Linking Calgary area physicians and clinician together to improve patient care.
Specialist LINK Data Year End Report April 2019
Specialist LINK
Specialist LINK Data Year End Report, April 2019 (Fiscal Year March to April)
Table of Contents INTRODUCTION ...... 4 I. History Health System Support Specialty Integration ...... 4 II. Historical HSS Timelines Overview ...... 5 III. History Specialist LINK ...... 5 IV. Specialist LINK Activities For 2018-2019 ...... 6 V. Method ...... 7 SPECIALIST LINK PHONE CALL VOLUME ...... 7 SPECIALIST LINK WEBSITE METRICS HISTORY ...... 8 I. Web based connection ...... 8 II. Website Traffic ...... 9 III. Access and Enhanced Pathway Downloads by Specialty ...... 9 1. Access Pathway ...... 9 2. Enhanced Primary Care Pathways ...... 10 IV. Resources Downloads by Specialty ...... 11 V. Other Resources Downloads/Consultation ...... 12 1. Physician Resources (data collection since January 2019) ...... 12 2. News Items (data collection since August 2017) ...... 12 VI. Testimonials (data collection since January 15, 2019) ...... 13 SPECIALIST LINK SURVEYS ...... 13 Calgary Zone PCN Physician Survey Results ...... 14 I. Physicians Demographics ...... 14 II. Awareness of Specialist LINK telephone advice request service and utilization ...... 15 III. Satisfaction with telephone advice request service ...... 15 1. Specialist LINK telephone Advice Request impact on patients care (n=80) ...... 15 2. Overall satisfaction with Specialist LINK telephone Advice Request (n=210) ...... 15 IV. Enhanced primary care pathways ...... 16 1. Utilization (n=329) ...... 16 2. Most helpful pathways to family physicians’ practice ...... 16
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3. Specialist LINK Primary Care Pathways impact on patients care (n=131) ...... 17 Fall PCN Physician Survey Results ...... 17 I. Specialist LINK telephone advice request service utilization ...... 17 II. Reasons for call ...... 17 III. Outcome of calls ...... 18 IV. Patient presence during the call ...... 18 V. Feedback on Pathways...... 19 SPECIALIST SURVEY RESULTS ...... 19 I. Caller’s information...... 20 1. Caller’s type (up to March 2019 n=974) ...... 20 2. Caller’s unique identification (up to March 2019) ...... 20 II. Call information ...... 20 III. Patients information ...... 21 IV. Reasons for call ...... 21 V. Specialist Recommendation ...... 22 VI. Outcome of calls ...... 23 VII. Appropriate use of Specialist LINK ...... 24 VIII. Service feedback ...... 24 1. Feedback about the experience of providing advice ...... 24 2. Call support ...... 25 IX. Diagnosis & Theme of Call ...... 25 SPECIALIST LINK COST ANALYSIS ...... 27 I. Analysis based on Survey Results ...... 27 1. Direct Cost ...... 27 2. Direct Savings ...... 28 3. Call Survey Analysis ...... 28 II. Analysis based on Call Volume ...... 29 1. Direct Cost ...... 29 2. Direct Savings ...... 29 III. Extrapolated Savings ...... 31 IV. Indirect Savings and Other Direct Savings...... 31 APPENDIX ...... 32
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I. Tables ...... 32 Table 1. Specialties included in Specialist LINK ...... 32 Table 2. Specialist LINK Call Volume by specialty ...... 32 Table 3. Physicians requesting telephone advice through the website by specialty ...... 33 Table 4. Access Pathways included in Specialist LINK website ...... 33 Table 5. Enhanced Primary Care Pathways included in Specialist LINK website ...... 33 Table 6. Resources included in Specialist LINK website...... 34 Table 7. Length of call by specialty ...... 34 Table 8. Patients’ age by specialty...... 35 Table 9. Call reasons by specialty ...... 35 Table 10. Specialist recommendation by specialty ...... 36 Table 11. Outcome of calls by specialty ...... 37 Table 12. Specialist LINK diagnosis themes by specialty ...... 38 Table 13. Specialist initial face-to-face consultation fee by specialty ...... 41 Table 14. Emergency Visits and Diagnostic Testing ...... 42 Table 15. Average cost and savings per survey by year...... 42 Table 16. Call Savings Per Specialty ...... 42 II. Figures ...... 43 Figure 1. Historical Website Traffic ...... 43 Figure 2. How many times have family physicians used Specialist LINK ...... 44 Figure 3. Reasons to not having used Specialist LINK ...... 44 III. Specialist survey verbatim answers for open-ended questions ...... 44 1. Specialist Recommendation ...... 44 2. Outcome of calls ...... 47 3. Appropriate use of Specialist Link ...... 47 4. Service feedback ...... 48 5. Diagnosis & Theme of Call ...... 49 REFERENCES ...... 55 Tech talk: Connecting primary and specialty care in Calgary ...... 55
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INTRODUCTION
Calgary Area Primary Care Networks and Alberta Health Services stakeholders partnered to develop the Health Systems Support (HSS) specialty Integration Task Group. Family doctors working closely together with specialist to improve patient care. Empowering the Patient’s Medical Home to provide care for patients through co-created access and enhanced primary care pathways, supported by specialist support through a dedicated telephone advice and website “Specialist LINK”.
Specialist LINK provides real time telephone non-urgent advice that improves efficiency and enhances the coordination of patient care delivery while strengthening the relationships between primary and specialty care.
The telephone advice line operates Monday to Friday from 8 am to 5 pm (except Chronic pain service until 4 pm). Family physicians can either visit the Specialist LINK website and click on the preferred specialty or phone a centralized number and select a specialty from the automated list and leave their name and a direct call-back number. Through an automated phone system, specialists are connected and return the call within 1 hour.
Specialist LINK phone advice and website have been instrumental for the HSS specialty integration work.
I. History Health System Support Specialty Integration Since early 2006 partnerships between specialty care, AHS and specific primary care networks were established. Supporting patients’ needs within each PCN boundary. These innovative projects provided great learnings and informed some of the Calgary Zone solutions.
In 2012, seven Calgary Area Primary Care Networks and Alberta Health Services stakeholders partnered and developed a Calgary Zone Primary Care Action Plan (CZPCAP), to increase the pace of primary care development by focusing efforts on those areas common to all eight partners for a more coordinated and sustainable effort. (CZPCAP,2012)
In the same year, the Primary Care Council and Secretariat identified a priority to enhance the relationship between primary care and acute care to address issues of access, comprehensive and coordinated care delivery, informational continuity, communication and provide health care value to patients, providers, system & funder.
The Calgary Zone HSS Specialty Integration task group was created in 2013. Family doctors working closely together with specialists to improve patient care. Starting with specialty groups that provided the biggest concerns regarding access and coordinated care for patients. Specialist LINK was piloted, and access and enhanced primary care pathways were co-created. (HSS,2016)
The rapid growth of Specialist LINK over the past years highlights the continued progress made by the Calgary Zone Health System Supports task group. This group continues to work with a variety of specialty groups to improve access and care for their patients. Adding specialties to the tele-advice line, as well as develop clinical pathways for conditions commonly seen in primary care.
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II. Historical HSS Timelines Overview
2013 2014 2016 2017 2018 2019
HSS Calgary Zone Enhanced Primary Access Pathways & Specialist LINK & Patient RAAPID partnership HSS specialty Care pathways improvement eReferral advice engagement Integration working projects request partnership with specialty care with CFHI
Alberta Referral eReferral Advice Directory Specialist Specialist LINK Specialist LINK Specialist LINK Request (local and LINK & eReferral website and phone Phone Advice Line website provincial) partnership line redesign
2014 2015 2017 2017 2019
III. History Specialist LINK Since 2014, Specialist LINK telephone advice line has been providing timely clinical collaboration between over 1,700 family physicians and specialists physicians in the Calgary Zone.
Since 2016 the Specialist LINK website has become a central communication platform that links primary and specialty care. Supporting family physicians and specialists with patient care solutions through pathways on enhanced primary care, simplified access to specialty care, news items on quality improvement projects and direct connection to the Specialist LINK phone advice line.
Specialist LINK now includes a total of 16 specialty services.
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IV. Specialist LINK Activities For 2018-2019 In the last fiscal year, through the Canadian Foundation Health Improvement (CFHI) grant we worked closely with eReferral Advice Request to offer two unique complementary modalities for non-urgent advice that provide physicians with a choice to receive specialty advice depending on their practice style and patient needs. Specialist LINK provides advice within 1 hour and eReferral Advice Request within 5 calendar days through eReferral platform. The two modalities combined provide family physicians access to advice from a total of 26 specialties. (Tech Talk,2018)
Through the CFHI partnership we updated our phone line and redesigned our Specialist LINK website, providing a new service that permits to doctors and support staff to request a tele-advice online via a desktop computer, laptop, tablet, cell phone or other mobile devices. The new version of the website includes now physicians’ resources, updates, patients and physicians’ testimonials and specialist resource tab. (Specialist LINK,2019)
The Specialist LINK family physician annual survey was completed in June 2018. 343 family physicians completed the survey with representation from each of the Calgary Zone PCN’s. 3/7 PCNs embedded questions into their annual surveys, 4/7 sent out a separate link for the survey. Due to the different data collection dates there was wide range of dates in which the survey was completed. Highlights of the results are noted in this report. (Specialist LINK,2018)
In July 2018 AHS completed independent Specialist LINK evaluation, to measure Specialist LINK awareness among family physicians in Calgary and Area Primary Care Networks, Alberta. Results indicated that the awareness and utilization of Specialist LINK is very high among family physicians. 89% of family physicians are aware of Specialist LINK, 72% use it in their practice, 73% said using Specialist LINK changed their patient management, 55% are aware of the clinical pathways of those, 74% are accessing and following pathways in their practice, 78% of users said the pathways have changed their clinical practice. (Alberta Health Services, 2018) In September 2018, Calgary Foothills PCN embedded Specialist LINK family physician survey questions 165 family physicians completed the survey. Highlights of the results are noted in this report. (CFPCN, 2018) Calgary Zone Health Systems Support (HSS) Specialty Integration task group focused on patient engagement framework with the result of having patient advisors present in our working groups.
In the fall of 2018 Specialist LINK cost savings analysis showed that we surpassed $1 million savings. (Specialist LINK, 2019)
Through the success of Specialist LINK in the Calgary Zone there has been high interest from other regions in Alberta and other provinces. A Specialist LINK toolbox was created to support spread and scale of the Specialist LINK advice line in other regions. To understand the area of coverage serving Calgary Zone a spot check was performed. Results showed that from 2001 calls made between October 1st, 2018 and January 22nd, 2019, 1986 phone numbers could be identified and 99.4% of these calls were from Alberta, Calgary 81.3%. However, 13 calls were from outside the province (Saskatchewan, Ontario, New Brunswick and Nova Scotia). (Area of coverage, 2019)
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V. Method Specialist LINK report provides cumulative data being tracked by Specialist LINK. Data is derived from phone system, physician surveys, Google analytics and other physician reported resources. Both quantitative and qualitative data is collected. Fiscal year noted is from April to March. Since launching in December 2014, specialist groups joined at different intervals. Specialists are requested to submit a feedback survey at the end of each call in the first 9 to 12 months after joining the service. Family physicians are surveyed once a year, additional long-term metrics are still being identified and defined for this program.
