PEDIATRICS Vol. 110 No. 5 November 2002, pp. 865-872
Caller Satisfaction With After-Hours Telephone Advice: Nurse Advice Service Versus On-Call Pediatricians
* Emergency Medicine Center, David Geffen School of Medicine at UCLA, Los Angeles, California
McKesson Access Health Services, Broomfield, Colorado
Mattel Children’s Hospital, Los Angeles, California
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ABSTRACT |
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Objective. To compare caller satisfaction with after-hours medical advice provided by a for-profit nurse advice service with advice provided by on-call pediatricians.
Methods. The study setting was the general pediatrics faculty practice of an urban university medical center. Participants were parents or guardians of a population of 
6000 children calling for after-hours medical advice over a 10-month period from January 18 to November 20, 2000. After-hours medical advice calls were randomized to either a nurse advice service or the on-call pediatrician. Caller satisfaction and subsequent health care utilization were measured by a telephone survey of callers and review of all health care visits within 3 days of the initial telephone advice call.
Results. Five hundred sixty-six (48%) callers were enrolled in the on-call pediatrician group, and 616 (52%) were enrolled in the advice nurse group. Caller satisfaction was rated as very good or excellent significantly more often for the on-call pediatrician than for the nurse advice service as follows: telephone call overall (68.5% vs 55.0%; 95% confidence interval [CI] of difference: 8.0%–19.0%), thoroughness and competence of the person they spoke with (74.0% vs 59.1%; 95% CI of difference: 9.6%–20.2%), courtesy and friendliness of the person they spoke with (77.4% vs 73.9%; 95% CI of difference: -1.4%-8.4%), length of time spent waiting (70.8% vs 60.1%; 95% CI of difference: 5.4%–16.2%), time spent talking with the on-call pediatrician or advice nurse (68.2% vs 52.4%; 95% CI of difference: 10.2%–21.3%), and the medical advice given (68.6% vs 53.9%; 95% CI of difference: 9.2%–20.1%). Compliance with the advice given was significantly higher for office care in the on-call pediatrician group (51.5% vs 29.6%; 95% CI of difference: 8.9%–34.2%). Repeat calls for advice were significantly more frequent for the nurse advice service, both within 4 hours (13.0% vs 4.8%; 95% CI of difference: 5.0%–11.4%), and within 72 hours (23.4% vs 13.3%; 95% CI of difference: 5.8%–14.5%).
Conclusion. Callers were less satisfied with medical advice provided by a nurse advice service compared with the traditional on-call pediatrician. The lower satisfaction was associated with somewhat poorer compliance with recommended triage dispositions and more frequent repeat calls for medical advice.
Key Words: telephone advice • primary care • pediatrics • family practice • management • triage • decision making • satisfaction • randomized controlled trial
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INTRODUCTION |
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Medical advice by telephone has been a traditional part of most primary care practices, especially pediatrics, where it is perceived as a value-added obligation of the chosen physician. Changes in the health care marketplace have altered this traditional model, and have led to an increased emphasis on telephone interactions as a means to reduce expenses associated with medical care, especially emergency department visits. This form of "gatekeeping" has been referred to as telephone triage or demand management.1–3 Demand management includes all methods to decrease the demand for services and to reduce the costs of these services. In this model, the basic operating unit is a clinical call-taker who processes requests for medical advice from a layperson-caller. The call-taker gives information regarding the appropriate level and timing of medical care, as well as limited self-care medical advice.
Many telephone triage systems have developed into sophisticated large-scale operations. The telephone interaction has evolved from unstructured protocols, which rely heavily on the subjective judgment of the call-taker, to physician-developed clinical algorithms, usually in the form of binary decision trees that address the most common medical complaints. Most large call-centers employ specially trained full-time call-takers, usually nurses, who often use computerized algorithms in conjunction with their clinical judgment to gather information and give medical advice.
By the end of 1996, telephone triage services were available to 35 million people and were expected to reach 100 million people by the end of 2001.4 This rapid growth is primarily a market-driven response, with some telephone triage providers claiming to save payers $2 in health care costs for every $1 spent.5 The few existing studies in pediatric populations have also suggested the potential for significant nonmonetary benefits. These include the following: high patient satisfaction,6–9 high physician satisfaction,6,10,11 improved quality of information gathering,12,13 and improved access by patients to medical advice.14
Despite the potential for significant benefits, little medical research has been done to evaluate the process of telephone triage by nonphysicians. The recent and rapid growth of telephone triage in the delivery and the control for access to health services may not have allowed time for such research. The process is also difficult to study in a formal manner. Telephone contacts are not part of the documented medical record, and access to the content of telephone conversations is limited. The few existing studies of telephone triage services employing nonphysicians have reported >90% caller satisfaction.6,8,15,16 However, these studies evaluated telephone triage services managed by their respective authors, raising suspicion of bias.
