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Design. —Randomized trial. Setting. —A primary care clinic. Patients. —Four hundred ninety-seven men aged 54 years or older. Objective. —We examined the hypothesis that substituting clinician-initiated telephone calls (telephone care) for some clinic visits would reduce medical care utilization without adversely affecting patient health. Intervention. —Clinicians were asked to double their recommended interval for face-to-face follow-up and schedule three intervening telephone contacts; for control patients, the follow-up interval recommended by their clinician was unchanged. Main Outcome Measures. —Use of medical services and health status. Results. —During the 2-year follow-up period, 7% of patients withdrew or became unavailable. Telephone-care patients had fewer total clinic visits, scheduled and unscheduled, than usual-care patients (19%, P P =.006), fewer admissions, and shorter stays in the hospital (28% fewer total hospital days, P =.005), and 41% fewer intensive care unit days ( P =.03). Estimated total expenditures for telephone care were 28% less per patient for the 2 years ($1656, P =.004). For the subgroup of patients with fair or poor overall health at the beginning of the study (n= 180), savings were somewhat greater ($1976, P =.01). In this subgroup, improvement in physical function from baseline ( P =.02) and a possible reduction in mortality ( P =.06) were also observed. Conclusion. —We conclude that substituting telephone care for selected clinic visits significantly reduces utilization of medical services. For more severely ill patients, the increased contact made possible by telephone care may also improve health status and reduce mortality. ( JAMA . 1992;267:1788-1793)

Address correspondence to: John H. Wasson, MD, (170), Veterans Administration Hospital, White River Junction, VT 05001. nurse practitioners, and four physician assistants) at a rural Veterans Administration General Medical Clinic (VAGMC) provided medical care to the study patients during the study period 1979-1982. To be included in the study, a patient had to be a man aged 55 years or older, and his one-way mileage from home to the VAGMC had to be 90 miles or less. Patients

In Reply.— We share the curiosity expressed by Drs Flynn and Kiel about how provider continuity accounts for significant differences in duration of hospitalization in our study. However, we do not share their concern that the finding was an artifact caused by some unrecognized difference in the two large groups of prospectively randomized patients that made up our study population. Table 2, which demonstrated comparability of patients prior to the analysisperiod of the study, was shortened prior to publication. An appended Table 2 is published in this letter. In a separate manuscript, currently in preparation, we demonstrate that broad descriptions that profile patient health status forecast subsequent use of service better than disease diagnoses. Table 2 demonstrated that health status measures, as well as diagnoses, were comparable in both groups prior to the analysis period of the study.

P6 an outpatient repeatedly sees the same practitioner, is his care influenced? This double-blind randomized trial examines the effects of outpatient health care provider continuity on the process and outcome of the medical care for 776 men aged 55 years and older. Participants were randomized to two different groups of provider care: provider discontinuity and provider continuity. The outcome of the continuity group was significantly different from that of the discontinuity group. During an 18-month period, patients who had been randomized to the continuity group had fewer emergent admissions (20% v 39%) and a shorter average length of stay (15.5 v 25.5 days). These patients also perceived that the providers were more knowledgeable, thorough, and interested in patient education. We conclude that continuity of outpatient provider care for men aged 55 years and older results in more patient satisfaction, shorter hospitalizations, and fewer emergent hospital admissions.