SPECIALIST LINK PHONE CALL VOLUME
Specialist LINK now includes a total of 16 specialty services (Table 1). In the last fiscal year 4 new specialties joined and 75% increase of call volume. Since 2014, over 11,777 advice calls have been received.
Total Calls received by Fiscal Year 6,441
3,670
1,264 67 335 FY 14-15 FY 15-16 FY 16-17 FY 17-18 FY 18-19
Call Volume by Specialty* FY18-19 2704 FY17-18 FY16-17 1985 1801 FY15-16 1497 FY14-15 1097 Total 532 622 517 298 292 54 88 121 24 65 80
*See Table 2. Specialist LINK Call Volume by specialty for more details.
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SPECIALIST LINK WEBSITE METRICS HISTORY
I. Web based connection In January 2019, a redesigned version of the website was launched, providing a new service that permits to doctors and support staff to make a web-based connection by sending a text through the website to the specialty of choice.
Since the launch of the web-based connection to Specialist LINK telephone advice line, overall, 890 (45%) requests have been made through the website, in contrast to 1,102 (55%) requests through the phone connection. Access to the service through the website has been significantly increasing from 22% in January to 58% in March. During the last 2 and a half months, 262 physicians (including 1 rheumatologist) and 1 nurse practitioner have requested the service through the website at least once (Table 3). Web-based and Phone Connections Comparison (Jan 15 to Mar 31, 2019) 78% 58%
49% 51% 42%
254 22% 206
56
01/2019 02/2019 03/2019 Web-based Connection Phone Connection Physicians using the service
Number of times telephone advice requested by unique physicians* 162
47
No. Physicians of 24 11 4 3 2 3 0 2 1 0 1 0 0 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Times of telephone advice requests to Specialist Link * See Table 3. Physicians requesting telephone advice through the website by specialty for more details.
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II. Website Traffic Compared to last fiscal year, the total visits to the Specialist LINK website increased by 71%. The average duration visitors spent on the website decreased from 1.92 min in FY 17-18 to 1.57 min in this fiscal year. 11% of Specialist LINK visitors used a mobile device. Graph below shows a summary of the website traffic, refer to Figure 1 for further details.
Website Traffic Metrics by Fiscal Year 46,364
21,458 17,402 10,120 9,608 5,746 2,288 4,964
FY 16-17 FY 17-18 FY 18-19 Total Visits Total page views Downloads
III. Access and Enhanced Pathway Downloads by Specialty Working closely with family physicians, specialists, specialty central access and triage, specialty care initiated several access improvement projects to streamline and simplify access. One-page simplified guideline(s) were developed to support family physicians accessing specialty care and enhanced care pathways to support family physicians with the care of their patients.
1. Access Pathway This fiscal year, 3 new access pathways were posted on Specialist LINK website. Total of 6 access pathways are now available on the website (Table 4). Access Pathway Downloads
583 401 389 476 213 242 93 80 144 FY 17-18 FY 18-19
Endocrinology Neurology Rheumatology Respirology* Palliative Care* Urology*
*2018/2019 pathways: Respirology (October), Palliative Care (December) and Urology (January).
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2. Enhanced Primary Care Pathways This fiscal year, 5 new enhanced primary care pathways were posted on Specialist LINK website. Total of 17 enhanced primary care pathways are now available on the website (Table 5). Top 3 enhanced pathways that were downloaded were NAFL, IBS and gout pathway.
Enhanced Primary Care Pathway Downloads by Specialty
2458
935 1055 1695 647 1374 527 1201 420 189
FY 17-18 FY 18-19
Gastroenterology * Hepatology Neurology Rheumatology Endocrinology Respirology
*GI specific pathway data available since September 2017, prior pathways were accessed through GI website (GI pathway)
Specific Enhanced Primary Care Pathway Downloads (data collection since April 2017)
FY 18-19 FY 18-19 Gastroenterology Neurology FY 17-18 FY 17-18 New 213 New Chronic Diarrhea Migraine 574 0 0 Constipation 343 119 Diabetic peripheral 183 72 H. Pylori 287 107 Vertigo Algorithm 55 518 89 Dyspepsia 156 Vertigo 378 419 346 GERD 144 Tremor 302 678 291 IBS 317 0 Parkinsons Disease 203 GI Pathway 92 257
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FY 18-19 FY 18-19 Rheumatology FY 17-18 Hepatology FY 17-18 New Peripheral 363 Arthritis 0 NAFLD 1280 527 Radiograph for p. 213 New arth 211 Liver requisition 103 0 Gout Algorithm 71 122
Gout 554 314
FY 18-19 Respirology FY 17-18 New Uncomplicated 123 obstructive sleep 0 apnea
IV. Resources Downloads by Specialty Total for this Fiscal year 16 new resources were posted on Specialist LINK website (Table 6).
Resources Downloads by Specialty*
184 163 15 FY 18-19 Gastroenterology Neurology Rheumatologyew Respirology Opioid use disorder
* Data collection since April 2018
Specific Resources Downloads (data collection since April 2018)
Gastroenterology Respirology Pulmonary 66 Calgary Zone Sleep Centre CZ gastroenterology referral 14 184 Referral Quick Reference Quick reference Calgary Zone Pulmonary Referral Quick Reference 83 Canadian Thoracic Society (CTS) 0 Respiratory Guidelines
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Opioid Use Disorder
Opioid use disorder telephone consultation service 0 Opioid Framework (w team) 5 Opioid Framework (w/o team) 3 Opioid Describing Framework (w team) 1 Opioid Describing Framework (w/o team) 1 Billing codes 2 Suboxone prescribtion 2 Poster 1 Health team integration video 0
V. Other Resources Downloads/Consultation 1. Physician Resources (data collection since January 2019) The new version of the website includes “Support Services at a Glance”, a page that allows family physicians in the Calgary area seeking specialist support to now choose from six great options: 911, RAAPID, Community Paramedics, Specialist LINK, eReferral Advice Request and Regular referrals. The collected data show cases only the hits to more information to the specific service.
Support Services at a glance activity ARD eReferral Advice Netcare Specilaist LINK
Community Paramedics Referral 848 RAAPID website 4 911 website 19
Main Page Hits to more information
2. News Items (data collection since August 2017) One ‘By the Numbers’ newsletter form FY 18-19 and two from the previous year as well as one quarterly report FY 18-19 and one from the previous year were published on the website.
Updates/Reports FY 18-19 FY 17-18
By the numbers 203 154
SL newsletter 23 67
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VI. Testimonials (data collection since January 15, 2019) The new version of the website includes two additional tabs: “patients’ stories” and “for specialists”, these tabs contain respectively patients’ perspectives and physicians’ testimonials concerning their experience with Specialist LINK. Testimonials
238 50
FY 18-19
Physicians Testimonials* Patients Perspectives
* Physician testimonials data collection started in March 2019
SPECIALIST LINK SURVEYS Specialists are requested to submit a feedback survey at the end of each call in the first 9 to 12 months after joining the service. As of September 2017 HSS, specialty integration task group mutual agreed that family physician feedback would be captured through an annual survey collected by all 7 PCN, this was completed in June 2018. Additionally, the Calgary Foothills Primary Care Network’s 2018 annual physician survey included a section about Specialist LINK that included specific questions that were not captured through the Calgary zone survey.
In 2018/2019 fiscal year 343 family physician (all 7 PCN annual survey), 165 family physicians (PCN specific annual physician survey) and 270 Specialist surveys were received. 4 Specialty services completed data collection. The analysis includes 2018-19 fiscal year results and when applicable a comparison to previous fiscal years and overall results.
Please note that all open-ended questions were coded for themes and direct quotations were used in all verbatim quotations, please refer to the Appendix FY 18/19 for a complete list of responses. Previous fiscal year appendix is available on request.
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Calgary Zone PCN Physician Survey Results
Calgary Zone Family Physician survey was completed between September 2017 and June 2018. Standardized questions were developed while the distribution of the surveys varied by PCN. 3 out of 7 PCNs embedded questions into their annual surveys, 4 out of 7 sent out a separate link for the survey. Due to the different data collection dates, there was a wide range of dates in which the survey was completed. Highlights of the results are noted below, and full report is available on request. (Specialist LINK, 2018)
I. Physicians Demographics 343 family physicians completed the survey with representation from each of the Calgary Zone PCN’s.
Respondents by PCN 174
102
# of # Respondents 19 19 13 9 5 2
Calgary South Calgary Highland Mosaic Bow Valley Calgary West Calgary Rural Not a member Foothills Central of a PCN
Years in Practice 89 82
50 43 44
33 # of # Respondents
0-5 6-10 11-15 16-20 21-25 25+ Years in practice
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II. Awareness of Specialist LINK telephone advice request service and utilization Family physicians were asked whether they were aware of the service or not and if they were aware of it, whether they have ever used it. 93% of the family physicians are aware of Specialist LINK telephone advice request service and 77% of the them have used it at least once, see Figure 2 for more details. 98 family physicians have reported not using the service for reasons related to personal choice, time, patients’ needs and applicability (Figure 3).
Awarness and Utilization of the service
Awareness (n=342) 93% 7%
Utilization (n=308) 77% 23%
Yes No
III. Satisfaction with telephone advice request service Family physicians who have used Specialist LINK at least once were asked to rate the service. 1. Specialist LINK telephone Advice Request impact on patients care (n=80) Specialist LINK telephone Advice Request Impact on Patients' Care 1% I now feel more confident, or better equipped, to 20% 60% 18% 1% support a patient in my practice. 1% I have confidence that Specialist LINK will equip 34% 59% 6% me to support patient care in the future.
Strongly agree Agree Neutral Disagree Strongly disagree
2. Overall satisfaction with Specialist LINK telephone Advice Request (n=210)
Satisfaction with Specialist LINK Telephone Advice Requests 54% Dissatisfaction Reasons (Themes): - Call back took too long 35% - Call did not provide me with more information than I already had - Access/navigation can be difficult 10% % of % Respondents 0% 2%
Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied
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Physicians were asked to explain their rating of the service (n=160). Overall, physicians’ comments were all positive about Specialist LINK telephone advice request.
Verbatim comments examples:
“Prompt advice and very pleasant and collegial interactions. Often saves patient a trip for a consult or furthers investigation or management while waiting for referral”.
“Rapid, friendly and informative service. reduces burden on system as a whole”
“Extremely useful for non-typical scenarios that just require a chat when I am uncertain what to do and can't find advice by reading.”
“Exceptional resource” wish that there were more specialties available. Must be saving the healthcare system money and prevents many unnecessary consults, improves patient care as I am able to start them on appropriate treatment immediately even if they still need to go and see the specialist”
IV. Enhanced primary care pathways 1. Utilization (n=329)
Have you referred to the enhanced primary care pathways? Haven’t referred because (n=181): - Not aware of pathways available (n=139) - Not needed for patients in my panel (n=42) Yes, 40% No, 60%
2. Most helpful pathways to family physicians’ practice
Most Helpful Pathways to the Practice
GERD 78 Dyspepsia 60 Chronic constipation 41 IBS 38 Helicobacter Pylori 38 Headache 36 Access to Rheumatology 32 Access to Endocrinology 29 Access to Neurology 28 Suspected essential tremor 27 Enhanced vertigo/simplified vertigo 27 Gout 22 Suspected parkinson's disease 17
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3. Specialist LINK Primary Care Pathways impact on patients care (n=131)
Impact of the Referral to Primary Care Pathways on Patients' Care 1% I now feel more confident, or better equipped, to support 31% 56% 11% 2% that type of patient in my practice. 1% I have confidence that Specialist LINK will continue to 51% 44% 5% equip me to support patient care in the future.