Although there have been studies of caller satisfaction with telephone advice nurses, no study to date has attempted a comparison of telephone triage services with the traditional physician on-call model. The purpose of this study was to compare caller satisfaction with the advice given by nurses of a large commercial provider of telephone triage services, with that given by the on-call physicians of a university general pediatrics practice.
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METHODS |
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Population
The study population was the callers for telephone advice for pediatric patients of the 16 full-time faculty pediatricians of a University General Pediatrics Faculty Practice. The patient population includes
6000 children. The patients are general pediatric patients and not the patients of the subspecialty pediatric clinics. Approximately 70% are white, 14% Asian, and 8% African American with the remainder being Latino, Native American, and other. More than 98% have health insurance: three-quarters are managed-care patients, with <2% with Medicaid or Medicare. Approximately 90% have some college education, and 40% have attended graduate school.
After-Hours Advice
Before the onset of the study protocol, all after office hours (Monday to Thursday 5 PM to 8 AM, weekends Friday 5 PM to Monday 8 AM, and holidays 8 AM to 8 AM), telephone calls, including those for medical advice, were forwarded to the medical center page operators who paged the pediatrician on-call. A member of the faculty practice (never a resident) was on-call on a rotating basis at all times for the group practice.
Inclusion and Exclusion Criteria
Inclusion criteria: All after-hours calls for the on-call pediatrician regarding patients in the university general pediatrics faculty practice. Exclusion criteria were as follows: 1) calls not for medical advice (prescription refill, etc), 2) emergency medical conditions (unconscious and not breathing, respiratory distress or choking, convulsions that have not stopped by the time of the call, rapid bleeding from traumatic injury, active labor), and 3) unable to consent (non-English speaking, caller is not the legal guardian or a minor). When an emergency medical condition was present, the page operator instructed the caller to call 911. All page operators complete a Medical Priority Dispatch Training course for communication center personnel involved in the activation of emergency medical services.
Consent
This investigation was approved by the institutional review board, which deemed that telephonic consent at the time of the call was appropriate. All families in the general pediatrics faculty practice were first notified of the study by a special mailing that described the study including the rationale and methods, and subsequently by an article in the quarterly general pediatrics newsletter mailed to all families. At the time of the after-hours call, the page operator attempted to obtain verbal telephone consent for patients who did not meet exclusion criteria. For callers who did not consent, the following information was collected: the reason for call and the age of the patient. Completeness of page operator enrollment attempts and data collection was determined by comparing page operator data forms with daily message prints of all pages to the on-call pediatric faculty.
Randomization
If the caller consented, the page operator collected the following information: date, time, name of caller, name of patient, patient date of birth and sex, and 2 telephone numbers for the follow-up telephone interview. After enrollment, the page operator selected a numbered envelope, which enclosed a 3x5 card with the word "Physician" or "Nurse." Cards were ordered using a random number table in which the group was determined by whether the last digit was odd or even. Based on this result, the telephone operator either paged the on-call pediatrician to speak with the parent, or forwarded the call directly to the advice nurse at the telephone triage service. All callers randomized to the advice nurse were told they would have the option of speaking to the on-call pediatrician after speaking to the nurse if they so desired. This is the standard policy of the nurse advice service.
When callers were randomized to the on-call pediatrician, the on-call pediatric faculty member was paged via an alpha-numeric pager. The message routinely included the name of the child, the caller’s phone number, the name of the child’s pediatrician, and the reason for the call. The general pediatric faculty members are all board-certified or eligible in pediatrics and function as a group practice. Medical care is provided at a multispecialty medical office building on the medical campus and at 5 satellite clinics in the Los Angeles area. All after-hours medical advice calls were routed to the page operator during this study.
When callers were assigned to the advice nurse, the page operator forwarded calls to a dedicated telephone number at the telephone triage service. This service is marketed as the nation’s premier health care information, referral, and teleservices marketing program. This service has >30 million enrolled members, 1500 employees, 6 care centers employing >500 nurses, and >1000 clients including health plans, government organizations, self-insured employers, providers, and integrated delivery networks. The telephone triage nurses use a physician-designed clinical guideline system to respond to common health care questions and to direct callers to physicians, hospitals, and community resources when necessary.
