Longitudinal cohort study describing persistent frequent attenders in Australian primary healthcare

Long- and short-term frequent attenders' perceptions of patient-centredness in Finnish primary healthcare: A cross-sectional survey and the equivalence of the factor structure of the 36-item patient-centred primary care instrument

AIM

The study aimed to compare long- and short-term frequent attenders' (FAs) perceptions of patient-centredness and to assess the equivalence of the factor structure of patient-centred primary care (PCPC) instrument for long- and short-term FAs.

METHODS

A cross-sectional survey of long-term (n = 234) and short-term (n = 261) FAs within the primary healthcare of one city in Finland. The data collected in January-July 2020 via 'the 36-item PCPC instrument' were analysed using Pearson's chi-squared test, Mann-Whitney U-test, Cronbach's alpha, and multigroup confirmatory factor analysis (MGCFA).

RESULTS

Long-term FAs had worse perceptions of patient-centredness than short-term FAs across all subscales: patients' preferences, physical comfort, coordination of care, continuity and transition, emotional support, access to care, information and education, and family and friends. The MGCFA indicated a good fit for the predicted eight-factor model.

CONCLUSIONS

Long-term FAs' care needs are currently not being met, indicating the need for considering how the way healthcare services are arranged and care is provided affects prolonged and high care needs. Various dimensions of patient-centredness need to be addressed when developing not only FAs' care but also wider service paths. A distinction should be made between long- and short-term frequent attendance when identifying and addressing FAs' service needs.

Patterns of acceptance and use of digital health services among the persistent frequent attenders of outpatient care: A qualitatively driven multimethod analysis

Objective

Utilising digital health services in the treatment of patients who frequently attend outpatient care could be beneficial for patients' health and the sustainability of health systems but carries the risk of digital exclusion. This study aimed to explore the patterns of acceptance and use of digital health services among frequent attenders (FAs), which may help in the assessment of patients' digital suitability.

Methods

Persistent FAs (N = 30) were recruited by random sampling from one Finnish municipality. The semistructured interviews were conducted in February-May 2021. We analysed the data with qualitative content analysis using the Unified Theory of Acceptance and Use of Technology (UTAUT) model. Additionally, we quantified the data for two-step cluster analyses to create separate cluster models that grouped FAs based on acceptance and use of (a) digital services for self-management of health and (b) telemedicine services.

Results

Based on digital self-management, FAs were defined as Self-Managers, Supported Self-Managers, and Non-Self-Managers. Based on telemedicine use, they were grouped into Telemedicine Users, Doubtful Telemedicine Users, and Telemedicine Refusers. The clusters described different opportunities, awareness, and interest in using digital health services. Referral from professionals seemed to promote digital service use. For some, digital services were not accessible.

Conclusions

Our findings emphasise the importance of assessing the suitability of FAs to digital health services, as their readiness to use may vary. Professionals should recommend digital services that support individual health to suitable patients. More accessible digital services could promote digital suitability despite functional limitations.

Use of Health Services and Rehabilitation before and after the Beginning of Long-Term Sickness Absence-Comparing the Use by Employment and Disability Pension Transition after the Sickness Absence in Finland

The objective of the study was to follow the health care and rehabilitation use before, during and after long-term sickness absence (LTSA), and to compare the use by post-LTSA labour market situation in terms of disability pension and employment. Individuals aged 18-58 with a ≥30-day LTSA spell in 2015 (N = 2427) were included from the total population of the city of Oulu, Finland. Register data included LTSA spells, outpatient health care visits, inpatient care spells and rehabilitation spells, disability pensions (DP), employment dates, and demographic, socioeconomic and disability-related covariates. The study population was followed for one year before, and three years after the start of LTSA. Negative binomial regression models were utilized to examine covariate-adjusted use of the three service types and group differences. The use of outpatient health care peaked at the start of the LTSA spell, and adjusted for covariates, the height of the peak was similar regardless of post-LTSA labour market situation. Adjusted for covariates, those who transferred to permanent DP after an LTSA used more outpatient (predicted mean 4.87 for attendance days quarterly, 95% CI 4.36-5.38) and inpatient (predicted mean 84 days quarterly, 95% CI 0.62-1.06) health care than others during three years after the start of LTSA. Individuals not employed after an LTSA showed the highest and increasing level of rehabilitation use. The results indicate that Individuals returning to employment after an LTSA are provided with relatively high amount of early outpatient care, possibly aiding the return. For individuals not employed after an LTSA, rehabilitation is used quite frequently but rather late in the disability process. The frequent use of health care among future disability pensioners is consistent with their increasing health problems leading to retirement.

Factors Contributing to Persistent Frequent Attendance in Primary Care Among the Oldest Old: Longitudinal Evidence From the AgeCoDe-AgeQualiDe Study

Objective

Since there is a lack of longitudinal studies in this area, our aim was to identify the determinants of persistent frequent attendance in primary care among the oldest old in Germany.

Methods

Longitudinal data (follow-up wave 7-9) were taken from the multicenter prospective cohort "Study on needs, health service use, costs, and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe), covering primary care patients ≥ 85 years (FU7 n = 741, mean age 88.9 years (SD 2.9; 85-100)). Persistent frequent attenders of general practitioner (GP) services (the patients in the top decile of the number of GP consultations in two or more consecutive waves) were our main outcome of interest. Logistic random-effects models were used.

