of a citywide network in which all calls are managed by a trained nursing staff, as the pediatricians have done in Denver, Colorado.⁵

Interpretations

This study should be interpreted in light of several limitations. First, it was conducted in 1 metropolitan region. It is possible that other regions of the US have different mechanisms or standards for handling after-hours calls. However, given the overwhelming number of offices in our study that required patients to make their own triage decisions, we believe this barrier is likely widespread.

Second, the answering services we surveyed knew we were not patients, and this may have affected their answers. However, even if only 10% of these calls were not forwarded to the physician on call, a significant number of calls might have been unnecessarily delayed and potentially put patients at risk.

The Institute of Medicine’s report on medical errors states: “Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing.”⁹ Errors in triage by the patient or the answering service may lead to dangerous delays in necessary patient care.

Our future research will focus on identifying adverse outcomes in this study population and prospectively in a practice-based research network. When a patient calls the primary care office after hours, the decisions should be simple and left to those who have the training to make those decisions based on their best medical judgment. We strongly urge all clinicians who use an answering service to examine their policies and procedures for potential sources of medical error.

Acknowledgments

We express our thanks to Tarek Arja, DO, Dan O’Brien, DO, Mark Cucuzzella, MD, and Jacqueline Stern, MD; for agreeing to review nonemergent calls, and Pamela Sullivan for her assistance in preparing the manuscript.

We found recently that about 10% of after-hours calls from patients were not forwarded by the answering service to the physician on call because the patient did not think the problem was an emergency.¹ In reviewing these calls, it became evident that many were indeed serious enough to require immediate contact with a medical professional.

The purpose of this study was to evaluate the management of after-hours phone calls made to primary care physicians’ offices and their answering services in a large metropolitan area. General descriptions of after-hours calls have been reported,^2,3,4 and the management of these calls by professional and nurse triage services have been studied.^5,6 However, the management of telephone triage by answering services has not been examined. No published data exist on the number of after-hours phone calls to US physicians.

Methods

This study had 2 components. In part 1, we surveyed 91 primary care offices (in family practice, internal medicine, obstetrics, and pediatrics) to determine how they handle after-hours phone calls. In part 2, we analyzed all calls from our previous study¹ that were not identified by the patient as an emergency and, hence, not forwarded to the on-call physician.

Survey of primary care physicians’ answering services

The physicians in each specialty were identified in their respective section of the telephone book,⁷ and, by using a systematic sampling technique, every fifth name was selected and surveyed. All surveys were completed in October and November 2001 after regular office hours, generally between 10:00 PM and 1:00 AM.

Using a structured survey interview form, the principal investigator indicated during each call that this was an anonymous research survey and asked if the answering service personnel could answer several questions. The information collected in each 3- to 5-minute interview included: whether there was a recorded message, whether the patient was instructed to call 911, who answered the call after the recorded message, what information was requested, who made the decision to initiate contact with the on-call physician, and what happened to calls that were not forwarded.

If the patient was instructed to choose an “option” from the medical office telephone system, this option was selected if it would lead to an answering service. If it offered to call or page the physician directly, then that survey was terminated. The name of the answering service was recorded to determine how many different services were used in this metropolitan area. We did not survey offices on how they managed the phone call reports received the next day or how they managed clinical calls during regular office hours.

Analysis of phone calls classified by patients as nonemergent

In our previous study,¹ we entered the chief complaint of all after-hours telephone calls made to our community-based family practice training program between April 2000 and March 2001 into an Access database program (Microsoft Access 97, Microsoft Corporation, Redmond, WA). These after-hours calls were routed to an answering service when the office was closed. Patients were asked by the answering service: “Is this an emergency?” Patients who were not certain were asked if they needed to speak directly with the physician. The calls were sent to the physician on call only if the patient stated to the answering service operator that the problem was an “emergency” or if they were uncertain and requested to speak directly with the physician.

For this study, we analyzed only the nonemergency calls that were not forwarded to a physician. We chose 4 local family physicians who were unaware of the purpose of the study to review these calls. We asked them to: “Indicate which of these complaints you want your after-hours answering service to forward to the physician on call and which can wait to be faxed to the office the following morning.” We analyzed their responses with descriptive statistics (SAS 8.0, SAS Institute, Cary, NC) and an overall multirater statistic (Magree macro 1.0, SAS Institute). The HealthOne Institutional Review Board approved this study.

Results

Survey of primary care physicians’ answering services

Table 1 presents the results of our survey of primary care physicians. Most physicians had a recorded message instructing the patient how to reach the physician after hours. In 4 cases, the message implied that the patient should not call unless that person had a “true emergency.”

