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Telephone consultations for respiratory conditions

Hilary Pinnock
MB ChB MRCGP MD
Senior Clinical Research Fellow Allergy & Respiratory Research Group Centre of Population Health Sciences
GP Section
University of Edinburgh

Traditionally, patients wanting professional advice have arranged a face-to-face consultation. Today's communication technology, however, offers other options, enabling flexible access to professional care for people with long-term conditions

Patients need support to enable them to look after their long-term conditions appropriately. People with variable conditions, such as asthma, need to know how to recognise the early signs that their condition is deteriorating, and what action to take to regain control.1 In progressive conditions, such as chronic obstructive pulmonary disease (COPD), patients and their carers not only need clinical advice for managing exacerbations, but also ongoing nursing and social support as they cope with the challenges of living with long-term disability.2

A useful concept is the familiar long-term conditions pyramid, which illustrates the increasing dependence on professional care as the severity and complexity of the patient's condition increases (see Figure 1).3 Although most patients are self-caring most of the time, they will all need to access professional support and care occasionally, so the access across the boundary between self-care and professional is crucial.

[[Fig 1 tel]]

The traditional "route" across the boundary is for the patient to arrange a face-to-face consultation in the surgery or, if they are housebound, to request a home visit. Today's communication technology, however, offers other options which our patients will increasingly expect to use when they need advice. This article reviews the current understanding of the role of telephone consultations to enable flexible access to professional care for people with long-term conditions.

Reviewing people with asthma
Regular review of people with asthma has been shown to improve morbidity and is a key recommendation of the British Thoracic Society/Scottish Intercollegiate Guideline Network British Guideline on Asthma Management.1 However, it is the experience of most practice nurses that many people with asthma are reluctant to attend for routine reviews. This is, perhaps, not surprising in a variable condition that affects busy younger people so that they consider that their asthma is "not serious enough" to warrant the investment of time and effort required to attend the surgery.4

Can telephone consultations help?
In our randomised, controlled trial of telephone consultations, consenting patients were allocated to telephone or face-to-face consultations for the routine review of their asthma.5
Telephone consultations reached 74% of the patients: only 48% responded to the invitation to attend the asthma clinic. Asthma morbidity at the end of the three-month trial was the same in both groups. With an average duration of 11 minutes, telephone reviews took half the time of the face-to-face consultations, an efficiency reflected in substantial cost savings.6 Many patients were impressed by the convenience of telephone reviews, particularly if they were experiencing few asthma symptoms at the time, although they considered that if their asthma was causing concern a face-to-face review would be preferable.7

Offer patients the choice
Trials, however, are contrived situations. In the real world, patients are not allocated to telephone or face-to-face reviews, but will choose the mode of consultation that seems most appropriate to their needs at that time. In our practice we have developed a review service that offers flexibility. Key features of the service are:

  • Reminders (invitation letters or memos attached to repeat prescriptions) offer patients the choice of booking a face-to-face appointment or arranging a telephone consultation.
  • Face-to-face or telephone consultations are booked into the asthma clinic, with telephone reviews allocated half the time of a face-to-face consultation reflecting the research evidence.5   
  • The nurse telephones the patient at the appropriate time in her clinic using the number the patient provided at the time of booking.
  • Patients who do not take up either of the options are telephoned opportunistically, either conducting the review on the phone, or arranging a face-to-face consultation if preferred or clinically appropriate.

We trialled this "telephone option" service in one group within our practice during 2004.8 Our new service achieved a routine review with 66% of the patients – 13% more than in the group only offering traditional face-to-face consultations. Interestingly, offering a telephone option did not increase the proportion of patients who responded to our invitation letters by making an appointment (although a fifth chose a telephone review). The additional patients reviewed were nonresponders whom the nurses phoned opportunistically, patients who otherwise would have been "exception reported" under the rules for the Quality and Outcomes Framework (QOF).9

Telephone consultations have also been used to "triage" patients with asthma, only arranging face-to-face appointments for those whose asthma was not well controlled. This approach increased the proportion of patients reviewed from 60–81%.10

Can a telephone consultation fulfil the functions of a review?
Most of the functions of an asthma review can be undertaken by telephone, although it may be necessary to adapt familiar "face-to-face" procedures to accommodate the loss of visual clues.11 Asthma control can be assessed by asking the Royal College of Physicians three questions (RCP-3Qs) (see Box 1).12 Current treatment can be discussed, concerns about side-effects and issues of concordance can be addressed, and treatment can be stepped up or down. Issuing a personalised asthma action plan, or reviewing an existing plan, is a crucial component of an asthma review.1,13 While initial self-management education may be easier face-to-face, patients can be directed to websites for further information and revised action plans can be posted after a telephone consultation. Excellent action plans are available from the National Asthma Campaign (www.asthma.org).

