Published online February 1, 2007
PEDIATRICS
Vol. 119
No. 2
February 2007, pp.
e305-e313
(doi:10.1542/peds.2006-1511)
Pediatric Telephone Call Centers: How Do They Affect Health Care Use and Costs?
Maya Bunik, MD, MSPHa,b,
Judith E. Glazner, MSc,
Vijayalaxmi Chandramouli, MSd,
Caroline Bublitz Emsermann, MSe,
Teresa Hegarty, RNb and
Allison Kempe, MD, MPHa,b,c
a Departments of Pediatrics
c Preventive Medicine and Biometrics
e Family Medicine
d Colorado Health Outcomes Program, University of Colorado at Denver and Health Sciences Center, Denver, Colorado
b Children's Outcomes Research Program, Children's Hospital, Denver, Colorado
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ABSTRACT
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OBJECTIVES. After-hours call centers have been shown to provide appropriate triage with high levels of parental and provider satisfaction. However, few data are available on the costs and outcomes of call centers from the perspective of the health care system. With this study we sought to determine these outcomes.
METHODS. Parents who called the Pediatric After-hours Call Center at the Children's Hospital of Denver from March 19, 2004, to April 19, 2004, were asked an open-ended question before triage: "We would like to know, what you would have done if you could not have called our call center this evening/today?"
RESULTS. The response rate for the survey was 77.8% (N = 8980). Parents reported that they would have (1) gone to an emergency department or urgent care facility (46%), (2) treated the child at home (21%), (3) called a physician's office the next day (12%), (4) asked another person for advice (13%), (5) consulted a written source (2%), or (6) other (7%). Of the 46% of callers who would have sought emergent care, only 13.5% subsequently were given an urgent disposition by the call center. Fifteen percent of cases in which the parents would have stayed at home were given an urgent disposition by nurses. Assuming that all callers followed the advice provided, the estimated savings per call, based on local costs, was $42.61 per call. Savings based on Medical Expenditure Panel Survey national payment data were $56.26 per call.
CONCLUSIONS. Two thirds of the cases in which parents reported initial intent to go to an emergency department or urgent care facility were not deemed urgent by the call center, whereas 15% of calls from parents who intended to stay home were deemed urgent. If call-center triage recommendations were followed in even half of all cases, then these results would translate into substantial cost savings for the health care system.
Key Words: telephone medicine • telephone triage • call center • health care use
Abbreviations: ED—emergency department • HMO—health maintenance organizations • PACC—Pediatric After-hours Call Center • UCC—urgent care center • MEPS—Medical Expenditure Panel Survey
Telephone triage services have grown rapidly since the 1990s in recognition of the need to reduce unnecessary emergency department (ED) visits and with the development of formal, algorithm-driven protocols.1–6 More than 25% of pediatricians nationwide sign out their after-hours calls to after-hours call centers.7,8 These call centers play a major role in after-hours care for children and usually are based at children's hospitals or service bureaus.9,10
Although most call centers are underwritten by hospitals, physicians also subsidize call centers to triage their calls.11 Historically, physicians have provided telephone triage care without reimbursement.11 Because both third-party payers and patients benefit from telephone triage expertise, recent attempts have been made to bill insurance companies for these calls using International Classification of Diseases, Ninth Revision codes and to collect copayments from patients. To date, these efforts have met with limited success. Because of inadequate reimbursement, call centers report a high operating loss that ranges from $50000 to more than $1 million annually, with an average of $440000 per year.12 Because of such losses, a few large call centers have closed in recent years.