After calling 5 pediatricians, it became clear that the pediatricians used a single, well-described nurse triage service for managing after-hours calls,⁵ and the pediatric offices were not included in further analysis. We have only partial data for 2 physicians because their answering service was too busy to complete the survey.

Fifty-six percent of the offices had recorded messages that instructed the caller to hang up and dial 911 if the problem was a “life-threatening” emergency. After the initial recorded message, 67% of the calls were answered by an answering service.

A full 93% of the answering services required the patient to decide whether to initiate contact with the on-call physician. Only those calls reported by the caller to be an “emergency” were forwarded to the on-call physician. In 2 cases, the answering service operator suggested to us that they were instructed to “use their judgment” in forwarding calls to the on-call physician. Five of the answering services commented that about 90% of the calls are forwarded to the physician and 10% are not forwarded, closely matching our previous findings.¹

Ninety-five percent of the answering services faxed reports on all calls, including those not forwarded during the night, to the offices the following business day. Twelve answering services were used by the 91 practices in our study: 2 handled only family practice offices, 1 handled only internal medicine offices, 1 handled only obstetric offices, and 8 handled calls for multiple specialties.

Analysis of phone calls classified by patients as nonemergent

Over 1 year, 2835 clinical calls (eg, not administrative or appointment cancellations) were made to the office after hours, and 90% were considered to be an emergency and forwarded to the oncall physician. The remaining 10% (288 calls) were faxed to the office the next day. Table 2 shows examples of those calls that were not forwarded. Our 4 physician reviewers of the nonemergency calls wanted to speak to the patient immediately at a mean of 50% of the calls rather than wait until the following business day (range, 22%%–77%, κ=.45).

TABLE 1
Telephone triage summary by specialty

TABLE 2
Sample of calls classified as nonemergent by patients

Discussion

In studying after-hours phone calls, we found several systematic barriers between patients and physicians: wrong numbers, messages necessitating a second phone call, and requirements that the patient decide whether the medical complaint was serious enough to initiate contact with the oncall physician. These barriers may negatively affect patient health due to unnecessary delays in evaluation and treatment.

Most patients asked to speak with the physician immediately about important clinical matters: medications, chest pain, contractions, or fever. However, some patients appeared unable to make appropriate triage decisions or persevere long enough to overcome the systematic barriers that prevented them from talking to a physician.

Our physician panel would have wanted to talk to the “no emergency” patients immediately in approximately half the cases. If 10% of 50 million to 100 million after-hours phone calls each year in the United States are not forwarded to the physician because the caller feels the complaint is not emergent, and if half those calls are potentially serious, there may be as many as 2.5 million to 5 million potentially dangerous delays in care each year.

We cannot expect an answering service operator or a parent to know how to triage an infant with a fever when physicians disagree on appropriate disposition.⁸ New parents with a sick infant, an older patient with chest pain, or a woman having preterm contractions during her first pregnancy might be uncertain as to what constitutes an “emergency.”

Solutions

Several solutions to this problem exist. We made a change in our office and now have all clinical calls forwarded to the on-call physician. No triage decisions are made by the patient or the answering service. This has led to an average increase of only 1 to 2 more patient calls per night. Offices also could become part of a citywide network in which all calls are managed by a trained nursing staff, as the pediatricians have done in Denver, Colorado.⁵

Interpretations

This study should be interpreted in light of several limitations. First, it was conducted in 1 metropolitan region. It is possible that other regions of the US have different mechanisms or standards for handling after-hours calls. However, given the overwhelming number of offices in our study that required patients to make their own triage decisions, we believe this barrier is likely widespread.

Second, the answering services we surveyed knew we were not patients, and this may have affected their answers. However, even if only 10% of these calls were not forwarded to the physician on call, a significant number of calls might have been unnecessarily delayed and potentially put patients at risk.

The Institute of Medicine’s report on medical errors states: “Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing.”⁹ Errors in triage by the patient or the answering service may lead to dangerous delays in necessary patient care.

Our future research will focus on identifying adverse outcomes in this study population and prospectively in a practice-based research network. When a patient calls the primary care office after hours, the decisions should be simple and left to those who have the training to make those decisions based on their best medical judgment. We strongly urge all clinicians who use an answering service to examine their policies and procedures for potential sources of medical error.

Acknowledgments

We express our thanks to Tarek Arja, DO, Dan O’Brien, DO, Mark Cucuzzella, MD, and Jacqueline Stern, MD; for agreeing to review nonemergent calls, and Pamela Sullivan for her assistance in preparing the manuscript.