Results

Our analysis included 1,891 observations (766 individuals). Across three waves, we identified 56 persistent frequent attenders. Results of random-effects logistic regressions showed that the odds of being persistent frequent attender were higher for widowed individuals (OR = 4.57; 95% CI [1.07-19.45]). Moreover, a one-point increase in the frailty score and having one more chronic condition increased the odds of being a persistent frequent attender by 68% (OR =1.68; 95% CI [1.05-2.69]) and 23% (OR=1.23, 95% CI [1.05-1.44]), respectively.

Conclusion

Our study stressed the longitudinal association between frailty and widowhood as well as chronic diseases and persistent frequent attendance among the oldest old in Germany.

The relationship between motherhood and use of mental health care services among married migrant and non-migrant women: a national register study

BACKGROUND

Giving birth to one's first child is a life changing event. Beyond the post-partum period, little is known about the association between becoming a mother and mental disorder among migrant women. This study investigates outpatient mental health (OPMH) service use, a proxy for mental disorder, among married migrant and non-migrant women who become mothers and those who do not.

METHODS

Using Norwegian register data, we followed 90,195 married women, aged 18-40 years, with no children at baseline between 2008-2013 to see if becoming a mother was associated with OPMH service use. Data were analysed using discrete time analyses.

RESULTS

We found an interaction between motherhood and migrant category. Married non-migrant mothers, both in the perinatal period and beyond, had lower odds of OPMH use than married non-mothers. There was no association between motherhood and OPMH service use for migrants. However, there was no significant interaction between motherhood and migrant category when we excluded women who had been in Norway less than five years. Among women aged 25-40 years, a stable labour market attachment was associated with lower odds of OPMH use for non-migrants but not migrants, regardless of motherhood status.

CONCLUSIONS

The perinatal period is not associated with increased odds of OPMH use and appears to be associated with lower odds for married non-migrant women. Selection effects and barriers to care may explain the lack of difference in OPMH service use that we found across motherhood status and labour market attachment for married migrant women. Married migrant women in general have a lower level of OPMH use than married non-migrants. Married migrant women with less than five years in Norway and those with no/weak labour market attachment may experience the greatest barriers to care. Further research to bridge the gap between need for, and use of, mental health care among migrant women is required.

Outpatient healthcare use before and during a long-term sickness absence spell: a register-based follow-up study comparing healthcare use by the length of sickness absence and transition to disability pension in Finland

OBJECTIVES

The objective of the study was to examine outpatient healthcare use before and during a long-term sickness absence (LTSA), and to compare the development of healthcare use between groups defined through LTSA lengths and disability pension (DP) transition.

DESIGN

Register-based longitudinal study with five 6-month periods before and after the start of the LTSA spell in early 2016.LTSA groups 1 (N=210) and 2 (N=187) went on to reach the statutory maximum LTSA length, with group 1 transitioning to DP. Group 3 (N=3082) had a shorter LTSA spell. Control group 4 (N=92 921) had no LTSA.

SETTING AND PARTICIPANTS

Non-retired individuals aged 20-59, with no LTSA during 2015 (N=96 400) were included from the total population of the city of Oulu, Finland. Register data were linked on LTSA spells and outpatient healthcare use 2013-2018, DP status in 2018, and various covariates.

MAIN OUTCOME MEASURES

Negative binomial regression models were used to examine the covariate-adjusted number of healthcare visits, and to examine the association of the LTSA groups with healthcare use before and after the start of LTSA (incidence rate ratios and predicted means).

RESULTS

Individuals eventually reaching the maximum LTSA length (groups 1 and 2) had a higher level of healthcare use before the LTSA and especially after the start of LTSA than others. Individuals transferring to DP after the maximum LTSA (group 1) used healthcare the most after the start of LTSA.

CONCLUSIONS

The risk for at least 1 year's disability may be identified by frequent outpatient healthcare use years before LTSA. However, future disability retirees could not be identified through their pre-LTSA healthcare use. Instead, their high use of healthcare after the start of the LTSA was consistent with their increasing health problems leading to retirement.

Why parents bring their children with minor health problems to their family practitioners: An unmatched case-control study

Background:

Parents' of young children who frequently attend primary health care (PHC) services for mild health problems (MHPs) can present a complex and difficult challenge for staff. This phenomenon can expose the child to inappropriate overprescribing, unnecessary medical interventions and may impair the quality of life of parents and children.

Aim:

To define driving factors for frequent attenders (FAs) preschool children in PHC services in Kuwait.

Design and Setting:

An unmatched case-control study was conducted in the PHC setting in Kuwait.

Method:

A sample comprised of 300 parents from 10 PHC centres was selected. The top third children with higher frequency (FAs) visits to their family practitioners (FPs) were compared with the lower third with lower frequency (NFAs) visits to their FPs during the same duration. The Brief Illness Perception Questionnaire (Brief IPQ) was used to assess parents' response to their children's illness. The sociodemographic data for both groups were collected. Culture and background heath status for child and family were collected (order of the child in the family, if the family is living with the extended family and additional help received regarding childcare). The previous medical history of parent, child, and siblings was also included.

Results:

The mean number of consultations in FAs versus NFAs within the previous year was 15.5 ± 7.6 and 4.3 ± 2.1, respectively. There was no significant difference in means between the two groups of parents in responses to the questions of the adapted Brief IPQ. FAs were more likely to be the first-order child (odds ratio (OR) 2.4; 95% confidence interval (CI) =1.2–4.6), have chronic disease (OR 4.7; 95% CI = 2.1–10.6), and live with the extended family (OR 1.8; 95% CI = 1.1–3.3). They experienced an acute, potentially life-threatening episode previously (OR 2.6; 95% CI = 1.1–6.4), with the same applying to a sibling (OR 72.6; 1.2–6.2) or parent (OR 2.6; CI = 1.1–6.4).