Despite a variety of benefits that are provided by call centers, including high parental and provider satisfaction, parental compliance, and high rate of appropriateness of urgent referrals,4–6,13 the potential economic advantages of call centers have not been well described. Cost savings are difficult to measure in this arena because most call-center subscribers are not governed by a closed system of care. Limited data have been published to suggest cost savings associated with call centers in closed systems of care, such as health maintenance organizations (HMOs).14,15 Moreover, earlier studies included relatively small numbers of patients and were not conducted in call centers that serve large populations. More data are needed to assess cost savings to the health care system that can be achieved with call centers, especially those that are not part of managed care systems. The objectives of the present study were to (1) compare what parents with a sick child report that they would have done without the availability of call-center advice with what actually was recommended by the triaging nurse, (2) characterize features of calls in which parents would have gone to the ED but the triage nurse judged the call to be nonurgent ("potential overuse calls") and calls in which parents would have stayed at home when the triage nurse judged the call to require urgent evaluation ("potential underuse calls"), and (3) estimate projected cost savings to the health system associated with call-center triage.
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METHODS
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This study was reviewed and approved by the Colorado Multiple Institutional Review Board as exempt research, and informed consent was not required.
Study Setting
The Children's Hospital Pediatric After-Hours Call Center (PACC) was started in 1988 and currently is used by 95% of Denver and 90% of Colorado private pediatricians. The number of after-hours calls averages 3000 to 4000 per week. The PACC is staffed by 2 nurse managers and 24 full-time-equivalent pediatrics nurses. A pediatrician director is responsible for quality oversight. Triage calls are handled by trained pediatric nurses using computerized protocol software. Triage nurses initially assess presenting symptoms, select appropriate protocols on the basis of the chief complaint, and ask key questions to assess urgency. Finally, parents are given a recommended triage disposition. On average, nurse dispositions are "urgent/emergent" (need to be seen within 4 hours) 20% of the time; "next-day office visit" (>4 hours but <24 hours) or "later visit" (>24 hours but within 72 hours) 30% of the time, or "home care and advice" 50% of the time.16 A small percentage (in this study, n = 303 [4.3%]) of calls are classified as "second-level" triage calls. Pediatric practices have the option of requesting that any patient call that is deemed urgent by the nurses be referred to the on-call physician for secondary triage. A previous study showed that 50% of these secondary triage calls are deemed urgent by physicians and 50% are seen in the physician office the next day.16
Study Design
Our study was a prospective survey of all parents who called the PACC at the Children's Hospital of Denver from March 19, 2004, to April 19, 2004. An underlying assumption of the study was that parents who were calling the call center for after-hours advice did not have access to another provider for after-hours telephone advice. We believed that this was a reasonable assumption because all calls were from families who were cared for by physicians who had given the call center responsibility to act on their behalf for after-hours coverage. Practicing physicians in our area who do sign out their call to the call center would be extremely unlikely to deliver after-hours telephone care for a patient who was not part of their practice. Parents, guardians, or adult relatives who called were asked an open-ended question before triage: "We would like to know, what you would have done if you could not have called our call center this evening/today?" When no response was given, nurses prompted parents with the following choices: I would have
- called 911 now;
- gone to ED or urgent care now;
- called an ED;
- called physician office tomorrow for advice;
- read a book for more information;
- visited the Web;
- asked a relative or a friend;
- stayed home, treated my child at home;
- called an 800 insurance line;
- called another telephone line (eg, Ask-a-Nurse);
- called or asked a pharmacist for advice;
- been unsure of what to do; or
- refused to answer.
Nurses were instructed to defer asking the survey question when they sensed that the child's clinical situation was emergent or when they believed that the parents were extremely anxious about their child.
Data Analysis
"Potential overuse calls" were defined as calls in which parental intent was for urgent evaluation but nurses did not recommend urgent care, and "potential underuse calls" were those in which parents intended to stay home but nurses believed that urgent evaluation was needed. 
2 analysis was used to compare call characteristics for calls in the potential overuse and underuse categories.