Strongly Agree Agree Neutral Disagree Strongly disagree
*Full Report is available on request, survey included questions on future direction for HSS specialty integration group.
Fall PCN Physician Survey Results
165 Calgary Foothills PCN Family Physician completed Specialist LINK section within annual survey in September 2018. Capturing questions that were not included in the Calgary Zone survey. This data has been compared with the overall data received from Calgary Zone family physicians last fiscal year.
I. Specialist LINK telephone advice request service utilization
Have you used the Specialist LINK telephone advice service in the past 12 months?
Fall 2018 Yes, 75% No, 25%
II. Reasons for call Physicians who reported having used the Specialist LINK telephone advice service in the past 12 months were asked about the reasons of their call.
Reasons to call Specialist LINK 87% Needed advice for patient care plan 99% Needed advice while waiting for 30% referral 28% Had a question on a care pathway 11%
6% Needed advice for a closed referral 4%
2018 Fall PCN Physican Survey (n=125) 17-18 Physican Survey (n=106) 17 May 21, 2019 Specialist LINK
III. Outcome of calls Physicians who responded to whether they were contemplating a specialist referral before using the telephone advice service were asked to specify which outcomes resulted.
Of the physicians who were contemplating a specialist referral before calling the service, 60% of the respondents to the 17-18 physician survey reported still needing the referral, while 43% of the respondents to the 2018 Fall PCN physician survey reported still needing the referral.
Were you contemplating a specialist referral before calling the telephone-advice service?
Outcomes to 'YES' (n=102): Outcomes to 'YES' (n=80): 1% did not specify outcomes 3% did not specify outcomes 56% No longer need the referral 40% No longer need the referral 43% Still need the referral 60% Still need the referral Outcomes to 'No' (n=21): Outcomes to 'No' (n=20): 5% did not specify outcomes 70% Still do not need a referral 86% Still do not need a referral 30% Now need a referral 10% Now need a referral
Yes, 83% No, 17% Yes, 80% No, 20%
2018 Fall PCN Physican Survey 17-18 Physican Survey (n=123) (n=100)
IV. Patient presence during the call Physicians who used the Specialist LINK telephone advice service were asked to think about all the calls they have made to Specialist LINK over the past year and answer the questions around circumstance of the call (n=123). 82% of the physicians reported that patients were aware of the advice call and overall, 41% of them reported that patients were either in the room or waiting at the clinic.
Was your patient aware of the advice call? 72% 20% 8%
Was your patient present in the room when you 4% 14% 82% made the call with the specialist? Was your patient waiting at your clinic when you 7% 34% 60% made the call with the specialist?
Yes, always Yes, sometimes No
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V. Feedback on Pathways
Have you used the enhanced primary care pathway, on www.specialistlink.ca, for supporting patient care 54% 39% 7% planning? (n=165) Yes No Not aware of this resource Having used this (these) pathway(s), I now feel more 1% confident, or better equipped, to support that type of 90% 7% patient in my practice. (n=87) 2%
Strongly agree/Agree Neither agree nor disagree Disagree/Strongly disagree Not applicable
SPECIALIST SURVEY RESULTS Specialists submitted their feedback surveys after calls via fax or an online survey link. Data collection process is considered complete when the number of surveys exceeded the target sample size, calculated based on their annual call volume. In 18-19 fiscal year, 269 surveys were completed adding up to a total of 1121 surveys since February 2015. Number of surveys received by Specialty (total =1121)
Rheumatology (254, 22.7%) 21 196 37 Endocrinology (244, 21.8%) 97 57 90 Neurology (216, 19.3%) 131 85 Gastroenterology (98, 8.7%) 26 23 49 Hepatology (90, 8.0%) 11 47 32 Chronic Pain (83, 7.4%) 79 4 Psychiatry (35, 3.1%) 35 Nephrology (29, 2.6%) 8 21 Vascular surgery (23, 2.1%) 23 Respirology (20, 1.8%) 4 16 Palliative Care (17, 1.5%) 17 Sport Medicine (6, 0.5%) 6 podiatric surgery (3, 0.3%) 3 Unknown (2, 0.2%) 11 Urology (1, 0.1%) 1 Pediatricians CHF
FY14-15 FY15-16 FY16-17 FY17-18 FY 18-19
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I. Caller’s information
1. Caller’s type (up to March 2019 n=974)
Family physicians, Specialties using Specialist LINK 945 (97%) telephone advice: Dentist, Geriatric, Nephrology, Palliative Care, Pharmacist, Psychiatry and Rheumatology.
Nurse Practitioners, 6 Specialists, 23 (2%) (1%)
2. Caller’s unique identification (up to March 2019) 867 surveys included the caller’s name, 844 (97%) were family physicians, 6 (0.7%) were nurse practitioners and 17 (2%) were specialists.
A total of 530 unique family physicians have been identified by specialty using Specialist LINK from 1 to 13 times. Out of the 98 callers that requested advice in FY 18-19, 79 were new (not reported previously).
Times unique family physicians have used Specialist LINK (up to March 2019) 382 (72%)
87 (16%) No. Physicians of 24 (5%) 11 (2%) 10 (2%) 6 (1%) 2 5 (1%) 1 1 0 0 1
1 2 3 4 5 6 7 8 9 10 11 12 13 Times of surveys completed to Specialist Link
II. Call information Since 2015, information around the length of call was reported in 929 surveys. The average length of call is between 6 – 10 minutes.
Specialties to which the telephone advice required over 15 minutes in average are Chronic Pain (average of 25.5 min in 77 calls) and Palliative care Pain (average of 16.9 min in 17 calls), see Table 7 for more details.
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Length of Call in minutes
47% 45% Up to Mar 2019 (n=929)
FY 18-19 (n=229) 27% 29% 18% 14% 7% 8% 3% 0% 2% 0%
1-5 6-10 11-15 16-25 26-35 >35
III. Patients information
The overall average patients’ age is 52 years old (3 to 96 years). Palliative Care is the specialty that included the highest overall patients’ age (78 years old) while Psychiatry included the lowest overall patients’ age (42 years old), see Table 8 for more details.
Patients age 28% up to March 2019 (n=864) 24% FY 18-19 (n=218) 21% 19% 18% 17% 17% 15% 13% 14%
7% 6%
0.3% 0.5% 0.3% 1%
Under 5 6 to 15 16 to 25 26 to 35 36 to 45 46 to 55 56 to 65 Over 65
IV. Reasons for call The reason of call question was included in the specialist survey starting February 2016. Specialists were asked to select one or more reasons for the call. Overall, 88% of the respondents reported that the reason of the call is a
21 May 21, 2019 Specialist LINK routine advice on management (73%), diagnostic testing (53%) and therapeutic (27%). See Table 9 for Reasons for call from Physicians (n=1065)
Routine, 88%
Routine advice on (n=936): 73% management 53% Diagnostic testing 27% Therapeutics
Urgent, 12% Referral Status at Advice on Primary are Central Triage, 4% Emergency, 0% Other, 2% Pathway(s), 2%
V. Specialist Recommendation Specialist recommendation question was included in the specialist survey starting February 2016. Specialists were asked to select one or more recommendations. For more details about specialist recommendations by specialty see Table 10. up to March 2019 (n=971) Specialist Recommendation FY 18-19 (n=220)
Advice provided 41% 40% Reassurance of physician's care plan 39% 47% Medication recommendation 32% 34% Additional diagnostic testing 29% 17% Specialist follow-up required and referred 26% 20% Advice on primary care pathways 5% 6% Other 5%
Referred to ER 2% 2% More info needed 2% 2%
Specialists who specified ‘Advice provided’ as one of their recommendations were asked to specify and their responses were themed, please refer to the appendix for the complete list of verbatim responses.
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Advice Medication Referral Advice Other testing
Up to March 2019 (n=186) 101 (54%) 21 (11%) 51 (27%) 13 (7%)
FY 2018-2019 (n=70) 28 (40%) 13 (19%) 18 (26%) 11 (16%)
VI. Outcome of calls Specialists were asked to specify if a consult, an ER visit, a diagnostic test and/or lab test were avoided after the telephone advice. Overall, 46% of the respondents reported that the call avoided a consult, 34% an ER visit, 12% a diagnostic test and 8% a lab test. For more details about outcome of calls by specialty see Table 11.
In your opinion, did the phone conversation AVOID: Up to March 2019 (n=1035) 48% 46% FY 18-19 (n=247) 34%
20% 12% 12% 8% 5%
A consult An ER visit* Diagnostic Test(s) Lab Test(s)
* Note that the top 3 specialties that reported having avoided ER visits were Vascular Surgery, Rheumatology and Psychiatry & Hepatology, while the top 3 higher number of surveys completed by specialties that were collecting data in FY 18-19 were Psychiatry, Hepatology and Nephrology. Table 11.
Diagnostic tests avoided: Up to March 2019 (n=83) 45% FY 18-19 (n=20) 40% 37% 30% 25% 24%
15% 12% 6% 3% 2% 2% 2%
MRI CT X-ray ECG Barium HBT PFT DEXA Other
Specialists who answered ‘other diagnostic tests and/or lab tests’ were asked to specify their answer, please refer to the appendix for the complete list of verbatim responses.
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VII. Appropriate use of Specialist LINK
Was this an appropriate use of Specialist LINK?
FY 18-19 (n=230) Yes, 94% No, 6%
Up to March 2019 (n=978) Yes, 93% No, 7%
Specialists who answered ‘No’ were asked to specify their answer, please refer to the appendix for the complete list of FY 18-19 verbatim responses.
Not Appropriate (12/13, 92% responses) Urgent nature (1/13, 8% responses)
“referred to private endocrinologist already but seeking “urgent referral, not "routine phone advice" advice for same reason before the other endo sees”
VIII. Service feedback 1. Feedback about the experience of providing advice The Experience in providng Advice was:
FY 18-19 (n=186) 98% 2%
Up to March 2019 (n=732) 97% 2%
2% positive negative other
Specialists were asked to explain their answer (“Positive” n=42, “Negative” n=4 and “Other” n=6, FY18-19), please refer to the appendix for the complete list of verbatim responses.
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2. Call support Specialists were asked to select one or more areas that the call supported. Overall, 81% of the respondents reported that the call supported mutual collegial support, 76% advice and education, and 72% enhanced patient care.
Did the call support any of the following: Up to March 2019 (n=824) FY 18-19 (n=225) 81% 77% 80% 72% 76% 62%
2% 1%
Enhanced patient care Mutual collegial support Advice/Education Other
Specialists who answered “other” were asked to explain their answer (n=3, FY18-19), please refer to the appendix for the complete list of verbatim responses.
