|Tipo di tesi||Tesi di dottorato di ricerca|
|Titolo||QUALITA' E MIGLIORAMENTO DELLA CONSULTAZIONE TELEFONICA MEDICA|
|Titolo in inglese||Telephone medical consultation quality and improvement|
|Settore scientifico disciplinare||MED/09 - MEDICINA INTERNA|
|Corso di studi||Scuola di D.R. in CLINICAL AND EXPERIMENTAL MEDICINE (CEM) - MEDICINA CLINICA E SPERIMENTALE|
|Data inizio appello||2017-03-27|
|Disponibilità||Accessibile via web (tutti i file della tesi sono accessibili)|
Background The ability to consult by telephone has become an integral part of modern healthcare. Safety and legal concerns come from studies showing the clinical quality of medical telephone consultation (MTC) is low. Little is know about the quality of MTC in Italy. No systematic review is currently available to address specific training of health professionals on MTC. Computerised decision support systems (CDSS) could play a role in improving MTC quality but their effectiveness is not clear, especially when CDSS are applied to telephone triage (clinical cases urgency estimate). The e-learning, the integration between educational programmes and interactive electronic systems, could be useful to deliver these skills but little is known about its effectiveness in comparison with traditional training. Objectives 1) To assess the clinical quality of MTC in a high MTC rate service. 2) To systematically review the literature on the efficacy of CDSS on mortality and morbidity prevention, e-learning in comparison with traditional learning, training intervention to improve clinicians telephone skills 3) To test the efficacy and safety of a CDSS for telephone triage in a high MTC rate service 4) To study barriers and facilitators toward the uptake of CDSS Methods A cross sectional study detected the MTC quality in a high MTC rate service; an off-topic Cochrane review was performed to learn Cochrane methodology; three systematic reviews (two Cochrane and one non-Cochrane) found and pooled the results of existing studies (estimating their risk of bias) about CDSS efficacy on mortality and morbidity prevention, about e-learning efficacy in comparison with traditional learning and about training intervention for telephone skills improvement; a randomised control trial assessed the efficacy and safety of a CDSS for telephone triage and one more cross sectional study addressed barriers and facilitators towards CDSS uptake. Main results The clinical quality of MTC in the study setting was low: doctors asked only about 30% of the obligatory questions. CDSS use did not affect mortality but a significant effect was detected in the prevention of morbidity, even if selective outcome reporting and publication bias are not excluded. The off-topic Cochrane systematic review showed the main two drugs for Multiple Sclerosis are similar in terms of relapse rate, progression and imaging outcomes. E-learning when compared to traditional learning does not improve patient outcomes and health professionals behaviours; it possibly leads to slightly less improvement in health professionals skills but no difference on health professionals knowledge. We found no evidence about training interventions for improving clinicians telephone communication skills on patient or clinicians outcomes. Due to technical problems the RCT assessing the efficacy of a CDSS for telephone triage failed to collect reliable results: the CDSS could not be used to a sufficient extent and this resulted in a loss of power and a irreversible imbalance between the study arms. The protocol about barriers and facilitators of CDSS uptake was performed in a study by the other researchers and they could design a model to guide the adoption of CDSS. Authors' conclusions Despite the phone is a very frequently used tool, the clinical quality of the MTC in Italy seems low. The currently available evidence on how to address the improvement of clinicians telephone skills is poor but CDSS proved to be effective even if specific CDSS for the MTC remain to be tested. Once evidence is available on how to improve, e-learning will be a potential cost-effective training way: it seems as effective as traditional training in terms of transmission of knowledge even if potentially little less effective on skills transmission.