Cost Analysis
We performed a net-cost analysis to estimate costs/savings that were attributable to the telephone advice line. We compared the cost of the caller's intended action (eg, ED visit, physician visit, home care) with the cost of the nurse's recommended disposition. Actual outcome for the calls was not available; therefore, our cost results should be regarded as potential savings. The approach that we used entailed estimating variable costs that were associated with each health care service (eg, ED visits), because variable costs are those that vary with the level of use. Unless new capital investment is required, variable costs are those that are considered when decisions to increase or add services are made. A consequence of this approach is that we excluded overhead costs, such as rent, because they do not vary with the level of use. We assigned costs to ED, urgent care center (UCC), and physician visits, as well as 911 calls, including emergency transport and ED visits that resulted from 911 calls. The general method used to calculate savings was [(
i – r)/N] – C = S, where i is the product of the unit cost of each intent category and the number of calls with that intent, r is the product of the unit cost of each recommendation category and the number of calls with that recommendation, N is total number of calls to advice line, C is unit cost of the advice line, and S is net savings. We used unit costs that were provided by local (Denver) providers and unit payments from a national survey, the Medical Expenditure Panel Survey (MEPS).
Local Cost Data Sources
We collected original local variable cost data from the accounting office of the Children's Hospital in Denver for ED and UCC visits, including physician and facility costs. At this hospital, the UCC and ED are operated together and constitute a single cost center; their per-visit costs, therefore, are the same. The Children's Hospital's accounting office also estimated physician visit costs, which included physician salaries but excluded items such as profit, cost-shifting, and other items that contribute to charges. This estimate was based on an informal survey of private physicians' offices that was performed by the Children's Hospital accounting office. Denver Health and Hospital Authority, which operates the 911 and ambulance services in Denver, provided costs for emergency transport. These were visit costs only; they did not include other products and services (eg, laboratory tests, drugs, admissions). All financial data were costs, not charges. All other care intentions—home care, calling a pharmacist, asking a relative or friend, calling another advice line, and calling an insurance 800 number—were valued at 0, usually because they involved little or no cost to the health care system. A simple average of advice line nurse salaries for the period of operation was used to estimate the telephone advice program's variable costs. Also included in the program's variable costs were the cost of a computer, amortized over 2 years; telephone installation; and the monthly cost of a telephone line.
National Data Sources
We wished to estimate costs on the basis of national averages, rather than only local costs, to improve generalizability. The best information that was available for the services that were included in this study was the 2003 MEPS data on national average payments for ED visits and office-based visits for children. MEPS does not estimate payments for other items, such as ambulance services, that were included in this analysis; therefore, local cost estimates were used to estimate 911 and ambulance costs for national data. MEPS payment figures include all services that are delivered at the site of care, including laboratory, imaging, and other costs that occur during the visit. In addition to this, the MEPS figures for office-based visits include payments for all specialties. This differs from the cost data that were used in our local estimates, which reflect general pediatrician practices only. The MEPS is designed to produce national and regional estimates of the health care use, expenditures, sources of payment, and insurance coverage of the US civilian noninstitutionalized population. The sample design of the survey includes stratification, clustering, multiple stages of selection, and disproportionate sampling. Furthermore, the MEPS sampling weights reflect adjustments for survey nonresponse and adjustments to population control totals from the Current Population Survey.17 Average ED and outpatient payments were calculated for all MEPS children using the data fields ERFEXP03 and ERDEXP03 from the ED visit file and OBDEXP03 from the office-based physician visit file. Average ED payments were taken for children who reported at least 1 ED visit during the survey year. Likewise, average office-based payments were taken for children who reported at least 1 office visit during the survey year. MEPS reports costs by age. We therefore weighted MEPS payments for both office and ED visits by the age of the child (0–4 and 5–17 years) on whose behalf calls were made to the advice line. All MEPS analyses were performed using SUDAAN 9.1 (Research Triangle Institute, Research Triangle Park, NC) software and the MEPS 03 person weight.
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RESULTS
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The total number of calls to the call center for the survey month was 10227. Of these, 1247 calls were not eligible for the following reasons: the call was for information only or a medication question (n = 405), the call was not triaged because the person who made the initial call could not be reached (n = 626), the call was a duplicate contact for the same problem in the same child (n = 145), the call was to schedule a laboratory visit only (n = 42), the call was sent directly to the poison control center (n = 18), or the call was referred to a dentist (n = 11). Of the remaining 8980 eligible calls, no intent was documented by the nurses for 1967, yielding a total study population of 7013 calls and a response rate of 78%.