We found recently that about 10% of after-hours calls from patients were not forwarded by the answering service to the physician on call because the patient did not think the problem was an emergency.¹ In reviewing these calls, it became evident that many were indeed serious enough to require immediate contact with a medical professional.

The purpose of this study was to evaluate the management of after-hours phone calls made to primary care physicians’ offices and their answering services in a large metropolitan area. General descriptions of after-hours calls have been reported,^2,3,4 and the management of these calls by professional and nurse triage services have been studied.^5,6 However, the management of telephone triage by answering services has not been examined. No published data exist on the number of after-hours phone calls to US physicians.

Methods

This study had 2 components. In part 1, we surveyed 91 primary care offices (in family practice, internal medicine, obstetrics, and pediatrics) to determine how they handle after-hours phone calls. In part 2, we analyzed all calls from our previous study¹ that were not identified by the patient as an emergency and, hence, not forwarded to the on-call physician.

Survey of primary care physicians’ answering services

The physicians in each specialty were identified in their respective section of the telephone book,⁷ and, by using a systematic sampling technique, every fifth name was selected and surveyed. All surveys were completed in October and November 2001 after regular office hours, generally between 10:00 PM and 1:00 AM.

Using a structured survey interview form, the principal investigator indicated during each call that this was an anonymous research survey and asked if the answering service personnel could answer several questions. The information collected in each 3- to 5-minute interview included: whether there was a recorded message, whether the patient was instructed to call 911, who answered the call after the recorded message, what information was requested, who made the decision to initiate contact with the on-call physician, and what happened to calls that were not forwarded.

If the patient was instructed to choose an “option” from the medical office telephone system, this option was selected if it would lead to an answering service. If it offered to call or page the physician directly, then that survey was terminated. The name of the answering service was recorded to determine how many different services were used in this metropolitan area. We did not survey offices on how they managed the phone call reports received the next day or how they managed clinical calls during regular office hours.

Analysis of phone calls classified by patients as nonemergent

In our previous study,¹ we entered the chief complaint of all after-hours telephone calls made to our community-based family practice training program between April 2000 and March 2001 into an Access database program (Microsoft Access 97, Microsoft Corporation, Redmond, WA). These after-hours calls were routed to an answering service when the office was closed. Patients were asked by the answering service: “Is this an emergency?” Patients who were not certain were asked if they needed to speak directly with the physician. The calls were sent to the physician on call only if the patient stated to the answering service operator that the problem was an “emergency” or if they were uncertain and requested to speak directly with the physician.

For this study, we analyzed only the nonemergency calls that were not forwarded to a physician. We chose 4 local family physicians who were unaware of the purpose of the study to review these calls. We asked them to: “Indicate which of these complaints you want your after-hours answering service to forward to the physician on call and which can wait to be faxed to the office the following morning.” We analyzed their responses with descriptive statistics (SAS 8.0, SAS Institute, Cary, NC) and an overall multirater statistic (Magree macro 1.0, SAS Institute). The HealthOne Institutional Review Board approved this study.

Results

Survey of primary care physicians’ answering services

Table 1 presents the results of our survey of primary care physicians. Most physicians had a recorded message instructing the patient how to reach the physician after hours. In 4 cases, the message implied that the patient should not call unless that person had a “true emergency.”

After calling 5 pediatricians, it became clear that the pediatricians used a single, well-described nurse triage service for managing after-hours calls,⁵ and the pediatric offices were not included in further analysis. We have only partial data for 2 physicians because their answering service was too busy to complete the survey.

Fifty-six percent of the offices had recorded messages that instructed the caller to hang up and dial 911 if the problem was a “life-threatening” emergency. After the initial recorded message, 67% of the calls were answered by an answering service.

A full 93% of the answering services required the patient to decide whether to initiate contact with the on-call physician. Only those calls reported by the caller to be an “emergency” were forwarded to the on-call physician. In 2 cases, the answering service operator suggested to us that they were instructed to “use their judgment” in forwarding calls to the on-call physician. Five of the answering services commented that about 90% of the calls are forwarded to the physician and 10% are not forwarded, closely matching our previous findings.¹

Ninety-five percent of the answering services faxed reports on all calls, including those not forwarded during the night, to the offices the following business day. Twelve answering services were used by the 91 practices in our study: 2 handled only family practice offices, 1 handled only internal medicine offices, 1 handled only obstetric offices, and 8 handled calls for multiple specialties.

