DETELPROG Study. Effectiveness of a New Model of Scheduled Telephone Referral from Primary Care to Internal Medicine. A Randomised Controlled Study

Jou nal o Clinical Medicine A icle DETELPROG S udy. E ec i eness o a New Model o Scheduled Telephone Re e al om P ima y Ca e o In e nal Medicine. A Randomised Con olled S udy Luis Miguel Azogil-López 1, Juan JoséPé ez-Láza o 2,3, Es he Ma ía Med ano-Sánchez 4, Juan Gómez-Salgado 5,6,* and Valle Co onado-Vázquez 7 1Family and Communi y Medicine, Val e de del Camino Heal h Cen e, 21600 Huel a, Spain; [email p o ec ed] 2Andalusian School o Public Heal h, 18080 G anada, Spain; [email p o ec ed]s 3Biosani a y Resea ch Ins i u e o G anada, 18080 G anada, Spain 4 School o Nu sing, Physio he apy and Podia y, Uni e si y o Se illa, 41013 Se illa, Spain; [email p o ec ed] 5Depa men o Sociology, Social Wo k and Public Heal h, Uni e si y o Huel a, 21007 Huel a, Spain 6Sa e y and Heal h Posg ade P og am, Uni e sidad Espí i u San o, Guayaquil 091650, Ecuado 7Gene al Di ec o a e o Heal h Assis ance-A agonese Heal h Se ice, 50071 Za agoza, Spain; [email p o ec ed] *Co espondence: [email p o ec ed] o [email p o ec ed]; Tel.: +34-699-999-168 Recei ed: 2 Ap il 2019; Accep ed: 13 May 2019; Published: 16 May 2019   Abs ac : In Spain, he a e age wai ing ime o a specialis consul a ion is 58 days. A de e minan ac o ha con ibu es o his si ua ion is he poo communica ion be ween p ima y ca e and specialised ca e, which is mainly due o he wai ing days o a consul a ion, numbe o a oided/a oidable ace- o- ace e e als, and wai ing days o he esolu ion o he p ocess. DETELPROG is a e e al sys em in which he amily physician eques s a scheduled ou pa ien in e nal medicine consul a ion, in eg a ed in o he usual consul a ions agenda o bo h physicians, he amily, and he ou pa ien clinic physician, in o de o ha e a elephone consul a ion. A andomized con olled clinical ial has been ca ied ou o assess he e ec i eness o DELTELPROG. In a sample o 255 pa ien s, he expe imen al g oup was e e ed ia a scheduled elephone call, and hose in he con ol g oup, by ace- o- ace hospi al consul a ion a ea. The esul s showed s a is ically signi ican di e ences be ween bo h g oups o 27 days (95% con idence in e al (CI): 20–33) ega ding specialised consul a ion, 47 days (95% CI: 17–74) as o he esolu ion o he p ocess, and 91.7% o a oided ace- o- ace consul a ions. The DETELPROG esul ed as a low co e age sys em (53%), which makes i a complemen a y e e al model. I is necessa y o make an in-dep h analysis o he causes ha ha e led o his echnologically low co e age. Keywo ds: e e al; eConsul ; cu bside consul a ion; elemedicine; p ima y heal h ca e; wai ing lis ; pa ien sa e y; quali y o heal h ca e 1. In oduc ion In Spain, as o 30 June 2017, he a e age wai ing ime o a specialis consul a ion is o 58 days [ 1 ], and he pe cep ion o pa ien s abou he e olu ion o hese wai ing lis s is nega i e: 46.3% o pa ien s hink ha i emains he same as he p e ious yea and 28% o pa ien s belie e ha i has wo sened. Less han 9% o pa ien s hink ha i has imp o ed, acco ding o a ecen Heal h Depa men su ey [ 2 ]. This p oblem is also p esen in he as majo i y o de eloped coun ies [ 3 – 5 ], as Canada, as esul ed in he Commonweal h Fund Su ey [ 5 ], o Uni ed Kingdom, No way, Finland, he Ne he lands, Denma k, Sco land, New Zealand, Canada, Aus alia, and he Uni ed S a es o Ame ica (USA), whe e J. Clin. Med. 2019,8, 688; doi:10.3390/jcm8050688 www.mdpi.com/jou nal/jcm J. Clin. Med. 2019,8, 688 2 o 10 a ious p og ammes aimed a sol ing one o he majo a ou ing ac o s a e being implemen ed: poo communica ion be ween p ima y ca e and specialised ca e [4,5]. The e a e se e al ways [ 6 – 8 ] o imp o e such communica ion, bu i is elemedicine, including asynch onous consul a ions pla o ms [ 3 – 5 , 9 – 15 ] (e-Consul a ions) and eal- ime elephone consul a ions (Cu bside Consul a ion) [ 16 – 22 ], which has opened new possibili ies o heal h ca e, ob ained pa icula ly good esul s in he wai ing imes o he i s consul a ion, dec eased ace- o- ace specialised consul a ions, and inc eased pa ien s and p o essionals’ sa is