Of all calls, 99% were made by a parent, guardian, or adult relative and only 1% by adolescents about themselves. The children about whom parents called were an average of 4.1 year of age (SD: 5.7 months). The calls, on average, took <10 minutes for the advice nurse to triage. Evenings and weekends were the times during which most calls were received. A comparison of the study population with nonrespondents (those with no recorded response to intent question), as shown in Table 1, demonstrated statistically significant differences in age; gender; and the percentage of calls in the evening and nighttime and on weekends. Although these differences were statistically significant because of the large numbers involved, they reflected fairly small differences between the 2 populations. The nonrespondent group, on average, was only 1 year older than the respondent group. Most other differences were small, although the difference between the 2 groups in the percentage of weekend calls was 
7 percentage points.
Comparison of Parental Intent Before Triage With Triaging Nurse's Disposition Recommendation
Parental callers' intended actions compared with nurse recommended triage dispositions are shown in Fig 1. As demonstrated, parents most often said that they would go to an UCC or ED (46% including "would call 911" calls) or would deal with the problem at home (21%). Nurses, conversely, were far less likely to refer for urgent/emergent care (22%) and more likely to suggest treatment in the physician's office on the next day (24%) or at a later time (7%). The most common nursing disposition was home care (45%).
The bar graphs in Fig 2 directly compare nurse recommendations with parental intent. Among the 45% of parents who intended to use urgent care, nurses recommended that only 29% go to the ED or a UCC. Conversely, among the 21% who intended to keep their children home, the triage nurse recommended that 15% seek urgent care and that 20% see a physician the next day.
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FIGURE 2 Parents' intended actions of urgent (A), next-day (B), and home care (C) versus subsequent nurse-recommended triage dispositions.
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Characterization of Potential Overuse and Underuse Calls
Table 2 stratifies calls in which parents had intended to seek urgent evaluation before triage according to whether the nurse triaged the calls as urgent or nonurgent. The first column, in which the nurse designated the calls as nonurgent, represents the potential overuse calls. As shown, potential overuse calls tended to be about younger children, the mean length of call tended to be longer, and these calls more often occurred on a weekend. Importantly, the most commonly used protocols were the same for both groups.
Similar data for potential underuse calls, in which parents' intent was to stay home but nurses deemed the call urgent, also showed differences in age: a mean age of 4.9 years (SD: 5 months) for the underuse group versus 3.5 years (SD: 4 months) for the overuse group (P < .01). The only other difference noted was a lower percentage (11.7%) of nighttime calls in the underuse group versus the group for which nonurgent recommendations were made (17.1%; P = .03). Frequencies of the 5 most commonly used protocols were similar.
Net Cost Analysis
Table 3 shows the distribution of services that callers intended to use, the distribution of services that were advised by the call center, and the costs of each distribution using local costs and using MEPS payment data. Had the callers implemented their intentions, the cost to the health care system would have been more than $1 million. Using local health care costs, had the recommendations that were made by the advice line been heeded in every case, the cost to the health care system would have been $410615 less than the intended services. The savings per call, assuming that all advice was taken, would have been $58.55. The cost per call for the advice line, consisting primarily of nurse salaries, was $15.94, resulting in a net savings of $42.61 per call. Using national MEPS physician and ED payment data, the net savings was $56.26 per call.
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TABLE 3 Difference Between the Local Cost of Services That Callers Intended to Use and Those Recommended and Payments as Measured in the MEPS for Services That Callers Intended to Use and Those Recommended
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Because previous studies have shown that not all parents take the advice that is given them about when to have their child seen, we performed a sensitivity analysis to estimate savings under several assumptions. We assumed that when the nurse's advice agreed with the caller's intent these recommendations were followed but that all other recommendations were complied with only half the time and then recalculated savings under these assumptions. Under this set of assumptions, net savings per call using local costs was $9.15 and with national MEPS data was $11.12 per call (Table 4).
