Healthdirect study highlights lack of after-hours care

(Medical Xpress)—A study examining the appropriateness of referrals to the Royal Perth Hospital emergency department by the national telephone triage service healthdirect has spotlighted the lack of access to after-hours health care.

The study's authors, including Professor of Daniel Fatovich, of The University of Western Australia's Centre for Medical Research, and Dr Joseph Ng, and registrar in emergency medicine at RPH, found a significant number of people who attended the RPH emergency department after contact with healthdirect had done so despite advice to stay away.

Just over 52% of people who presented at the ED and were traced back to the healthdirect database had either been given advice on self-care or told to seek treatment from their GP or a non-emergency service.

Professor Fatovich said it could be argued that the healthdirect-referred patients in the study had low rates of compliance.  However, data showing a prominence of out-of-hours attendance by people in that group suggested it had more to do with the limited availability of after-hours health services.

"It's hard enough to access health services during the daytime hours let alone after hours," Professor Fatovich said.

The result might also reflect the inherent fallibility of a telephone consultation model.

"Really you need a face to face assessment, you can't diagnose over the phone," Professor Fatovich said.  "In any case patients will interpret the advice they're given in the context of their own perceptions and their own situation."

The study, in the November 5 edition of the , compared attendances by people who went to the RPH ED after contact with healthdirect with attendance by people who had self-referred, and people referred by .

Although the authors had hypothesised that healthdirect referrals would be more appropriate than self-referrals, they found instead that the two had similar rates, at 72.9% and 73.8% respectively.

GP referrals had the highest level of appropriateness, with 89.7% of referrals deemed appropriate by the definition used in the study.  GP referrals also had the highest rate of appropriate ambulance use, and the highest rate of admission.

The study, which used data from 2008 and 2009, was the first time the appropriateness of referrals from healthdirect had been thoroughly evaluated.

Professor Fatovich said while healthdirect was very highly rated by the community and got high satisfaction scores from those who used it, there was no evidence that it reduced demand on EDs - one of the arguments used to justify the cost of providing the service.

"The lay public needs and wants easy access to health information and advice and this is invaluable.  Many people see it as a lifeline, but to justify the cost of the service by saying this is going to reduce demand on EDs is not supported by any research.  What we say in the paper is that's a misplaced argument."

The authors wrote that such an argument perpetuated the myth that EDs are overrun with patients who could more appropriately receive care in a general practice setting.

"This is a simplistic explanation of the complex issue of ED overcrowding," they wrote.  "To date, it has been shown that telephone triage services have limited capacity to influence ED use or workload."

Professor Fatovich said the study showed people were very good at working out that they are seriously ill and require ED services, with self-referred patients showing the highest level of acuity and the only deaths amongst those studied.  It also showed those receiving GP referrals were more likely to be older patients, while those using healthdirect were more likely to be younger, and female.

Limitations of the study included that there was no gold standard definition of 'appropriateness'.  The results also may have limited external generalisability because they focused on adult referrals, even though parents calling for advice about children usually formed the major component of telephone triage services.

Healthdirect Australia is a free, 24-hour nationwide telephone triage service funded by State and Federal governments. It is staffed by registered nurses, although last year an after-hours GP helpline was added to the service.

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