IX. Diagnosis & Theme of Call 1065 archived and recent (Feb 2015 to March 2019) surveys completed by specialists were reviewed. In order to find out the most common reasons of calls to the Specialist LINK telephone advice service, we explored the theme of calls (241) and diagnosis (218), as well as in some cases a combination with the comments when the other fields were incomplete or hard to read. Subsequently, 250 call reasons were themed.
The following table displays the list of top 3 themes (pathologies) by specialty. Note that the percentages might exceed 100% as in some cases more than one pathology was discussed with the specialist, therefore, each pathology was counted as a separate theme. See Table 12 for more details.
The top three pathologies that were more frequently reported in FY 18-19 were depression, NAFLD and hormonal disorder.
Verbatim responses are included in the appendix.
Up to March 2019 (n=250) FY 18-19 (n=152) Chronic Pain MSK pain 7 Chronic pain 1
Osteoarthritis 6
Chronic pain 3 Endocrinology Hormonal disorder 7 Hormonal disorder 7 Diabetes 4 Diabetes 4
Thyroid nodule 3 Thyroid nodule 3
Gastroenterology Gout 2
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Iron deficiency 2 Hepatology NAFLD 9 NAFLD 9
Hepatitis C/B 7 Hepatitis B 4
Liver enzymes disorder 3 Liver enzymes disorder 3 Nephrology Chronic Kidney Disease (CKD) 8 Chronic Kidney Disease (CKD) 6 Hematuria 5 Hematuria 5
Acute kidney injury 4 Acute kidney injury 3
Neurology Abnormal EEG results 1
Brain Injury 1
Results interpretation 1 Palliative Care Cancer - Lung 4 Cancer - Lung 4
Dementia 4 Dementia 4 Podiatric Surgery Fracture 1 Fracture 1 MSK injury 1 MSK injury 1
Vascular malformation 1 Vascular malformation 1 Psychiatry Depression 15 Depression 15 Alcohol abuse 5 Alcohol abuse 5
Bipolar disorder 5 Bipolar disorder 5 Rheumatology MSK pain 7 MSK pain 1
Gout 5
Rheumatoid Arthritis 5 Sport Medicine AC joint separation 1 AC joint separation 1
Achilles tendon rupture 1 Achilles tendon rupture 1
Ankle sprain 1 Ankle sprain 1 Back strain 1 Back strain 1
Grade 1 spondylolisthesis 1 Grade 1 spondylolisthesis 1 TFCC injury 1 TFCC injury 1 Urology Renal stone 1 Renal stone 1 Vascular Surgery Abdominal Aortic Aneurysm (AAA) 4 Abdominal Aortic Aneurysm (AAA) 4
Carotid artery stenosis 3 Carotid artery stenosis 3
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SPECIALIST LINK COST ANALYSIS
Estimation of net potential savings is based on a simple cost analysis factoring in direct costs for Specialist face to face consult request, Emergency (ER) visits and when applicable certain diagnostic tests avoided through Specialist LINK Program. Cost and Savings variables per call are calculated based on the following inherent assumptions: ➢ Direct Cost: Both the Family Physicians and the Specialist billed for the tele-advice services. ➢ Direct Savings: All the recommendations from the specialist on avoiding ER consult, specialist consult and or further diagnostic testing were followed by the family physician, relevant direct variable costs were avoided.
I. Analysis based on Survey Results 1. Direct Cost Both family physicians and the specialists billed for the tele-advice services. Family physicians billed $32 for each call and specialists $76, except for Podiatric Surgery specialists who billed $66.87 per call (Alberta Medical Association Fee Navigator). Chronic Pain line is managed by nurse practitioners, both family physicians and specialists were unable to bill therefore Chronic Pain cost was not included in the cost factor at this time, (83X $108 = $8,964) has been deducted from total.
Cost by number of surveys received:
Specialty 14-15 15-16 16-17 17-18 18-19 Total per specialty Gastroenterology 26 23 49 - - 98 Respirology 4 16 - - 20 Neurology 131 85 - 216 Endocrinology 97 57 90 244 Rheumatology 21 196 37 254 Hepatology 11 47 32 90 Pediatricians - - 0 Chronic pain 79 4 83 Nephrology 8 21 29 Podiatric Surgery 3 3 Psychiatry 35 35 Congestive Heart Failure 0 0 Vascular Surgery 23 23 Palliative Care 17 17 Sport Medicine 6 6 Urology 1 1 Unknown 2 - - 2 Total Surveys received 26 27 327 472 269 1,121
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Cost (FP fee $32 + Specialist phone Total Cost consultation fee $76- except for podiatric $ 2,808 $ 2,916 $ 35,316 $ 42,444 $ 28,593 surgery $66.87) $ 112,077
2. Direct Savings Direct savings were calculated based on the cost of ER visits, specialist consults and or further diagnostic testing avoided as a result of the call. See Table 13 and Table 14 for more details about specialists’ consultation fees, ER visits fees and major diagnostic testing fees.
Saving by number of avoidances reported in surveys received:
Avoided (% of total surveys received) 14-15 15-16 16-17* 17-18 18-19 Total per avoidance Face to Face consult 11 (42%) 15 (56%) 142 (43%) 186 (39%) 122 (45%) 476 (42%) ER visit 16 (62%) 15 (56%) 103 (31%) 172 (36%) 49 (18%) 356 (32%) MRI 0 0 20 (6.1%) 6 (1.3%) 5 (1.9%) 31 (3%)
CT Scan 0 0 8 (2.4%) 3 (0.6%) 9 (3.3%) 20 (2%) X-ray 0 0 5 (1.5%) 2 (0.4%) 2 (0.7%) 9 (1%)
Savings (consult $93.15 to $207 + ER $350 to $ Total Savings 386.1 + MRI $658.81 + CT $623.33 + X-ray $130) $7,712 $8,190 $82,725 $97,976 $49,968 $246,571 *Survey expanded in Feb 2016 to include diagnostic testing
Overall Percent of Avoidance across the years: Avoidance types and numbers varied according to specialties with different patients’ needs and forms of care.
Consults avoided ER visits avoided Diagnostics avoided 42% 32% (MRI, CT, Xray) 5%
3. Call Survey Analysis Average cost and savings were calculated based on the specialists surveys completed every fiscal year as well as across the fiscal years, see Table 15 for average cost and saving per survey by year.
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Savings based on all surveys: (1,121 surveys 2014-2019)
Total Savings Total Cost TOTAL NET SAVINGS = $134,494 An average savings of $120 per call, $246,571 $112,077 plus other direct or indirect costs saved
II. Analysis based on Call Volume Analysis on call volume was based on the assumption that data follows similar pattern from survey data calculation. 1. Direct Cost Direct cost of the total of 11,777 calls was calculated based on the estimated cost and savings per survey across the years (Table 15).
14-15 15-16 16-17 17-18 18-19 Across the years Average Cost per Survey $108 $108 $108 $90 $106 Number of Calls 67 335 1264 3,670 6,441 11,777 Total Cost $7,236 $36,180 $136,512 $330,300 $682,746 $1,192,974
2. Direct Savings Direct savings of the total of 11,777 calls were calculated based on the assumption that data follows similar pattern of ER visits and specialist consults avoidance from survey data calculation.
No. of avoidance: 14-15 15-16 16-17 17-18 18-19 Total estimated Consults 28 186 549 1446 2898 5,107 ER visits 41 186 398 1337 1159 3,121
Avoided Consults = 5,107 patients Avoided ER visits = 3,121 patients
Average savings of calls per specialty were estimated and results indicated that the top three specialties that had the highest average savings per call were Vascular Surgery, Sport Medicine and Rheumatology. See Table 16 for more details about cost savings by specialties.
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Direct savings by number of calls received:
Specialty 14-15 15-16 16-17 17-18 18-19 Total Gastroenterology 67 327 542 786 982 2,704
Respirology 8 91 155 278 532
Neurology 276 746 963 1,985
Endocrinology 219 587 995 1,801
Rheumatology 103 603 791 1,497
Hepatology 33 222 367 622
Pediatricians 410 687 1,097
Chronic pain 123 175 298
Nephrology 24 268 292
Podiatric Surgery 4 50 54
Psychiatry 10 507 517
Congestive Heart Failure 88 88 Vascular Surgery 121 121
Palliative Care 24 24
Sport Medicine 65 65
Urology 80 80 Total of Calls received 67 335 1,264 3,670 6,441 11,777 Average Savings per Survey $ 297 $ 303 $ 253 $ 208 $ 186 Total Savings (no. of calls X $ 19,899 $ 101,505 $ 319,792 $ 763,360 $ 1,198,026 $ 2,402,582 average savings per survey for each FY)
Overall savings based on all calls received: (11,777 calls 2014-2019)
TOTAL PROJECTED NET SAVINGS Total Projected Total Cost Savings = $1,209,608 $1,192,974 $2,402,582 (+74% of savings since last fiscal year)
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III. Extrapolated Savings Prospective cumulative savings to the end of FY 2020 based on trend and current service delivery were plotted in the figure below. Based on these trends, a total projected net savings of 2 million could be reached in Q4 of fiscal year 2019-20.