Conclusion:

Identification of the hidden reasons that affect parents' decisions to consult their FPs frequently for their children's MHPs were important predictors for defining preschool FAs children in the PHC centres and can help the staff provide effective management plans to help them.

Associations of Medical Visits with Dentist Visits: A Register-Linkage Study of a Working-Age Population in Finland

Studies have usually addressed the utilization of either medical or dental services, and less is known about how medical and dentist visits are associated. As oral health is linked to systemic health, knowledge on care coordination between dental and medical services is important to gain understanding of the overall functioning of health care. Register data on 25-64-year-old residents of the city of Oulu, Finland, were used for the years 2017-2018 (N = 91,060). Logit models were estimated to analyze the probability of dentist visits, according to the number of medical visits in total and by three separate health care sectors. The majority, 61%, had visited both a medical professional and a dentist. All sectors combined, as few as one to two visits increased the odds of dentist visits (OR: 1.43, CI: 1.33, 1.53). When separated by medical professionals' health care sectors, for one to two visits, the strongest association was found with public (OR: 1.17, CI: 1.12, 1.22) and private sector (OR: 1.35, CI: 1.30, 1.41). For occupational health service visits, the odds increased only after six or more visits. The results support the idea of integrated medical and dental care. However, the result may also arise from individual health behavior where health-conscious persons seek both medical and dental care independently.

Risk factors for the frequent attendance of older patients at community health service centers in China: a cross-sectional study based on stratified sampling

Background

This study aimed to investigate the characteristics of frequent attenders (FAs) among older patients in Shanghai, China, and explore the associated factors.

Methods

This cross-sectional study was conducted in six community health service centers in Shanghai, China, from August to December 2018 based on stratified sampling. On the basis of our preliminary study, FAs were defined as those attending at least four consultations in a month. A self-administered questionnaire was used to collect the clinicodemographic data of the participants. Social support, pain severity, depression, and anxiety were evaluated using the Social Support Revalued Scale, six-point Behavioral Rating Scale, Patient Health Questionnaire–9, and Generalized Anxiety Disorder Scale, respectively.

Results

This study included 619 patients aged > 60 years. Among these patients, 155 (25%) were FAs to a community health service center, 366 (59.1%) had 1 or 2 chronic diseases, 179 (28.9%) had ≥3 chronic diseases, 313 (50.4%) opted for a family doctor service, and 537 (86.8%) chose a community health service center for the first consultation. The following were identified as independent risk factors for frequent attendance: widowed status, unmarried status, the presence of > 3 chronic diseases, first consultation at a community health service center, high medical expenses, frequent attendance of the spouses, long-term medication, the use of both traditional Chinese and Western medicine services, and depression.

Conclusions

This study summarizes the characteristics of older FAs to community health service centers in China and identifies 10 risk factors significantly associated with frequent attendance.

Sociodemographic characteristics and disability pensions of frequent attenders in occupational health primary care - a follow-up study in Finland

BACKGROUND

Work disability is a complex issue that requires preventive efforts from healthcare systems and individuals, and that too often results in disability pensions (DP). While many studies have attempted to characterize risk factors of work disability, many showing for example a link between socioeconomic positions, working conditions and frequent attendance to OH primary care it is not known if frequent attendance is associated with DP despite the sociodemographic factors. This study aims to address this gap and examine the association between frequent attendance to OH primary care and DP, when adjusted by sociodemographic factors.

METHODS

This study combines routine medical record data of an occupational health service provider with comprehensive national registers. Medical record data were used to define groups of frequent attenders to OH primary care (FA) (1-year-FA, 2-year-FA, persistent-FA and non-FA) from 2014 to 2016. The sociodemographic factors (including i.e. educational level, occupational class, unemployment periods) were derived from Statistic Finland and DP decisions were derived from Finnish Centre for Pensions. Association of frequent attendance to OH primary care with DP decisions were analyzed and adjusted by sociodemographic factors.

RESULTS

In total, 66,381 patients were included. Basic and intermediate education along with manual and lower non-manual work predicted frequent attendance to OH primary care. Unemployment in 2013 did not predict frequent attendance to OH primary care. Frequent attendance to OH primary care was associated with DP within next two years, even when adjusted for sociodemographic factors. The association of frequent attendance to OH primary care with DP grew stronger as high service use persisted over time.

CONCLUSIONS

Frequent attendance to OH primary care is associated with DP risk in the near future despite the underlying sociodemographic differences. Patients using OH primary care services extensively should be identified and rehabilitative needs and measures necessary to continue in the work force should be explored. Sociodemographic issues that co-exist should be explored and considered when planning interventions.

How GPs can Recognize Persistent Frequent Attenders at Finnish Primary Health Care Using Electronic Patient Records

Introduction:

The proportion of patients who are frequent attenders (FAs) varies from few percent to almost 30% of all patients. A small group of patients continued to visit GPs year after year. In previous studies, it has been reported that over 15% of all 1-year FAs were persistent frequent attenders (pFAs).

Objectives:

This study aimed to identify typical features of pFAs from the textual content in their medical entries, which could help GPs to recognize pFAs easily and facilitated treatment.Methods: A retrospective register study was done, using 10 years of electronic patient records. The data were collected from Finnish primary health care centers and used to analyze chronic symptoms and diagnoses of pFAs and to calculate the inverse document frequency weight (IDF) of words used in the patient records. IDF was used to determine which words, if any, are typical for pFAs. The study group consisted of the 5-year pFAs and control group of 1-year FAs. The main background variables were age, gender, occupation, smoking habits, use of alcohol, and BMI.