ac ion [ 3 , 5 , 11 , 12 , 16 , 17 , 23 ]. Howe e , s udies ha p o ide da a on he wai ing imes un il he esolu ion o he p oblem ha ga e ise o he e e al ha e no been ound. In addi ion, e-Consul a ions equi e impo an in es men s and ins i u ional in ol emen , as well as leade ship and wo king hou s on he pa o physicians [ 12 ]. Wi h eal- ime elephone consul a ions, communica ion p oblems [ 15 ] we e de ec ed o incomple e o agmen ed in o ma ion [ 7 , 9 – 15 , 19 – 23 ], di icul ies o choose he p o essional o be consul ed [ 24 ], unp edic able in e up ions ha a e ime consuming, as hey a e no scheduled, e c. [18]. In Spain, heal h ca e is a igh o ci izens and public unds p o ide i s unding. Howe e , he o ganisa ion i sel is sub oga ed o he egional go e nmen s, which e i o ially di ide hei su ace in heal h a eas o manage he p o ision o heal h ca e. Each o hese heal h a eas consis s o se e al basic a eas o p ima y ca e and a hospi al, whe e pa ien s om each a ea could be e e ed o, i necessa y. Each basic p ima y ca e a ea includes one o mo e p ima y ca e medical cen e s, wi h one o mo e amily physicians in each. Each pa ien is assigned a amily physician in ela ion o p oximi y o his/he home. The pa ien s can change hei amily physician whene e hey wish, ha is, hey can choose hei amily physician among he ones wo king a he closes medical cen e o hei home. Ou heal h a ea, he No h o Huel a Heal h Managemen A ea (NHHMA), depends on he egional go e nmen o Andalusia, in sou he n Spain. I is a u al a ea, which consis s o six basic p ima y ca e a eas and a dis ic hospi al o second le el, whe e ace- o- ace e e al is he only possibili y o FPs ( amily physician) o p o ide a specialised assessmen , he e is a ch onic sa u a ion in he ou pa ien in e nal medicine consul a ions (OIMC), since hese assume hei own e e als, bu also hose o se e al o e loaded special ies (ca diology, pulmonology, gas oen e ology...), and o o he special ies ha a e no a ailable a ou hospi al ( heuma ology, neu ology, neph ology...). Faced wi h his si ua ion, i was decided o ca y ou his s udy, in which a sys em o scheduled elephone e e al (DETELPROG, o i s ac onym in Spanish) was c ea ed as an al e na i e o ace- o- ace e e al, in which he FP eques s a scheduled OIMC, which is in eg a ed in o he usual consul a ions agenda o bo h physicians, in o de o ha e a elephone consul a ion wi h he in e nis while he pa ien is in he FP consul a ion. The objec i e is o imp o e he wai ing imes ega ding ace- o- ace e e al and o a oid unnecessa y ace- o- ace consul a ions, elimina ing he ba ie s o o he ypes o elemedicine desc ibed in he p e ious sec ion. In he i s phase o he s udy [ 25 ], a educ ion in wai ing imes o he i s in e nal medicine consul a ion (IMC) was ound. Now, an assessmen o he exis ence o di e ences in he wai ing imes o he esolu ion o he p ocess be ween he g oups and he numbe o ace- o- ace consul a ions ha we e a oided in he expe imen al g oup will be ca ied ou . 2. Ma e ials and Me hods 2.1. Design Randomised con olled clinical ial o wo a ms (expe imen al and con ol) wi hou blinding. Blinding was no possible due o he impossibili y o blind a ace- o- ace e e al whe e he pa ien physically goes o he hospi al as compa ed o he DETELPROG, in which he pa ien is a he amily physician’s o ice. J. Clin. Med. 2019,8, 688 3 o 10 2.2. Sample Pa ien s who li ed in one o he six basic heal h a eas o he No h o Huel a Heal h Managemen A ea (NHHMA) equi ed a e e al o OIMC. 2.3. Sample Size The is e a.com [ 26 ] sample calcula o was used o he compa ison o he wo samples in o de o ob ain a ep esen a i e sample, es ima ing he inclusion o 85 pa ien s pe g oup (expe imen al and con ol) and conside ing a 15% expec ed p opo ion o d opou s. 2.4. Randomisa ion A andomisa ion o he FPs wi h quo a was pe o med in he NHHMA ( andomisa ion o pa ien s by blocks), and hey we e o de ed by dec easing numbe o e e als o IM (In e nal medicine) in 2014. Subsequen ly, hey we e in o med and o med by a one-hou aining mee ing on he p ojec o each o he FP. Those FP who ag eed o pa icipa e and signed an in o med consen we e andomly di ided in o expe imen al