Reasons for after-hours calls

Previous studies of after-hours calls to family physicians focused on caller demographics, medical triage skills, and patient satisfaction, and were usually conducted for a limited time. We examined the frequency and nature of calls to a family practice residency over 1 year. Caller and patient information, date, time, and chief complaint were obtained from answering service logs. The 5 most frequent chief complaints related to medications, pain, obstetric issues, fever, and nausea. Interestingly, 56 “high utilizers” (0.6% of all patients) accounted for 23% of the calls.

Although telephone calls may account for 10% to 25% of all patient contacts,^1,2 few studies have examined the frequency and nature of these calls over an extended time. A month-long study³ found that patients who telephoned after hours were 3 times more likely to rate their problem in the highest severity category compared with the physician’s rating of the problem. This study, done in July, may not reflect the diversity of patient problems, because of seasonal variations; also, it did not appear to include obstetric problems, which are a prominent reason for calls to family practice physicians.^4,5 Many physician groups use answering services to screen calls as a method for decreasing the number of calls. The purpose of this study was to document the frequency and nature of after-hours calls to a family practice office over 1 year.

METHODS

All after-hours telephone calls (5 PM to 8 AM, weekends and holidays) made to a freestanding community-based family practice training program were collected for the 12-month period between April 2000 and March 2001. A recorded message directed the caller to call 911 for a life-threatening emergency or stay on the line for operator assistance. Emergency calls were forwarded to the resident physician on call. Sixteen family medicine residents supported by 8 faculty physicians took primary calls on a rotating basis. The practice had approximately 9000 active patients (at least 1 visit in the last 3 years), and about 1350 patient visits per month. Approximately 30% were covered by Medicaid, 10% by Medicare, 35% by managed care, and 12% by indemnity insurance; 13% were uninsured.

The operator recorded date and time, caller’s and patient’s first and last names, primary care physician, patient’s pregnancy status, date of last office visit, chief complaint(s), and whether the caller felt the situation was an emergency.

Previous studies variously classified patient calls based on diagnostic group, chief complaint, symptom, treatment and medication, injury, and organ system affected.^1,3,6-10 We followed the lead of Benjamin⁸and Perkins and colleagues,¹ who used the patient’s chief complaint to categorize calls. We classified the patient’s chief complaint by searching for key words such as “heart” (eg, “fast heartbeat,” “pains near heart,” or “isn’t feeling well, heart failure a couple of years ago”). This allowed for the broad inclusion of chief complaints while avoiding the risk of premature diagnosis.

A research assistant entered information from the operator’s records into a Microsoft Access Database. Patients who called more than 6 times after hours during the year were arbitrarily defined as “high utilizers.” We also gathered data on these callers’ hospital emergency room visits and admissions to affiliated hospitals. The HealthOne Institutional Review Board approved the study.

RESULTS

A total of 3538 calls were made by 1564 patients; 2465 were clinical calls, and key words or phrases were used to classify them under chief complaint headings. If a caller had a multiple-symptom complaint (ie, fever and headache), it was classified under all appropriate headings and counted twice. The total number of complaints is therefore higher than the total number of calls. Table 1 presents the frequency and percentage of after-hours clinical calls for all subjects, and separately for high utilizers. Table 2 presents the average number of clinical calls organized by season and day of the week. Thirty-three percent of all calls were made by the patient, 31% by a proxy (spouse, parent, friend), and 36% by other parties (nurse, pharmacy, unidentified party).

Although the rankings of calls for all patients and high utilizers in Table 1 were similar, several differences stand out. High utilizers account for only 0.6% of patients, but 23% of all calls. High utilizers called substantially more for complaints relating to medication, pain, asthma/breathing and chest problems; 39% of their calls were for medication or pain concerns. Of the high utilizers, 39% (22/56) made 46 emergency room visits, but only 7% (4/56) were hospitalized during the year.