Jou nal o
Clinical Medicine
A icle
DETELPROG S udy. E ec i eness o a New Model o
Scheduled Telephone Re e al om P ima y Ca e o
In e nal Medicine. A Randomised Con olled S udy
Luis Miguel Azogil-López 1, Juan JoséPé ez-Láza o 2,3, Es he Ma ía Med ano-Sánchez 4,
Juan Gómez-Salgado 5,6,* and Valle Co onado-Vázquez 7
1Family and Communi y Medicine, Val e de del Camino Heal h Cen e, 21600 Huel a, Spain;
[email p o ec ed]
2Andalusian School o Public Heal h, 18080 G anada, Spain; [email p o ec ed]s
3Biosani a y Resea ch Ins i u e o G anada, 18080 G anada, Spain
4
School o Nu sing, Physio he apy and Podia y, Uni e si y o Se illa, 41013 Se illa, Spain; [email p o ec ed]
5Depa men o Sociology, Social Wo k and Public Heal h, Uni e si y o Huel a, 21007 Huel a, Spain
6Sa e y and Heal h Posg ade P og am, Uni e sidad Espí i u San o, Guayaquil 091650, Ecuado
7Gene al Di ec o a e o Heal h Assis ance-A agonese Heal h Se ice, 50071 Za agoza, Spain;
[email p o ec ed]
*Co espondence: [email p o ec ed] o [email p o ec ed]; Tel.: +34-699-999-168
Recei ed: 2 Ap il 2019; Accep ed: 13 May 2019; Published: 16 May 2019


Abs ac :
In Spain, he a e age wai ing ime o a specialis consul a ion is 58 days. A de e minan
ac o ha con ibu es o his si ua ion is he poo communica ion be ween p ima y ca e and specialised
ca e, which is mainly due o he wai ing days o a consul a ion, numbe o a oided/a oidable
ace- o- ace e e als, and wai ing days o he esolu ion o he p ocess. DETELPROG is a e e al
sys em in which he amily physician eques s a scheduled ou pa ien in e nal medicine consul a ion,
in eg a ed in o he usual consul a ions agenda o bo h physicians, he amily, and he ou pa ien clinic
physician, in o de o ha e a elephone consul a ion. A andomized con olled clinical ial has been
ca ied ou o assess he e ec i eness o DELTELPROG. In a sample o 255 pa ien s, he expe imen al
g oup was e e ed ia a scheduled elephone call, and hose in he con ol g oup, by ace- o- ace
hospi al consul a ion a ea. The esul s showed s a is ically signi ican di e ences be ween bo h
g oups o 27 days (95% con idence in e al (CI): 20–33) ega ding specialised consul a ion, 47 days
(95% CI: 17–74) as o he esolu ion o he p ocess, and 91.7% o a oided ace- o- ace consul a ions.
The DETELPROG esul ed as a low co e age sys em (53%), which makes i a complemen a y e e al
model. I is necessa y o make an in-dep h analysis o he causes ha ha e led o his echnologically
low co e age.
Keywo ds:
e e al; eConsul ; cu bside consul a ion; elemedicine; p ima y heal h ca e; wai ing lis ;
pa ien sa e y; quali y o heal h ca e
1. In oduc ion
In Spain, as o 30 June 2017, he a e age wai ing ime o a specialis consul a ion is o 58 days [
1
],
and he pe cep ion o pa ien s abou he e olu ion o hese wai ing lis s is nega i e: 46.3% o pa ien s
hink ha i emains he same as he p e ious yea and 28% o pa ien s belie e ha i has wo sened.
Less han 9% o pa ien s hink ha i has imp o ed, acco ding o a ecen Heal h Depa men su ey [
2
].
This p oblem is also p esen in he as majo i y o de eloped coun ies [
3
–
5
], as Canada, as
esul ed in he Commonweal h Fund Su ey [
5
], o Uni ed Kingdom, No way, Finland, he Ne he lands,
Denma k, Sco land, New Zealand, Canada, Aus alia, and he Uni ed S a es o Ame ica (USA), whe e
J. Clin. Med. 2019,8, 688; doi:10.3390/jcm8050688 www.mdpi.com/jou nal/jcm
J. Clin. Med. 2019,8, 688 2 o 10
a ious p og ammes aimed a sol ing one o he majo a ou ing ac o s a e being implemen ed: poo
communica ion be ween p ima y ca e and specialised ca e [4,5].