g oup and con ol g oup using a able o andom numbe s [ 27 ]. The andomiza ion p ocedu e was pe o med wi h he FP. FP we e andomly assigned ei he o he expe imen al o he con ol g oup. All o he pa ien s ha we e associa ed o each FP we e assigned o he same g oup han hei FP. The FPs, al eady so ed in bo h g oups, assessed o eligibili y o e e y pa ien who equi ed a e e al, acco ding o he inclusion and exclusion c i e ia. Subsequen ly, eligible pa ien s we e in o med, and w i en consen was ob ained. In his way, hose in he con ol g oup e e ed pa ien s ia ace- o- ace and only collec ed he equi ed da a om hei pa ien s, and hose om he expe imen al g oup e e ed pa ien s ia DETELPROG. As an exclusion c i e ia o he FP, hose FPs, who, belonging o he con ol g oup, did no collec da a on a leas 50% o hei e e ed pa ien s o IM we e excluded, as well as hose belonging o he expe imen al g oup who did no eques any DETELPROG. 2.5. In e en ion To ca y ou he DETELPROG, ou appoin men s o 15 min each we e included in he IM consul a ions agendas o eplace wo o he appoin men s o 30 min ha a e usually scheduled o each pa ien who a ends he co esponding physician’s o ice o he i s ime. These appoin men s we e se up by FPs and, subsequen ly, hey se up, in hei own consul ing oom, he same day and a he same ime, h ee consul a ions ollowed by six minu es, so ha bo h physicians could ha e ime o he elephone con e sa ion. The e e al pe iods we e om 1 Ma ch o 10 June and om 3 Oc obe o 12 Decembe 2016, when each FP e e ed hei pa ien s h ough DETELPROG o in-pe son consul a ion, acco ding o hei g oup. On he day o he appoin men , in he expe imen al g oup, he FP called an IMC phone numbe ha was speci ically designed o his pu pose, wi h he pa ien p esen and he hands- ee op ion o he connec ed elephone. In his consul a ion, he ea men s, complemen a y es s, and p edic able e iews we e ag eed ia elephone o in pe son, bo h p o essionals lea ing eco d o e e y hing in he pa ien ’s digi al eco d. The eques s, consen s, and co esponding appoin men s o complemen a y es s we e sen o he pa ien ’s add ess, and hese would ha e o be pe o med ei he a he heal h cen e (blood es s, X- ay es s) o a he hospi al. All o he pa ien s we e subsequen ly ollowed up o a yea o up o discha ge om IMC. 2.6. Inclusion C i e ia Pa ien s who equi ed a e e al o IMC a he disc e ion o hei FP. 2.7. Exclusion C i e ia A. Pa ien s whose FP, belonging o he expe imen al g oup, conside ed ha hey would no bene i om he elephone e e al o any eason and eques ed a ace- o- ace e e al. J. Clin. Med. 2019,8, 688 4 o 10 B. Pa ien s who did no ag ee o elephone e e al, e en i hei FP belonged o he expe imen al g oup. 2.8. D opou s C i e ia •Pa ien s who did no a end he eques ed complemen a y es s. •Pa ien s who did no a end he eques ed e iews. •Pa ien s who died du ing he s udy. •Pa ien s whose p ocess had no been esol ed wi hin he yea o ollow-up. 2.9. Regis e ed Va iables, Measu emen Techniques and Follow-up o Pa icipan s As independen a iables o he pa ien s, he ollowing we e eco ded: in e en ion, sex, age, deg ee o u ali y o he popula ion in which li e [ 28 ] (index indica ing he deg ee o u ali y, being ze o he a e age alue o u ali y. Fo i s elabo a ion, he ageing o he popula ion, economic dependence, ag icul u al occupa ion, habi abili y o he dwellings, and popula ion densi y we e aken in o accoun ), and he dis ance o he Hospi al o Rio in o om hei popula ion. As esul a iables, he ollowing we e assessed: - Wai ing days o IM consul a ion as he numbe o days elapsed be ween he day o he consul a ion eques by he FP and he day o he same. - Numbe o a oided/a oidable ace- o- ace e e als, such as hose pa ien s who ha e had no medical e iew in IMC o who had had jus one, since he la es medical e iew a IMC is always pe o med as a non- ace- o- ace consul a ion o he comple ion o he discha ge epo ha will be sen by pos . The e o e, in pa ien s wi h 0 o 1 e iews belonging o he expe imen al g oup, he ace- o- ace consul a ion will be a oided, and, in he con ol g oup, he ace- o- ace consul a ion could be a oidable. - Wai ing days o he esolu ion o he p ocess as numbe o days