Repeat Callers
All calls for enrolled children within 72 hours of the initial call were excluded from reenrollment and randomization and were included in a group called "Repeat Calls." Repeat callers were asked whether they spoke to the physician or nurse. If they had been randomized to speak with the physician, then the physician on-call was paged again. If they had been randomized to the nurse, they were given the option of speaking with the nurse again, or having the physician on-call paged. The decision to call back within 4 hours and ask to speak to a pediatrician after speaking with the advice nurse was used as a proxy for caller satisfaction (unless the caller had been instructed to call back).
Follow-up Telephone Interview
All participating callers were called back between 5 PM and 9 PM 72 to 96 hours after the initial call for medical advice. If no contact was made, repeat calls were made at 4, 5, and 6 days after the initial call. In all cases, the follow-up questionnaire was completed with the person who made the original call for medical advice. The interview elicited information about the recommended level of care, parent compliance with the recommendation, any provider contact made within 72 hours of the initial telephone call, and the satisfaction with the initial telephone contact. Callers were asked to rate their satisfaction with the physician or nurse on the: 1) overall telephone call, 2) thoroughness and competence, 3) courtesy and friendliness, 4) length of time spent waiting, 5) time spent talking, and 6) medical advice. They were given a 5-point Likert scale: poor, fair, good, very good and excellent. We analyzed these results by dichotomizing responses ("excellent" or "very good" in 1 category, the remainder in another), and by converting to a linear scale (0–100), as has been done previously.17 Because results were similar for both analyses, we present the results from dichotomizing the Likert scale only.
Follow-up Medical Care
Claims data were obtained from the university billing system for all enrolled patients for all provider contact (emergency department, urgent care, and office visits) within 72 hours of the initial telephone call for medical advice. Compliance with care was determined by comparing the advice reportedly given by either the physician on-call or the nurse advice service with the action taken by the caller as determined from claims data. To determine compliance with care not provided within the university health care enterprise, parents were asked at the time of the follow-up telephone interview to report all health care visits for the child within 72 hours of the call. With parental consent, we obtained the medical records for nonuniversity-affiliated visits and included these visits in the compliance data as well.
The advice was determined as follows: the physician on-call provided a daily faxed record of advice for after-hours telephone calls, and the commercial nurse advice service provided a computer-generated record of the advice given by their nurses. When the advice nurse told the caller to page the on-call pediatrician, the advice of the on-call pediatrician was used; these callers were still included in the nurse advice group (intention-to-treat analysis). When the advice as reported by the physician or the nurse advice service was missing, we used the advice as reported by the caller.
The categories of advice were combined to create 3 clearly distinct triage groups: 1) emergency department (ED)/Urgent Care (Call 911, ED, and Urgent Care), 2) Office Care (office visit within 72 hours), and 3) Self Care (self care recommended). The caller was considered compliant with ED/Urgent Care advice if they sought care at an ED or after-hours Urgent Care facility, Office Care if they visited a clinic, and Self Care if no care was sought within 72 hours.
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RESULTS |
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During the 44-week study period from January 18, 2000, to November 20, 2000, there were a total of 4085 calls to the page operator for the pediatrician on call (Fig 1). The page operators did not attempt to enroll 808 (19.8%) of these callers in the study and did not complete a study data form. When operators were very busy, they did not have the time to follow the study protocol, ie, obtain informed consent and collect enrollment data. Data were collected by the page operators for the remaining 3278 calls from 2221 individual callers. Of these, 97.4% were medical advice calls. Eighty-five calls were not for telephone advice including prescription refill (52), authorization for medical treatment (6), laboratory results (5), and others (22). Of the 3193 calls for medical advice, 30 were excluded: medical emergency (23), not English-speaking (4), not legal guardian (2), and hearing-impaired caller (1). Of the remaining 3162 calls for medical advice, 410 had already been enrolled in the previous 72 hours and were excluded as repeat callers. Of the 2753 eligible calls, 1569 (57%) declined to participate, and 1184 (43%) agreed to participate. Nine hundred forty-four individual children were enrolled. Five hundred sixty-six (48%) callers were enrolled in the on-call pediatrician group; 616 (52%) in the advice nurse group, and 2 were erroneously consented. Telephone interviews were successfully completed for 1168 (98.8%) of the 1182 calls. However, satisfaction with telephone advice was not reported by 16 callers in the physician group and 31 callers in the nurse group, most often because the physician or nurse was not reached.
