TABLE 1
Percentage of after-hours calls, by chief complaint
| Number of complaints (%)* | ||
|---|---|---|
| Chief complaint | All subjects except utilizers (n = 1564) | High utilizers (n = 56) |
| Medication | 288 (15.1) | 110 (19.7) |
| Pain | 197 (10.3) | 107 (19.1) |
| Obstetric† | 195 (10.2) | 32 (5.7) |
| Fever | 191 (10.0) | 28 (5.0) |
| Nausea/vomiting | 108 (5.7) | 31 (5.5) |
| Blood/bleeding | 84 (4.4) | 32 (5.7) |
| Infection | 72 (3.8) | 24 (4.3) |
| Stomach | 70 (3.7) | 16 (2.9) |
| Headache/migraine | 67 (3.2) | 19 (3.4) |
| Asthma/breathing | 58 (3.0) | 32 (5.7) |
| Back | 55 (2.9) | 16 (2.9) |
| Laboratory results | 54 (2.8) | 8 (1.4) |
| Cough | 46 (2.4) | 6 (1.1) |
| Eye | 42 (2.2) | 8 (1.4) |
| Diarrhea | 41 (2.2) | 7 (1.2) |
| Throat | 38 (2.0) | 6 (1.1) |
| Fall | 36 (1.9) | 10 (1.8) |
| Rash | 34 (1.8) | 3 (0.5) |
| Ear | 33 (1.7) | 7 (1.2) |
| Chest | 30 (1.6) | 19 (3.4) |
| Total of top 20 complaints | 1739 | 521 |
| All other complaints | 625 (32.7) | 184 (32.9) |
| Total complaints | 2364 | 705 |
| Total calls | 1906 | 559 |
| Multiple complaint calls | 458 (24.0) | 146 (26.1) |
| Average calls per subject | 1.3 | 10.0 |
| *Information-only calls (n = 1073) not included. | ||
| †Includes nonobstetric problems in pregnant patients. | ||
TABLE 2
Average number of clinical calls by season and day of week
| Season | Mon | Tue | Wed | Thur | Fri | Sat | Sun | Seasonal average |
|---|---|---|---|---|---|---|---|---|
| Winter (Dec–Feb) | 8.9 | 8.7 | 6.1 | 8.1 | 9.1 | 16.6 | 11.5 | 9.9 |
| Spring (March–May) | 10.0 | 8.5 | 8.2 | 8.5 | 8.2 | 16.2 | 13.6 | 10.4 |
| Summer (Jun–Aug) | 12.5 | 8.8 | 8.8 | 8.8 | 8.2 | 15.5 | 12.0 | 10.6 |
| Fall (Sep–Nov) | 9.1 | 6.5 | 8.4 | 6.7 | 8.4 | 12.3 | 9.0 | 8.6 |
| Daily average | 10.1 | 8.1 | 7.8 | 8.0 | 8.5 | 15.6 | 11.5 |
DISCUSSION
This study expands on previous work by describing the total variety of after-hours phone calls to a family practice office over an entire year. Our findings on reasons for call, time of call, and demographics are similar to those of previous work.3,10 However, our study is one of the first to describe the subset of high utilizers. Introducing a patient health handbook, practice Web site, pharmacy help line, or other practice management tools might reduce the number of “information only” calls. Contrary to our expectation, the highest numbers of average daily calls were in the spring and summer and not in the winter. Saturdays and Sundays were the busiest days of the week for such calls.
Patients called for diverse clinical reasons (Table 1) and therefore physicians might focus their attention on the most frequent reasons for calls, in order to improve the effectiveness of their educational efforts. For example, physicians might discuss the patient’s medication concerns, give specific recommendations to talk to the pharmacist, and possibly offer an automated medication “tracking system” to alert patients during the week when their medications were running out, as a way of reducing the number of calls and allaying patient concerns.
Pain symptoms clearly account for a substantial number of calls. Although some of these calls might be serious emergencies (chest pain) and require immediate action, other calls, such as for migraine headaches, may point to a need to educate and set limits with patients during their regular appointments. For example, patients could be told that migraine headaches are not a “life-threatening” emergency and be urged to use self-management strategies until the next day.
Discussing fever management with new parents at well-child visits might decrease future calls. There is some research to suggest that providing new parents with specific guidelines about when to call if their child has a fever can dramatically reduce after-hours visits to the emergency room.11 Obstetric calls represent an important group requiring immediate callback with very specific questions (eg, fetal movement, bleeding), and might be a target area for physician education.
Out of approximately 9000 patients in the practice and 1564 patients who called the practice during the year, we identified 56 high utilizers (0.6% of all patients). They averaged nearly 10 calls per year in contrast to 1.3 calls for all other callers. Future research might be directed at trying to determine why these patients feel a need to call at nearly 10 times the rate of other patients.
These findings should be interpreted in light of several limitations. Because our findings are based on a family practice residency, the patient population may be different from the typical private family practice office and have less continuity. However, the wide range of calls is likely to be typical of the diverse problems managed by family physicians. This study did not collect information on the management and disposition of these after-hours calls. Certainly, understanding the entire episode of after-hours contact (reason for call, management, outcome, satisfaction) is important, and is the next step in our research.
The diversity and seriousness of medical problems addressed by the after-hours physician highlight the need to provide specific training to physicians for dealing with patient calls and educating patients on the many issues leading to after-hours calls.
ACKNOWLEDGMENTS
The authors thank Ellie Jensen for help with data collection, entry, and analysis.