Analysis of phone calls classified by patients as nonemergent

Over 1 year, 2835 clinical calls (eg, not administrative or appointment cancellations) were made to the office after hours, and 90% were considered to be an emergency and forwarded to the oncall physician. The remaining 10% (288 calls) were faxed to the office the next day. Table 2 shows examples of those calls that were not forwarded. Our 4 physician reviewers of the nonemergency calls wanted to speak to the patient immediately at a mean of 50% of the calls rather than wait until the following business day (range, 22%%–77%, κ=.45).

TABLE 1
Telephone triage summary by specialty

TABLE 2
Sample of calls classified as nonemergent by patients

Discussion

In studying after-hours phone calls, we found several systematic barriers between patients and physicians: wrong numbers, messages necessitating a second phone call, and requirements that the patient decide whether the medical complaint was serious enough to initiate contact with the oncall physician. These barriers may negatively affect patient health due to unnecessary delays in evaluation and treatment.

Most patients asked to speak with the physician immediately about important clinical matters: medications, chest pain, contractions, or fever. However, some patients appeared unable to make appropriate triage decisions or persevere long enough to overcome the systematic barriers that prevented them from talking to a physician.

Our physician panel would have wanted to talk to the “no emergency” patients immediately in approximately half the cases. If 10% of 50 million to 100 million after-hours phone calls each year in the United States are not forwarded to the physician because the caller feels the complaint is not emergent, and if half those calls are potentially serious, there may be as many as 2.5 million to 5 million potentially dangerous delays in care each year.

We cannot expect an answering service operator or a parent to know how to triage an infant with a fever when physicians disagree on appropriate disposition.⁸ New parents with a sick infant, an older patient with chest pain, or a woman having preterm contractions during her first pregnancy might be uncertain as to what constitutes an “emergency.”

Solutions

Several solutions to this problem exist. We made a change in our office and now have all clinical calls forwarded to the on-call physician. No triage decisions are made by the patient or the answering service. This has led to an average increase of only 1 to 2 more patient calls per night. Offices also could become part of a citywide network in which all calls are managed by a trained nursing staff, as the pediatricians have done in Denver, Colorado.⁵

Interpretations

This study should be interpreted in light of several limitations. First, it was conducted in 1 metropolitan region. It is possible that other regions of the US have different mechanisms or standards for handling after-hours calls. However, given the overwhelming number of offices in our study that required patients to make their own triage decisions, we believe this barrier is likely widespread.

Second, the answering services we surveyed knew we were not patients, and this may have affected their answers. However, even if only 10% of these calls were not forwarded to the physician on call, a significant number of calls might have been unnecessarily delayed and potentially put patients at risk.

The Institute of Medicine’s report on medical errors states: “Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing.”⁹ Errors in triage by the patient or the answering service may lead to dangerous delays in necessary patient care.

Our future research will focus on identifying adverse outcomes in this study population and prospectively in a practice-based research network. When a patient calls the primary care office after hours, the decisions should be simple and left to those who have the training to make those decisions based on their best medical judgment. We strongly urge all clinicians who use an answering service to examine their policies and procedures for potential sources of medical error.

Acknowledgments

We express our thanks to Tarek Arja, DO, Dan O’Brien, DO, Mark Cucuzzella, MD, and Jacqueline Stern, MD; for agreeing to review nonemergent calls, and Pamela Sullivan for her assistance in preparing the manuscript.

Previous studies of after-hours calls to family physicians focused on caller demographics, medical triage skills, and patient satisfaction, and were usually conducted for a limited time. We examined the frequency and nature of calls to a family practice residency over 1 year. Caller and patient information, date, time, and chief complaint were obtained from answering service logs. The 5 most frequent chief complaints related to medications, pain, obstetric issues, fever, and nausea. Interestingly, 56 “high utilizers” (0.6% of all patients) accounted for 23% of the calls.

Although telephone calls may account for 10% to 25% of all patient contacts,^1,2 few studies have examined the frequency and nature of these calls over an extended time. A month-long study³ found that patients who telephoned after hours were 3 times more likely to rate their problem in the highest severity category compared with the physician’s rating of the problem. This study, done in July, may not reflect the diversity of patient problems, because of seasonal variations; also, it did not appear to include obstetric problems, which are a prominent reason for calls to family practice physicians.^4,5 Many physician groups use answering services to screen calls as a method for decreasing the number of calls. The purpose of this study was to document the frequency and nature of after-hours calls to a family practice office over 1 year.