Results:

Out of 4392 frequent attenders, 6.6% were pFAs for 3 years and 1.1% were pFAs for 5 years. Of the pFAs, 65% were female and 35% were male. The study group had significantly more depressive episodes (P = .004), heart failure (P = .019), asthma (P = .032), COPD (P = .036), epilepsy (P = .035), and lumbago (P = .046) compared to the control group. GPs described their 5-year pFAs by words related to lung and breathing issues, but there was no statistical difference to the 1-year FAs’ descriptions.

Conclusion:

A typical pFA seems to be a woman, aged about 55 years with depressive episodes, asthma or COPD, and lower back pain. Physicians describe pFAs with ordinary words in patient records. It was not possible to differentiate pFAs from 1-year FAs in this way.

Frequent attenders of three outpatient health care schemes in Finland: characteristics and association with long-term sickness absences, 2016-2018

OBJECTIVES

Frequent attenders (FAs) impose a significant burden on service capacity and public health funding. Although the characteristics of the group and their risk for sickness absences (SA) have been studied, an understanding of FAs in different health care schemes is lacking. The aim of the study was to investigate FAs and their SA risk in the working-age population in public care, occupational health services (OHS) and private care schemes. The average number of SA days was also examined by diagnostic group.

SETTING AND PARTICIPANTS

Register data on the use of outpatient health care, sickness allowance spells and background characteristics (2015-2018) for 25-64 year old residents of the city of Oulu, Finland, (n = 91,737) were used. Subjects were categorized into non-attenders, non-frequent attenders and FAs (top decile of attenders) both for all outpatient health care and specifically for each care scheme in 2016. The number of sickness absence days was measured yearly in 2016, 2017 and 2018. The data were analyzed with descriptive methods and negative binomial regression models.

RESULTS

FAs consumed 31 to 44% of all visits depending on scheme in 2016. Frequent attendance was common among low socioeconomic groups in the public scheme, among lower non-manual employees and manual workers in OHS, and among entrepreneurs in the private scheme. FAs had a higher average number of SA days than others in each scheme, although group differences decreased from 2016 to 2017 and 2018. In public care, the adjusted effect of frequent attendance was strong especially for SA due to mental disorders (adjusted incidence rate ratio [IRR] for FAs 13.40), and in OHS for SA due to musculoskeletal disorders (adjusted IRR for FAs 8.68).

CONCLUSION

In each outpatient health care scheme, frequent attenders pose a great challenge both by consuming services and through their increased risk of disability. FAs in different schemes have partially different characteristics and risks. Common patient registers covering various service schemes would enable an identification of FAs visiting multiple schemes and services. Better coordinated services are needed for public care FAs in particular.

Determinants of Frequent Attendance in Primary Care. A Systematic Review of Longitudinal Studies

Introduction: There is a lack of a systematic review synthesizing longitudinal studies investigating the determinants of frequent attendance in primary care. The goal of our systematic review was to fill this gap in knowledge.

Methods: Three electronic databases (Medline, PsycINFO, and CINAHL) were searched. Longitudinal observational studies analyzing the predictors of frequent attendance in primary care were included. Data extraction covered methods, sample characteristics, and main findings. Selection of the studies, extracting the data and evaluation of study quality was performed by two reviewers. In the results section, the determinants of frequent attendance were presented based on the (extended) Andersen model.

Results: In total, 11 longitudinal studies have been included in our systematic review. The majority of studies showed that frequent attendance was positively associated with the predisposing characteristics lower age, and unemployment. Moreover, it was mainly not associated with enabling resources. Most of the studies showed that need factors, and in particular worse self-rated health, lower physical functioning and physical illnesses were associated with an increased likelihood of frequent attendance. While most studies were of good quality, several of the included studies did not perform sensitivity analysis or described how they dealt with missing data.

Discussion: Our systematic review showed that particularly lower age, unemployment and need factors are associated with the likelihood of becoming a frequent attender. Enabling resources are mainly not associated with the outcome measure. Future research should concentrate on the determinants of persistent frequent attendance due to the high economic burden associated with it.

When Love Hurts - Mental and Physical Health Among Recently Divorced Danes

The last decades of research have consistently found strong associations between divorce and adverse health outcomes among adults. However, limitations of a majority of this research include (a) lack of “real-time” research, i.e., research employing data collected very shortly after juridical divorce where little or no separation periods have been effectuated, (b) research employing thoroughly validated and population-normed measures against which study results can be compared, and (c) research including a comprehensive array of previously researched sociodemographic- and divorce-related variables. The current cross-sectional study, including 1,856 recently divorced Danes, was designed to bridge these important gaps in the literature. Mental and physical health were measured using the Short Form 36 (SF-36)-2. Analyses included correlational analyses, t-test comparisons, and hierarchical multiple regression analyses. The study found that the health-related quality of life of Danish divorcees was significantly worse than the comparative background population immediately following divorce. Across gender, higher levels of divorce conflict were found to predict worse mental health, and worse physical health for women, even when controlling for other socio-demographic variables and divorce characteristics. Among men, lower age and higher income predicted better physical health, while more children, more previous divorces, participant divorce initiation, new partner status, and lower levels of divorce conflict predicted better mental health. Among women, higher income, fewer previous divorces, new partner status, and lower levels of divorce conflict predicted better physical health while higher income, participant divorce initiation, new partner status, and lower levels of divorce conflict predicted better mental health. The findings underscore the relevance of providing assistance to divorcees who experience higher levels of divorce conflict immediately following divorce, in seeking to reduce potential long-term negative health effects of divorce.

