Telephone-based interventions in outpatient care.

Telephone calls have long been integral to health care delivery. Patients often contact physicians to determine whether symptoms require a face to face visit, and physicians call patients to follow up oYce visits. As it became increasingly clear that patient education for chronic disease requires time beyond a single oYce visit, telephone-based intervention became viewed as a potential eVective way to overcome pragmatic obstacles (for example, space, time) to educate patients in already busy outpatient settings. Telephone contacts also provide an excellent vehicle through which to monitor patients’ health between oYce visits, particularly when patients need to travel long distances to receive medical care. More than a decade ago, we began to examine the impact of proactively using telephone-based interventions for patients with osteoarthritis (OA). An uncontrolled, longitudinal study observed that, following biweekly telephone calls during a six month period, patients withOA reported significant improvements in functional status. Perhaps more surprisingly, six months after telephone calls were ceased, improvements in functional status persisted. Unfortunately, this investigation lacked a control group. Thus, we conducted a randomised controlled trial to evaluate whether telephone-based or oYce-based interventions, or both, improved functional status of patients with OA. The intervention consisted of brief interviews during which trained non-medical personnel reviewed patients: (1) medications, (2) joint pain symptoms, (3) gastrointestinal complaints related to use of non-steroidal antiinflammatory drugs, (4) reporting of early warning signs of hypertension, heart disease, diabetes, chronic obstructive pulmonary disease (when applicable), (5) scheduled outpatient visits, (6) an existing process by which patients could telephone a provider during evenings and weekends, and (7) barriers to keeping their appointments. These personnel also provided specific suggestions to encourage patients to ask questions of their providers. At one year, compared with the control group, persons receiving telephone contacts reported significantly less physical disability and pain, as well as a trend towards better psychological status. 3 Interestingly, patients receiving the oYce-based intervention had worse physical health, although neither pain nor psychological health was aVected. The latter finding provides additional support for delivering such interventions by telephone, instead of during regularly scheduled primary care visits. The telephone intervention was relatively inexpensive to deliver, yet reaped clinical benefits in the range achieved during trials of drug therapy for OA. Subsequently, other investigators have evaluated telephone-based interventions among patients with rheumatological problems.One randomised trial compared two telephone-based strategies (symptom monitoring, treatment counselling) against usual care among patients with OA and rheumatoid arthritis (RA). The two intervention strategies diVered in that treatment counselling was more elaborate and was multi-faceted. The authors found that treatment counselling had a clear advantage over either symptom monitoring or usual care, a finding that was also seen among patients with systemic lupus erythematosus (SLE). In addition, an early study suggests that person centred counselling, which focuses on the aVective state of the person (including coping with emotional stress), may be eVective among persons with SLE, although not in RA. Outside rheumatology, Wasson et al used a randomised controlled trial to evaluate whether telephone care could substitute for oYce visits. For patients in the intervention group, clinicians’ recommended follow up visit intervals were doubled (for example, from three to six months), and three intervening telephone calls were substituted. Compared with patients in the control group, patients in the intervention group had significantly fewer oYce visits, less medication use, fewer hospital admissions, shorter stays in the hospital (both wards and intensive care units), and health care expenditures. Notably, for patients reporting fair or poor overall health at baseline (36% of the sample), there was a trend (p=0.06) towards an advantage in survival for the intervention group. This study shows the potent eVects of telephone-based interventions.