METHODS

All after-hours telephone calls (5 PM to 8 AM, weekends and holidays) made to a freestanding community-based family practice training program were collected for the 12-month period between April 2000 and March 2001. A recorded message directed the caller to call 911 for a life-threatening emergency or stay on the line for operator assistance. Emergency calls were forwarded to the resident physician on call. Sixteen family medicine residents supported by 8 faculty physicians took primary calls on a rotating basis. The practice had approximately 9000 active patients (at least 1 visit in the last 3 years), and about 1350 patient visits per month. Approximately 30% were covered by Medicaid, 10% by Medicare, 35% by managed care, and 12% by indemnity insurance; 13% were uninsured.

The operator recorded date and time, caller’s and patient’s first and last names, primary care physician, patient’s pregnancy status, date of last office visit, chief complaint(s), and whether the caller felt the situation was an emergency.

Previous studies variously classified patient calls based on diagnostic group, chief complaint, symptom, treatment and medication, injury, and organ system affected.^1,3,6-10 We followed the lead of Benjamin⁸and Perkins and colleagues,¹ who used the patient’s chief complaint to categorize calls. We classified the patient’s chief complaint by searching for key words such as “heart” (eg, “fast heartbeat,” “pains near heart,” or “isn’t feeling well, heart failure a couple of years ago”). This allowed for the broad inclusion of chief complaints while avoiding the risk of premature diagnosis.

A research assistant entered information from the operator’s records into a Microsoft Access Database. Patients who called more than 6 times after hours during the year were arbitrarily defined as “high utilizers.” We also gathered data on these callers’ hospital emergency room visits and admissions to affiliated hospitals. The HealthOne Institutional Review Board approved the study.

RESULTS

A total of 3538 calls were made by 1564 patients; 2465 were clinical calls, and key words or phrases were used to classify them under chief complaint headings. If a caller had a multiple-symptom complaint (ie, fever and headache), it was classified under all appropriate headings and counted twice. The total number of complaints is therefore higher than the total number of calls. Table 1 presents the frequency and percentage of after-hours clinical calls for all subjects, and separately for high utilizers. Table 2 presents the average number of clinical calls organized by season and day of the week. Thirty-three percent of all calls were made by the patient, 31% by a proxy (spouse, parent, friend), and 36% by other parties (nurse, pharmacy, unidentified party).

Although the rankings of calls for all patients and high utilizers in Table 1 were similar, several differences stand out. High utilizers account for only 0.6% of patients, but 23% of all calls. High utilizers called substantially more for complaints relating to medication, pain, asthma/breathing and chest problems; 39% of their calls were for medication or pain concerns. Of the high utilizers, 39% (22/56) made 46 emergency room visits, but only 7% (4/56) were hospitalized during the year.

TABLE 1
Percentage of after-hours calls, by chief complaint

TABLE 2
Average number of clinical calls by season and day of week

DISCUSSION

This study expands on previous work by describing the total variety of after-hours phone calls to a family practice office over an entire year. Our findings on reasons for call, time of call, and demographics are similar to those of previous work.^3,10 However, our study is one of the first to describe the subset of high utilizers. Introducing a patient health handbook, practice Web site, pharmacy help line, or other practice management tools might reduce the number of “information only” calls. Contrary to our expectation, the highest numbers of average daily calls were in the spring and summer and not in the winter. Saturdays and Sundays were the busiest days of the week for such calls.

Patients called for diverse clinical reasons (Table 1) and therefore physicians might focus their attention on the most frequent reasons for calls, in order to improve the effectiveness of their educational efforts. For example, physicians might discuss the patient’s medication concerns, give specific recommendations to talk to the pharmacist, and possibly offer an automated medication “tracking system” to alert patients during the week when their medications were running out, as a way of reducing the number of calls and allaying patient concerns.

Pain symptoms clearly account for a substantial number of calls. Although some of these calls might be serious emergencies (chest pain) and require immediate action, other calls, such as for migraine headaches, may point to a need to educate and set limits with patients during their regular appointments. For example, patients could be told that migraine headaches are not a “life-threatening” emergency and be urged to use self-management strategies until the next day.

Discussing fever management with new parents at well-child visits might decrease future calls. There is some research to suggest that providing new parents with specific guidelines about when to call if their child has a fever can dramatically reduce after-hours visits to the emergency room.¹¹ Obstetric calls represent an important group requiring immediate callback with very specific questions (eg, fetal movement, bleeding), and might be a target area for physician education.

Out of approximately 9000 patients in the practice and 1564 patients who called the practice during the year, we identified 56 high utilizers (0.6% of all patients). They averaged nearly 10 calls per year in contrast to 1.3 calls for all other callers. Future research might be directed at trying to determine why these patients feel a need to call at nearly 10 times the rate of other patients.