elapsed om he day o e e al o IMC un il he day o esolu ion o he p ocess (maximum one yea ), when conside ing his day as he one in which he FP eco ds in he digi al medical his o y ha he p oblem o which he pa ien was e e ed has been esol ed, o he day in which his physician d aws up he discha ge epo . Pa ien s’ cases o exclusion we e also collec ed. Fo his, a ques ionnai e was c ea ed o he FPs, whe e he ollowing causes appea ed: pa ien ’s e usal, and six possible causes o FPs’ e usal (Figu e 1), based on he mos equen ba ie s ha we e de ec ed in o he s udies [ 15 , 18 , 19 , 24 ] and on some p oblems de ec ed in his s udy. The a iables eco d was ca ied ou in wo ways: h ough a da a collec ion shee and h ough he al eady exis ing da a in he digi al clinical his o y sys em o he Andalusian heal h sys em. The ollow-up o each pa ien was ca ied ou o one yea o un il he day o he esolu ion o he p ocess. J. Clin. Med. 2019,8, 688 5 o 10 J. Clin. Med. 2019, 8, x FOR PEER REVIEW 4 o 10 2.8. D opou s C i e ia • Pa ien s who did no a end he eques ed complemen a y es s. • Pa ien s who did no a end he eques ed e iews. • Pa ien s who died du ing he s udy. • Pa ien s whose p ocess had no been esol ed wi hin he yea o ollow-up. 2.9. Regis e ed Va iables, Measu emen Techniques and Follow-up o Pa icipan s As independen a iables o he pa ien s, he ollowing we e eco ded: in e en ion, sex, age, deg ee o u ali y o he popula ion in which li e [28] (index indica ing he deg ee o u ali y, being ze o he a e age alue o u ali y. Fo i s elabo a ion, he ageing o he popula ion, economic dependence, ag icul u al occupa ion, habi abili y o he dwellings, and popula ion densi y we e aken in o accoun ), and he dis ance o he Hospi al o Rio in o om hei popula ion. As esul a iables, he ollowing we e assessed: - Wai ing days o IM consul a ion as he numbe o days elapsed be ween he day o he consul a ion eques by he FP and he day o he same. - Numbe o a oided/a oidable ace- o- ace e e als, such as hose pa ien s who ha e had no medical e iew in IMC o who had had jus one, since he la es medical e iew a IMC is always pe o med as a non- ace- o- ace consul a ion o he comple ion o he discha ge epo ha will be sen by pos . The e o e, in pa ien s wi h 0 o 1 e iews belonging o he expe imen al g oup, he ace- o- ace consul a ion will be a oided, and, in he con ol g oup, he ace- o- ace consul a ion could be a oidable. - Wai ing days o he esolu ion o he p ocess as numbe o days elapsed om he day o e e al o IMC un il he day o esolu ion o he p ocess (maximum one yea ), when conside ing his day as he one in which he FP eco ds in he digi al medical his o y ha he p oblem o which he pa ien was e e ed has been esol ed, o he day in which his physician d aws up he discha ge epo . Pa ien s’ cases o exclusion we e also collec ed. Fo his, a ques ionnai e was c ea ed o he FPs, whe e he ollowing causes appea ed: pa ien ’s e usal, and six possible causes o FPs’ e usal (Figu e 1), based on he mos equen ba ie s ha we e de ec ed in o he s udies [15,18,19,24] and on some p oblems de ec ed in his s udy. Figu e 1. Causes o exclusion o elephone e e al. 9 19.57% 16 34.78% 4 8.70% 3 6.52% 6 13.04% 5 10.87% 3 6.52% 0 5 10 15 20 Pa ien 's e usal Complex pa ien Lack o ime I o go Subs i u e Physician O he causes Ad ice om Eme gency Se ices Coun Figu e 1. Causes o exclusion o elephone e e al. 2.10. S a is ical Analysis The ollowing independen a iables ega ding he pa ien s we e assessed: pa ien s in he expe imen al and con ol g oups, pa ien s who we e excluded, and pa ien s emo ed a e es ima ions o sex equencies, as well as he median calcula ion (25 pe cen ile–75 pe cen ile) in he o he h ee a iables, o ailing o mee no mali y c i e ia. To assess he exis ence o s a is ically signi ican di e ences be ween g oups ega ding he independen a iables, he chi squa ed es was calcula ed o sex, and he non-pa ame ic es by K uskall–Wallis o he o he h ee a iables, wi h a le el o signi icance o 0.05 and a con idence in e al o 95%. Calcula ing he equencies o a oided/a oidable consul a ions, and median (25 pe cen ile–75 pe cen ile) o he o he wo a iables, o no mee ing he no