Differentiating middle-aged long-term and short-term frequent attenders by means of the Northern Finland Birth Cohort 1966 Study

BACKGROUND

Frequent attendance is largely a temporary phenomenon, but only few previous studies have made a distinction between long-term frequent attenders (FAs) and short-term FAs.

AIMS

The aim of this study is to compare the characteristics of middle-aged long-term FAs and short-term FAs.

METHODS

Data from a large Northern Finland Birth Cohort 1966 study's (NFBC1966) 46-year follow-up study (performed in 2012, N = 10 321) were used. The participants (n = 4390) had used public primary healthcare (PPHC) services at least once during 2013-2016 according to Finnish national register data on outpatient visits. A FA was considered a patient who had used PPHC services ≥8 times during 1 year. A long-term FA: a patient who was a FA in at least 3 years during 2013-2016. A short-term FA: a patient who was a FA in 1 or 2 years in 2013-2016. Cross-tabulation, Pearson's chi-squared test, Mann-Whitney U test, and univariate and multivariate binary logistic regression analyses were used.

RESULTS

Of the 4390 participants, 132 (3.0%) were long-term FAs, 645 (14.7%) were short-term FAs, and 3613 (82.3%) were non-FAs. During 2013-2016, long-term FAs accounted for 34.8% of PPHC visits, while short-term FAs accounted 15.4%. Compared to short-term FAs, depression and high income (preventive attribute) were associated with long-term FAs. Female gender and managing usual activities were associated with short-term FAs. Poor self-reported health was associated with both long-term FAs and short-term FAs but increased the risk of being a long-term FA over three times compared to short-term FAs.

CONCLUSIONS

Middle-aged long-term FAs and short-term FAs have distinct characteristics; namely, depression and high income differentiate long-term FAs from short-term FAs. Poor self-reported health was associated with long-term FAs in particular. In order to identify FAs with prolonged service needs and to develop far-reaching interventions, the focus of research should be on long-term FAs.

The effects of nurse-led health coaching on health-related quality of life and clinical health outcomes among frequent attenders: A quasi-experimental study

OBJECTIVE

To evaluate the effects of the nurse-led health coaching on health-related quality of life and clinical health outcomes among frequent attenders in primary healthcare.

METHODS

A quasi-experimental study design. A total of 110 patients were enrolled in the study. The experimental group (n = 52) received nurse-led health coaching and the control group (n = 58) received the usual care at primary health care centres in Finland. The data were collected before the intervention and 12 months via a questionnaire of health-related quality of life and clinical health outcomes as measured by health-coaching nurses.

RESULTS

This study found frequent attenders have low health-related quality of life. The nurse-led health coaching showed no differences in health-related quality of life between the experimental and control groups. However, the nurse-led health coaching had statistically significant effects on the blood pressure and health-related quality of life among the experimental participants, especially in emotional role limitation and energy.

CONCLUSIONS

This study suggests that nurse-led health coaching may lead to an improvement in the health-related quality of life and blood pressure among frequent attenders.

PRACTICE IMPLICATIONS

The health-coaching sessions with own health-coaching nurses and action plans support the frequent attenders´ health promotion goals and implementation.

Determinants of Frequent Attendance in Primary Care. Study Protocol for a Systematic Review of Longitudinal Studies

Thus far, no study has systematically synthesized longitudinal studies investigating the determinants of frequent attendance in primary care. Consequently, the purpose of our systematic review is to give an overview of evidence based on longitudinal observational studies analyzing the determinants of frequent attendance. Three electronic databases (Medline, PsycINFO, CINAHL) will be searched. Moreover, the reference lists of studies included in our systematic review will be searched manually. Longitudinal observational studies examining the determinants of frequent attendance in primary care will be included. Disease-specific samples will be excluded. Data extraction focuses on methods (e.g., measurement of frequent attendance, statistical analysis), characteristics of the sample and key results. Furthermore, the quality of the studies included will be examined using an appropriate tool. Two reviewers will perform study selection, data extraction, and quality assessment. A meta-analysis will be conducted (if possible).

Health-related quality of life among frequent attenders in Swedish primary care: a cross-sectional observational study

OBJECTIVES

The aim was to examine health-related quality of life (HRQoL), patient characteristics and reasons for visits to general practitioners (GPs) by frequent attenders (FAs) and a comparison group (CG) in primary care.

METHODS

Patients aged 18-64 years were eligible for the study. Medical records were scrutinised concerning reasons for visits. Questionnaires including short-form health survey (SF-36) were mailed to 331 FAs (≥5 visits at GPs during 2000) and 371 patients in a CG randomly selected from two healthcare centres and returned by 49% and 57%, respectively. FAs' SF-36 health profiles were compared both to CG and general Swedish population norms.

RESULTS

FAs report lower HRQoL than CG and below the general Swedish population norms in all eight SF-36 domains including both mental and physical component summary scores (MCS and PCS). Effect sizes (ESs) for differences between FAs and norms ranged from 0.79 to 1.08 for specific domains and was 0.94 for PCS and 0.71 for MCS. ESs of FAs versus CG ranged between 0.60 and 0.95 for the domains and was 0.76 for PCS and 0.49 for MCS. There were no significant differences between the FAs and CG with regard to sex, being married or cohabiting, number of children in household or educational level. FAs were more often unemployed, obese, slightly older and used complementary medicine more frequently. Except for injuries, all health complaints as classified in 10 categories were more common among FAs than CG, particularly musculoskeletal pain and psychosocial distress related to compromised HRQoL.

