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

Importance: 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. Objective: To examine associations between tele-emergency care receipt, modality, and clinician type, and subsequent outcomes. Design, Setting, and Participants: 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. Exposures: Tele-emergency care vs usual care, tele-emergency care modality (phone vs video), and tele-emergency care clinician type (physician vs advanced practice clinician). Main Outcomes and Measures: 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. Results: 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%). Conclusions and Relevance: 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.