The characteristics of high and low attenders at two general practices

Changing circumstances drive changing attendance: A longitudinal cohort study of time varying predictors of frequent attendance in primary health care

OBJECTIVE

To investigate risk factors for frequent attendance in primary care over time, contrasting models based on baseline and time-varying characteristics.

METHODS

Analysis of data from the Personality and Total Health (PATH) Through Life Project: a representative community cohort study from the Canberra region of Australia. A balanced sample of 1734 respondents, initially aged in their early 40s, were assessed on three occasions over 8 years. The survey assessed respondents' experience of chronic physical conditions, self-reported health, depression symptoms, personality, life events, socio-demographic characteristics and self-reported medication use. Survey data were linked to respondent's own administrative health service use data, and used to generate an objective measure of general practitioner (GP) consultations over a 12-month period. For each gender, respondents in the (approximate) highest decile of GP consultations at each time point were defined as frequent attenders (FAs).

RESULTS

Analysis showed chronic health conditions, self- reported health, mental health and medication use measured at baseline was associated with FA status, with some gender differences evident. However taking into account of changing circumstances improved the model fit and the prediction over FA status over time.

CONCLUSIONS

The study showed that there is considerable variability in frequent attender status over the study period. While baseline characteristics can predict current and future frequent attender status, it is clear that frequent attender in primary care does reflect changing circumstances over time.

Longitudinal cohort study describing persistent frequent attenders in Australian primary healthcare

OBJECTIVES

To describe patterns of frequent attendance in Australian primary care, and identify the prospective risk factors for persistent frequent attendance.

DESIGN, SETTING AND PARTICIPANTS

This study draws on data from the Personality and Total Health (PATH) Through Life Project, a representative community cohort study of residents from the Canberra region of Australia. Participants were assessed on 3 occasions over 8 years. The survey assessed respondents' experience of chronic physical conditions, self-reported health, symptoms of common mental disorders, personality, life events, sociodemographic characteristics and self-reported medication use. A balanced sample was used in analysis, comprising 1734 respondents with 3 waves of data. The survey data for each respondent were individually linked to their administrative health service use data which were used to generate an objective measure of general practitioner (GP) consultations in the 12 months surrounding their interview date.

MAIN OUTCOME MEASURES

Respondents in the (approximate) highest decile of attenders on number of GP consultations over a 12-month period at each time point were defined as frequent attenders (FAs).

RESULTS

Baseline FAs (8.4%) were responsible for 33.4% of baseline consultations, while persistent FAs (3.6%) for 15.5% of all consultations over the 3 occasions. While there was considerable movement between FA status over time, consistency was greater than expected by chance alone. While there were many factors that differentiated non-FAs from FAs in general, persistent frequent attendance was specifically associated with gender, baseline reports of depression, self-reported physical conditions and disability, and medication use.

CONCLUSIONS

The degree of persistence in GP consultations was limited. The findings of this study contribute to our understanding of the risk factors that predict subsequent persistent frequent attendance in primary care. However, further detailed investigation of longitudinal patterns of frequent attendance and consideration of time-varying determinants of frequent attendance is required.

Insecure attachment and frequent attendance in primary care: a longitudinal cohort study of medically unexplained symptom presentations in ten UK general practices

BACKGROUND

In primary care frequent attenders with medically unexplained symptoms (MUS) pose a clinical and health resource challenge. We sought to understand these presentations in terms of the doctor-patient relationship, specifically to test the hypothesis that such patients have insecure emotional attachment.

METHOD

We undertook a cohort follow-up study of 410 patients with MUS. Baseline questionnaires assessed adult attachment style, psychological distress, beliefs about the symptom, non-specific somatic symptoms, and physical function. A telephone interview following consultation assessed health worry, general practitioner (GP) management and satisfaction with consultation. The main outcome was annual GP consultation rate.