mali y c i e ia ei he , we e uses o desc ip i ely assessing he ou come a iables. Subsequen ly, whe he he e we e s a is ically signi ican in e -g oup di e ences was analysed using he chi squa ed echnique o he i s a iable and, o he o he wo, h ough he Mann–Whi ney U non-pa ame ic es , wi h a signi icance le el o 0.05 and a con idence in e al o 95%, subsequen ly applying he Hodges–Lehman median di e ence es ima o o independen samples. A desc ip i e analysis o he causes o wi hd awal was also conduc ed by calcula ing equencies, hus analysing he exis ence o s a is ically signi ican di e ences be ween he expe imen al and he con ol g oups h ough he chi squa ed echnique. 2.11. E hical and Legal Aspec s The Resea ch E hics Commi ee o he P o ince o Huel a has e alua ed and au ho ized his s udy. In addi ion, as a andomised con olled ial, i has been egis e ed wi h T ial Regis a ion Numbe ACTRN12617001536358. 3. Resul s The 17 FPs o he con ol g oup e e ed 164 pa ien s, o whom 63 (38.4%) we e wi hd awn om he s udy. Table 1desc ibes he sociodemog aphic cha ac e is ics o he popula ion. J. Clin. Med. 2019,8, 688 6 o 10 Table 1. Sociodemog aphic cha ac e is ics o he included and excluded amily physicians (FPs) by g oups. Sociodemog aphic Cha ac e is ics FPs Excluded (n=20) Expe imen al G oup (n=13) Con ol G oup (n=17) p-Value Sex n(%) Male Female 13 (65%) 7 (35%) 7 (53.8%) 6 (46.8%) 14 (82.4%) 3 (17.6%) 0.236 Age in yea s a57.5 (36–60) 59 (43–61.5) 54 (43–58.5) 0.624 Dis ance o hospi al in kilome es b44.5 (±25.4) 3.9 (±11.4) 32 (±24.4) 0.551 Heal h insu ance ca ds adjus ed by age b1.747 (±590) 1.756 (±635) 1.804 (±570) 0.926 N o e e als in 2014 a32 (22–45) 27 (20–49) 21 (18–32) 0.101 Ru ali y deg ee b−0.53 (±0.54) −0.57 (±0.41) −0.57 (±0.51) 0.768 a: Median (qua ile ange P25–P75); b: Mean (±s anda d de ia ion). FP: amily physician. The 13 FPs o he expe imen al g oup e e ed 172 pa ien s, o which 91 (53%) we e e e ed h ough DETELPROG and 81 (47%) h ough ace- o- ace consul a ion. These las 81 pa ien s we e excluded o mee ing one o he exclusion c i e ia, being P ima y ca e (PC) di icul y o pa ien s’ managemen he mos common c i e ion (Figu e 1). O he 91 pa ien s in he expe imen al g oup, 19 (20.9%) we e wi hd awn om he s udy o mee ing one o he wi hd awal c i e ia (Figu e 2), wi h he e being s a is ically signi ican di e ences ega ding he numbe o wi hd awn pa ien s be ween he expe imen al and he con ol g oups (38.4% s. 20.9%; p=0.04), bu no in he dis ibu ion o wi hd awals acco ding o hei causes p=0.88. J. Clin. Med. 2019, 8, x FOR PEER REVIEW 6 o 10 excluded o mee ing one o he exclusion c i e ia, being P ima y ca e (PC) di icul y o pa ien s’ managemen he mos common c i e ion (Figu e 1). O he 91 pa ien s in he expe imen al g oup, 19 (20.9%) we e wi hd awn om he s udy o mee ing one o he wi hd awal c i e ia (Figu e 2), wi h he e being s a is ically signi ican di e ences ega ding he numbe o wi hd awn pa ien s be ween he expe imen al and he con ol g oups (38.4% s. 20.9%; p = 0.04), bu no in he dis ibu ion o wi hd awals acco ding o hei causes p = 0.88. Figu e 2. Wi hd awn pa ien s’ coun by wi hd awal cause. Table 2 desc ibes he pa ien s’ independen a iables, inding s a is ically signi ican di e ences ega ding he dis ance o he hospi al and he deg ee o u ali y o he a ea. Table 2. Sociodemog aphic cha ac e is ics o he included and excluded pa ien s by g oups. Sociodemog aphic Cha ac e is ics Excluded Pa ien s (n = 81) Wi hd awn Pa ien s (n = 82) Expe imen al G oup (n = 72) Con ol G oup (n = 101) p-Value Sex n (%) Male Female 33 (40.7%) 48 (59.3%) 33 (40.2%) 49 (59.8%) 31 (43.1%) 41 (56.9%) 41 (40.6%) 60 (59.4%) 0.985 Age in yea s a 56(44.42–69.50) 54.8(39.75–71.34) 56 (41.25–66) 56 (43–69.30) 0.92 Ru ali y deg ee a −0.9(−0.92–−0.59) −0.78(−1.09–−0.59) −0.69(−0.92–−0.42) −0.78(−1.13–−0.43) 0.02 Dis ance o hospi al in kilome es a 30.5 (27–35) 27 (3.7–41.22) 36.2 (27–44.9) 23 (0–41.3) ˂0.01 a: Median (qua ile ange P25–P75). Rega ding he pa ien s’ diseases, Table 3 summa izes he esul s o he medical special y, whe e he pa ien s we e e e ed. Table 3. F equency o e e al diseases by g oups. Medical