$2,200,000 R² = 0.9979 $2,000,000
$1,800,000
$1,600,000
$1,400,000 $1,209,608 $1,200,000
$1,000,000
$800,000 $694,328
$600,000 CummulativeTotal Savings
$400,000 $261,268
$200,000 $77,988 $12,663 $-
IV. Indirect Savings and Other Direct Savings Greater saving is expected once we account for other cost such as indirect patient savings through avoided travel and lost wages, decreased productivity for attending visits, health outcomes associated with shorter waiting times. Patient Physicians & Specialist Other Direct Savings Wait time Appointment time Wait time Diagnostic tests Travel time & parking Direct physician’s office time Lab tests Travel cost Admin cost Pharmaceutical interventions Lost wages no show cost Travel & parking for Lab/DI tests Time off work/ loss of productivity Physician burnout Medical equipment/supplies Translation consequences caregiver time/ lost wages
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APPENDIX
I. Tables Table 1. Specialties included in Specialist LINK
Fiscal Year Specialty Service FY 14-15 Gastroenterology (December) FY 15-16 Respirology (February) FY 16-17 Neurology (July) Endocrinology (October) Rheumatology (December) Hepatology (March) FY 17-18 Pediatricians (April) Chronic Pain (July) Nephrology (February) Podiatric Surgery (March) Psychiatry (March) Congestive Heart Failure (March) FY 18-19 Vascular Surgery (March 2018) Palliative Care (September 2018) Sport Medicine (November 2018) Urology (January 2019)
Table 2. Specialist LINK Call Volume by specialty
Specialty 14-15 15-16 16-17 17-18 18-19 Total per specialty Gastroenterology 67 327 542 786 982 2,704
Respirology 8 91 155 278 532
Neurology 276 746 963 1,985
Endocrinology 219 587 995 1,801
Rheumatology 103 603 791 1,497
Hepatology 33 222 367 622
Pediatricians 410 687 1,097
Chronic pain 123 175 298
Nephrology 24 268 292
Podiatric Surgery 4 50 54
Psychiatry 10 507 517
Congestive Heart Failure 0 88 88 Vascular Surgery 121 121
Palliative Care 24 24
Sport Medicine 65 65
Urology 80 80 Total of all 67 335 1,264 3,670 6,441 11,777
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* Volume of calls are extracted from the phone record, unsuccessful connections and repeat calls from same call identifier matching same return id within 3 hours of first call have not been included in the total volume reporting
Table 3. Physicians requesting telephone advice through the website by specialty Specialty Number of Callers’ ID Number of Unique Callers’ ID Chronic Pain 16 15 Congestive Heart Failure 16 10 Endocrinology 68 57 Gastroenterology 58 44 Hepatology 30 27 Nephrology 20 17 Neurology 84 67 Palliative Care 4 4 Pediatricians 50 42 Psychiatry 34 29 Respirology 20 16 Rheumatology 57 48 Sports Medicine 19 15 Urology 35 29 Vascular Surgery 16 13
Table 4. Access Pathways included in Specialist LINK website
Fiscal Year Access Pathway Posted Date Specialty Area FY 16-17 Neurology Access Pathway January 2017 Neurology FY 17-18 Endocrinology Access Pathway May 2017 Endocrinology Rheumatology Access Pathway June 2017 Rheumatology FY 18-19 Respirology Access Pathway October 2018 Respirology Palliative Care Access Pathway December 2018 Palliative Care Urology Access Pathway January 2019 Urology
Table 5. Enhanced Primary Care Pathways included in Specialist LINK website Fiscal Year Name of Primary Care Pathway Posted Date Specialty Area FY 15-16 IBS June 2015 (GI website first) Gastroenterology GERD June 2015 (GI website first) Gastroenterology
Dyspepsia June 2015 (GI website first) Gastroenterology
H. Pylori March 2016 (GI website first) Gastroenterology FY 16-17 Launch Specialist LINK Website June 2016 Constipation Sept 2016 Gastroenterology
Parkinson’s Disease Dec 2016 Gastroenterology
Essential Tremor Feb 2017 Neurology FY 17-18 Dizziness / Vertigo Enhanced/ simplified pathway May 2017 Neurology
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Gout Enhanced/simplified pathway Sept 2017 Rheumatology Radiographs for peripheral Arthritis Dec 2017 Rheumatology
Non-Alcoholic Fatty Liver Disease (NAFLD) Jan 2018 Hepatology
Diabetic Peripheral Neuropathy Jan 2018 Neurology FY 18-19 Headache and Migraine May 2018 Neurology Thyroid Nodule May 2018 Endocrinology
Peripheral Arthritis May 2018 Rheumatology
Chronic Diarrhea Oct 2018 Gastroenterology Uncomplicated Obstructive Sleep Apnea Nov 2018 Respirology
Table 6. Resources included in Specialist LINK website
Year Specialty Area Name of Resource Posted Date FY 18-19 Gastroenterology Calgary Zone Gastroenterology Referral Quick Reference June 2015
Neurology Department of Clinical Neurosciences/ Program and Clinics July 2016 Headache App- treatment strategies for a primary headache May 2017
Respirology Canadian Thoracic Society (CTS) Respirology Guidelines Calgary Zone Feb 2016
Pulmonary Referral Quick Reference
Calgary Zone Sleep Centre Referral Quick Reference Oct 2018
Calgary Zone Pulmonary Referral Quick Reference Oct 2018 Opioid use disorder telephone consultation service February 2019 Opioid Framework (w team) February 2019 Opioid Framework (w/o team) February 2019
Opioid use disorder Opioid Describing Framework (w team) March 2019 Opioid Describing Framework (w/o team) March 2019 Billing codes March 2019 Suboxone prescription March 2019 Poster March 2019 Health team integration video March 2019
Table 7. Length of call by specialty
No. of Range Mean 2-5 min 6-10 min 11-15 min 16-25 min 26-35 min >35 min surveys Gastroenterology 69 2 - 25 10.0 min 9 (13%) 48 (70%) 9 (13%) 3 (4%) Respirology 17 5 - 15 8.8 min 3 (18%) 12 (71%) 2 (12%) Neurology 194 2 - 20 7.9 min 67 (35%) 103 (53%) 20 (10%) 4 (2%) Endocrinology 217 3 - 30 9.6 min 71 (33%) 90 (41%) 39 (18%) 16 (7%) 1 (1%) Rheumatology 171 2 - 41 9.7 min 37 (22%) 95 (56%) 26 (15%) 10 (6%) 1 (1%) 2 (1%) Hepatology 73 2 - 20 7.2 min 41 (56%) 24 (34%) 6 (8%) 1 (1%) Chronic Pain* 77 5 - 60 25.5 min 2 (3%) 10 (13%) 7 (9%) 22 (29%) 24 (31%) 12 (16%) Nephrology 28 3 - 20 8.3 min 12 (43%) 13 (46%) 2 (7%) 1 (4%) Podiatric Surgery 2 3 - 7 5.0 min 1 (50%) 1 (50%) Psychiatry 35 5 - 1 8 10.9 min 5 (14%) 17 (49%) 11 (31%) 2 (6%)
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Vascular Surgery 20 1 - 15 10.0 min 1 (5%) 13 (65%) 5 (25%) Palliative Care 17 5 - 25 16.9 min 1 (6%) 1 (6%) 6 (35%) 9 (53%) Sport Medicine 6 6 - 10 7.2 min 1 (17%) 5 (83%) Urology 1 5 - 5 5.0 min 1 (100%) *Note: Chronic Pain service is managed by nurse practitioners
Table 8. Patients’ age by specialty
Number of surveys Range (years) Mean (years) Gastroenterology 79 18 - 96 55.5 Respirology 11 26 - 85 60.5 Neurology 175 12 - 92 47.8 Endocrinology 199 16 - 94 48.4 Rheumatology 183 3 - 91 51.9 Hepatology 71 5 - 85 50.6 Chronic Pain 70 20-85 53.5 Nephrology 23 19-84 61.1 Podiatric Surgery 2 63 - 68 65.5 Psychiatry 35 14 - 81 42.3 Vascular Surgery 21 55 - 94 72.5 Palliative Care 16 60 - 92 78.4 Sport Medicine 5 16 - 70 46.4 Urology 1 74 74
Table 9. Call reasons by specialty
Routine Routine Advice on Urgent Emergency Referral Advice on Other Advice Status at Primary Care Management Diagnostic Therapeutics Central Pathway(s) testing Triage Gastroenterology 78 (83%) 49 (64%) 42 (32%) 17 (22%) 17 2 (2%) 4 (4%) 1 (1%) 8 (9%) n=94 (18%) Respirology 18 (90%) 15 (83%) 11 (61%) 1 (6%) 1 (5%) 1 (5%) 0 0 0 n=20 Neurology 178 127 (77%) 98 (60%) 44 (27%) 34 0 11 (5%) 4 (2%) 0 n=208 (86%) (16%) Endocrinology 232 126 (62%) 119 (59%) 37 (18%) 13 (5%) 0 5 (3%) 4 (3%) 0 n=241 (96%) Rheumatology 193 121 (81%) 96 (64%) 60 (40%) 33 0 19 (8%) 6 (3%) 6 (3%) n=229 (84%) (14%) Hepatology 70 (82%) 28 (44%) 41 (65%) 2 (3%) 14 0 3 (4%) 1 (1%) n=85 (16%) Chronic Pain 77 (96%) 47 (94%) 2 (4%) 20 (40%) 0 0 0 0 3 (4%) n=81 Nephrology 23 (85%) 20 (91%) 11 (50%) 5 (23%) 5 (19%) 0 1 (4%) 1 (4%) 1 (4%) n=27
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Podiatric Surgery 3 (100%) 3 (100%) 0 0 0 0 0 0 0 n =3 Psychiatry 24 (73%) 19 (83%) 0 16 (70%) 9 (27%) 1 (3%) 1 (3%) 0 2 (6%) n= 33 Vascular Surgery 20 (95%) 17 (89%) 9 (47%) 5 (26%) 3 (14%) 1 (5%) 0 0 0 n=21 Palliative Care 13 (81%) 11 (85%) 3 (23%) 7 (54%) 1 (6%) 0 0 0 2 (13%) n=16 Sport Medicine 4 (80%) 4 (100%) 1 (25%) 1 (25%) 2 (40%) 0 0 0 1 (20%) n=5 Urology 1 (100%) 1 (100%) 1 (100%) 0 0 0 0 0 1 n=1 (100%)
Table 10. Specialist recommendation by specialty
Advice Additional Specialist Reassurance Medication Referred More Other Advice on provided diagnostic follow-up of recommenda to ER info primary testing required physician’s tion needed care and care plan pathways referred Gastroenterology 41 (45%) 32 34 25 17 8 3 9 0 (n=92) (35%) (37%) (27%) (18%) (9%) (3%) (10%) Respirology 9 12 6 0 5 1 0 1 (6%) 0 (n=18) (50%) (67%) (33%) (28%) (6%) Neurology 77 (40%) 68 71 43 43 7 2 10 3 (n=194) (35%) (37%) (22%) (22%) (4%) (1%) (5%) (2%) Endocrinology 96 (41%) 66 47 91 49 1 10 (4%) 4 (2%) 12 (n=237) (28%) (20%) (38%) (21%) (0.4%) (5%) Rheumatology 82 (37%) 73 52 114 109 0 3 0 23 (n=113) (33%) (23%) (51%) (49%) (1%) (10%)