[[Box 1 tel]]

In our practice, we agreed that a face-to-face consultation was preferable in certain circumstances; for example, young children or those with severe asthma, although even in these situations a telephone consultation may be appropriate to establish contact with a reluctant attender. An important disadvantage is the inability to observe inhaler technique on the telephone. Pragmatically, if control is good (as judged by negative responses to the RCP-3Qs) there seems little need for concern. However, poor inhaler technique should be considered as a cause of suboptimal control and a surgery appointment arranged to assess appropriate devices considered.14

Telephone consultations for people with COPD
There is less evidence to inform the appropriate use of telephone consultations for people with COPD, although there would seem to be a number of situations where a telephone consultation might be particularly helpful.

  • The patient with mild COPD, minimally troubled by symptoms, may be reluctant to attend the surgery for a routine review. The degree of breathlessness can be assessed using the MRC dyspnoea score15 (see Box 2) and, if the patient is still asymptomatic, all that may be clinically required is to enquire about smoking status and offer cessation advice.  (The QOF, of course, requires annual spirometry, which would mean attendance at the surgery.)9
  • As the disease progresses and symptoms become more troublesome, patients will require increasing professional input (see Figure 1). In this context, the telephone can provide flexible access to professional advice perhaps to clarify when to start an emergency supply of antibiotics, or whether to tail-off or just stop a course of steroids.
  • Patients disabled by their breathlessness may want to ask about whether they would qualify for a "blue badge" to enable them to park nearer the shops or where to borrow a wheelchair for use on holiday. Such simple queries do not warrant the time and effort required to attend the surgery, and can addresed as effectively by telephone (or indeed email).
  • Once any immediate danger is passed, a telephone call may be an efficient means of following up acute exacerbations. The increasing use of telemonitoring, which can transmit critical parameters, such as oxygen saturation and lung function, is likely to facilitate remote management of exacerbations.

[[Box 2 tel]]

Do nurses need special training for telephone consultations?
Asthma or COPD consultations should only be undertaken by nurses who have specialist training in respiratory care, and providing advice by telephone is probably more comfortable for a nurse with some experience. The loss of visual clues in a telephone consultation can be worrying to both patient and nurse, particularly in acute situations, and specific training may be helpful. Some recommendations for safe use of telephone consulting are included in Box 3.

[[Box 3 tel]]

Summary
Telephone consultations offer a valuable alternative to face-to-face consultations for the ongoing management of long-term conditions. They can facilitate convenient reviews for people with respiratory conditions, especially when symptoms are mild. Those with more severe disease benefit from flexible access to professional advice in order to support self-care and telephone calls can be useful options. A key principle is that the patient should choose the mode of consultation most appropriate to the problem they wish to discuss. Clinicians should arrange a face-to-face consultation if concerns (for the patient or nurse) remain at the end of the telephone call.

Acknowledgements
Thanks to Gaylor Hoskins, Stephanie Wolfe and Kathy Ellis who provided helpful comments on an initial draft  of this article.

Hilary Pinnock is supported by a Primary Care Research Career Award from the Chief Scientist's Office, Scottish Government.

References
1. British Thoracic Society Scottish Intercollegiate Guideline Network. British Guideline on the Management of Asthma. Thorax 2008;63(Suppl IV): iv1–121.
2. National Institute for Health and Clinical Excellence. National clinical guideline management of chronic obstructive pulmonary disease in adults primary and secondary care. Thorax 2004;59
(Suppl 1):S1–232.
3. Department of Health. Improving chronic disease management. Available from: http://www.dh.gov.uk/assetRoot/04/07/52/13/04075213.pdf
4. Gruffydd-Jones K, Nicholson I, Best L,
Connell E. Why don't patients attend the asthma clinic? Asthma Gen Pract 1999;7:36–8.
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6. Pinnock H, McKenzie L, Price D, Sheikh A.
Cost-effectiveness of telephone or surgery asthma reviews: health economic analysis of a pragmatic primary care randomised controlled trial. Br J Gen Pract 2005;55:119–24.
7. Pinnock H et al. Telephone or surgery asthma reviews? Preferences of participants in a primary care randomised controlled trial. Prim Care
Respir J 2005; 14:42–6.
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9. NHS Confederation, British Medical Association. New GMS Contract 2003: Investing in general practice. London: BMA.
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11. Pinnock H. Reviewing people with asthma. General Practice Airways Group 2008. Available from: http://www.gpiag.org
12. Pearson MG, Bucknall CE, eds. Measuring clinical outcome in asthma : a patient-focused approach. London: Royal College of Physicians; 1999.
13. Gibson PG et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No: CD001117.
14. Haughney J, Price D, Kaplan A, Chrystyn H, Horne R, May N, et al. Achieving asthma control in practice: understanding the reasons for poor control. Respir Med 2008;102:1–13.
15. Fletcher CM, Elmes PC, Fairbairn AS, Wood CH. The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. BMJ 1959;2:257–66.