CONCLUSION

The HRQoL is compromised in FAs, both when compared with patients who do not often seek care and to general Swedish population norms. Commonly reported reasons for visiting GPs among FAs were musculoskeletal pain and psychosocial distress. Thus, perceived ill health, particularly pain and distress, seems important for high utilisation of healthcare resources.

Determinants of Frequent Attendance of Outpatient Physicians: A Longitudinal Analysis Using the German Socio-Economic Panel (GSOEP)

There is a lack of population-based longitudinal studies which investigates the factors leading to frequent attendance of outpatient physicians. Thus, the purpose of this study was to analyze the determinants of frequent attendance using a longitudinal approach. The used dataset comprises seven waves (2002 to 2014; n = 28,574 observations; ranging from 17 to 102 years) from the nationally representative German Socio-Economic Panel (GSOEP). The number of outpatient physician visits in the last three months was used to construct the dependent variable “frequent attendance”. Different cut-offs were used (top 25%; top 10%; top 5%). Variable selection was based on the “behavioral model of health care use” by Andersen. Accordingly, variables were grouped into predisposing, enabling, and need characteristics as well as health behavior, which are possible determinants of frequent attendance. Conditional fixed effects logistic regressions were used. As for predisposing characteristics, regressions showed that getting married and losing one’s job increased the likelihood of frequent attendance. Furthermore, age was negatively associated with the outcome measure. Enabling characteristics were not significantly associated with the outcome measure, except for the onset of the “practice fee”. Decreases in mental and physical health were associated with an increased likelihood of frequent attendance. Findings were robust across different subpopulations. The findings of this study showed that need characteristics are particularly important for the onset of frequent attendance. This might indicate that people begin to use health services frequently when medically indicated.

Personality and psychopathology as predictors of patient-initiated overuse in general practice

OBJECTIVE

We aimed to characterize, by means of the MCMI, the psychopathological profile of users above the 95th percentile in the distribution of patient-initiated, face-to-face consultations. Additionally, we sought to determine the specific contribution of the patterns assessed by the Millon inventory in differentiating between the groups above or below this cut-off point.

METHODS

A total of 16803 users who initiated at least one face-to-face consultation with a GP at any of 13 PHC practices over one year, were eligible. After discarding those meeting our exclusion criteria, 129 cases and 109 controls matched by gender and age completed the MCMI-III.

RESULTS

The profile of users above the 95th percentile showed elevated scores for compulsivity and narcissism, reflecting rigidity and perfectionism with anxious symptomatology but with no physical or psychosomatic complaints. Regarding differentiation between the two groups, the results showed elevated scores for dependency to increase the probability of belonging to the group above the 95th percentile; conversely, elevated scores for compulsivity appeared to be protective, decreasing the probability of belonging to this same group. Furthermore, elevated scores for anxiety and major depression also increased the probability of belonging to this group. The results for clinical syndromes present a profile of overusers reporting anxiety and somatic complaints associated with low self-esteem.

CONCLUSIONS

Excessive patient-initiated consultations can be an easily detectable marker for underlying psychological problems. The results suggest that overusers of patient-initiated consultations above the 95th percentile show an MCMI profile associated with dependency, compulsivity, anxiety, and major depression.

Occasional and persistent frequent attenders and sickness absences in occupational health primary care: a longitudinal study in Finland

OBJECTIVES

Frequent attenders (FAs) create a substantial portion of primary care workload but little is known about FAs' sickness absences. The aim of the study is to investigate how occasional and persistent frequent attendance is associated with sickness absences among the working population in occupational health (OH) primary care.

SETTING AND PARTICIPANTS

This is a longitudinal study using medical record data (2014-2016) from an OH care provider in Finland. In total, 59 676 patients were included and categorised into occasional and persistent FAs or non-FAs. Sick-leave episodes and their lengths were collected along with associated diagnostic codes. Logistic regression was used to analyse associations between FA status and sick leaves of different lengths (1-3, 4-14 and ≥15 days).

RESULTS

Both occasional and persistent FA had more and longer duration of sick leave than non-FA through the study years. Persistent FAs had consistently high absence rates. Occasional FAs had elevated absence rates even 2 years after their frequent attendance period. Persistent FAs (OR=11 95% CI 7.54 to 16.06 in 2016) and occasional FAs (OR=2.95 95% CI 2.50 to 3.49 in 2016) were associated with long (≥15 days) sickness absence when compared with non-FAs. Both groups of FAs had an increased risk of long-term sick leaves indicating a risk of disability pension.

CONCLUSION

Both occasional and persistent FAs should be identified in primary care units caring for working-age patients. As frequent attendance is associated with long sickness absences and possibly disability pensions, rehabilitation should be directed at this group to prevent work disability.

Comparing occasional and persistent frequent attenders in occupational health primary care - a longitudinal study

Background

The aim of the study was to compare occasional and persistent frequent attenders in occupational health (OH) primary care and to identify the diagnoses associated with persisting frequent attendance.

Methods

This is a longitudinal study using electronic medical record data from 2014 to 2016 from an OH service provider. Frequent attenders were defined as patients in the top decile of annual visits to healthcare professionals (frequent attender 10%, FA10). FA10 were categorized to three groups according to the persistence of frequent attendance (1-year-FA, 2 year-FA, and persistent-FA = frequent attenders in all three years). This was used as the dependent variable. We used patient sex, age, employer size, industry and distribution of visits and diagnostic codes to characterize the different frequent attender groups.