The e a e se e al ways [
6
–
8
] o imp o e such communica ion, bu i is elemedicine,
including asynch onous consul a ions pla o ms [
3
–
5
,
9
–
15
] (e-Consul a ions) and eal- ime elephone
consul a ions (Cu bside Consul a ion) [
16
–
22
], which has opened new possibili ies o heal h ca e,
ob ained pa icula ly good esul s in he wai ing imes o he i s consul a ion, dec eased ace- o- ace
specialised consul a ions, and inc eased pa ien s and p o essionals’ sa is ac ion [
3
,
5
,
11
,
12
,
16
,
17
,
23
].
Howe e , s udies ha p o ide da a on he wai ing imes un il he esolu ion o he p oblem ha ga e
ise o he e e al ha e no been ound. In addi ion, e-Consul a ions equi e impo an in es men s
and ins i u ional in ol emen , as well as leade ship and wo king hou s on he pa o physicians [
12
].
Wi h eal- ime elephone consul a ions, communica ion p oblems [
15
] we e de ec ed o incomple e
o agmen ed in o ma ion [
7
,
9
–
15
,
19
–
23
], di icul ies o choose he p o essional o be consul ed [
24
],
unp edic able in e up ions ha a e ime consuming, as hey a e no scheduled, e c. [18].
In Spain, heal h ca e is a igh o ci izens and public unds p o ide i s unding. Howe e , he
o ganisa ion i sel is sub oga ed o he egional go e nmen s, which e i o ially di ide hei su ace in
heal h a eas o manage he p o ision o heal h ca e. Each o hese heal h a eas consis s o se e al basic
a eas o p ima y ca e and a hospi al, whe e pa ien s om each a ea could be e e ed o, i necessa y.
Each basic p ima y ca e a ea includes one o mo e p ima y ca e medical cen e s, wi h one o mo e
amily physicians in each. Each pa ien is assigned a amily physician in ela ion o p oximi y o his/he
home. The pa ien s can change hei amily physician whene e hey wish, ha is, hey can choose
hei amily physician among he ones wo king a he closes medical cen e o hei home.
Ou heal h a ea, he No h o Huel a Heal h Managemen A ea (NHHMA), depends on he
egional go e nmen o Andalusia, in sou he n Spain. I is a u al a ea, which consis s o six basic
p ima y ca e a eas and a dis ic hospi al o second le el, whe e ace- o- ace e e al is he only
possibili y o FPs ( amily physician) o p o ide a specialised assessmen , he e is a ch onic sa u a ion
in he ou pa ien in e nal medicine consul a ions (OIMC), since hese assume hei own e e als, bu
also hose o se e al o e loaded special ies (ca diology, pulmonology, gas oen e ology...), and o o he
special ies ha a e no a ailable a ou hospi al ( heuma ology, neu ology, neph ology...). Faced wi h
his si ua ion, i was decided o ca y ou his s udy, in which a sys em o scheduled elephone e e al
(DETELPROG, o i s ac onym in Spanish) was c ea ed as an al e na i e o ace- o- ace e e al, in
which he FP eques s a scheduled OIMC, which is in eg a ed in o he usual consul a ions agenda o
bo h physicians, in o de o ha e a elephone consul a ion wi h he in e nis while he pa ien is in he
FP consul a ion. The objec i e is o imp o e he wai ing imes ega ding ace- o- ace e e al and o
a oid unnecessa y ace- o- ace consul a ions, elimina ing he ba ie s o o he ypes o elemedicine
desc ibed in he p e ious sec ion.
In he i s phase o he s udy [
25
], a educ ion in wai ing imes o he i s in e nal medicine
consul a ion (IMC) was ound. Now, an assessmen o he exis ence o di e ences in he wai ing imes
o he esolu ion o he p ocess be ween he g oups and he numbe o ace- o- ace consul a ions ha
we e a oided in he expe imen al g oup will be ca ied ou .
2. Ma e ials and Me hods
2.1. Design
Randomised con olled clinical ial o wo a ms (expe imen al and con ol) wi hou blinding.
Blinding was no possible due o he impossibili y o blind a ace- o- ace e e al whe e he pa ien
physically goes o he hospi al as compa ed o he DETELPROG, in which he pa ien is a he amily
physician’s o ice.
J. Clin. Med. 2019,8, 688 3 o 10
2.2. Sample
Pa ien s who li ed in one o he six basic heal h a eas o he No h o Huel a Heal h Managemen
A ea (NHHMA) equi ed a e e al o OIMC.