These findings should be interpreted in light of several limitations. Because our findings are based on a family practice residency, the patient population may be different from the typical private family practice office and have less continuity. However, the wide range of calls is likely to be typical of the diverse problems managed by family physicians. This study did not collect information on the management and disposition of these after-hours calls. Certainly, understanding the entire episode of after-hours contact (reason for call, management, outcome, satisfaction) is important, and is the next step in our research.

The diversity and seriousness of medical problems addressed by the after-hours physician highlight the need to provide specific training to physicians for dealing with patient calls and educating patients on the many issues leading to after-hours calls.

ACKNOWLEDGMENTS

The authors thank Ellie Jensen for help with data collection, entry, and analysis.

Previous studies of after-hours calls to family physicians focused on caller demographics, medical triage skills, and patient satisfaction, and were usually conducted for a limited time. We examined the frequency and nature of calls to a family practice residency over 1 year. Caller and patient information, date, time, and chief complaint were obtained from answering service logs. The 5 most frequent chief complaints related to medications, pain, obstetric issues, fever, and nausea. Interestingly, 56 “high utilizers” (0.6% of all patients) accounted for 23% of the calls.

Although telephone calls may account for 10% to 25% of all patient contacts,^1,2 few studies have examined the frequency and nature of these calls over an extended time. A month-long study³ found that patients who telephoned after hours were 3 times more likely to rate their problem in the highest severity category compared with the physician’s rating of the problem. This study, done in July, may not reflect the diversity of patient problems, because of seasonal variations; also, it did not appear to include obstetric problems, which are a prominent reason for calls to family practice physicians.^4,5 Many physician groups use answering services to screen calls as a method for decreasing the number of calls. The purpose of this study was to document the frequency and nature of after-hours calls to a family practice office over 1 year.

METHODS

All after-hours telephone calls (5 PM to 8 AM, weekends and holidays) made to a freestanding community-based family practice training program were collected for the 12-month period between April 2000 and March 2001. A recorded message directed the caller to call 911 for a life-threatening emergency or stay on the line for operator assistance. Emergency calls were forwarded to the resident physician on call. Sixteen family medicine residents supported by 8 faculty physicians took primary calls on a rotating basis. The practice had approximately 9000 active patients (at least 1 visit in the last 3 years), and about 1350 patient visits per month. Approximately 30% were covered by Medicaid, 10% by Medicare, 35% by managed care, and 12% by indemnity insurance; 13% were uninsured.

The operator recorded date and time, caller’s and patient’s first and last names, primary care physician, patient’s pregnancy status, date of last office visit, chief complaint(s), and whether the caller felt the situation was an emergency.

Previous studies variously classified patient calls based on diagnostic group, chief complaint, symptom, treatment and medication, injury, and organ system affected.^1,3,6-10 We followed the lead of Benjamin⁸and Perkins and colleagues,¹ who used the patient’s chief complaint to categorize calls. We classified the patient’s chief complaint by searching for key words such as “heart” (eg, “fast heartbeat,” “pains near heart,” or “isn’t feeling well, heart failure a couple of years ago”). This allowed for the broad inclusion of chief complaints while avoiding the risk of premature diagnosis.

A research assistant entered information from the operator’s records into a Microsoft Access Database. Patients who called more than 6 times after hours during the year were arbitrarily defined as “high utilizers.” We also gathered data on these callers’ hospital emergency room visits and admissions to affiliated hospitals. The HealthOne Institutional Review Board approved the study.

RESULTS

A total of 3538 calls were made by 1564 patients; 2465 were clinical calls, and key words or phrases were used to classify them under chief complaint headings. If a caller had a multiple-symptom complaint (ie, fever and headache), it was classified under all appropriate headings and counted twice. The total number of complaints is therefore higher than the total number of calls. Table 1 presents the frequency and percentage of after-hours clinical calls for all subjects, and separately for high utilizers. Table 2 presents the average number of clinical calls organized by season and day of the week. Thirty-three percent of all calls were made by the patient, 31% by a proxy (spouse, parent, friend), and 36% by other parties (nurse, pharmacy, unidentified party).

Although the rankings of calls for all patients and high utilizers in Table 1 were similar, several differences stand out. High utilizers account for only 0.6% of patients, but 23% of all calls. High utilizers called substantially more for complaints relating to medication, pain, asthma/breathing and chest problems; 39% of their calls were for medication or pain concerns. Of the high utilizers, 39% (22/56) made 46 emergency room visits, but only 7% (4/56) were hospitalized during the year.