Hepatology 30 (36%) 16 25 24 3 1 0 8 3 (n=84) (19%) (30%) (29%) (4%) (1%) (10%) (4%) Chronic Pain 16 (29%) 2 0 22 42 1 0 0 0 (n=56) (4%) (39%) (75%) (2%) Nephrology 7 5 2 16 5 2 1 0 1 (n=29) (24%) (17%) (7%) (55%) (17%) (7%) (3%) (3%) Podiatric Surgery 2 1 1 0 0 0 0 0 0 (n=3) (67%) (33%) (33%) Psychiatry 10 (28%) 1 4 23 25 1 0 0 2 (n=36) (3%) (11%) (64%) (69%) (3%) (6%)
Vascular Surgery 13 (57%) 3 7 14 4 0 0 0 1 (n=23) (13%) (30%) (61%) (17%) (4%) Palliative Care 11 (65%) 1 0 5 13 0 0 0 3 (n=17) (6%) (29%) (76%) (18%) Sport Medicine 5 0 1 3 1 0 0 0 1 (n=6) (83%) (17%) (50%) (17%) (17%) Urology 1 (100%) 0 0 1 0 1 (100%) 0 0 0
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(n=1) (100%)
Table 11. Outcome of calls by specialty
Consult ER visit Diagnostic Test (s) avoided avoided avoided MRI CT X-ray ECG Barium HBT PFT DEXA other
Gastroenterology 35 (41%) 48 (56%) 0 1 2 0 0 0 0 0 0 n=85
Respirology 5 (25%) 6 (30%) 0 0 0 0 0 0 0 0 0 n=20 Neurology 78 (38%) 62 (30%) 17 6 1 0 0 0 0 0 0 n=207 Endocrinology n=236 130 (55%) 48 (20%) 4 1 0 0 0 0 0 0 1
Rheumatology n=232 105 (45%) 129 (56%) 5 3 4 2 2 2 2 2 0
Hepatology 39 (50%) 18 (23%) 0 0 0 0 0 0 0 0 1 n=78 Chronic Pain n=62 25 (40%) 13 (21%) 0 0 1 3 0 0 0 0 0
Nephrology 15 (52%) 2 0 0 0 0 0 0 0 0 1 n=29 (7%) Podiatric Surgery n=3 0 1 0 0 0 0 0 0 0 0 0 (33%)
Psychiatry 15 (43%) 5 0 0 0 0 0 0 0 0 0 n=35 (14%) Vascular Surgery 11 (50%) 17 (74%) 3 9 1 0 0 0 0 0 0 n=22
Palliative Care n=17 9 3 0 0 1 0 0 0 0 0 0 (53%) (18%) Sport Medicine n=6 4 4 2 0 0 0 0 0 0 0 0 (67%) (67%)
Urology 0 0 0 0 0 0 0 0 0 0 0 n=1 Unknown* 2 (100%) 0 0 0 0 0 0 0 0 0 0 n=2 *unknown – surveys completed with no information on specialty
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Table 12. Specialist LINK diagnosis themes by specialty
Specialty Diagnosis themes (n=248, Feb 2015 to Mar 2019) Count Chronic Pain MSK pain /Injury 7 (n=29) Osteoarthritis 6
Chronic pain 3 Arthritis 2
Degenerative disc disease 2 Fibromyalgia 2
Opioid Medication 2
Polytrauma/Post-traumatic pain 2 Peripheral Neuropathy 2
Spinal Stenosis 1 Neuropathic pain 1
Post herpetic neuralgia 1
Psoriatic arthritis 1 Rheumatoid Arthritis 1 Vascular necrosis 1 Endocrinology Hormonal disorder 7 (n=28) Diabetes 4
Thyroid nodule 3 Cortisol 2
Bone fragilization 1 Cancer- Ovary 1
Constipation 1
Gender transition 1 Hyperkalemia 1
Hyperthyroidism 1 Mucco-edema with optic nerve compression 1
Pancreatic cyst 1
Pituitary 1 T3 toxicosis 1 Vitamin D 1 Weight gain 1 Gastroenterology Gout 2 (n=9) Iron deficiency 2
Cognitive impairment 1 Helicobacter 1
Investigation/Testing 1 Pain 1
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Ulcerative colitis 1 Hepatology NAFLD 9 (n=24) Hepatitis C/B 7
Liver enzymes disorder 3 Autoimmune Hepatitis (AIH) 1
Hemangioma 1 Hepatic abscess 1
Hepatocellular Carcinoma/Diarrhea 1 Wilson's disease 1 Nephrology Chronic Kidney Disease (CKD) 8 (n=27) Acute kidney injury 4
Hyperkalemia 3 Proteinuria 3
Diabetic nephropathy 2 Hyponatremia 2
Nephrectomy 1
Hematuria (synpharyngitic hematuria, acute kidney injury, Medullary Sponge Kidney) 5 Hypokalemia 1
Potassium 1 Neurology Abnormal EEG results 1 (n=3) Brain Injury 1
Results interpretation 1 Palliative Care Cancer - Lung 4 (n=16) Dementia 4
Cancer - Colon 2 Cancer - Prostate 2
Pain 2 Cancer 1
Cancer - Bone 1
Cancer - Breast 1 Cancer - Liver 1
Cancer - Ovary 1 COPD 1 Chronic Heart Failure 1 PSNP 1 Podiatric Surgery Fracture 1 (n=3) MSK injury 1
Vascular malformation 1 Psychiatry Depression 15
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(n=35) Alcohol abuse 5 Bipolar disorder 5
Anxiety 3 Drug abuse 3
Psychosis 3 ADHD 1
Fetal Alcohol Spectrum Disorders (FASD) 1
Insomnia 1 Mania 1
OCD 1 Panic disorder 1
Paranoia 1 Paranoid personality disorder 1 Personality Disorder 1 Rumination syndrome 1 Schizoaffective Disorder 1 Rheumatology MSK pain 7 (n=52) Gout 5
Rheumatoid Arthritis 5 Autoimmune disease 3
Inflammatory arthritis 3 Polyarthralgia 3
Osteoarthritis 2
AMS (morning stiffness) 1 Arthralgias 1
Arthritis 1 Chronic pain 1
Crystal Arthropathy 1
Diffuse idiopathic skeletal hyperostosis (DISH) 1 DM/HTN 1
Hidradenitis suppurative 1 Hypermobility syndrome 1
IBD 1
Inflammatory pain 1 Investigation/Testing 1
Osteoporosis 1 Painful Metatarsophalangeal Nodules (MTPS) 1
Polymyalgia rheumatica (PMR) 1 Psoriasis 1
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Reiter's syndrome/celiac disease arthralgia 1 Results interpretation 1 Sarcoidosis 1 Scleroderma 1 Sjogren syndrome 1 Skin Bruising 1 SLE 1 Tendinopathy 1 Transient arthritis 1 Sport Medicine AC joint separation 1 (n=5) Achilles tendon rupture 1
Ankle sprain 1 Back strain 1
Grade 1 spondylolisthesis 1 TFCC injury 1 Urology Renal stone 1 (n=1) Vascular Surgery Abdominal Aortic Aneurysm (AAA) 4 (n=22) Carotid artery stenosis 3
Claudication 2 Foot ulcer 2
Peripheral Vascular Disease (PVD) 2 Aortic Atherosclerosis 1
Carotid Tortuosity 1
Celiac Astesy Compression Syndrome 1 Chronic pain 1
Cyanotic toes 1 Groin pain 1 PAD 1 Raynaud's Syndrome 1 Vertebral Art Dissection 1
Table 13. Specialist initial face-to-face consultation fee by specialty
Specialty Face-to-face consultation fee* Gastroenterology $192 Respirology $207 Neurology $198 Endocrinology $195.12 Rheumatology $198
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Hepatology $186.95 Pediatrics $200.30 Chronic Pain n/a Podiatric Surgery $93.15 Nephrology $199.63 Psychiatry $187.88 Vascular Surgery $160.56 Congestive Heart Failure $175.00 Palliative Care $175.00 Sport Medicine $122.84 Urology $93.38 Anesthesiology $104.12 *Source: Alberta Health Care Insurance Plan Schedule of Medical Benefits, effective April 1, 2018
Table 14. Emergency Visits and Diagnostic Testing
Saving Variables 14-15 15-16 16-17 17-18 18-19 ER visit* $350 $350 $350 $350 $386.1 MRI** n/a n/a $658.81 $658.81 $658.81 CT scan** n/a n/a $623.33 $623.33 $623.33 X-ray** n/a n/a $130 $130 $130 ** Source: Canadian MIS Database (CMDB), CIHI, FY 2015/16 provided by the Canadian Institute for Health Information for Average ED cost per visit for all hospitals in Alberta which include direct expenses only. And average ER cost in Alberta: Trends in Hospital Expenditure, 2005– 2006 to 2017–2018 — Data Tables — Series B: Hospital Expenditure by Functional Area ***Source: information from Interactive Health Data Application, Govt of AB FY 2016-17 (MRI, CT Scan, X-ray (range of X-ray cost from $106 to $154)
Table 15. Average cost and savings per survey by year
14-15 15-16 16-17 17-18 18-19 Across the years Average Cost per Survey $108 $108 $108 $90 $106 $100 Average Savings per Survey $297 $303 $253 $208 $186 $220 Average NET savings per survey $189 $195 $145 $118 $80 $120
Table 16. Call Savings Per Specialty
Total Total No. of % No. of % ED No. of % MRI No. of % CT No. of % X-Ray Average cost Average savings no. of no. of calls avoided calls avoided calls avoided calls Scan calls avoided avoidance per per call (subtract calls surveys avoided SP avoid per SP avoided per SP avoided a avoided avoided per SP call FP & SP call fees) SP Consult ed ED an MRI CT scan per SP an X-ray consults per SP visits Gastroenterology 2704 98 35 36% 48 49% 0 0% 1 1% 2 2% $ 267 $ 159
Respirology 532 20 5 25% 6 30% 0 0% 0 0% 0 0% $ 168 $ 60
Neurology 1985 216 78 36% 62 29% 17 8% 6 3% 1 0% $ 252 $ 144
Endocrinology 1801 244 130 53% 48 20% 4 2% 1 0% 0 0% $ 193 $ 85
Rheumatology 1497 254 105 41% 129 51% 5 2% 3 1% 4 2% $ 300 $ 192
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Hepatology 622 90 42 47% 18 20% 0 0% 0 0% 0 0% $ 164 $ 56
Pediatrics 1097 0
Chronic Pain 298 83 25 30% 13 16% 0 0% 0 0% 1 1% $ 62 $46
Nephrology 292 29 15 52% 2 7% 0 0% 0 0% 0 0% $ 130 $ 22
Podiatric Surgery 54 3 0 0% 1 33% 0 0% 0 0% 0 0% $ 129 $ 30
Psychiatry 517 35 15 43% 5 14% 0 0% 0 0% 0 0% $ 136 $ 28
Congestive Heart 88 0 Failure Vascular Surgery 121 23 11 48% 17 74% 3 13% 9 39% 0 0% $ 692 $ 584
Palliative Care 24 17 9 53% 3 18% 0 0% 0 0% 1 6% $ 168 $ 60
Sport Medicine 65 6 4 67% 4 67% 2 33% 0 0% 0 0% $ 559 $ 451
Urology 80 1 0 0% 0 0% 0 0% 0 0% 0 0%
Unknown - 2 2 100% 0 0% 0 0% 0 0% 0 0% $ 199 $ 91
Total 11777 1121 476 42% 356 32% 30 3% 20 2% 9 1%
*Chronic Pain service is managed by nurse practitioners, both NP and FP do not bill separately for phone consultation. Indirect costs/ other direct costs were not included in the cost analysis due to an absence of data for these variables.
