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Volume and Nature of Patient Telephone Calls in a Large Movement Disorders Center O.R. Adam, MD; L.G. Aguilar Tabora, MD; J. Ferrara, MD; M. Nashatizadeh,

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Presentation on theme: "Volume and Nature of Patient Telephone Calls in a Large Movement Disorders Center O.R. Adam, MD; L.G. Aguilar Tabora, MD; J. Ferrara, MD; M. Nashatizadeh,"— Presentation transcript:

1 Volume and Nature of Patient Telephone Calls in a Large Movement Disorders Center O.R. Adam, MD; L.G. Aguilar Tabora, MD; J. Ferrara, MD; M. Nashatizadeh, MD; J. Jankovic, MD The Parkinsons Disease Center and Movement Disorders Clinic Baylor College of Medicine Houston, Texas

2 Background Parkinson Disease Center and Movement Disorders Center (PDCMDC), Baylor College of Medicine, Houston, Texas Established in 1977 – a total of 26,000 patients in database, averaging 1,500 new patients/year/last 5 years 4 fellows rotate on callbacks one week at a time On-call schedule for after hours and weekend patient calls

3 Background One fellow at Columbia University Medical Center: –263 new patients/year –116 follow up patients/year –15 inpatient consults/year –Patient care: 25 hours/week Above volume and experience are comparable to that at the PDCMDC, BCM Fellowship training in Movement Disorders –Clinic patients (new, follow-up) –Botulinum Toxin –DBS –Video rounds –Conferences and lectures –Movement Disorders Journal Club –Research Portera-Cailliau C, Victor D, Frucht S, Fahn S., Movement Disorders Fellowship Training Program at Columbia University Medical Center in ; Mov Disord 2005;21:

4 Background DiagnosisNew patientsFollow-up patients PD50.9%60.6% Atypical Parkinsonism11.6%12.6% Dystonia10.8%7.2% Tremor5.7% Tardive4.4%4.2% Psychogenic3.7% 9% Tourette and tics3.5% Ataxia2.2% Myoclonus 7% Chorea Other movement disorders Non-movement disorders Portera-Cailliau C, Victor D, Frucht S, Fahn S., Movement Disorders Fellowship Training Program at Columbia University Medical Center in ; Mov Disord. 2005;21:

5 Background Patient telephone calls are part of the movement disorders fellow training Mini follow-ups providing the opportunity for the fellows to make independent decisions regarding the patients management Movement disorders patients are unique

6 Objective The nature, volume, and time allocation of patient-related telephone calls in a movement disorders center. A secondary aim of this study was to determine the distribution of movement disorders diagnostic categories requiring callbacks.

7 Methods Patient telephone calls received by movement disorders fellows and faculty physicians at the PDCMDC, Baylor College of Medicine Period: 2 months (08/06/08 – 10/06/08) Excluded: medication refills, pharmacy calls, study related questions, authorization and other health insurance related calls

8 Methods Date Time Means Caller Demographics Diagnosis Date of last clinic visit Number of medications and number of changes in the medications at the last visit Reason and outcome of the telephone call Telephone call duration

9 Methods Call Reason Disease related Medication related Side effects Test results Feedback call Other Call Outcome Changed medications Scheduled earlier appointment Restated assessment and plan Reported test results Ordered additional tests Directed to ER Other Not reached

10 Results Total number of callbacks: 633 Total number of patients: 397 Patient type: –New: 80 (20.15%) –Established: 317 (79.85%) Mean age: ± Average amount of time spent on the phone: –Per call: 6.59 min –Per day: 95 min (time recorded only by fellows)

11 Results CallerPercentage Patient48.82% Other 51.18% OtherPercentage Spouse20.22% Parent12.01% Child8.85% Other6.16% Health care3.00% Sibling0.47% N/A0.47%

12 Results MeansNumberPercentage Phone % Fax / / Letter132.05% Total633100%

13 Results Call ReasonFrequency Percentage Disease related % Medication related % Other % Side effects % Test results386.00% Feedback call193.00% Unidentified10.16% Total %

14 Results OutcomeFrequencyPercentage Changed medications % Other % Restated assessment and plan % Reported test results355.53% Scheduled earlier appointment162.53% Ordered additional tests152.37% Not reached132.05% Directed to ER81.26% Unidentified81.26% Total %