TABLE 1
Percentage of after-hours calls, by chief complaint

TABLE 2
Average number of clinical calls by season and day of week

DISCUSSION

This study expands on previous work by describing the total variety of after-hours phone calls to a family practice office over an entire year. Our findings on reasons for call, time of call, and demographics are similar to those of previous work.^3,10 However, our study is one of the first to describe the subset of high utilizers. Introducing a patient health handbook, practice Web site, pharmacy help line, or other practice management tools might reduce the number of “information only” calls. Contrary to our expectation, the highest numbers of average daily calls were in the spring and summer and not in the winter. Saturdays and Sundays were the busiest days of the week for such calls.

Patients called for diverse clinical reasons (Table 1) and therefore physicians might focus their attention on the most frequent reasons for calls, in order to improve the effectiveness of their educational efforts. For example, physicians might discuss the patient’s medication concerns, give specific recommendations to talk to the pharmacist, and possibly offer an automated medication “tracking system” to alert patients during the week when their medications were running out, as a way of reducing the number of calls and allaying patient concerns.

Pain symptoms clearly account for a substantial number of calls. Although some of these calls might be serious emergencies (chest pain) and require immediate action, other calls, such as for migraine headaches, may point to a need to educate and set limits with patients during their regular appointments. For example, patients could be told that migraine headaches are not a “life-threatening” emergency and be urged to use self-management strategies until the next day.

Discussing fever management with new parents at well-child visits might decrease future calls. There is some research to suggest that providing new parents with specific guidelines about when to call if their child has a fever can dramatically reduce after-hours visits to the emergency room.¹¹ Obstetric calls represent an important group requiring immediate callback with very specific questions (eg, fetal movement, bleeding), and might be a target area for physician education.

Out of approximately 9000 patients in the practice and 1564 patients who called the practice during the year, we identified 56 high utilizers (0.6% of all patients). They averaged nearly 10 calls per year in contrast to 1.3 calls for all other callers. Future research might be directed at trying to determine why these patients feel a need to call at nearly 10 times the rate of other patients.

These findings should be interpreted in light of several limitations. Because our findings are based on a family practice residency, the patient population may be different from the typical private family practice office and have less continuity. However, the wide range of calls is likely to be typical of the diverse problems managed by family physicians. This study did not collect information on the management and disposition of these after-hours calls. Certainly, understanding the entire episode of after-hours contact (reason for call, management, outcome, satisfaction) is important, and is the next step in our research.

The diversity and seriousness of medical problems addressed by the after-hours physician highlight the need to provide specific training to physicians for dealing with patient calls and educating patients on the many issues leading to after-hours calls.

ACKNOWLEDGMENTS

The authors thank Ellie Jensen for help with data collection, entry, and analysis.

Previous studies of after-hours calls to family physicians focused on caller demographics, medical triage skills, and patient satisfaction, and were usually conducted for a limited time. We examined the frequency and nature of calls to a family practice residency over 1 year. Caller and patient information, date, time, and chief complaint were obtained from answering service logs. The 5 most frequent chief complaints related to medications, pain, obstetric issues, fever, and nausea. Interestingly, 56 “high utilizers” (0.6% of all patients) accounted for 23% of the calls.

Although telephone calls may account for 10% to 25% of all patient contacts,^1,2 few studies have examined the frequency and nature of these calls over an extended time. A month-long study³ found that patients who telephoned after hours were 3 times more likely to rate their problem in the highest severity category compared with the physician’s rating of the problem. This study, done in July, may not reflect the diversity of patient problems, because of seasonal variations; also, it did not appear to include obstetric problems, which are a prominent reason for calls to family practice physicians.^4,5 Many physician groups use answering services to screen calls as a method for decreasing the number of calls. The purpose of this study was to document the frequency and nature of after-hours calls to a family practice office over 1 year.

METHODS

All after-hours telephone calls (5 PM to 8 AM, weekends and holidays) made to a freestanding community-based family practice training program were collected for the 12-month period between April 2000 and March 2001. A recorded message directed the caller to call 911 for a life-threatening emergency or stay on the line for operator assistance. Emergency calls were forwarded to the resident physician on call. Sixteen family medicine residents supported by 8 faculty physicians took primary calls on a rotating basis. The practice had approximately 9000 active patients (at least 1 visit in the last 3 years), and about 1350 patient visits per month. Approximately 30% were covered by Medicaid, 10% by Medicare, 35% by managed care, and 12% by indemnity insurance; 13% were uninsured.

The operator recorded date and time, caller’s and patient’s first and last names, primary care physician, patient’s pregnancy status, date of last office visit, chief complaint(s), and whether the caller felt the situation was an emergency.