2.3. Sample Size
The is e a.com [
26
] sample calcula o was used o he compa ison o he wo samples in o de
o ob ain a ep esen a i e sample, es ima ing he inclusion o 85 pa ien s pe g oup (expe imen al and
con ol) and conside ing a 15% expec ed p opo ion o d opou s.
2.4. Randomisa ion
A andomisa ion o he FPs wi h quo a was pe o med in he NHHMA ( andomisa ion o pa ien s
by blocks), and hey we e o de ed by dec easing numbe o e e als o IM (In e nal medicine) in 2014.
Subsequen ly, hey we e in o med and o med by a one-hou aining mee ing on he p ojec o each o
he FP. Those FP who ag eed o pa icipa e and signed an in o med consen we e andomly di ided
in o expe imen al g oup and con ol g oup using a able o andom numbe s [
27
]. The andomiza ion
p ocedu e was pe o med wi h he FP. FP we e andomly assigned ei he o he expe imen al o he
con ol g oup. All o he pa ien s ha we e associa ed o each FP we e assigned o he same g oup
han hei FP. The FPs, al eady so ed in bo h g oups, assessed o eligibili y o e e y pa ien who
equi ed a e e al, acco ding o he inclusion and exclusion c i e ia. Subsequen ly, eligible pa ien s
we e in o med, and w i en consen was ob ained. In his way, hose in he con ol g oup e e ed
pa ien s ia ace- o- ace and only collec ed he equi ed da a om hei pa ien s, and hose om he
expe imen al g oup e e ed pa ien s ia DETELPROG. As an exclusion c i e ia o he FP, hose FPs,
who, belonging o he con ol g oup, did no collec da a on a leas 50% o hei e e ed pa ien s
o IM we e excluded, as well as hose belonging o he expe imen al g oup who did no eques
any DETELPROG.
2.5. In e en ion
To ca y ou he DETELPROG, ou appoin men s o 15 min each we e included in he IM
consul a ions agendas o eplace wo o he appoin men s o 30 min ha a e usually scheduled o
each pa ien who a ends he co esponding physician’s o ice o he i s ime. These appoin men s
we e se up by FPs and, subsequen ly, hey se up, in hei own consul ing oom, he same day
and a he same ime, h ee consul a ions ollowed by six minu es, so ha bo h physicians could
ha e ime o he elephone con e sa ion. The e e al pe iods we e om 1 Ma ch o 10 June and
om 3 Oc obe o 12 Decembe 2016, when each FP e e ed hei pa ien s h ough DETELPROG o
in-pe son consul a ion, acco ding o hei g oup. On he day o he appoin men , in he expe imen al
g oup, he FP called an IMC phone numbe ha was speci ically designed o his pu pose, wi h
he pa ien p esen and he hands- ee op ion o he connec ed elephone. In his consul a ion, he
ea men s, complemen a y es s, and p edic able e iews we e ag eed ia elephone o in pe son, bo h
p o essionals lea ing eco d o e e y hing in he pa ien ’s digi al eco d. The eques s, consen s, and
co esponding appoin men s o complemen a y es s we e sen o he pa ien ’s add ess, and hese
would ha e o be pe o med ei he a he heal h cen e (blood es s, X- ay es s) o a he hospi al. All
o he pa ien s we e subsequen ly ollowed up o a yea o up o discha ge om IMC.
2.6. Inclusion C i e ia
Pa ien s who equi ed a e e al o IMC a he disc e ion o hei FP.
2.7. Exclusion C i e ia
A.
Pa ien s whose FP, belonging o he expe imen al g oup, conside ed ha hey would no bene i
om he elephone e e al o any eason and eques ed a ace- o- ace e e al.
J. Clin. Med. 2019,8, 688 4 o 10
B.
Pa ien s who did no ag ee o elephone e e al, e en i hei FP belonged o he
expe imen al g oup.
2.8. D opou s C i e ia
•Pa ien s who did no a end he eques ed complemen a y es s.
•Pa ien s who did no a end he eques ed e iews.
•Pa ien s who died du ing he s udy.
•Pa ien s whose p ocess had no been esol ed wi hin he yea o ollow-up.
2.9. Regis e ed Va iables, Measu emen Techniques and Follow-up o Pa icipan s
As independen a iables o he pa ien s, he ollowing we e eco ded: in e en ion, sex, age,
deg ee o u ali y o he popula ion in which li e [
28
] (index indica ing he deg ee o u ali y, being ze o
he a e age alue o u ali y. Fo i s elabo a ion, he ageing o he popula ion, economic dependence,
ag icul u al occupa ion, habi abili y o he dwellings, and popula ion densi y we e aken in o accoun ),
and he dis ance o he Hospi al o Rio in o om hei popula ion.