15 Diagnosis Distribution Callback (CB) vs Clinic Sample DiagnosisCB FrequencyCB PercentageClinic FrequencyClinic PercentageP Value PD * Atypical Parkinsonism * Tourette * Dystonia <0.0001* ET * Parkinsonism * Chorea * Tardive syndromes * Psychogenic * RLS * Other * Total % % *Two-sample t-test

16 Statistically significant

17 One Time Callers (OC) vs Repeat Callers (RC) OCRCP Value Number Number of calls generated Age (mean ± SD, range, years)58 ± 21, ± 23, * Call duration (mean ± SD, range, min)6 ± 3.93, ± 5.27, * Days between last visit and first call (mean ± SD)81.8 ± ± * *two sample t-test

18 Average amount of time spent on the phone OC: –6 min / patient / call RC: –7.07 min / patient / call –Average number of calls / patient: 2.87 –Time spent on the phone: min / patient / 2 months

19

20 How are OC different from RC ? OCRCP Value Number of medications at last visit (mean ± SD, range)6.25 ± 3.92, ± 3.7, * Number of medication changes at last visit (mean ± SD)1.12 ± ± * ER/urgent referral (% of patients)1.48%1.1%0.67* Scheduled earlier appointment * * two sample t-test

21 Is the Diagnosis Distribution of RC different from OC? OCRCP value FrequencyPercentageFrequencyPercentage PD % %0.93* Atypical Parkinsonism124.43%97.14%0.26* Parkinsonism82.95%10.79%0.17* Dystonia259.23%86.35%0.33* Chorea82.95%32.38%0.74* Tourette2910.7% %0.09* Tardive103.69%53.97%0.89* Psychogenic62.21%00%0.09* ET197.01%86.35%0.8* RLS82.95%32.38%0.74* Other165.9%75.56%0.89* *two-sample t-test

22 Characteristics OC vs RC OCRCP value FrequencyPercentFrequencyPercent Disease related % %0.002* Medication related % %0.15* Side effects % %0.14* Feedback call20.74%174.7%0.0039* Test results228.12%164.42%0.05* Other % %0.39* Unidentified10.37%00%0.24* *two-sample t-test

23 Call Reason Distribution per Diagnostic Groups Medication related Side effects Disease related Test results OtherFeedback Call Unidentified PD27.95%17.39%32.92%1.55%16.46%3.73%0% Atypical Parkinsonism 12.5%6.25%43.75%6.25%28.13%3.13%0% Parkinsonism30%0%30%20% 0% Dystonia14.81%12.96%38.89%5.56%18.52%9.26%0% Chorea16.67%0%38.89%5.56%38.89%0% Tourette16.25%13.75%42.5%2.5%23.75%1.25%0% Tardive10%35%45%0%10%0% Psychogenic16.67% 0%16.67% ET13.51% 35.14%16.22%21.62%0% RLS16.67%22.22%27.78% 5.56%0% Other8.33%11.11%25%30.56%25%0% Average21.32%15.32%35.07%6%19.11%3%0.15% (p<0.0001, Chi Square)

24 Results Discrepancy between the diagnosis at the initial evaluation and at the last follow up visit: 26 patients (6.55%) Most common misdiagnosis: PD > Atypical Parkinsonism

25 Conclusions Patient telephone calls are time consuming: average 90 minutes/day/fellow Patients who call more often and/or require longer conversations are: –PD (48%) –Atypical parkinsonism (5%) –Tourette syndrome (13%) The main questions asked are: –Disease related (35%) –Medication related (21%) –Side effects (15%) The main outcomes are: –Changes in medications (43%) –Counseling (21%) –Referral to the ER (1%) 51% of calls were placed by someone other than the patient

26 Possible Solutions Education at the initial visit (disease, prognosis, complications, treatment, medication side effects etc.) Written educational hand-outs Support groups Internet education Family education

27 Study Caveats Short period: 2 months Situation specific biases Patient population bias Cross sectional not longitudinal

28 Future Studies Longitudinal Methods to reduce the volume of callbacks Assess the possible situation specific variation of callbacks distributed over particular diagnostic groups


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