RESULTS

Of consecutive attenders, 18% had an MUS. This group had a high mean consultation frequency of 5.24 [95% confidence interval (CI) 4.79-5.69] over the follow-up year. The prevalence of insecure attachment was 28 (95% CI 23-33) %. A significant association was found between insecure attachment style and frequent attendance, even after adjustment for sociodemographic characteristics, presence of chronic physical illness and baseline physical function [odds ratio (OR) 1.96 (95% CI 1.05-3.67)]. The association was particularly strong in those patients who believed that there was a physical cause for their initial MUS [OR 9.52 (95% CI 2.67-33.93)]. A possible model for the relationship between attachment style and frequent attendance is presented.

CONCLUSIONS

Patients with MUS who attend frequently have insecure adult attachment styles, and their high consultation rate may therefore be conceptualized as pathological care-seeking behaviour linked to their insecure attachment. Understanding frequent attendance as pathological help seeking driven by difficulties in relating to caregiving figures may help doctors to manage their frequently attending patients in a different way.

Frequent attenders in general practice care: A literature review with special reference to methodological considerations

OBJECTIVE

To describe the basis on which our knowledge of frequent attendance in general practice rests and to propose recommendations for further research on frequent attenders (FAs).

DESIGN

The literature review (finished February 2004) encompassed peer-reviewed articles in English describing contacts with general practice in terms of frequency. Searches were performed in the Medline, CINAHL, EMBASE, PsycINFO, Social Sciences Expanded Index and ISI Citation databases with additional searches in reference lists and the 'related articles' function in the ISI Citation database and Medline.

SETTING

General practice.

SUBJECTS

Sixty-one articles (54 studies).

MEASURES

The articles were assessed according to the following design variables: setting; definition of FAs; sampling; sample size; control groups; study aim; study design; data sources; effect measure; and main results.

RESULTS

There was no generally accepted definition of frequent attendance. Research designs differed substantially. Eight articles gave sufficient information on all design variables. The top 10% of attenders accounted for 30-50% of all contacts, and up to 40% of FAs were still FAs the following year. More than 50% of FAs had a physical disease, more than 50% of FAs suffered from psychological distress, social factors (low social support, unemployment, divorce) were associated with frequent attendance in more than 50% of FAs, multiproblems (physical, psychological and social) were found in one-third of FAs, and frequent attendance was associated with increasing age and female gender.

CONCLUSION

The diversity of designs, definitions and methods in the current literature on FAs in general practice hampers comparison of their precision, validity and generalizability, and calls for cautious interpretation and adoption of a common, generally acceptable definition in future studies.

Physical, mental and social factors associated with frequent attendance in Danish general practice. A population-based cross-sectional study

Knowledge of which factors are prompting patients to seek primary care is important to the ongoing effort to improve management in general, and management of frequent attenders (FAs) in particular. We conducted a cross-sectional population-based study with the aim at examining associations between physical, mental and social factors and frequent attendance in general practice. We collected questionnaire and registry data in the County of Aarhus (630,000 inhabitants), Denmark. Half of the county general practices (132 practices, 220 GPs) were selected randomly. FAs were defined as the top 10% attenders over the past 12 months. A questionnaire including SF-36 and questions about physical and mental health and social conditions was sent to age and gender stratified samples of FAs and non-FAs from these practices. Impairments (SF-36) associated with frequent attendance were physical in 54-71% (prevalence difference (PD): 16-33%, adjusted prevalence ratio (adj. PR): 1.1-1.7), mental in 58-70% (PD: 17-25%, adj. PR:1.1-1.4) and social in 40-59% (PD: 13-28%, adj. PR:0.9-1.5). Among FAs, 46-88% had used three or more different drugs (PD: 26-39%, adj. PR:1.5-2.3) and 27-41% had been referred one or more times to outpatient specialists (PD: 4-19%, adj. PR:1.2-2.5). Although our data cannot determine the direction of causality, they clearly demonstrate that FAs carry a large burden of physical, mental and social impairments which underpins the complexity and heterogeneity of the problems which they present. The results make clear that biopsychosocial management is a core issue in FA management in general practice.

