Acute Care Use and Mortality by Tele-Emergency Care Use, Modality, and Clinician Type.

Abstract

While tele-emergency care pilots have demonstrated potential utility as a model for assessing patients with acute concerns without requiring in-person emergency department evaluation, large-scale evaluations are lacking, and important questions regarding implementation remain. To examine associations between tele-emergency care receipt, modality, and clinician type, and subsequent outcomes. This cohort study included veterans who called the nurse advice line from January 2018 through April 2024 during business hours and were triaged as requiring urgent or emergent evaluation in a national, multicenter setting within the Veterans Health Administration. Tele-emergency care vs usual care, tele-emergency care modality (phone vs video), and tele-emergency care clinician type (physician vs advanced practice clinician). The primary outcome was emergency department visit within 7 days, and the secondary outcomes were hospitalization within 7 days and 30-day mortality. Propensity score weighting was applied, and heterogeneous difference-in-differences models were estimated. The study included 2 511 932 nurse advice line calls from 719 028 veterans (mean [SD] age, 62.3 [16.0] years; 627 515 [87.3%] male). After tele-emergency care implementation, 99 994 of eligible nurse calls (17.4%) resulted in a tele-emergency care visit. Tele-emergency care receipt was associated with a lower probability of emergency department visits within 7 days compared with propensity-weighted calls that did not (28.5% vs 45.0%; average treatment effect, -16.5%; 95% CI, -18.6% to -14.4%), with similar associations for hospitalization and no difference in mortality. The average treatment effect was greater for calls triaged as emergent (-22.0%; 95% CI, -24.1% to -19.9%) vs urgent (-5.6%; 95% CI, -8.4% to -2.9%). Minimal differences were observed by tele-emergency care modality or clinician type. At the facility level, tele-emergency care implementation was associated with a small reduction in emergency department visits for emergent calls (average treatment effect, -2.6%; 95% CI, -5.0% to -0.2%). In this cohort study, tele-emergency care receipt was associated with lower emergency department use, particularly for higher-acuity calls, regardless of modality or clinician type, though facility-level differences were limited. Broader implementation of tele-emergency care could be a solution for health systems seeking to mitigate emergency department crowding while addressing patients' acute care needs.