II. Figures
Figure 1. Historical Website Traffic
Historical Website Traffic (data since Nov 2016) 6000
5000
4000
3000
2000
1000
0
04/2018 08/2018 06/2016 07/2016 08/2016 09/2016 10/2016 11/2016 12/2016 01/2017 02/2017 03/2017 04/2017 05/2017 06/2017 07/2017 08/2017 09/2017 10/2017 11/2017 12/2017 01/2018 02/2018 03/2018 05/2018 06/2018 07/2018 09/2018 10/2018 11/2018 12/2018 01/2019 02/2019 03/2019
Downloads Page Views Total Visits
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Figure 2. How many times have family physicians used Specialist LINK
How many times have you used Specialist LINK (n=239)
57%
21%
10% 12% # of # Respondents
1 2-5 6-10 10+ Times used
Figure 3. Reasons to not having used Specialist LINK
Reasons respondents have not used Specialist LINK (n=98)
Time constraint for making phone calls between 36 appointments Have heard about the service but don't know the 19 details of it
Patients' needs met by current system 18
Not needed for patients in my panel 12
Patient hasn't met the profile for use 11
I'm not interested in a telephone advice request 1 service
Other: Patient usually wants to 'see' a specialist 1
III. Specialist survey verbatim answers for open-ended questions 1. Specialist Recommendation Specialists who specified ‘Advice provided’ as one of their recommendations: (n=70) Response themes by Specialty: (Advice, Medication, Referral, Other testing)
Endocrinology n=29 Advice 11/29, 38% responses • Asked a colleague for bone question- provided advice by email • Out of my scope of expertise, will consult with a colleague about case and get back to by email
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• FNA-can be done by EFW • desiccated thyroid contra-indicated in pregnancy • call patient to see if symptomatic • check if patient using biotin--& gt; stop it--& gt; repeat thyroid levels in 2 weeks at OFC 's if still abnormal (high T4, high T3, high TSH) refer to endo CAT • Advised diet may have A, Advised lower Cartus to 20 u qhs and r/a • Treat hypothyroidism + recheck PRL • Advised that hypothyroidism unilateral • Recommended checking for lyses + bicarb to 100 h for DKA. If +DKA --> ER. I f - DKA -->urgent referral • Consider referral depending on response to current treatment and monitoring
Medication 6/21, 17% responses • Decrease testosterone dose and monitor hct • stop raloxifene • Kenalog not a substitution for emergency dose of IM hydro cortisol when ill. • I recommended starting bisphosphonate. concerned about nonadherence: if IV Aclost possible. I responded that it is usually given if po not tolerated and typically with assessment through op clinic • Advised to lower to 800-2000/d then r/a --> F/u Dr • Recommended dividing injection into 2 and considering Lantus for longer coverage
Referral 7/29, 24% responses • refer to osteo clinic • start tapazole, refer to endo as urgent • FT4, MRI sella refer to endo • FT4, MRI sella refer to endo • work up for pcos but minus the ultrasound refer to peds endo esp re weight management • Referred to care pathway • Suggested referral- eval with FCY, cytes, PRL, IUFI--> already on pred 15 mg/d for PmRL. Cautioned re: taper and need to evaluate for AI
Other 5/29, 17% responses • MRI sella • MRI sella • check 8AM serum cortisol • Cortisol 238 probably needs out AI • Recommend repeating fasting am PRL, avoiding stimulation Hepatology n=1 Advice 1/1, 100% responses • risk of hbv reactivation reviewed Nephrology n=2 Advice 1/2, 50% responses • Repeat labs in about 3 months
Medication 1/2, 50% responses • Re hydrate pin. Topic/step steroids. Higher dose of spirendolone. Check urine lytes/ ismes + continue replacement with KCl Palliative Care n=5 Advice 1/5, 20% responses • try medication again, request community consult for ongoing care needs
Treatment 1/5, 20% responses • opioid titration
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Referral 3/5, 60% responses • call TBCC nurse and request P&SM clinic referral • refer to home care, titrate opioid • use hemostat dressing. LTC most appropriate place for EOL for dementia pt Podiatric Surgery n=2 Advice 1/2, 50% responses • NWB/ cast/ crutches
Referral 1/2, 50% responses • call a shoulder specialist as podiatry is a specialty limited to foot and ankle Psychiatry n=10 Advice 2/10, 20% responses • Agreed that Certification was more likely harm than good
Medication 4/10, 40% responses • discussed possible personality disorder, role of antipsychotics and options • discussed options of lamotrigine vs lithium • suggested betablocker while awaiting Geriatric Psych intake • first choice is to stop Aripiprazole, but probably not high risk
Referral 4/10, 40% responses • Suggested a couple names • To call Admission Coordinator at Claresholm Care Ctr • Referral to Community Extension Team for interim • encouraged routine referral through Access Mental Health
Other 1/10, 10% responses • Screen for abuse/trauma, further diagnostic clarification Rheumatology n=4 Advice 1/4, 25% responses • will update c. triage
Referral 1/4, 25% responses • consider wound clinic referral
Other 2/4, 50% responses • repeat x-ray at EFW if report is consistent with erosive OA, focus on pain optimization with Tylenol, NSAIDS, (oral/topical) if she wants a rheum opinion ok to refer but rx for erosive OA is limited, need for rheum assessment now • recheck ENA in mitogen (lupus panel), in the absence of systemic sx start with a dermatology assessment, periorbital rash from lupus is very unusual, no need for rheum referral now Sport Medicine n=4 Advice 3/4, 75% responses • Symptomatic management and MRI arthrogram of wrist • Continue PT and symptomatic management • management, bracing, progression of RTW
Referral 1/4, 25% responses • Contact given to discuss with foot/ankle orthopedic surgeon Urology n=1
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Other 1/1, 100% responses • perform to u B Vascular Surgery n=12 Advice 8/12, 67% responses • No further testing • ulcer care strategy • Conservative management • No vascular Pathology • u/s to f/o pseudo-areaways • No further w/u • Send to ER • no need CTA
Medication 1/12, 8% responses • ASA, Statins
Referral 1/12, 8% responses • send consult < link
Referral 2/12, 17% responses • confirm patency with ultrasound (2)
2. Outcome of calls Specialists who specified ‘Other’ for Diagnostic tests and Lab tests avoided: Other Diagnostic tests avoided: (n=6) Lab tests avoided: (n=6) Endocrinology (n=3) Endocrinology (n=2) • Doc was wondering about TSHoma which is unlikely • TRAB • U/S • T3 levels-not helpful, don't check • ANS: yes Hepatology (n=2) Nephrology (n=1) • Liver biopsy • U/S • Liver biopsy Rheumatology (n=1) Sport Medicine (n=1) • Aspiration • Error- no lab tests needed Vascular Surgery (n=1) Vascular Surgery (n=1) • CTA • blood work
3. Appropriate use of Specialist Link 6% (14/234) of specialists answered ‘No’ to whether the call was an appropriate use of Specialist Link
Specialists who answered ‘no’ explained: (n=13) Not Appropriate (12/13, 92% of responses) • wrong specialist interrupted • Not a nephrology issue • already referred to fertility clinic • referred to private endocrinologist already but seeking advice for same reason before the other endo sees • Calming anxiety • it was the patient's wife calling for advice
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• Patient is on both list patient of specialist anyway • Patient has a nephrologist and family doctor should have directed concerns there. • I don't think it was intended that we (specialist link) update central triage i.e. status of patient • Needs referral • referral was declined by central triage as pt thought to have OA, GP and patient want specialist appt to reassure not missing other problem due to young age, poly articular involvement, & family history • Already managed by a nephrologist. Urgent nature (1/13, 8%) • urgent referral, not "routine phone advice""
4. Service feedback Specialists commented on experience in providing feedback (n=52): Positive, comments n=42 • better if peds endo would do phone consult • family physician needed reassurance • great to provide education and speak to family MD colleague • I was able to help her understand the appropriate channels to find help. • Always good to help a colleague in an area they are not familiar/comfortable with - they know for next time. • Happy to help • Good to help a colleague who is not familiar with opioid titration. Next time he will know how to do it. • WAs able to help support a GP • The FP was uncertain in an area where I have had experience. Happy to help. • Clarified that Certification and transfer to ER required • Quick double check about medication advice • able to encourage rereferral with appropriate terminology • helped with referral language to assist correct management by central referral • Difficult clinical situation - really needs something other than primary care, but what? • Great interaction with GP • Tough case, good to share options for future • GP was expressing gratefulness that psych was on specialty link • Therapeutic option which GP had not experience with: moclobemide • Unlikely that patient would accept referral, so best to work with relationship in Primary Care • Challenging - sudden worsening of probable longer-term illness • Collaborative - did take extra time and return call to look up risks • Difficult situation - however I did not have the dose of drug handy, so had to look it up • Shared responsibility for VERY difficult patient and situation • able to assist GP during period leading to full consult in clinic (already referred) • Challenging case - good to discuss • Extra time to look up risks and called back • Challenging case, but excellent care in primary care supported by Specialist Link • Negative, comments • ? sarcoid arthropathy- telephone advice • review of result, reassurance for MD & patient re: hand OA • telephone advice, PMR unlikely, hold off on prednisone and observe • Easy exchange of info • referring physician was happy to avoid complex work up • Easy interaction, guide resolution • Collaborative care plan arranged • Shared learning about PAD is octogenarian • primary care doc wanting to investigate patient complaint efficiently • Provided reassurance and F/U plan • Friendly exchange of unique u/s findings
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• Good interaction, grateful colleague • avoided unneeded cost to AHS • Primary care doc's plan was appropriate, and reassurance was given Negative, comments (n=4) • I felt like a middleman and suggested many times that the other nephrologist should be contacted for both patients • The case was not discussed by the NP caller w/the physician looking after the patient at the care home • interrupted while performing surgery, ORTHO is not one of the specialties in the program, cannot begin to understand how anyone thought that I should be called for this shoulder injury; should we be using AHS resources for WCB injuries? • I spent at least 5-10 minutes trying to call back and entering the number different ways. It was a waste of my time. Number provided was not in service - what do we do when this happens? Other, comments (n=6) • Today is day 4 since advice given. There is no CT performed and when I called CT booking there is no record of a CT ordered region-wide. I question whether advice acted upon, therefore what's the point? • Hard to find such consultants • GP is advocating on patient's behalf • no lab results available at time of call, CCP+ RF+, I will see next week • except this is a pediatric patient- recommended paging ped rheum on-call in future if further problems in pts < =18 yr old, ANA not a good screen for pts w/ fatigue, ANA 1:40 is not significant • Neutral-this is a patient of another urologist already
“Did the call support any of the following…” Other, comments n=3 • day 7 still no CT results • Name for court report • Medico-legal support
5. Diagnosis & Theme of Call Chronic Pain Diagnosis (n=1) Theme of call (n=1)
• Chronic C, T, L spine pain Management 1/1, 100% responses • management of increased pain Endocrinology Diagnosis (n=4) Theme of call (n=29)