Results

In total, 66,831 patients were included, of which 592 persistent frequent attenders (0.9% of the study population) consulted the OH unit on average 13 times a year. They made altogether 23,797 visits during the study years. The proportion of women and employees of medium and large employers increased among persistent-FAs when compared to the other groups. Multinomial logistic regression accentuated musculoskeletal disorders and to a lesser extent diseases of the respiratory and nervous system and mental disorders. One in five FA becomes a persistent-FA.

Conclusions

Our results indicate that in the context of a working population the association of musculoskeletal disorders and persistent frequent attendance is emphasized. Persistent frequent attenders also create a substantial demand on physician resources. When planning interventions aimed at working age frequent attenders, subgroups suffering from musculoskeletal disorders should be identified as they are associated with persisting frequent attendance.

Which factors lead to frequent attendance in the outpatient sector among individuals in the second half of life? Evidence from a population-based longitudinal study in Germany

BACKGROUND

Despite only constituting a small percentage of the population, frequent attenders place a tremendous burden on the healthcare system in Germany. Whilst there are some cross-sectional studies that examine the correlates of frequent attendance among older adults, there are only a few longitudinal studies that analyze the factors that lead to frequent attendance among middle-aged or older adults. Thus, the aim of this study was to investigate the factors leading to frequent attendance in the outpatient sector longitudinally.

METHODS

Data was drawn from three waves of a large, population-based sample of community-dwelling individuals aged 40 and above in Germany (n = 1049 in fixed effects regression). Individuals were classified as frequent attenders (GP visits) if they had, on average, visited a GP every second month in the previous 12 months. The same logic was applied for specialist visits.

RESULTS

Conditional FE logistic regressions showed that the onset of frequent attendance (GP visits) was negatively associated with age [OR: 0.91, 95% CI: 0.87-0.95], a change in employment status from employed to unemployed [OR: 2.26, 1.17-4.39], decreases in physical functioning [OR: 0.98, 0.97-0.99], worsening self-rated health [OR: 1.40, 1.11-1.78], and increases in physical illnesses [OR: 1.18, 1.06-1.32]. Similarly, the onset of frequent attendance (specialist visits) was associated with age [OR: 0.95, 0.92-0.98], decreases in physical functioning [OR: 0.99, 0.98-1.00], worsening self-rated health [OR: 1.50, 1.25-1.79], and increases in physical illnesses [OR: 1.24, 1.13-1.35].

CONCLUSIONS

Need factors in particular were associated with the onset of frequent attendance. This relation did not vary by gender nor education, which may indicate that individuals only start to use health services more frequently when their needs increase.

Frequent attendance and the concordance between PHQ screening and GP assessment in the detection of common mental disorders

OBJECTIVE

Frequent Attenders (FAs) have high rates of both common mental disorders (CMD) and physical disorders, partly justifying this service use behaviour. This study examines both case and non-case concordance between CMDs as estimated by a self-report screening questionnaire and as rated by the general practitioner (GP), in FAs compared to Other Attenders (OAs).

METHODS

2275 patients of an overlapping sample of 55 GPs from 2 surveys performed 10 years apart, completed in the waiting room the Patient Health Questionnaire (PHQ) and Client Service Receipt Inventory on 6-month service use. For each patient, the GP rated mental health on a 0-4 scale, with a clear indication that scores of 2 and above referred to caseness. PHQ-CMDs included major and other depressive, anxiety, panic, and somatoform disorders, identified using the original PHQ DSM-IV criteria-based algorithms. FA was defined as the top 10% of attenders in age, sex and survey-year stratified subgroups.

RESULTS

FAs had higher rates of PHQ-CMDs (42% versus 23% for OAs, p < .0001). They reported more personal and social problems, disability and had higher GP-rated physical illness. Survey-day antidepressant/anxiolytic medication prescription was higher for FAs (p < .0001), with (p = .02) but also without a CMD (p < .0001). Both GP/PHQ case and non-case concordance differed between FAs and OAs, with a non-case concordance odds ratio of 0.5 (95% CI: 0.3-0.7, p = .001) for FAs compared to OAs.

CONCLUSION

Despite a greater likelihood of GPs detecting CMDs in FAs, our findings suggest a potential risk of 'over-detection' of patients not reaching CMD threshold criteria among FAs.

Frequent attenders at primary care out-of-hours services: a registry-based observational study in Norway

Background

Out-of-hours (OOH) services are often consulted for problems that are non-urgent. Some of these patients are frequent attenders (FAs) who may constitute a heavy burden on the OOH service. The aim of the present study was to analyse FAs in a comprehensive material, covering all patients who have visited OOH services in Norway during a 10-year period.

Methods

FA was defined as a patient having ≥5 consultations during one year. A cohort of all 15,172 FAs in 2008 was followed until 2017, with a description of demographics, consultations, and diagnoses for each year. FAs in 2017 were also analysed with more extreme definitions (≥10, ≥20, ≥30 consultations). To analyse predictors for FA a logistic regression analysis was performed on the 2017 data.

