Abstract
OBJECTIVES: To assess whether a medical telephone helpline and the use of a computer-assisted structured triage tool led to a reduction in demand for acute and emergency care in hospital emergency departments (EDs) or other ambulatory out-of-hour (OOH) services. DESIGN: We conducted an ecological study using secondary data on outpatient care. SETTING: The study was conducted in 10 out of 16 federal states of Germany. PARTICIPANTS: The analysis was based on ambulatory claims data for the years 2016-2020 by 11 Associations of Statutory Health Insurance Physicians (ASHIPs) covering more than 64% of the total German population. INTERVENTIONS: The evaluated intervention comprised two components. The first was the introduction of a 24/7 medical helpline (116117), established to assist individuals with medical concerns in accessing appropriate care. The second component was the introduction of the computer-assisted triage tool SmED (Strukturierte medizinische Ersteinschätzung in Deutschland, Structured medical initial assessment in Germany) to support call-takers by suggesting medically relevant questions to identify red flags and determine the urgency of treatment and a possible treatment facility. For the analysis, approximately 3 years before and 1 ½ years during the intervention were considered. OUTCOME MEASURES: Main outcome was the effect on acute and emergency care which was measured as the number of personal doctor-patient contacts (1) in EDs (ED cases, data of 10 ASHIPs could be considered) and (2) in EDs or other OOH services (ED and OOH cases, data of 11 ASHIPs could be considered). RESULTS: The analysis was limited by legal changes mandating intervention components across all study sites-leading to a loss of control groups and delayed implementation-and the onset of the COVID-19 pandemic. Across all ASHIPs and counties, the number of calls to 116117 and the number of SmED assessments showed a negative association with the number of ED cases (total change: 295.0 cases to 224.5 cases per 100 000 inhabitants, 116117 calls: r=-0.04; 95% CI -0.04 to -0.035; p≤0.001, SmED: r=-0.15; 95% CI -0.35 to 0.05; p=0.138) as well as with the combined number of ED and OOH cases (total change: 516.4 cases to 400.3 cases per 100 000 inhabitants, 116117 calls: r=-0.02; 95% CI -0.03 to -0.001; p≤0.01, SmED: r=-0.58; 95% CI -0.98 to -0.19; p≤0.01). However, the association between the number of SmED assessments and ED cases was not statistically significant. Moreover, the magnitude and direction of effects varied across ASHIPs. Sensitivity analyses restricted to time periods preceding the onset of the COVID-19 pandemic showed a non-significant negative association for 116117 calls and a significant positive association for SmED assessments with both ED cases and combined ED and OOH cases (ED cases: 116117 calls: r=-0.001; 95% CI -0.019 to -0.018; p=0.928; SmED: r=0.37; 95% CI 0.29 to 0.45; p≤0.001; ED and OOH services cases: 116117 calls: r=-0.03; 95% CI -0.06 to 0.003; p=0.077; SmED: r=0.34; 95% CI 0.20 to 0.48; p≤0.001). CONCLUSIONS: Our findings indicate a trend suggesting that implementation of a 24/7 medical helpline may reduce the demand for acute and emergency care at EDs and OOH services, although clear evidence is lacking. The impact of SmED use remains inconclusive. Further research should ideally incorporate data linkage and controls and assess the effectiveness and efficiency of the triage process, as well as the quality of subsequent care at the individual level.