Standard nurse phone triage versus tele–emergency care pilot on Veteran use of in‐person acute care: An instrumental variable analysis

OBJECTIVES: Use of acute care telemedicine is growing, but data on quality, utilization, and cost are limited. We evaluated a Veterans Affairs (VA) tele–emergency care (tele‐EC) pilot aimed at reducing reliance on out‐of‐network (OON) emergency department (ED) care, a growing portion of VA spending. With this service, an emergency physician virtually evaluated selected Veterans calling a nurse triage line. METHODS: Calls to the triage line occurring January–December 2021 and advised to seek care acutely within 24 h were included. We described tele‐EC user characteristics, common triage complaints, and patterns in referral to and management by tele‐EC. The primary outcome was acute care visits (ED, urgent care, and hospitalizations at VA and OON sites) within 7 days of the index call. Secondary outcomes included mortality, OON acute care spending, and the effect of tele‐EC visit modality (phone vs. video). We used both standard regression and instrumental variable (IV) analysis, using the tele‐EC physician schedule as the instrument. RESULTS: Of 7845 eligible calls, 15.5% had a tele‐EC visit, with case resolution documented in 57%. Compared to standard nurse triage, tele‐EC users were less likely to be Black, had more prior ED visits, and were triaged as higher acuity. Calls concerning dizziness/syncope, blood in stool, and chest pain were most likely to have a tele‐EC visit. Tele‐EC was associated with fewer ED visits than standard nurse triage in both regression (average marginal effect [AME] −16.8%, 95% confidence interval [CI] −19.2 to −14.4) and IV analyses (AME −17.5%, 95% CI −25.1 to −9.8), lower hospitalization rate (AME −3.1%, 95% CI −6.2 to −0.0), and lower OON spending (AME –$248, 95% CI −$458 to −$38). CONCLUSIONS: Among Veterans initially advised to seek care within 24 h, use of tele‐EC compared to standard phone triage led to decreased ED visits, hospitalizations, and OON spending within 7 days.