As esul a iables, he ollowing we e assessed:
-
Wai ing days o IM consul a ion as he numbe o days elapsed be ween he day o he consul a ion
eques by he FP and he day o he same.
-
Numbe o a oided/a oidable ace- o- ace e e als, such as hose pa ien s who ha e had no
medical e iew in IMC o who had had jus one, since he la es medical e iew a IMC is always
pe o med as a non- ace- o- ace consul a ion o he comple ion o he discha ge epo ha
will be sen by pos . The e o e, in pa ien s wi h 0 o 1 e iews belonging o he expe imen al
g oup, he ace- o- ace consul a ion will be a oided, and, in he con ol g oup, he ace- o- ace
consul a ion could be a oidable.
-
Wai ing days o he esolu ion o he p ocess as numbe o days elapsed om he day o e e al
o IMC un il he day o esolu ion o he p ocess (maximum one yea ), when conside ing his
day as he one in which he FP eco ds in he digi al medical his o y ha he p oblem o which
he pa ien was e e ed has been esol ed, o he day in which his physician d aws up he
discha ge epo .
Pa ien s’ cases o exclusion we e also collec ed. Fo his, a ques ionnai e was c ea ed o he
FPs, whe e he ollowing causes appea ed: pa ien ’s e usal, and six possible causes o FPs’ e usal
(Figu e 1), based on he mos equen ba ie s ha we e de ec ed in o he s udies [
15
,
18
,
19
,
24
] and on
some p oblems de ec ed in his s udy.
The a iables eco d was ca ied ou in wo ways: h ough a da a collec ion shee and h ough he
al eady exis ing da a in he digi al clinical his o y sys em o he Andalusian heal h sys em.
The ollow-up o each pa ien was ca ied ou o one yea o un il he day o he esolu ion o
he p ocess.
J. Clin. Med. 2019,8, 688 5 o 10
J. Clin. Med. 2019, 8, x FOR PEER REVIEW 4 o 10
2.8. D opou s C i e ia
• Pa ien s who did no a end he eques ed complemen a y es s.
• Pa ien s who did no a end he eques ed e iews.
• Pa ien s who died du ing he s udy.
• Pa ien s whose p ocess had no been esol ed wi hin he yea o ollow-up.
2.9. Regis e ed Va iables, Measu emen Techniques and Follow-up o Pa icipan s
As independen a iables o he pa ien s, he ollowing we e eco ded: in e en ion, sex, age,
deg ee o u ali y o he popula ion in which li e [28] (index indica ing he deg ee o u ali y, being
ze o he a e age alue o u ali y. Fo i s elabo a ion, he ageing o he popula ion, economic
dependence, ag icul u al occupa ion, habi abili y o he dwellings, and popula ion densi y we e
aken in o accoun ), and he dis ance o he Hospi al o Rio in o om hei popula ion.
As esul a iables, he ollowing we e assessed:
- Wai ing days o IM consul a ion as he numbe o days elapsed be ween he day o he
consul a ion eques by he FP and he day o he same.
- Numbe o a oided/a oidable ace- o- ace e e als, such as hose pa ien s who ha e had no
medical e iew in IMC o who had had jus one, since he la es medical e iew a IMC is always
pe o med as a non- ace- o- ace consul a ion o he comple ion o he discha ge epo ha will
be sen by pos . The e o e, in pa ien s wi h 0 o 1 e iews belonging o he expe imen al g oup,
he ace- o- ace consul a ion will be a oided, and, in he con ol g oup, he ace- o- ace
consul a ion could be a oidable.
- Wai ing days o he esolu ion o he p ocess as numbe o days elapsed om he day o e e al
o IMC un il he day o esolu ion o he p ocess (maximum one yea ), when conside ing his
day as he one in which he FP eco ds in he digi al medical his o y ha he p oblem o which
he pa ien was e e ed has been esol ed, o he day in which his physician d aws up he
discha ge epo .
Pa ien s’ cases o exclusion we e also collec ed. Fo his, a ques ionnai e was c ea ed o he FPs,
whe e he ollowing causes appea ed: pa ien ’s e usal, and six possible causes o FPs’ e usal (Figu e
1), based on he mos equen ba ie s ha we e de ec ed in o he s udies [15,18,19,24] and on some
p oblems de ec ed in his s udy.
