Standard Nurse Phone Triage vs Tele-Emergency Care Pilot on Veteran Use of In-person Acute Care: An Instrumental Variable Analysis

Acad Emerg Med. 2023 Feb 9. doi: 10.1111/acem.14681. Online ahead of print.

ABSTRACT

OBJECTIVES: Use of acute care telemedicine is growing, but data on quality, utilization, and cost are limited. We evaluated a Veterans Affairs (VA) tele-emergency care (tele-EC) pilot aimed at reducing reliance on out-of-network (OON) emergency department (ED) care, a growing portion of VA spending. With this service, an emergency physician virtually evaluated selected Veterans calling a nurse triage line.

METHODS: Calls to the triage line occurring January-December 2021 and advised to seek care acutely within 24 hours were included. We described tele-EC user characteristics, common triage complaints, and patterns in referral to and management by tele-EC. The primary outcome was acute care visits (ED, urgent care, and hospitalizations at VA and OON sites) within 7 days of the index call. Secondary outcomes included mortality, OON acute care spending, and the effect of tele-EC visit modality (phone vs video). We used both standard regression and instrumental variable (IV) analysis, using the tele-EC physician schedule as the instrument.

RESULTS: Of 7845 eligible calls, 15.5% had a tele-EC visit, with case resolution documented in 57%. Compared to standard nurse triage, tele-EC users were less likely to be Black, had more prior ED visits, and were triaged as higher acuity. Calls concerning dizziness/syncope, blood in stool, and chest pain were most likely to have a tele-EC visit. Tele-EC was associated with fewer ED visits than standard nurse triage in both regression (average marginal effect [AME] -16.8%; 95% confidence interval [CI], -19.2 to -14.4) and IV analyses (AME -17.5%; 95% CI, -25.1 to -9.8), similar hospitalization rate (AME -3.1%; 95% CI, -6.2 to -0.0), and lower OON spending (AME -$248; 95% CI, -458 to -38).

CONCLUSIONS: Among Veterans initially advised to seek care within 24 hours, use of tele-EC compared to standard phone triage led to decreased ED visits and OON spending within 7 days.

PMID:36757685 | DOI:10.1111/acem.14681