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TABLE 4 Sensitivity Analysis: Difference Between the Cost of Services That Callers Intended to Use and the Cost of Recommended Services Assuming That Recommendations Are Followed 50% of the Time
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DISCUSSION
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Nurses at telephone call centers currently triage after-hours calls for more than one quarter of pediatricians in the United States.8 An increasing body of evidence demonstrates that call-center triage by nurses is safe and is associated with high rates of provider and patient satisfaction with care.5,8,16 Whether it also is associated with cost savings previously was not well studied but, given the financial problems that call centers face, is important to assess. The present study is the first to compare directly parental intent before triage with the outcomes of triage in a large, population-based sample and to assess the potential savings to the health care delivery system of call-center triage. Our study demonstrates that, of calls in which parents intended to seek urgent care, nurses recommended such action in fewer than half of cases, instead recommending nonurgent evaluation or care at home. This difference translated into substantial potential cost savings per call, even under the assumption that there was only 50% compliance for cases in which parental intent and the nurse's final disposition did not match. Cost savings also were substantial using national, rather than local, data in the calculation of cost differences, making these data more generalizable to other areas of the United States.
Only 2 other studies previously compared parental intention with nurse triage decisions and tried to assess issues of relative cost. Bogdan et al15 compared parents' intention with nurse triage disposition for 266 calls at a call center that provided daytime and nighttime triage for an urban safety net health network population. Because this study included daytime triage as well as after-hours triage, possible disposition categories differed slightly from the present study, making direct comparisons difficult. In addition, in that study, parental intention was assessed in a follow-up call up to 7 days after the original triage, thereby introducing potential problems with parental recall of initial intention as well as contamination of what parents recalled by the actual disposition recommended by the nurse. Nonetheless, results of this study also showed lower levels of acuity for nurses' decisions relative to parental intent. Nurses recommended that 20% of cases be seen urgently compared with a parental intent of 29%. Nurses also recommended care at home without a visit for 36% of cases, and parental intent would have dictated that only 16% be cared for at home. Estimated cost savings that resulted from these shifts was assessed at $54.77 in charges avoided per patient. A similar study of 300 callers to a nurse line in a managed health plan that also inquired about initial parental intention retrospectively after actual triage estimated a potential cost savings of $54.42 per call.14 The method of the present study, in which parental intent was determined at the time when parents were seeking help and before receiving advice and triage from a nurse, makes more unbiased estimates of potential cost savings possible.
Our data also suggest that in addition to potentially decreasing unnecessary urgent care use, the call-center nurses refer for urgent evaluation a substantial number of children whose parents' initial intention was to stay home rather than to seek help for their child's problem. Our data, of course, cannot assess whether these children actually needed urgent evaluation, but data from previous studies at the same call center suggest that physicians agree with the necessity of urgent referral for 80% of patients who are seen after an urgent referral.5 In addition, hospitalization rates among children who are referred for urgent care are 4 times that of children who are not so referred, suggesting a high degree of selectivity in nurse triage.18 Our data, therefore, also demonstrate the potential for call-center triage to decrease underreferral with the possibility for subsequent morbidity related to delay in care.
Our attempt to find characteristics that differentiated potential overuse or underuse calls from others was not revealing. In particular, although we hypothesized that certain symptom complexes might predispose to either overreaction or underreaction on the part of parents, the type of protocol used, corresponding to symptom complaints, did not discriminate between these calls. The study protocol did not permit us to collect additional sociodemographic data or information about attitudes or beliefs that might discriminate better between callers who potentially might overuse or underuse medical care when their child is ill.