Figu e 1. Causes o exclusion o elephone e e al.
9
19.57%
16
34.78%
4
8.70% 3
6.52%
6
13.04% 5
10.87% 3
6.52%
0
5
10
15
20
Pa ien 's
e usal
Complex
pa ien
Lack o ime I o go Subs i u e
Physician
O he causes Ad ice om
Eme gency
Se ices
Coun
Figu e 1. Causes o exclusion o elephone e e al.
2.10. S a is ical Analysis
The ollowing independen a iables ega ding he pa ien s we e assessed: pa ien s in he
expe imen al and con ol g oups, pa ien s who we e excluded, and pa ien s emo ed a e es ima ions
o sex equencies, as well as he median calcula ion (25 pe cen ile–75 pe cen ile) in he o he h ee
a iables, o ailing o mee no mali y c i e ia.
To assess he exis ence o s a is ically signi ican di e ences be ween g oups ega ding he
independen a iables, he chi squa ed es was calcula ed o sex, and he non-pa ame ic es by
K uskall–Wallis o he o he h ee a iables, wi h a le el o signi icance o 0.05 and a con idence
in e al o 95%.
Calcula ing he equencies o a oided/a oidable consul a ions, and median (25 pe cen ile–75
pe cen ile) o he o he wo a iables, o no mee ing he no mali y c i e ia ei he , we e uses o
desc ip i ely assessing he ou come a iables. Subsequen ly, whe he he e we e s a is ically signi ican
in e -g oup di e ences was analysed using he chi squa ed echnique o he i s a iable and, o he
o he wo, h ough he Mann–Whi ney U non-pa ame ic es , wi h a signi icance le el o 0.05 and a
con idence in e al o 95%, subsequen ly applying he Hodges–Lehman median di e ence es ima o
o independen samples.
A desc ip i e analysis o he causes o wi hd awal was also conduc ed by calcula ing equencies,
hus analysing he exis ence o s a is ically signi ican di e ences be ween he expe imen al and he
con ol g oups h ough he chi squa ed echnique.
2.11. E hical and Legal Aspec s
The Resea ch E hics Commi ee o he P o ince o Huel a has e alua ed and au ho ized his
s udy. In addi ion, as a andomised con olled ial, i has been egis e ed wi h T ial Regis a ion
Numbe ACTRN12617001536358.
3. Resul s
The 17 FPs o he con ol g oup e e ed 164 pa ien s, o whom 63 (38.4%) we e wi hd awn om
he s udy. Table 1desc ibes he sociodemog aphic cha ac e is ics o he popula ion.

J. Clin. Med. 2019,8, 688 6 o 10
Table 1.
Sociodemog aphic cha ac e is ics o he included and excluded amily physicians (FPs)
by g oups.
Sociodemog aphic Cha ac e is ics FPs Excluded
(n=20)
Expe imen al G oup
(n=13)
Con ol G oup
(n=17) p-Value
Sex n(%)
Male
Female
13 (65%)
7 (35%)
7 (53.8%)
6 (46.8%)
14 (82.4%)
3 (17.6%) 0.236
Age in yea s a57.5 (36–60) 59 (43–61.5) 54 (43–58.5) 0.624
Dis ance o hospi al in kilome es b44.5 (±25.4) 3.9 (±11.4) 32 (±24.4) 0.551
Heal h insu ance ca ds adjus ed by age b1.747 (±590) 1.756 (±635) 1.804 (±570) 0.926
N o e e als in 2014 a32 (22–45) 27 (20–49) 21 (18–32) 0.101
Ru ali y deg ee b−0.53 (±0.54) −0.57 (±0.41) −0.57 (±0.51) 0.768
a: Median (qua ile ange P25–P75); b: Mean (±s anda d de ia ion). FP: amily physician.
The 13 FPs o he expe imen al g oup e e ed 172 pa ien s, o which 91 (53%) we e e e ed
h ough DETELPROG and 81 (47%) h ough ace- o- ace consul a ion. These las 81 pa ien s we e
excluded o mee ing one o he exclusion c i e ia, being P ima y ca e (PC) di icul y o pa ien s’
managemen he mos common c i e ion (Figu e 1). O he 91 pa ien s in he expe imen al g oup, 19
(20.9%) we e wi hd awn om he s udy o mee ing one o he wi hd awal c i e ia (Figu e 2), wi h
he e being s a is ically signi ican di e ences ega ding he numbe o wi hd awn pa ien s be ween
he expe imen al and he con ol g oups (38.4% s. 20.9%; p=0.04), bu no in he dis ibu ion o
wi hd awals acco ding o hei causes p=0.88.