Special y G oup To al Con ol (n) Expe imen al (n) Re e al disease Ca dio ascula 15 11 26 Endoc inology 6 5 11 Neu ology 9 2 11 Gas oen e ology 52 33 85 Oncology 0 2 2 Neph ology 1 2 3 Rheuma ology 4 4 8 O he s 14 13 27 To al 101 72 173 21 1 13 28 73 9 0 10 20 30 No a ending o i s IM consula ion Dea h No a ending PC o e iew No discha ged a e he ollow- up yea Coun Cause o wi hd awal Con ol Expe imen al Figu e 2. Wi hd awn pa ien s’ coun by wi hd awal cause. Table 2desc ibes he pa ien s’ independen a iables, inding s a is ically signi ican di e ences ega ding he dis ance o he hospi al and he deg ee o u ali y o he a ea. Table 2. Sociodemog aphic cha ac e is ics o he included and excluded pa ien s by g oups. Sociodemog aphic Cha ac e is ics Excluded Pa ien s (n=81) Wi hd awn Pa ien s (n=82) Expe imen al G oup (n=72) Con ol G oup (n=101) p-Value Sex n(%) Male Female 33 (40.7%) 48 (59.3%) 33 (40.2%) 49 (59.8%) 31 (43.1%) 41 (56.9%) 41 (40.6%) 60 (59.4%) 0.985 Age in yea s a56(44.42–69.50) 54.8(39.75–71.34) 56 (41.25–66) 56 (43–69.30) 0.92 Ru ali y deg ee a−0.9(−0.92–−0.59) −0.78(−1.09–−0.59) −0.69(−0.92–−0.42) −0.78(−1.13–−0.43) 0.02 Dis ance o hospi al in kilome es a30.5 (27–35) 27 (3.7–41.22) 36.2 (27–44.9) 23 (0–41.3) <0.01 a: Median (qua ile ange P25–P75). J. Clin. Med. 2019,8, 688 7 o 10 Rega ding he pa ien s’ diseases, Table 3summa izes he esul s o he medical special y, whe e he pa ien s we e e e ed. Table 3. F equency o e e al diseases by g oups. Medical Special y G oup To al Con ol (n) Expe imen al (n) Re e al disease Ca dio ascula 15 11 26 Endoc inology 6 5 11 Neu ology 9 2 11 Gas oen e ology 52 33 85 Oncology 0 2 2 Neph ology 1 2 3 Rheuma ology 4 4 8 O he s 14 13 27 To al 101 72 173 Wi h ega d o he esul a iables (Table 4), 91.7% o he DETELPROG a oided a ace- o- ace consul a ion wi h he in e nis , wi h 85.1% o he con ol g oup consul a ions being p edic ably a oidable and no inding s a is ically signi ican di e ences be ween bo h g oups. Table 4. Summa y and di e ences be ween g oups o he dependen a iables. Va iable Expe imen al G oup (n=72) Con ol G oup (n=101) p-Value Medians Di e ences in Days (CI 95%) A oided/a oidable ace- o- ace e e als n(%) 66 (91.7) 86 (85.1) p=0.290 No s a is ically signi ican di e ences Wai ing ime o IM consul a ion, in days a11 (7–19) 41 (23–56) p<0.001 27 (20–33) Wai ing ime o esolu ion o he p ocess, in days 104.5 (39.5–169) 147 (74–228) p=0.002 46 (17–74) a: Median (qua ile ange P25–P75). IM: in e nal medicine; CI: con idence in e al. Rega ding he wai ing days o IM consul a ion and up o he esolu ion o he p ocess, s a is ically signi ican di e ences we e ound be ween bo h o he g oups (p<0.001 and p=0.002 espec i ely), wi h a di e ence o 27 (CI 95%: 20–33) and 46 (CI: 95%: 17–74) days, espec i ely. Du ing he s udy, 9.3% o he o al ime designed o i s consul a ions in PC was de o ed o DETELPROG. DETELPROG ep esen ed abou 9% o all he e e als o IM. Thus, his p ocess a oided he o he wo ypes o e e al. 4. Discussion In his s udy, we ound ha DETELPROG, as compa ed o ace- o- ace e e al ( he only exis ing model o e e al in he NHHMA), conside ably dec eases he wai ing days o he esolu ion he p ocess o which he pa ien is e e ed, a oiding ace- o- ace specialised consul a ion in almos all cases. In he Canadian RACE p og am [ 22 ], one o he mos powe ul immedia e elephone consul a ion p og ams in he wo ld, he e is no wai ing any longe , as he call is answe ed in eal ime. Howe e , only 60% o he elephone consul a ions a oids ace- o- ace consul a ion, in con as o he 91% a oided wi h DETELPROG. Wi h ega d o e-consul a ions, he wai ing days o he specialis ’s esponse a e be ween 0 and ou days, bu da a on a oided ace- o- ace specialis consul a ions a e highly a iable, be ween 12% and 85% [3–5,14]. In he case o egula mee ings wi h a e e ence specialis , in an Andalusian s udy also on PC and IM [7], only 73% o ace- o- ace consul a ions we e a oided. J. Clin. Med. 2019,8, 688 8 o 10 Da a on he wai ing days o he esolu ion o he p ocess ha e no been ound in he s udies, which was conside ed o be he mos impo an measu e in his s udy o being he ac ual ime