Many pediatricians sleep well at night because they utilize call centers to respond to after-hours calls. The first call center was introduced in 1988 as a uniquely pediatric innovation. This month’s article presents a brief history of call centers, discusses their advantages, and describes how they will improve patient care.
A brief history
In the mid-1970s, researchers affiliated with the Children’s Hospital Medical Center (now Boston Children’s Hospital) in Boston, Massachusetts, performed a feasibility study in which nonmedical “health assistants” used algorithms to refer patients for urgent care.1,2 Health assistant triage recommendations were compared with those made by emergency department (ED) physicians and nurses. In the study, 60% of callers were advised by health assistants to seek urgent care, compared with 44% of those who spoke directly with medical providers. Although the overreferral rate was striking, the study established that algorithms could be used effectively, even by nonmedical personnel. The researchers speculated that “call centers” could be developed similar to “poison centers” that were common at the time.2,3
The first pediatric call center was introduced in 1988 at the Children’s Hospital Colorado, Aurora, with 10 subscribing physicians, and in 4 years it grew to serve 92 pediatricians. Physicians were charged on a per call basis, initially $10 per call, later decreasing to $8.25 per call. For most physicians, payments to the call center were estimated to be about 1% of practice revenue. Nurses were trained to use telephone triage protocols4 developed by Barton Schmitt, MD (one of the authors of this article), to triage calls into 1 of 3 categories: 1) patient to be seen immediately; 2) patient to be seen next day; or 3) home advice only given.
Logs were reviewed regularly, and nurses continued to receive training to improve their triage abilities. In the first 4 years of the program, the call center managed a total of 107,938 calls. Fever, rash, vomiting, injury, earache, cough, diarrhea, sore throat, fussiness, and abdominal pain were the top 10 triaged complaints (in order of decreasing frequency). Twenty percent of these calls fell into the “immediate care” category; 28% were advised to be seen the next day; and 52% were given home care advice only. One percent of calls resulted in the patient being hospitalized.5
The call center continued to grow and serve an increasing number of Colorado pediatricians. During a 1-year survey conducted from 1999 to 2000, 141,922 calls were answered, representing over 1000 calls per enrolled pediatrician. Disposition rates changed little from those reported 11 years earlier, with 21 % of callers advised to be seen immediately, 45% given home care instructions, and 30% advised to follow up with their pediatricians the following day.6
Acceptance and growth
Eventually, many healthcare systems and hospitals developed call centers that served adults as well as children, and today these call centers receive an equal number of calls regarding adults as well as children. Overwhelmingly, physicians, patients, hospitals, and insurance companies have been advocates because call centers ensure that medical care is provided in the most appropriate, most cost-effective location.
Traditionally, patients are overusers of ED services. The New England Healthcare Institute (NEHI), Cambridge, Massachusetts, estimated in 2010 that on average an ED visit costs $580 more than an office visit, and that 67 million, or about 56%, of 120 million annual ED visits were avoidable.7 The institute estimated that more than $38 billion is wasted each year from ED overuse. It posited that reduction in costs associated with these unnecessary ED visits, could be achieved by:
Aligning patients with a medical home;
Providing primary care weekend and evening hours; and
Providing access to a call center.
It is worth noting that 25% of patient calls to Children’s Hospital Colorado’s pediatric call center are from patients without a medical home. Also of note is that a recent study indicated that access to retail-based clinics did not result in a significant reduction in low-acuity ED visits.8
A follow-up study looked at the cost savings associated with recommendations made by the call center at Children’s Hospital Colorado during 2004. Researchers discovered that two-thirds of the cases in which parents reported initial intent to go to an ED or urgent care facility were not deemed “urgent” by nurse triage, whereas 15% of calls from parents who intended to stay home were triaged as “urgent.”9
Had the callers implemented their initial intentions, the cost to the healthcare system would have been more than $1 million. Had the recommendations that were made by the nurse advice line been heeded in every case, the cost to the healthcare system would have been $410,615 less than the intended services. This amount translated into a saving of $42.61 per call after expenses. The conclusion: Advice offered by call centers can save patients unnecessary healthcare costs and reduce ED overuse substantially.9