J. Clin. Med. 2019, 8, x FOR PEER REVIEW 6 o 10
excluded o mee ing one o he exclusion c i e ia, being P ima y ca e (PC) di icul y o pa ien s’
managemen he mos common c i e ion (Figu e 1). O he 91 pa ien s in he expe imen al g oup, 19
(20.9%) we e wi hd awn om he s udy o mee ing one o he wi hd awal c i e ia (Figu e 2), wi h
he e being s a is ically signi ican di e ences ega ding he numbe o wi hd awn pa ien s be ween
he expe imen al and he con ol g oups (38.4% s. 20.9%; p = 0.04), bu no in he dis ibu ion o
wi hd awals acco ding o hei causes p = 0.88.
Figu e 2. Wi hd awn pa ien s’ coun by wi hd awal cause.
Table 2 desc ibes he pa ien s’ independen a iables, inding s a is ically signi ican di e ences
ega ding he dis ance o he hospi al and he deg ee o u ali y o he a ea.
Table 2. Sociodemog aphic cha ac e is ics o he included and excluded pa ien s by g oups.
Sociodemog aphic
Cha ac e is ics
Excluded Pa ien s
(n = 81)
Wi hd awn Pa ien s
(n = 82)
Expe imen al G oup
(n = 72)
Con ol G oup
(n = 101) p-Value
Sex n (%)
Male
Female
33 (40.7%)
48 (59.3%)
33 (40.2%)
49 (59.8%)
31 (43.1%)
41 (56.9%)
41 (40.6%)
60 (59.4%) 0.985
Age in yea s a 56(44.42–69.50) 54.8(39.75–71.34) 56 (41.25–66) 56 (43–69.30) 0.92
Ru ali y deg ee a −0.9(−0.92–−0.59) −0.78(−1.09–−0.59) −0.69(−0.92–−0.42) −0.78(−1.13–−0.43) 0.02
Dis ance o hospi al
in kilome es a 30.5 (27–35) 27 (3.7–41.22) 36.2 (27–44.9) 23 (0–41.3) ˂0.01
a: Median (qua ile ange P25–P75).
Rega ding he pa ien s’ diseases, Table 3 summa izes he esul s o he medical special y, whe e
he pa ien s we e e e ed.
Table 3. F equency o e e al diseases by g oups.
Medical Special y G oup To al
Con ol (n) Expe imen al (n)
Re e al disease
Ca dio ascula 15 11 26
Endoc inology 6 5 11
Neu ology 9 2 11
Gas oen e ology 52 33 85
Oncology 0 2 2
Neph ology 1 2 3
Rheuma ology 4 4 8
O he s 14 13 27
To al 101 72 173
21
1
13
28
73
9
0
10
20
30
No a ending o
i s IM
consula ion
Dea h No a ending
PC o e iew
No discha ged
a e he ollow-
up yea
Coun
Cause o wi hd awal
Con ol
Expe imen al
Figu e 2. Wi hd awn pa ien s’ coun by wi hd awal cause.
Table 2desc ibes he pa ien s’ independen a iables, inding s a is ically signi ican di e ences
ega ding he dis ance o he hospi al and he deg ee o u ali y o he a ea.
Table 2. Sociodemog aphic cha ac e is ics o he included and excluded pa ien s by g oups.
Sociodemog aphic Cha ac e is ics Excluded Pa ien s
(n=81)
Wi hd awn Pa ien s
(n=82)
Expe imen al G oup
(n=72)
Con ol G oup
(n=101) p-Value
Sex n(%)
Male
Female
33 (40.7%)
48 (59.3%)
33 (40.2%)
49 (59.8%)
31 (43.1%)
41 (56.9%)
41 (40.6%)
60 (59.4%) 0.985
Age in yea s a56(44.42–69.50) 54.8(39.75–71.34) 56 (41.25–66) 56 (43–69.30) 0.92
Ru ali y deg ee a−0.9(−0.92–−0.59) −0.78(−1.09–−0.59) −0.69(−0.92–−0.42) −0.78(−1.13–−0.43) 0.02
Dis ance o hospi al in kilome es a30.5 (27–35) 27 (3.7–41.22) 36.2 (27–44.9) 23 (0–41.3) <0.01
a: Median (qua ile ange P25–P75).