Our net cost analysis revealed that operation of a telephone advice line is likely to result in substantial savings to the health care system as a whole. If all advice were to be followed, then the savings would be substantial, at more than $42 per call, but even if compliance with nurses' advice occurred only in half of cases about which parents and nurses disagreed, the savings would exceed the cost per call by $9 to $11. Other studies have shown that compliance with urgent and home dispositions is closer to 75%,16,18 suggesting that the actual cost savings for the call-center studies would fall between these 2 estimates. Who stands to benefit from these cost savings depends on one's point of view. Although triage involves extensive work, malpractice risk, and practice or call-center expense, after-hours care currently is not reimbursed by the majority of health plans.12 Historically, this is based on 2 major factors.11,12 First, care that is provided by nurses currently is not part of the telephone codes in the Current Procedural Terminology manual. Second, although most after-hours triage involves dealing with problems that never result in visits, many plans contend that telephone care is part of previsit and postvisit care office evaluation and management codes. Under the current system, therefore, the benefits of after-hours telephone call centers in the private sector accrue to patients and health plans, whereas the costs often are borne by providers who pay fees to the call center or hospitals who help to subsidize these call centers.12 Currently, the American Academy of Pediatrics and affiliate institutions are exploring solutions to address problems of payment for telephone care, both during and after office hours.12 From the point of view of health care organizations, the estimated cost savings described in this study have more direct relevance to closed systems of care, such as a group- or staff-model HMO, in which cost savings that are associated with decreasing unnecessary after-hours care would be realized directly by the HMO. Finally, when call centers provide services for patients with public insurance or without insurance and without access to an after-hours provider, savings likely will be realized by state and federal government entities that are responsible for Medicaid and indigent care programs.
Our study has several limitations. All of our cost savings estimates reflect only potential savings that are based on the initial decision regarding use of health care. Assessing actual costs of different triage decisions to the health care system would require not only knowing about initial use decisions but also the eventual outcomes of the care sought and the costs that were associated with these outcomes. Also, we used 2 different measures of cost in our analysis: for the estimate that was based on local data, we used actual costs, or resource use; the MEPS data that we used for making national estimates were actual payments, including patient and insurer payments. These 2 may not be the same, because payments, to some extent, are a reflection of payer negotiations with providers. Presumably, providers' negotiations reflect costs at least in part, so the difference between the 2 estimates may not be substantial. In any case, the local estimates can be viewed as one measure of health care system costs and the MEPS estimates as another. In addition, our study did not measure compliance with call-center advice or actual outcomes of care. We were able to estimate, however, a lower bound for cost savings on the basis of minimal compliance by using sensitivity analysis. Our survey was conducted for 1 month during the spring, and its results may not be generalizable to other times of year. Finally, although we were able to estimate potential savings on the basis of national cost figures, average cost of visits vary by institution and geographic region; therefore, our estimates may not reflect accurately costs in every area of the United States.
Evidence is accumulating that after-hours care by trained nurses at pediatric call centers is safe, is satisfying to parents and patients, and results in appropriate care.4–6,13 The present study also documents the potential cost savings that are associated with call-center triage, information that is important to understanding better the potential value of this type of care to the overall structure of health care delivery. The belief that providers should be paid for after-hours care is gaining momentum within the private sector on a national level, and reimbursement for telephone care by pediatricians has evolved into a policy priority for the American Academy of Pediatrics.11 Data such as these will be valuable to providers and health plans in making future decisions about optimal methods of provision of after-hours care for their patients.
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ACKNOWLEDGMENTS
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This project was funded by the Center for Research in Pediatric Telephone Care, the Children's Hospital (Denver, CO). Dr Bunik was supported by Health Services Research Administration Primary Care Research Fellowship grant 1D14HP00153.
We thank Patricia Shobe, MPH, for help in preparation of the manuscript.
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FOOTNOTES
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Accepted Sep 1, 2006.
Address correspondence to Maya Bunik, MD, Children's Hospital, 1056 E 19th Ave, B032, Denver, CO 80218. E-mail: bunik.maya{at}tchden.org
Portions of this work were presented at the meetings of the Pediatric Academic Societies; May 17, 2005; Washington, DC.
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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ABSTRACT
METHODS