elapsed un il he esolu ion o he pa ien ’s p oblem, and because his is conside ably educed wi h DETELPROG when compa ed o ace- o- ace e e als. As o he di e ences ha we e ound be ween he g oups ega ding he dis ance o he hospi al, he mos ele an di e ence is ound be ween he expe imen al and he con ol g oup in 10.4 km (19.6–5.1). Thus, i is possible o sugges ha pa ien s who li e close o he hospi al a e mo e likely o ejec he elephone e e al, al hough he di e ences in dis ance a e so small ha i is no possible o con i m his idea, based on he da a ha we e ob ained in his s udy. As o he deg ee o u ali y, a possible endency is de ec ed o no using new echnologies o e e als, al hough he di e ences, albei minimal, go in he opposi e di ec ion. As o he low co e age o DETELPROG (53% o he pa ien s in he expe imen al g oup), we belie e i o be necessa y o unde ake a quali a i e s udy o analyse ba ie s, di icul ies, and possible a eas o imp o emen ega ding DETELPROG a g ea e leng h, so as o op imise his ype o e e al and make i possible o implemen his sys em in ou heal h a ea, and e en expo i o o he a eas. The e o e, we conside ha DETELPROG, as compa ed o ace- o- ace e e al ( he only exis ing model o e e al in he NHHMA), conside ably dec eases he wai ing days o he esolu ion he p ocess o which he pa ien is e e ed (pa ame e no alued in s udies on o he models o e e al), a oiding ace- o- ace specialised consul a ion in almos all cases. The educ ion o wai ing days o he i s IM consul a ion wi h DETELPROG is no as ele an as i is in he case o eal- ime elephone consul a ions o in he case o e e als h ough elec onic pla o ms. Howe e , i is a e e al me hod ha does no equi e any ex ao dina y economic o poli ical suppo , which educes wai ing days wi h espec o ace- o- ace e e al, and ha does no imply he ba ie s o eal- ime elephone consul a ions ha a e caused by immediacy and a lack o p og ammabili y. In addi ion, we canno o ge ha his is he model ha mo e ace- o- ace e e als a oid acco ding o he da a ha a e ound in he li e a u e. We also belie e ha his model o scheduled elephone e e al would be applicable o o he special ies in which e e als wi h good esul s we e al eady applied h ough asynch onous elec onic pla o ms and/o immedia e elephone consul a ions [ 14 , 22 ], bo h in u al and u ban en i onmen s. Howe e , speci ic s udies would be needed in hese special ies and o he a eas o suppo his hypo hesis. As a limi a ion, we conside ha he educ ion o wai ing days is lowe han in he o he models o eal- ime elephone consul a ions and e-consul a ions, bu no addi ional expendi u e o in ol emen o he adminis a ions is equi ed o DETELPROG, as is he case o e-consul a ions, being his a model ha is only applicable i p o essionals eques i . On he o he hand, wi h his new ype o e e al, no p oblems a e de i ed om he immediacy and he lack o p og ammabili y o eal- ime elephone e e als. 5. Conclusions As in he p e ious a icle, we do no conside DETELPROG o complex pa ien s (34.8% o pa ien s excluded) [ 25 ], whose diagnoses a e no mo e o less ou lined om PC o ega ding pa ien s who equi e a mo e specialised clinical managemen o examina ion. Howe e , we belie e ha he low co e age o DETELPROG (53%) does no make i an exclusi e e e al model, bu a complemen o o he echniques. I necessa y o conduc in-dep h analysis o he causes ha ha e led o his echnologically low co e age. Au ho Con ibu ions: Concep ualiza ion, L.M.A.-L. and J.J.P.-L.; Da a cu a ion, L.M.A.-L., J.J.P.-L. and E.M.M.-S.; Fo mal analysis, L.M.A.-L., J.J.P.-L. and E.M.M.-S.; Funding acquisi ion, L.M.A.-L.; In es iga ion, L.M.A.-L., J.J.P.-L. and E.M.M.-S.; Me hodology, J.J.P.-L., E.M.M.-S., J.G.-S. and V.C.-V.; P ojec adminis a ion, L.M.A.-L. and J.J.P.-L.; Resou ces, L.M.A.-L. and V.C.-V.; So wa e, L.M.A.-L. and J.J.P.-L.; Supe ision, V.C.-V.; Valida ion, L.M.A.-L., J.J.P.-L. and E.M.M.-S.; Visualiza ion, E.M.M.-S., J.G.-S. and V.C.-V.; W i ing—o iginal d a , L.M.A.-L., J.J.P.-L., E.M.M.-S. and J.G.-S.; W i ing— e iew & edi ing, V.C.-V. J. Clin. Med. 2019,8, 688 9 o 10 Funding: This a icle is pa o he doc o al hesis P ojec by Luis Miguel Azogil-L ó pez, de eloped wi h he help o he Andalusian Socie y o Family and Communi y Medicine -SAMFyC- (Reco d e . 