J. Clin. Med. 2019,8, 688 7 o 10
Rega ding he pa ien s’ diseases, Table 3summa izes he esul s o he medical special y, whe e
he pa ien s we e e e ed.
Table 3. F equency o e e al diseases by g oups.
Medical Special y G oup To al
Con ol (n) Expe imen al (n)
Re e al disease
Ca dio ascula 15 11 26
Endoc inology 6 5 11
Neu ology 9 2 11
Gas oen e ology 52 33 85
Oncology 0 2 2
Neph ology 1 2 3
Rheuma ology 4 4 8
O he s 14 13 27
To al 101 72 173
Wi h ega d o he esul a iables (Table 4), 91.7% o he DETELPROG a oided a ace- o- ace
consul a ion wi h he in e nis , wi h 85.1% o he con ol g oup consul a ions being p edic ably
a oidable and no inding s a is ically signi ican di e ences be ween bo h g oups.
Table 4. Summa y and di e ences be ween g oups o he dependen a iables.
Va iable Expe imen al G oup
(n=72)
Con ol G oup
(n=101) p-Value
Medians
Di e ences in
Days (CI 95%)
A oided/a oidable ace- o- ace e e als n(%) 66 (91.7) 86 (85.1) p=0.290
No s a is ically
signi ican
di e ences
Wai ing ime o IM consul a ion, in days a11 (7–19) 41 (23–56) p<0.001 27 (20–33)
Wai ing ime o esolu ion o he p ocess, in days 104.5 (39.5–169) 147 (74–228) p=0.002 46 (17–74)
a: Median (qua ile ange P25–P75). IM: in e nal medicine; CI: con idence in e al.
Rega ding he wai ing days o IM consul a ion and up o he esolu ion o he p ocess, s a is ically
signi ican di e ences we e ound be ween bo h o he g oups (p<0.001 and p=0.002 espec i ely),
wi h a di e ence o 27 (CI 95%: 20–33) and 46 (CI: 95%: 17–74) days, espec i ely.
Du ing he s udy, 9.3% o he o al ime designed o i s consul a ions in PC was de o ed o
DETELPROG. DETELPROG ep esen ed abou 9% o all he e e als o IM. Thus, his p ocess a oided
he o he wo ypes o e e al.
4. Discussion
In his s udy, we ound ha DETELPROG, as compa ed o ace- o- ace e e al ( he only exis ing
model o e e al in he NHHMA), conside ably dec eases he wai ing days o he esolu ion he
p ocess o which he pa ien is e e ed, a oiding ace- o- ace specialised consul a ion in almos
all cases.
In he Canadian RACE p og am [
22
], one o he mos powe ul immedia e elephone consul a ion
p og ams in he wo ld, he e is no wai ing any longe , as he call is answe ed in eal ime. Howe e ,
only 60% o he elephone consul a ions a oids ace- o- ace consul a ion, in con as o he 91% a oided
wi h DETELPROG.
Wi h ega d o e-consul a ions, he wai ing days o he specialis ’s esponse a e be ween 0 and
ou days, bu da a on a oided ace- o- ace specialis consul a ions a e highly a iable, be ween 12%
and 85% [3–5,14].
In he case o egula mee ings wi h a e e ence specialis , in an Andalusian s udy also on PC and
IM [7], only 73% o ace- o- ace consul a ions we e a oided.
J. Clin. Med. 2019,8, 688 8 o 10
Da a on he wai ing days o he esolu ion o he p ocess ha e no been ound in he s udies, which
was conside ed o be he mos impo an measu e in his s udy o being he ac ual ime elapsed un il
he esolu ion o he pa ien ’s p oblem, and because his is conside ably educed wi h DETELPROG
when compa ed o ace- o- ace e e als.
As o he di e ences ha we e ound be ween he g oups ega ding he dis ance o he hospi al,
he mos ele an di e ence is ound be ween he expe imen al and he con ol g oup in 10.4 km
(19.6–5.1). Thus, i is possible o sugges ha pa ien s who li e close o he hospi al a e mo e likely o
ejec he elephone e e al, al hough he di e ences in dis ance a e so small ha i is no possible
o con i m his idea, based on he da a ha we e ob ained in his s udy. As o he deg ee o u ali y,
a possible endency is de ec ed o no using new echnologies o e e als, al hough he di e ences,
albei minimal, go in he opposi e di ec ion.
As o he low co e age o DETELPROG (53% o he pa ien s in he expe imen al g oup), we
belie e i o be necessa y o unde ake a quali a i e s udy o analyse ba ie s, di icul ies, and possible
a eas o imp o emen ega ding DETELPROG a g ea e leng h, so as o op imise his ype o e e al
and make i possible o implemen his sys em in ou heal h a ea, and e en expo i o o he a eas.