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The children in the group who refused consent were slightly younger (3.1 vs 3.5 years old; 95% confidence interval [CI] of difference: 0.1–0.7 years), and the proportions of the reasons for calls were significantly different for 6 of 15 reasons recorded. The greatest difference in complaints between the enrolled versus refused groups was for the complaint of cough: enrolled, 16.7%; refused, 11.4%; difference, 5.3%; 95% CI: 2.6%–7.9%. There were no significant differences in the mean age, sex, ethnic group, insurance status, timing of after-hours calls, location of callers as determined by area code, or proportion of complaints between the 2 enrolled study groups (Table 1).
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Table 2 presents the results of the follow-up telephone interviews regarding caller satisfaction with the initial telephone advice. Callers in the on-call pediatrician group were significantly more satisfied with the 1) telephone call overall, 2) thoroughness and competence of the person they spoke with, 3) length of time spent waiting, 4) time spent talking with the on-call pediatrician or advice nurse, and 5) medical advice given. There was no difference in the satisfaction with the courtesy and friendliness of the on-call pediatrician or the advice nurse.
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We hypothesized that these differences in satisfaction might be attributable to the fact that many (17.1%) in the advice nurse group were instructed by the advice nurse to call the on-call pediatrician and they would have been more satisfied had they spoken with the on-call pediatrician in the first place. Therefore, we reanalyzed the caller satisfaction in the advice nurse group with the calls with the advice to page the on-call pediatrician excluded. This did not result in a significant change in the satisfaction results (overall satisfaction in the nurse group increased from 55.0% to 56.2%).
Table 3 presents the comparison between the initial telephone advice and action the caller took. We considered this a proxy for patient satisfaction with the advice given. Although the distribution of advice given was similar, compliance was significantly higher in the on-call pediatrician group for office care (51.5% vs 29.6%; 95% CI of difference: 8.9%–34.2%).
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Repeat calls for advice were significantly more frequent for the nurse advice service. After excluding callers in the advice nurse group who were instructed to call the on-call pediatrician, repeat calls were more likely in the advice nurse group within 4 hours, 13.0% versus 4.8% (95% CI of the difference: 5.0%–11.4%) and within 72 hours, 23.4% vs 13.0% (95% CI of the difference: 5.8%–14.5%). Of the unsolicited 80 repeat calls within 4 hours in the advice nurse group, 92.5% asked to speak to the on-call pediatrician.
We postulated that the low enrollment was in part attributable to dissatisfaction with the nurse advice service. To test this hypothesis, we calculated the rate of participation by 4-week intervals in both study groups and the rate of repeat participation in both groups. Overall, the participation steadily declined as the study progressed, from 64% in the first month to 36% in the final month. In addition, the rate of subsequent consent in repeat callers who had been initially randomized to the on-call pediatrician was much higher than those initially randomized to the advice nurse (64.8% vs 47.2%; 95% CI of the difference, 5.8%–30.0%), which supports this hypothesis.
We postulated that the difference in satisfaction rates might vary with the length of time spent talking to the physician or nurse, and the length of time spent waiting. The nurse advice service maintains the total time spent with each caller, and was able to provide this information for 366 of the 616 calls in this group. We were able to calculate telephone times for the on-call pediatricians from mobile phone statements. We matched these statements with the dates and phone numbers of the callers and were able to obtain length of call times for 56 calls. The mean call length was significantly longer for the advice nurse group (14.5 minutes; 95% CI: 13.7–15.3 minutes) than for the on-call pediatricians (4.8 minutes; 95% CI: 3.1–6.5 minutes). The nurse advice service also provided us with the mean time spent on hold before speaking with a nurse, which was 38 seconds for all calls. From mobile phone statements and data from the page operator, we calculated that the mean time spent waiting for a call back from the on-call pediatrician was 10.5 minutes.
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DISCUSSION |
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By every measure, callers were more satisfied with the telephone advice provided by the on-call pediatrician than the advice nurses. Parents were significantly more satisfied with the telephone advice overall, the thoroughness and competence of the professional providing the advice, the length of time spent waiting and the time spent on the call, and with the medical advice given when they spoke with the on-call pediatrician.