Results

FAs constituted 2% of all patients (U-shaped age curve and female overrepresentation) and approximately 10% of all consultations each year. 59.8% of the cohort was never FA again, 17.7% had one relapse, 8.6% two, and 4.4% had three relapses. 22.8% was also a FA in 2009. Thereafter the percentage gradually declined to 6.2% in 2017. Only 0.8% of the original cohort were persistent FAs throughout the 10-year period. FAs were three times as likely to be given a psychological diagnosis as the average OOH patient, and this percentage increased in persistent and more extreme FAs. FAs tended to seek help at inconvenient hours (late evening and night), and increasingly so the more extreme they were. Also, they needed more consultation time and more often received home visits. The logistic regression analysis identified the following predictors for becoming FA (odds ratio = OR): Female (OR 1.17), age 0–1 years (OR 3.46), age 70+ (OR 1.57), small municipality (OR 1.61), psychological diagnosis (OR 10.00), social diagnosis (OR 5.97), cancer (OR 6.76), diabetes (OR 4.65), and chronic obstructive pulmonary disease (OR 7.81).

Conclusions

FAs were most common among the youngest children and among the elderly, increasing with age. Females were overrepresented, as were patients with psychosocial problems and various chronic somatic conditions. The majority were only temporary FAs.

Out-of-pocket costs, primary care frequent attendance and sample selection: Estimates from a longitudinal cohort design

This paper examines the effect of out-of-pocket costs on subsequent frequent attendance in primary care using data from the Personality and Total Health (PATH) Through Life Project, a representative community cohort study from Canberra, Australia. The analysis sample comprised 1197 respondents with two or more GP consultations, and uses survey data linked to administrative health service use (Medicare) data which provides data on the number of consultations and out-of-pocket costs. Respondents identified in the highest decile of GP use in a year were defined as Frequent Attenders (FAs). Logistic regression models that did not account for potential selection effects showed that out-of-pocket costs incurred during respondents' prior two consultations were significantly associated with subsequent FA status. Respondents who incurred higher costs ($15-$35; or >$35) were less likely to become FAs than those who incurred no or low (<AUS$15 per consultation) costs, with no difference evident between the no and low-cost groups. However, a counterfactual model that adjusted for factors associated with the selection into payment levels did not find an influence of payment, with only a non-significant gradient in the expected direction. Hence these findings raise doubts that price drives FA behaviour, suggesting that co-payments are unlikely to affect the number of GP consultations amongst frequent attenders.

[Frequent attendance in a Primary Health Care District]

OBJECTIVE

To describe the distribution of frequent attenders (FA) through the different primary care practices in Cordoba-Guadalquivir Health District (Córdoba, Spain).

METHODS

An ecological study was performed, including data from 2011 to 2015. Defining FA as those subjects who made12 or more appointments per year; independently analysed for nursing, general practice and paediatrics. Prevalence of frequent attendance and FA/professional ratio were used as dependent variables. Demographic characteristics from district population, number of health professionals and use of general facilities were also examinated. Aiming to understand FA distribution, primary health settings were classified according to facility size and environmental location (urban, suburban and rural).

RESULTS

The mean prevalence for FA was 10.86% (0.5 SE) for nursing; general practice 21.70% (0.7 SE) and for paediatrics 16.96% (0.7 SE). FA/professional ratios for the different professional categories were: 101.07 (5.0 SE) for nursing, 239.74 (9.0 SE) for general practice and 159.54 (9.8 SE) for paediatrics.

CONCLUSIONS

A major part of primary health care users make a high number of consultations. From this group, women overuse nursing and general practitioner services more compared to men. A higher prevalence of FAs was observed in smaller settings, in rural areas. Although taking the FAs:professional ratio as the bar, medium-size practices are more highly overused.

Is frequent attendance of longer duration related to less transient episodes of care? A retrospective analysis of transient and chronic episodes of care

OBJECTIVES

Frequent attenders (FAs) suffer more and consult general practitioners (GPs) more often for chronic physical and psychiatric illnesses, social difficulties and distress than non-FAs. However, it is unclear to what extent FAs present transient episodes of care (TECs) compared with non-FAs.

DESIGN

Retrospective analysis of all episodes of care (ECs) in 15 116 consultations in 1 year. Reasons for encounter (RFEs) linked to patients' problem lists were defined as chronic ECs (CECs), other episodes as TECs.

SETTING

1 Dutch urban primary healthcare centre served by 5 GPs.

PARTICIPANTS

All 5712 adult patients were enlisted between 2007 and 2009. FAs were patients whose attendance rate ranked within the top decile of their sex and age group in at least one of the years between 2007 and 2009.

OUTCOME MEASURES

Number of RFEs linked to TECs/CECs for non-FAs and 1-year (1yFAs), 2-year (2yFAs) and 3-year FAs (3yFAs), and the adjusted effect of frequent attendance of different duration on the number of TECs.

RESULTS

The average number of RFEs linked to TECs (non-FAs 1.4; 3yFAs 7.3) and to CECs (non-FAs 0.9; 3yFAs 6.2) increased substantially with the duration of frequent attendance. The ratio of TECs to all ECs differed little for FAs (52-54%) and non-FAs (64%). Compared with non-FAs, the adjusted additional number of TECs was 3.4 (95% CI 3.2 to 3.7, 1yFAs), 6.6 (95% CI 6.1 to 7.0, 2yFAs) and 9.4 (95% CI 8.8 to 10.1, 3yFAs).

CONCLUSIONS

FAs present more TECs and CECs with longer duration of frequent attendance. The constant ratio of TECs might be a sign of a low threshold for FAs to consult their GP. The large numbers of TECs in FAs might be associated with their high level of anxiety and low mastery. The consultation pattern of FAs may best be characterised by describing both TECs and CECs.

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.