• Low BmD off resituate x5 year with low absolute risk of Referral 2/29, 7% responses fracture referral to op dime • 33 F FNA thyroid. Suspicions for follicular neoplasm--> Referral • Dizzy lightened but Bb measured usually 2h after eating already made high protein food. Home Bb lowest 9.9-5.9 mmol/l. • Overt hyperthyroidism and asked for referral. Hypoglycemia not detected ever Clinical 27/29, 93% responses • Called re: intermittently high TSH9.5 c slightly high FT7 • Persistent Am low Bg in new LTSC facility testing Cantus 26 u qhs that improve. No sx of thyrotoxicosis. No interfering • Constipation unlikely repeated to PM and domperidone unlikely meds/biotin. No FHX of FOH or RTH. Recommended to help repeating in a few months’ time. • high TSH, of 10 and high PRL 45. Advised replace LT7 100-112 • Borderline Pm, Borderline I cholesterol. Asked re: mg/ then recheck high SH +PRL in around 2m time possible statin. Advised that it should be determined by • High weight 9 lbs in 2 weeks (75lbs since May). BMI >40 -- patient preference+ absolute risk reduction likely very >+++stretch marks. query testing is? small. • Whipple in Oct for pancreatic cyst (Benin). Admitted c inter abdominal colect---> started on metformin Hbaic 5.6%. Stop metformin shay. • T3 toxicosis c high manifestations ---> repeat
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• Cortisol 238 shay • Metformin 350 mb bid. Alc 6% GPR 36. Synthroid --->? adherence. YP stop metformin, target ALC < 8-5% • 4/6 thyroid nodules. 2 inf suspicious. High TPO --> FNA recommended • Nov 18 HbAc 10.3% --> NSCEMU --> ALC 8.5%. Metformin 500 bid Q: Is Jardiance shay to start offer MI • 53 F alcoholic with R femur #. High score to L-spine -9. High risk fracture • 35 M normal bio avail testosterone + fatigue • 65 M prior hx pit mucco edema resected 20 y ago in USA. MRI sella 10 y ago shows no recurrence. Biochemical testing normal. Addressed no further w/u unless symptoms present Leg down visual fields) • BSO 2016 for Fotx ovarian CA. D/C on BCP --> stopped last year - -->restarted. Has migraines c amra. YP advised HRT already referred to LMC • Transgender recently F-->M. Edmonton for school. Edmonton ends? • Mother (24 h K+ high) seen functional med care + desiccated thyroid • Daughter (high AM cortisol) seen functional med care + desiccated thyroid • 38 F pregnant 25 weeks GA, TSH 4.65 FC4 12.2 FT3 3.5. No preexistent thyroid. • High PRL 41 thyroid no SX • 49 F with vit D of about 70 nmol/l. reaching 50000IU qd • 19 F pregnant, 10 weeks gestation. TSH < 0.01 FC4 22.9 FT3 6.9 (TFTs ordered with no indication) • 60 F taking escalating doses on Levemir 60 -->100U qhs over last year with minimum effect. No obvious reason for hyperglycemia. Already seen by DEC and in queue for endo consult. • 61 F (thin) into DM for years not controlled on oral (metformin) TX, 6LPI agonist, SGLT2i Rx and presented with high BG + ketones in clinic • 74 F LTC wheelchair with T20m metformin 500 mg bid glagine 30 u qam, 12 u qhs NR 9/6/9 w/h meals. BG on target for breakfast + supper but high BG at lunch • 54 F, high Tg level. Incidental 1-5 cm, low echoic thyroid lesion -- > FNA rec • 82 F mucco edema with optic nerve compression • Acne + hair I over body = Pcos metforms spronolectone ? high foot size. Already seen by endocrino and recs already give on netcare. Hepatology Diagnosis (n=27) Theme of call (n=21)
• NAFLD r/o AIH (x2) Management 2/21, 10% responses • HBV (x2) • Management (x2) • increase LE Clinical 14/21, 67% responses • HBC Ab+ SAg- (x2) • r/o AIH (x3)
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• HCC and diarrhea (x2) • ? EtoH Hep • High liver enzymes • Monitoring (x2) • High ASMA, N LE • Rule out mass • Giant Hemangioma • safety of A/C • NAFLD • reassurance • HBV carrier • risk of reactivation with stopping Truvada • HBcAb positive • • NASH inconclusive SWE but also elevated ALP fatty liver • Fatty liver? drug induced • check cu studies • NAFLD (x2) • risk stratification, pt noncompliant • Elevated ALP • advice on wu and pathway • r/o Wilson's disease Diagnosis & testing 5/21, 24% responses • Hepatic Abscess • further workup • elevated LE • tests • NAFLD - not alpha 1 AT def • workup • NAFLD/ETOH/Meds • Investigations needed • refused from CAT for high risk NAFLD • Investigations • elevated ALP Nephrology Diagnosis (n=21) Theme of call (n=16)
• U11 Clinical 9/16, 56% responses • CKD (x5) • CKD (x4) • Hematuria • Medullary Sponge Kidney • AKI (x4) • Nephrectomy • Amc • consequences of hyponatremia, management plan • Hyperkalemia (x3) • diagnosis • hematuria/AKI • diminution of K+ (critically low K+) • Hyponatremia Management 7/16, 44% responses • hematuria and proteinuria • Appropriate management • CKD stage 3 a non-proteinuria • Management (x4) • DUI with diminution in K+ secondary to cisplatin • advice on management • Potassium • diagnosis/management Palliative Care Diagnosis (n=16) Theme of call (n=17)
• pain, on Keytruda Clinical 8/17, 47% responses • Ovarian cancer, recurrent UTZ's • antibiotics prophylaxis • Lung cancer, metastases to brain with SOB • Pain control • dementia, recurrent breast ca • Symptom conflict, palliation • Lung Ca (x2) • where to access resources e.g. thoracentesis • Colon Ca/ COPD/ CHF/ Dementia • Home care referral • bone mets, unknown primary • Pain and delirium control, with? EPS from Haldol • Lung Ca and frailty • Pain control (x2) • Dementia • Prostate Ca, Dementia Management 9/17, 53% responses • Prostate Ca • secretion management • Colon Cancer • Symptom management (x3) • PSNP • Help c symptom management • cervical ca • pain management • Curbasin Liver ca • available supports for this patient who lives alone, some symptom management • management of bleeding and also care placement
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• pain management Podiatric Surgery Diagnosis (n=3) Theme of call (n=3)
• WCB Clinical 2/3, 67% responses • fracture • should injury discovered offer pre-amble • Vascular malformation • what do I do? Pt weight bearing w/ ---- pain, 4 weeks Management 1/3, 33% responses • Management Psychiatry Diagnosis (n=35) Theme of call (n=35)
• Mania Referral 6/35, 17% responses • Insomnia • what is best disposition -? Certify and send to ED? • Depression - partial response • Trying to find expert for a court report • Depression • problems with getting services via Access Mental Health • Alcohol abuse • problems accessing care • Substance Use Disorder • How to refer to Dual Diagnosis in Claresholm Care Centre • alcohol use disorder (x2) • management and referral for further treatment • Major Depression in remission Medication 16/35, 46% responses • bipolar disorder - depressed phase • Can patient continue to use sleeping medication • "Rumination Syndrome" • Medication advice - concern about seizure risk with Ibuprofen • Psychosis with remote childhood history of seizures • OCD vs anxiety • Can MD continue high dose venlafaxine with stable patient • Major Depression - treatment resistant new to him • Major Depression • assistance with Rx selection - first choice side effect limited, • unclear - possibly paranoid personality disorder already scheduled to see consultant on consult via access • possible bipolar depression, past dx borderline pd, • Medication advice narcissistic pd • Treatment recommendation • Borderline PD and Alcohol Use Disorder / Stimulant • Alternative treatments? ECT Use Disorder (cocaine) • education re DSM5's approach to medication induced mania, • Major Depressive Disorder and Generalized Anxiety spoke about treatment options Disorder • What drugs are safe in lactation - ? Prozac • Schizoaffective Disorder • How to maintain antipsychotic treatment • Panic Disorder • pt weaned off 30yr diazepam use c/o anxiety. Multiple med • Depression & anxiety in lactation dx. Needed help managing request for diazepam • Paranoia secondary to neuro-syphilis • advice on meds in carded national team athlete on waitlist for • MDD in remission services • persistent depressive disorder, r/o bipolar 2 • safety of aripiprazole in pregnancy (augmenting agent) • Personality Disorder • Medication concerns, especially with stimulants in Bipolar • bipolar disorder - mixed state patient and longer-term approaches • Depression with Psychotic Features • medication management • Depression and Alcohol Use Disorder • request assistance with medical management in treatment • Dissociation resistant case with seizure disorder (poss. med related) • benzodiazepine use disorder Clinical 9/35, 26% responses • persistent depressive disorder and major • What to do with somebody who GP hasn't seen but is hearing depression about from wife who is threatening to complete suicide • Anxiety and pregnancy • difficult patient encounter, difficult marital relationship with • Bipolar Depression with Psychosis and ADHD unclear pathology • • FASD with psychosis Treatment resistant due to non-response or side effects - what next? • major depression, generalized anxiety disorder, • ADHD Dealing with paranoid patient - difficulty accepting treatment and medication
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• Patient well managed on antidepressant but wants to get pregnant and medication is contraindicated - what to do? • Whether or not to Certify in situation of threats which are not "imminent" • Dealing with psychosis and depression • Dissociative episodes in depression and Alcohol Use disorder • Unusual / rare syndrome diagnosed as psychosomatic, but what to do now? Management 3/35, 9% responses • Management • management of pt seen in ER and struggling • support and suggestions for future management Other 1/35, 3% responses • Wasn't able to call the number provided because the number provided was not in service Rheumatology Diagnosis (n=0) Theme of call (n=1)
Clinical 1/1, 100% responses • bilet hand pain Sport Medicine Diagnosis (n=6) Theme of call (n=5)
• TFCC injury Management 4/5, 80% responses • AC joint separation • Advice on Management • Achilles tendon rupture • Management (x2) • high ankle sprain • management advice • Back strain with X-ray findings of Grade 1 Other 1/5, 20% responses spondylolisthesis • Sports medicine Urology Diagnosis (n=1) Theme of call (n=1)
• Right Renal stone Clinical 1/1, 100% responses • New problem of stones right side on ultrasound Vascular Surgery
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Diagnosis (n=23) Theme of call (n=22)
• PVD Critical ischemia Referral 3/22, 14% responses • Aortic Atherosclerosis • need for referral and/or imaging. • Carotid artery stenosis • Should this patient be seen by vascular surgery • Carotid Stenosis (x3) • Plan = sent to ER for assessment • ischemic legs Diagnosis & testing 4/22, 18% responses • Cyanotic Toes • Review CTA and R/O Vascular Cause for pain • Raynaud's Syndrome • Investigation and management • Foot ulcer • Does pt. need further investigation • Abdo + chest pain NYD • Investigation of the groin pain • PAD Medication 4/22, 18% responses • Groin pain post femoral access for cardiac cath • Treatment f/u • AAA (x3) • Type II Endo leack • Carotid Tortuosity • Treatment f/u • Vertebral Art Dissection • medical treatment • AAA- Symptomatic? Management 11/22, 50% responses • PVD • Are investigation and referral necessary? • Claudication (x2) • management of carotid stenosis (x2) • Celiac Asthesy Compression Syndrome • management of foot ulcers • Management of worsening symptoms • Management of 94 y o with Foot ulcer
• Severe claudication? management
• u/s findings? management • management (x3)
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REFERENCES
Alberta Health Services (2018) Specialist LINK evaluation, Specialist LINK Survey Calgary Zone, Health System Evaluation and Evidence, Innovation and Research Management
Alberta Health Care Insurance Plan (2018): Schedule of Medical Benefits. https://open.alberta.ca/ publications/somb-2018-11-01
Alberta Medical Association Fee Navigator: https://www.albertadoctors.org/fee-navigator
Area of coverage (2019), Report response on specialty concern receiving calls from outside the Calgary Zone
Calgary Zone Primary Care Action Plan (CZPCAP,2012)
CFPCN (2018), Specialist LINK survey section, Annual Report
HSS (2016), Health System Support Project Charter
Specialist LINK (2018) Calgary Zone Annual Physician Survey, family physician survey completed by AHS
Specialist LINK (2019) Cost Analysis Report
Specialist LINK (2019) Updated website: https://www.specialistlink.ca/
Tech Talk(2018): CFHI :Connecting Primary Care and Specialty Care in Calgary, https://www.cfhi- fcass.ca/OurImpact/improvement-conversations/connecting-primary-and-specialty-care-in-calgary
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