Patient compliance with telephone triage recommendations: A meta-analytic review

Abstract

Objective

To systematically investigate the extent to which patients comply with triage advice from telenurses and to identify factors that potentially influence compliance.

Methods

Findings from 13 studies identified through interdisciplinary research databases (1990–2010) were meta-analyzed. Separate pooled analyses compared patients’ compliance rates for emergency services and office care (13 outcomes), emergency services and self care (13 outcomes), and self care and office care (12 outcomes).

Results

Overall patient compliance was 62%, but varied by intensity of care recommended with low compliance rates for advice to see a general practitioner. Reasons for noncompliance include patients reporting to have heard a different disposition, patients’ intentions and health beliefs.

Conclusion

Patient compliance to triage recommendations was influenced by the interactive role of patient perceptions and the quality of provider communication, both of which were mediated by access to health services. Further research is needed to clarify whether noncompliance is attributable to poor communication by the nurse or patient misinterpretation.

Practice implications

We highlight the need for communication-skills training in a telephone-consultation context that is patient centered, and specifically addresses building active listening and active advising skills and advantages to structuring the call.

Introduction

The method by which patients and healthcare practitioners communicate has changed dramatically over the past decade. Due in part to physician shortages and overcrowding in emergency departments, nurse-led telephone triage and advice services are becoming the most common method of delivering and communicating primary healthcare information worldwide [1], [2]. Patients can now receive medical advice or general health information over the telephone from a specially trained nurse, henceforth known as a telenurse, who helps determine the urgency of the problem and advises the best course of action, such as going to an emergency department, making an appointment with a general practitioner or performing self-care [3].

These services have significantly improved public access to healthcare information. For example, in Canada, Ontario's Telehealth service receives an average of 3100 calls each day [3]. In addition to high usage, previous reviews report high levels of patient satisfaction and show that these services provide safe advice [4], [5], [6], [7]. Despite this, patient compliance with triage advice varies considerably, with some researchers suggesting overall patient compliance is over 90% [8], [9], [10], [11], whereas others suggest it is less than 65% [12], [13], [14], [15], [16]. Moreover, some researchers argue that patient compliance is largely connected to the type of triage advice telenurses offer. That is, patients are more likely to comply with advice to use emergency services or perform self-care than they are to make an appointment with a general practitioner [17].

Patient compliance is an important outcome of telephone triage and advice services and helps to demonstrate the effectiveness of this service [18]. Previous research shows that patient compliance is lower when the treatment regimen is complex [19], [20] and when patients have difficulty reading and understanding medical instructions without the guidance of a healthcare practitioner [21], [22]. These factors emphasize the importance of communication between the healthcare provider and patient. In fact, research in general healthcare settings have shown relationships between patient compliance and the quality of patient-provider communication [23], [24], [25], [26]. In a telephone triage context, telenurses demonstrate quality of communication by active listening (e.g., asking about the patient's situation, listening to nonverbal cues), active advising (e.g., checking understanding and acceptance of advice), and structuring the call [27]. However, recent research on telenurses working at out-of-hours centers showed that quality of communication scores was rated relatively low [28]. Although telenurses asked the right medical questions, they rarely asked about the patients’ situation or opinion of the problem and typically give advice without checking if the patient understood or accepted the advice [28].

Besides quality of communication, patient-related factors such as motivations, health beliefs and intentions are also believed to influence patient compliance [29], [30], [31], [32]. According to the Health Belief Model [29], patients are more likely to comply on the basis of their perceived threat of the illness (e.g., severity and susceptibility) and the perceived benefits and barriers of the treatment. According to a meta-analysis of 27 studies [33], the odds of complying are almost 2.5 times higher if patients believed the illness was a potential threat. Moreover, patients are more likely to comply with healthcare recommendations when they believe that the healthcare practitioner is correct [34], [35], [36]. Despite extensive literature on the topic, there is little understanding how patients’ health beliefs, intentions, and trust in the healthcare practitioner influences whether or not they will comply [31].

As nurse-led telephone triage services continue to play a prominent role in how healthcare is communicated to patients, the factors contributing to patient compliance need to be understood. Therefore, the purpose of this study is to systematically review and critically evaluate research that examines patient compliance with advice offered by nurse-led telephone triage and advice services. Given the variation in patient compliance rates reported in previous research, we developed two research questions:

• Research question 1: What is the overall compliance rate for nurse-led telephone triage services?

• Research question 2: To what extent does patient compliance differ depending on the intensity of care recommended?

We further explore the factors influencing patient compliance by examining the methodological factors of the included studies, as well as the role of patient's intentions, reasons for noncompliance, and the subsequent action of patients who did not comply.