Consultation with the general practitioner triggered by advice from social network members

OBJECTIVE

To investigate whether advice from a person's social network triggers contact with the general practitioner (GP).

DESIGN

Case-crossover design comparing the frequency of advice given to seek medical attention in the period before contact with a GP and the frequency in matching control time periods for the same individual.

SETTING

Twenty-one Danish GPs working in single-handed practices.

SUBJECTS

322 patients, aged between 18 and 91 years, were interviewed by telephone after an unscheduled visit to their GP; 148 were interviewed again 3-6 months later.

MAIN OUTCOME AND MEASURES

The odds of individuals consulting their GP after receiving advice from network members in the period before they contacted their GP compared with the odds of those consulting their GP in the control period(s).

RESULTS

Being advised by others to seek medical attention increased the likelihood of seeking primary health care approximately fivefold--single men received advice significantly less frequently (7%) than women (18%) and cohabiting men (32%).

CONCLUSION

Advice from other social network members to seek medical attention is a frequent and influential cue prompting individuals to contact their GP.

Frequent consulters in general practice: a systematic review of studies of prevalence, associations and outcome

We conducted a systematic review of the observational literature on frequent consulters in general practice. Electronic searching identified 34 studies which met our inclusion criteria. Frequent consulters were identified in a wide range of primary health care settings, confirming that a small proportion of patients is responsible for a disproportionate number of consultations. A cutoff of 9-14 consultations per annum was used to define a frequent consulter in most studies. Studies have examined a variety of associated characteristics, and indicate that frequent consulters are highly heterogeneous, and have high rates of physical disease, psychiatric illness and social difficulties. Few are likely to conform to the "heartsink" stereotype. These patients are likely to have multiple, complex problems, often including chronic physical disease, with or without psychological and social problems. The natural history of frequent consulting behavior seems to be to persist in many cases. Implications for management are discussed.

Cold/flu knowledge, attitudes and health care practices: results of a two-city telephone survey

The purpose of this paper is to describe knowledge, attitudes and practices of cold and flu self-care and health care utilization, and to identify the predictors of health care utilization for the cold and flu among residents of London and Windsor. Using a random digit dialing survey method, 417 residents were interviewed between November-December, 1993 and February-March, 1994. This survey revealed good knowledge about colds and flu and understanding of appropriate physician visits. Only seven percent reported a doctor visit for their last cold. Socio-demographic, health status, attitude and knowledge level variables were subjected to a logistic regression analysis to identify which variables predicted self-reported physician visits. Only attitudes and health status showed statistically significant log odds (3.6 and 1.5, respectively). In summary, consistent with other studies, attitude and health status, not knowledge, appear to be significant predictors of physician visits for colds/flu.

Long-term outcome of patients with neurotic illness in general practice

OBJECTIVE

To determine the 11 year outcome of neurotic disorder in general practice.

DESIGN

Cohort study over 11 years.

SETTING

Two general practices in Warwickshire England.

SUBJECTS

100 patients selected to be representative of those identified nationally by general practitioners as having neurotic disorders.

MAIN OUTCOME MEASURES

Mortality, morbidity, and use of health services.

RESULTS

At 11 years 87 subjects were traced. The 11 year standardised mortality ratio was 173 (95% confidence interval 164 to 200). 47 were cases on the general health questionnaire, 32 had a relapsing or chronic psychiatric course, and 49 a relapsing or chronic physical course. Treatment for psychiatric illness was mainly drugs. The mean number of consultations per year was 10.8 (median 8.7). A persistent psychiatric diagnosis at one year follow up was associated with high attendance ( > 12 visits a year for 11 years) at follow up after age, sex, and physical illness were adjusted for. Severity of psychiatric illness (general health questionnaire score) at outset predicted general health questionnaire score at 11 year follow up, course of psychiatric illness, and high consultation rate.