By several proxy measures, callers also demonstrated greater satisfaction with the on-call pediatrician. There was a significantly higher rate of compliance with advice for an office visit within 72 hours given by the on-call pediatrician. Several previous studies have demonstrated the correlation between satisfaction and compliance.18–22 There were significantly more frequent callbacks within 4 and 72 hours for callers randomized to the advice nurse group, and these callers almost always requested to speak with the on-call pediatrician. Finally, there was also a much lower rate of consent for the study in repeat callers who previously were randomized to the advice nurse, and a resulting decline in the consent rate for the study during its course.
The finding that parents randomized to the advice nurse were significantly less satisfied was unexpected. Previous studies had reported a high satisfaction with these types of services.6,15,16 We had postulated that callers would find the detailed data gathering of the full-time professional advice nurses and their willingness to spend more time speaking on the telephone more satisfying. In 1 study, 54% of calls to physicians after midnight "provoked irritation," and 33% were judged by the physician to be "inappropriate."14 Primary care pediatricians devote 30% of their total work time to telephone consultation with patients,10 and a majority of pediatricians consider the telephone to be the most frustrating part of their practice.11 In many health care settings, the use of full-time call centers may improve access by patients to medical advice. Physicians may be difficult to reach, and patients may feel more intimidated about waking up a physician at night for a "minor" problem. We also hypothesized that the shorter time waiting to get advice from the nurses would favor this group. In 1 study, 15% of unsatisfied callers "thought the physician should have returned the call sooner."14 When callers were randomized to the nurse advice service, their call was transferred to that service immediately with only a minimal delay in speaking with the advice nurse, and there was no wait for the on-call pediatrician to be paged and call back.
Why, then, were callers in this population more satisfied with the on-call pediatrician than the advice nurses? Although the callers were given an almost identical distribution of advice from the nurses, spent less time waiting, and more time speaking on the phone, they were significantly less satisfied, less likely to comply with the advice, and more likely to call back within a short time for more advice.
Several studies have demonstrated that nonphysicians can be effective handling telephone advice calls, and in some aspects may even be superior to physicians, because physicians sometimes aren’t as compulsory about asking the "necessary" questions and may have less trained communication skills, sometimes ending phone calls "inappropriately."23,24 These studies, however, judge the quality of a telephone call by comparing it to predefined criteria, often generated by expert-panels. These criteria assume that the quantity and quality of questions, the completeness of information gathering, and the thoroughness of making sure the caller understands everything is equivalent to a well-handled call and a satisfied customer.
The inverse association of satisfaction with the length of call brings into question these previous assumptions. Surprisingly, callers reported a lower satisfaction for the advice nurse both with the time spent waiting, and with the time spent speaking on the phone. The callers were more satisfied with the shorter time spent talking on the phone with the on-call pediatrician than with the longer time spent talking with the advice nurse. When we analyzed satisfaction by call length, the calls rated as "excellent" in terms of time spent talking on the phone, were actually shorter in length for both groups (13.8 minutes vs 15.0 minutes for the advice nurse, and 4.1 minute vs 5.8 minutes for the on-call pediatrician). Our anecdotal experience with callers during follow-up interviews was that they tended to complain that the nurses "asked to many questions," and "took too long."
Limitations include: 1) the study results may not be generalizable to other telephone triage services and pediatric practice settings, 2) the low enrollment rate, and 3) the inability to blind the on-call physicians to the study. There may be specific aspects to any telephone triage service that could influence caller satisfaction, such as hold time, triage protocols, nursing personnel, and familiarity with local resources. However, the service we studied is the largest provider of telephone triage services, serving >25 million people, and uses call-takers that are registered nurses and have received special training in telephone triage. The triage algorithms are chief-complaint driven similar to other services, and have been field-tested and modified over a time period of 25 years. The average hold time of 38 seconds does not seem unusually long. Finally, the telephone triage service was provided with all necessary information to make local referrals to urgent care and emergency department facilities, as is their usual practice.
Most of the studies of caller satisfaction have been done with a different model of telephone advice service, ie, a children’s hospital call center. There are now >50 children’s hospitals that operate call centers. Both the mean call duration and cost per call are lower for these children’s hospital call centers.25 Therefore, satisfaction might have been greater had we chosen to use a hospital based service. However, all of these centers limit their services to the immediate surrounding area for business reasons.
