Clinicians' Levels of Experience and Roles Influence the Decisions Made in Telephone Clinic Consultations in Rheumatology

ABSTRACT

Background/Aims Since the outbreak of COVID-19, clinicians adapted by switching from face-to-face to remote consultations in order to limit transmission and continue delivering high-quality outpatient services. We aimed to investigate patient- and clinician-related factors which may affect outcomes in follow-up telephone consultations. Methods Patients who attended follow-up clinic appointments via telephone consultations in the month of March 2022 were retrospectively evaluated. Data collected were demographics, main active diagnosis, current treatment and the clinicians' grade. Factors associated with categorical outcomes i.e. decision to request a subsequent face-toface appointment, investigations, referrals to other specialties, and to discharge a patient, were assessed using univariate logistic regression analysis. Univariate linear regression analysis was performed to identify factors associated with the length of follow-up intervals. Results 314 patients were included;218 (69%) female, median (IQR) age 63 (53- 72) years. The most common diagnosis was rheumatoid arthritis (39%). 66% of patients were on DMARDs and 16% were on steroids. There were 48 (15.3%) requests for a subsequent face-to-face appointment and 28 (8.9%) discharges. There were more investigations (20.4%) requested compared to referrals (4.5%). Specialist nurses (SpNs) were the single largest group who conducted the telephone consultations (46%). SpNs were more likely to request face-to-face appointments [odds ratio (OR) 2.16 95%CI (1.16, 4.12) P=0.017] and investigations [OR 1.77 (1.02, 3.11) P=0.043] compared to other clinicians. In contrast, consultants were less likely to request investigations [OR 0.34 (0.16, 0.66) P=0.002]. Other factors associated with a subsequent face-to-face appointment were steroid [OR 3.00 (1.45, 6.02) P=0.002] and conventional DMARD therapy [OR 2.90 (1.50, 5.92) P=0.002]. In terms of discharges, consultants were more likely to discharge a patient [OR 4.05 (1.83, 9.46) P<0.001]. Patients with a diagnosis of inflammatory arthritis [OR 0.01 (0.00, 0.06) P<0.001] and on conventional DMARDs [OR 0.03 (0.00, 0.14) P<0.001] have a lower probability of being discharged. In terms of specialty referrals, there were no significant factors identified. An analysis of 197 clinic letters which specified follow-up intervals found that consultants were more likely to request longer follow-up intervals [beta coefficient 0.32 (0.13, 0.50) P<0.001] whereas SpNs were more likely to request shorter follow-up intervals [beta coefficient -0.52 (-0.65, -0.39), P<0.001]. Conclusion These findings suggest that clinicians' experiences and roles may influence the decisions made following a telephone clinic consultation. For example, SpNs are usually involved in drugmonitoring and therefore, have a higher likelihood to request face-to-face reviews, shorter followup intervals and investigations. The consultant's level of experience may explain the higher probability of discharging patients and the lower probability of requesting investigations. Further studies over a longer duration are needed to determine other factors which may affect the clinical decisions made from telephone clinic consultations.