The e o e, we conside ha DETELPROG, as compa ed o ace- o- ace e e al ( he only exis ing
model o e e al in he NHHMA), conside ably dec eases he wai ing days o he esolu ion he
p ocess o which he pa ien is e e ed (pa ame e no alued in s udies on o he models o e e al),
a oiding ace- o- ace specialised consul a ion in almos all cases.
The educ ion o wai ing days o he i s IM consul a ion wi h DETELPROG is no as ele an
as i is in he case o eal- ime elephone consul a ions o in he case o e e als h ough elec onic
pla o ms. Howe e , i is a e e al me hod ha does no equi e any ex ao dina y economic o
poli ical suppo , which educes wai ing days wi h espec o ace- o- ace e e al, and ha does no
imply he ba ie s o eal- ime elephone consul a ions ha a e caused by immediacy and a lack o
p og ammabili y. In addi ion, we canno o ge ha his is he model ha mo e ace- o- ace e e als
a oid acco ding o he da a ha a e ound in he li e a u e.
We also belie e ha his model o scheduled elephone e e al would be applicable o o he
special ies in which e e als wi h good esul s we e al eady applied h ough asynch onous elec onic
pla o ms and/o immedia e elephone consul a ions [
14
,
22
], bo h in u al and u ban en i onmen s.
Howe e , speci ic s udies would be needed in hese special ies and o he a eas o suppo his hypo hesis.
As a limi a ion, we conside ha he educ ion o wai ing days is lowe han in he o he models
o eal- ime elephone consul a ions and e-consul a ions, bu no addi ional expendi u e o in ol emen
o he adminis a ions is equi ed o DETELPROG, as is he case o e-consul a ions, being his a
model ha is only applicable i p o essionals eques i . On he o he hand, wi h his new ype o
e e al, no p oblems a e de i ed om he immediacy and he lack o p og ammabili y o eal- ime
elephone e e als.
5. Conclusions
As in he p e ious a icle, we do no conside DETELPROG o complex pa ien s (34.8% o pa ien s
excluded) [
25
], whose diagnoses a e no mo e o less ou lined om PC o ega ding pa ien s who
equi e a mo e specialised clinical managemen o examina ion. Howe e , we belie e ha he low
co e age o DETELPROG (53%) does no make i an exclusi e e e al model, bu a complemen
o o he echniques. I necessa y o conduc in-dep h analysis o he causes ha ha e led o his
echnologically low co e age.
Au ho Con ibu ions:
Concep ualiza ion, L.M.A.-L. and J.J.P.-L.; Da a cu a ion, L.M.A.-L., J.J.P.-L. and E.M.M.-S.;
Fo mal analysis, L.M.A.-L., J.J.P.-L. and E.M.M.-S.; Funding acquisi ion, L.M.A.-L.; In es iga ion, L.M.A.-L., J.J.P.-L.
and E.M.M.-S.; Me hodology, J.J.P.-L., E.M.M.-S., J.G.-S. and V.C.-V.; P ojec adminis a ion, L.M.A.-L. and J.J.P.-L.;
Resou ces, L.M.A.-L. and V.C.-V.; So wa e, L.M.A.-L. and J.J.P.-L.; Supe ision, V.C.-V.; Valida ion, L.M.A.-L.,
J.J.P.-L. and E.M.M.-S.; Visualiza ion, E.M.M.-S., J.G.-S. and V.C.-V.; W i ing—o iginal d a , L.M.A.-L., J.J.P.-L.,
E.M.M.-S. and J.G.-S.; W i ing— e iew & edi ing, V.C.-V.
J. Clin. Med. 2019,8, 688 9 o 10
Funding:
This a icle is pa o he doc o al hesis P ojec by Luis Miguel Azogil-L
ó
pez, de eloped wi h he help o
he Andalusian Socie y o Family and Communi y Medicine -SAMFyC- (Reco d e . 157/18), h ough he “ISABEL
FERNÁNDEZ” g an o he suppo o esea ch and doc o al hesis p ojec s, wi hin he SAMFyC 2018 call.
Con lic s o In e es :
The au ho s decla e no con lic o in e es . The unde s had no ole in he design o he
s udy; in he collec ion, analyses, o in e p e a ion o da a; in he w i ing o he manusc ip , o in he decision o
publish he esul s.
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