The on-call pediatricians in this study may not be representative of the general community. Although they are all general pediatricians, they are also full-time faculty of a university teaching hospital. Furthermore, the group of physicians is small and, therefore, the parent is likely to be talking to someone whom they have seen or spoken with before and whom they know is more familiar with the university health care system and its health care alternatives.
The study population may be different from other populations receiving telephone triage services. The parent population is extremely well educated (>80% with college or greater degree) and is used to speaking to a physician when they call for after-hours advice. The majority of callers refused to participate, indicating their bias for the readily available physician advice in our study setting. The expectation of physician advice may have biased the results in favor of the physician. Other characteristics of the population, such as age and chief complaints were similar to those reported in another study of an urban population.5 In many practice settings served by commercial call centers, parents may have more limited access to medical advice after-hours (or during hours advice for that matter). In these settings, parents and other callers may be grateful to have immediate and unlimited access to a health care professional and would likely have reported greater satisfaction. Many health care organizations already use nurses to screen physician advice calls. The use of a well-organized commercial nurse advice service would probably be met with far greater approval in these circumstances.
Another potential limitation of the study was the low overall enrollment rate (43%). We demonstrated that the low enrollment was in part attributable to dissatisfaction with the nurse advice service, and that the resulting bias from refusal to consent actually favored the nurse advice service. There was a tendency for repeat callers who consented after previously speaking with the advice nurse on their first call to give the advice nurse a higher overall satisfaction score than callers who refused. This was not true for callers who were randomized to the on-call pediatrician on their first call. Thus, callers who chose to consent again for the study after speaking with the advice nurse service were biased in favor of the nurse advice service. Elimination of this bias would increase the difference in satisfaction demonstrated.
A final limitation of the study was the lack of blinding of the pediatricians who participated. It is possible that because of the knowledge that they were being studied, they changed their usual behavior on-call to increase their satisfaction scores, perhaps by answering pages more promptly, being more friendly/courteous, more thorough, etc. Although the pediatricians were aware of this study, they were blinded to whether or not a particular patient had consented to the study. We also note that the parents reported that 4.5% of calls were not returned, and that 20% of calls required >30 minutes for a callback, suggesting the physicians were not taking any extraordinary measures to increase satisfaction scores. The advice nurses were not informed that a study was being done. However, their calls are regularly monitored for quality assurance.
Our results call into question the supposition that parents would not be less satisfied with nurse advice services when compared with an on-call pediatrician. Perhaps this should come as no surprise. However, although it might be expected that parents would prefer to speak to a pediatrician rather than a nurse when they seek medical advice, we had postulated that the reported high satisfaction with nurse advice services might be attributable to a preference for telephone calls answered by nurses who were specifically employed and trained to provide telephone advice, rather than the anecdotally irritated physician disturbed or awakened during after hours.
In the new paradigm of health care systems in which reduction of the cost of care is an increasingly significant factor, the doctor patient relationship is losing its special nature. Both patients and physicians lament this. The cost of providing after-hours advice has always been borne by pediatricians as a necessary part of their pediatric practice; there has traditionally been no additional reimbursement for this service. Insurers, however, have demonstrated that they are willing to pay for commercial entities to provide this service. This has been based on the assumption that the cost of this service will be offset by a reduction in the use of expensive medical care, especially emergency department visits. However, in this study there was no significant difference in the proportion of callers directed to emergency care.
Future studies should further reexamine the widespread acceptance and perceived satisfaction with telephone triage, evaluate ways to improve satisfaction, and determine whether the potential cost savings is worth the possible decline in patient satisfaction. Alternatives to nurse advice services may include expansion of physician-patient communications beyond telephone interaction, and development of other modalities to immediately access health information. The increasing availability of web based medical information and sites designed specifically to provide medical advice for parents concerning their child’s health may be an alternative for those parents with Internet access. In our parent population >90% have Internet access, and 30% already use the Internet for information about medical illness.
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ACKNOWLEDGMENTS |
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This study was funded by grant 3 RO1 HS10604 from the Agency for Healthcare Research and Quality.
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FOOTNOTES |
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Received for publication Sep 11, 2001; Accepted May 16, 2002.
Address correspondence to Larry J. Baraff, MD, UCLA Emergency Medicine Center, 924 Westwood Blvd, Suite 300, Los Angeles, CA 90024. E-mail: lbaraff{at}ucla.edu
Dr Johnson is an employee and shareholder of McKesson Inc.
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[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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