CONCLUSION

These data support the view that a neurotic illness can become chronic and is associated with raised mortality from all causes and high use of services. Such patients need effective intervention, particularly those with a more severe illness who do not recover within one year.

Social problems as factors affecting medical consultation: a comparison between general practice attenders and community probands with emotional distress

Comparison between general practice attenders and community subjects with emotional distress (as measured by GHQ-12) showed that women from a general practice sample reported more social problems than those from the community. In both men and women, problems with their spouse or partner were far more likely among general practice attenders than among community probands. Furthermore, women who consulted the general practitioners could count less often on the availability of friend confidants and had more well-defined physical disorder than their community counterparts. Results from a logistic regression analysis showed that in women (but not in men) problems in the relationship with spouse or partner increased the probability of being a general practice attender more than twofold. Physical health status did not exert a significant effect either in men or in women.

Center differences and cross-national invariance in help-seeking for panic disorder. A report from the cross-national collaborative panic study

Help-seeking behaviour for treatment of panic disorder was investigated in the sample of the Cross-National Collaborative Panic Study Second Phase. A total of 1168 patients were entered into this trial in 14 countries. Although there were significant center differences in prior treatment and utilization of health services there were also similarities. Treatment had been provided mainly by general practitioners. Drug treatment consisted mostly of prescription of classical tranquilizers and had a longer duration than treatment by psychotherapy. Patients with agoraphobic avoidance, past major depression and longer duration of illness used medical and psychiatric treatment facilities more intensely. Older and more severely disabled subjects were more frequently treated by medical health care providers and were more likely to receive psychotropic drugs. The results indicate that general practitioners carry an important load in the treatment of panic disorders but may need more information about recent development in pharmacotherapy for this condition.

Mental health and medical consultation in primary care settings

This paper examines the effect of psychiatric morbidity, as measured by the GHQ-60, on the probability of being in contact with a primary care physician, and the socio-demographic factors which influenced this effect. We found that the presence of psychiatric morbidity emerged as a major determinant of primary care utilization in both sexes, and about one-sixth of consultations in men and one-fifth of consultations in women could be attributed to it. Logistic modelling was used to investigate the joint effect on general practitioner consultation of psychiatric morbidity and seven socio-demographic variables. Sex, age, and psychiatric morbidity exerted independent, but not interactive, effects on consultation.

Not a medical problem? An intensive study of the attitudes and illness behaviour of low attenders with psychosocial difficulties

An intensive study of female low attenders with significant psychosocial difficulties is described. Among the reasons for low reliance upon the help of their general practitioners are unsatisfactory past experiences of seeking help; a belief that health conditions with a pronounced psychosocial component are not amenable to medical intervention; and the availability of professional medical or social advisors in the immediate social network. The implications for the provision of primary care are discussed.

The perception of social problems by husbands and wives in the community

The Social Problem Questionnaire (SPQ) was completed by 132 Italian married couples who were part of a stratified community sample of 207 families. Agreement between husbands and wives on problems in housing, finance, marriage, family and social relationships was assessed by product moment correlation coefficients, weighted kappas, specific agreement indices and three way analysis of variance. The results showed that couples agreed well on the absence but not on the presence of social problems. Although husbands' and wives' ratings on the severity of problems correlated significantly, wives consistently tended to give higher ratings than their husbands. The implications of these results for social research and community surveys are briefly discussed.

The General Practice Research Unit at the Institute of Psychiatry

The General Practice Research Unit (GPRU) was established at the Institute of Psychiatry in the late 1950s, under the honorary directorship of Professor Michael Shepherd. For 30 years it has been staffed by medically qualified workers and social scientists supported, at various times, by the Nuffield Foundation, the Mental Health Research Fund, and the Department of Health and Social Security, as well as by university monies.