Previous studies variously classified patient calls based on diagnostic group, chief complaint, symptom, treatment and medication, injury, and organ system affected.^1,3,6-10 We followed the lead of Benjamin⁸and Perkins and colleagues,¹ who used the patient’s chief complaint to categorize calls. We classified the patient’s chief complaint by searching for key words such as “heart” (eg, “fast heartbeat,” “pains near heart,” or “isn’t feeling well, heart failure a couple of years ago”). This allowed for the broad inclusion of chief complaints while avoiding the risk of premature diagnosis.

A research assistant entered information from the operator’s records into a Microsoft Access Database. Patients who called more than 6 times after hours during the year were arbitrarily defined as “high utilizers.” We also gathered data on these callers’ hospital emergency room visits and admissions to affiliated hospitals. The HealthOne Institutional Review Board approved the study.

RESULTS

A total of 3538 calls were made by 1564 patients; 2465 were clinical calls, and key words or phrases were used to classify them under chief complaint headings. If a caller had a multiple-symptom complaint (ie, fever and headache), it was classified under all appropriate headings and counted twice. The total number of complaints is therefore higher than the total number of calls. Table 1 presents the frequency and percentage of after-hours clinical calls for all subjects, and separately for high utilizers. Table 2 presents the average number of clinical calls organized by season and day of the week. Thirty-three percent of all calls were made by the patient, 31% by a proxy (spouse, parent, friend), and 36% by other parties (nurse, pharmacy, unidentified party).

Although the rankings of calls for all patients and high utilizers in Table 1 were similar, several differences stand out. High utilizers account for only 0.6% of patients, but 23% of all calls. High utilizers called substantially more for complaints relating to medication, pain, asthma/breathing and chest problems; 39% of their calls were for medication or pain concerns. Of the high utilizers, 39% (22/56) made 46 emergency room visits, but only 7% (4/56) were hospitalized during the year.

TABLE 1
Percentage of after-hours calls, by chief complaint

TABLE 2
Average number of clinical calls by season and day of week

DISCUSSION

This study expands on previous work by describing the total variety of after-hours phone calls to a family practice office over an entire year. Our findings on reasons for call, time of call, and demographics are similar to those of previous work.^3,10 However, our study is one of the first to describe the subset of high utilizers. Introducing a patient health handbook, practice Web site, pharmacy help line, or other practice management tools might reduce the number of “information only” calls. Contrary to our expectation, the highest numbers of average daily calls were in the spring and summer and not in the winter. Saturdays and Sundays were the busiest days of the week for such calls.

Patients called for diverse clinical reasons (Table 1) and therefore physicians might focus their attention on the most frequent reasons for calls, in order to improve the effectiveness of their educational efforts. For example, physicians might discuss the patient’s medication concerns, give specific recommendations to talk to the pharmacist, and possibly offer an automated medication “tracking system” to alert patients during the week when their medications were running out, as a way of reducing the number of calls and allaying patient concerns.

Pain symptoms clearly account for a substantial number of calls. Although some of these calls might be serious emergencies (chest pain) and require immediate action, other calls, such as for migraine headaches, may point to a need to educate and set limits with patients during their regular appointments. For example, patients could be told that migraine headaches are not a “life-threatening” emergency and be urged to use self-management strategies until the next day.

Discussing fever management with new parents at well-child visits might decrease future calls. There is some research to suggest that providing new parents with specific guidelines about when to call if their child has a fever can dramatically reduce after-hours visits to the emergency room.¹¹ Obstetric calls represent an important group requiring immediate callback with very specific questions (eg, fetal movement, bleeding), and might be a target area for physician education.

Out of approximately 9000 patients in the practice and 1564 patients who called the practice during the year, we identified 56 high utilizers (0.6% of all patients). They averaged nearly 10 calls per year in contrast to 1.3 calls for all other callers. Future research might be directed at trying to determine why these patients feel a need to call at nearly 10 times the rate of other patients.

These findings should be interpreted in light of several limitations. Because our findings are based on a family practice residency, the patient population may be different from the typical private family practice office and have less continuity. However, the wide range of calls is likely to be typical of the diverse problems managed by family physicians. This study did not collect information on the management and disposition of these after-hours calls. Certainly, understanding the entire episode of after-hours contact (reason for call, management, outcome, satisfaction) is important, and is the next step in our research.

The diversity and seriousness of medical problems addressed by the after-hours physician highlight the need to provide specific training to physicians for dealing with patient calls and educating patients on the many issues leading to after-hours calls.

ACKNOWLEDGMENTS

The authors thank Ellie Jensen for help with data collection, entry, and analysis.