157/18), h ough he “ISABEL FERNÁNDEZ” g an o he suppo o esea ch and doc o al hesis p ojec s, wi hin he SAMFyC 2018 call. Con lic s o In e es : The au ho s decla e no con lic o in e es . The unde s had no ole in he design o he s udy; in he collec ion, analyses, o in e p e a ion o da a; in he w i ing o he manusc ip , o in he decision o publish he esul s. Re e ences 1. Minis y o Heal h, Social Se ices and Equali y. SISLE-SNS. Si uaci ó n a 30 de junio de 2017. A ailable online: h p://www.mscbs.gob.es/es adEs udios/es adis icas/in o Recopilaciones/docs/Indicado es_ Resumen_Junio_2017.pd (accessed on 3 Janua y 2019). 2. Minis y o Heal h, Social Se ices and Equali y. Ba ó me o Sani a io 2016 (To al oleadas). A ailable online: h ps://www.mscbs.gob.es/es adEs udios/es adis icas/Ba ome oSani a io/Ba om_Sani _ 2016/BS2016_MAR.pd (accessed on 3 Janua y 2019). 3. Nase iasl, M.; Adham, D.; Jana i, A. E- e e al Solu ions: Success ul Expe iences, Key Fea u es and Challenges—A Sys ema ic Re iew. Ma e . Sociomed. 2015,27, 195–199. [C ossRe ] 4. W enn, K.; Ca schegn, S.; C uz, M.; Gleason, N.; Gonzales, R. Analysis o an elec onic consul a ion p og am a an academic medical cen e: P ima y ca e p o ide ques ions, specialis esponses, and p ima y ca e p o ide ac ions. J. Telemed. Teleca e 2017,23, 217–224. [C ossRe ] 5. Liddy, C.; Mo oz, I.; A kham, A.; Keely, E. Sus ainabili y o a P ima y Ca e–D i en eConsul Se ice. Ann. Fam. Med. 2018,16, 120–126. [C ossRe ] [PubMed] 6. On a io Medical Associa ion. P inciples and ecommenda ions: Models and p ocesses o deli e y o special y ca e. A ailable online: h ps://www.oma.o g/Resou ces/Documen s/ ModelsandP ocesseso Deli e y o Special yCa e.pd (accessed on 28 Feb ua y 2019). 7. Ga c í a-Aleg í a, J.; Jim é nez-Puen e, A.; Ruiz Solanes, F. Ano he model o in e nal medicine consul ing in p ima y heal h ca e. Med. Clin. (Ba c) 2004,123, 198. [C ossRe ] 8. Allepuz, A.; Galla do, C.; Pe ona, M. Coo dinaci ó n en e ni eles asis enciales: ¿qu é p io izan los p o esionales? A en. P ima ia 2012,44, 568–569. [C ossRe ] 9. Mo eno-Ram í ez, D.; Fe á ndiz, L.; Nie o-Ga c í a, A.; Villegas-Po e o, R. Telede ma ology. Med. Clin. (Ba c) 2008,130, 496–503. [C ossRe ] 10. Whi ed, J.D.; Hall, R.P.; Foy, M.E.; Ma b ey, L.E.; G ambow, S.C.; Dudley, T.K.; Da a, S.K.; Simel, D.L.; Oddone, E.Z. Pa ien and Clinician Sa is ac ion wi h a S o e-and-Fo wa d Telede ma ology Consul Sys em. Telemed. J. E Heal h 2004,10, 422–431. [C ossRe ] 11. Olayiwola, J.N.; Ande son, D.; Jepeal, N.; Asel ine, R.; Picke , C.; Yan, J.; Zla e a, I. Elec onic Consul a ions o Imp o e he P ima y Ca e-Special y Ca e In e ace o Ca diology in he Medically Unde se ed: A Clus e -Randomized Con olled T ial. Ann. Fam. Med. 2016,14, 133–140. [C ossRe ] [PubMed] 12. Tuo , D.S.; Leeds, K.; Mu phy, E.J.; Sa ka , U.; Lyles, C.R.; Mekonnen, T.; Chen, A.H. Facili a o s and ba ie s o implemen ing elec onic e e al and/o consul a ion sys ems: A quali a i e s udy o 16 heal h o ganiza ions. BMC Heal h Se . Res. 2015,15, 568. [C ossRe ] [PubMed] 13. Chen, A.H.; Mu phy, E.J.; Yee, H.F. eRe e al. A new model o in eg a ed ca e. N. Engl. J. Med. 2013 ,368, 2450–2453. [C ossRe ] [PubMed] 14. Liddy, C.; D osinis, P.; Keely, E. Elec onic consul a ion sys ems: Wo ldwide p e alence and hei impac on pa ien ca e—A sys ema ic e iew. Fam. P ac . 2016,33, 274–285. [C ossRe ] 15. Wadhwa, A.; Linga d, L. A quali a i e s udy examining ensions in in e doc o elephone consul a ions. Med. Educ. 2006,40, 759–767. [C ossRe ] 16. Cook, D.A.; So ensen, K.J.; Wilkinson, J.M. Value and p ocess o cu bside consul a ions in clinical p ac ice: A g ounded heo y s udy. Mayo Clin. P oc. 2014,89, 602–614. [C ossRe ] [PubMed] 17. Mye s, J.P. Cu bside consul a ion in in ec ious diseases: A p ospec i e s udy. J. In ec . Dis. 1984 ,150, 797–802. [C ossRe ] [PubMed] 18. Cook, D.A.; So ensen, K.J.; Wilkinson, J.M.; Be ge , R.A. Ba ie s and Decisions When Answe ing Clinical Ques ions a he Poin o Ca e. JAMA In e n. Med. 2013,173, 1962. [C ossRe ] [PubMed]