Struggling on my own: a cognitive perspective on frequent attenders' conception of life and their interaction with the healthcare system

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.

'Are they really allowed to treat me like that?' - A qualitative study to explore the nature of formal patient complaints about mental healthcare services in Sweden

The improvement of mental healthcare services requires patients' experiences to identify problems and possible deficits in care. In this study, we explored the nature and meaning of formal patient complaints about mental healthcare services in one region of Sweden using a descriptive design with a qualitative approach. A systematic random sample of 106 formal patient complaints about mental healthcare services in 1 Swedish county was selected and analysed thematically, based on descriptive phenomenology. Themes identified were: lack of access to mental healthcare services and specialist treatment, problems related to unmet needs and difficulties with healthcare staff, insufficient care and treatment and lack of continuity in care, and experiences of not been taken seriously or feeling abused by staff. The vulnerability of patients already in the system is a greater issue than realized. The human right to health and the healthcare of patients with mental ill health can be strengthened by increased access to care, listening to patients properly, and delivering continuity in care.

Frequent attenders' experiences of encounters with healthcare personnel: A systematic review of qualitative studies

Rather than measure demographic factors such as socioeconomics, the aim of this study was to examine the lived experience of frequent attenders by synthesizing findings on their encounters with healthcare personnel. The Scopus, CINAHL, PsycARTICLES, and PubMed (Medline) databases were searched in May 2020 in order to screen studies by title and abstract (n = 1794) and full-text (n = 20). Findings from the included studies (n = 6) were then pooled using meta-aggregation, yielding the following results: difficulties in resolving frequent attenders' situations may create "service circles," frustrating patients with their situation; frequent attenders' own expertise regarding their condition should be recognized and valued alongside that of healthcare professionals when performing collaborative care; a lack of empathy and disparagement may make frequent attenders feel misunderstood and unappreciated; frequent attenders should be recognized as individuals by taking their circumstances into account and providing support accordingly. Frequent attenders' experiences demonstrate the importance of shared decision-making, continuity of care, and acknowledging these patients' individual circumstances. Identifying the variety of frequent attenders' service needs by synthesizing their experiences is a practical way of organizing patient-centered healthcare services.

Experience of being a frequent user of primary care and emergency department services: a qualitative systematic review and thematic synthesis

BACKGROUND

Frequent users of healthcare services are often categorised as 'heavy-cost patients'. In the recent years, many jurisdictions have attempted to implement different public policies to optimise the use of health services by frequent users. However, throughout this process, little attention has been paid to their experience as patients.

OBJECTIVE

To thematically synthesise qualitative studies that explore the experience of frequent users of primary care and emergency department services.

DESIGN

Qualitative systematic review and thematic synthesis.

SETTING

Primary care and emergency department.

PARTICIPANTS

Frequent users of primary care and emergency department services.

METHODS

A qualitative systematic review was conducted using three online databases (MEDLINE with full text, CINAHL with full text and PsycINFO). This search was combined to an extensive manual search of reference lists and related citations. A thematic synthesis was performed to develop descriptive themes and analytical constructs.

STUDY SELECTION

Twelve studies were included. All included studies met the following inclusion criteria: qualitative design; published in English; discussed frequent users' experiences from their own perspectives and users' experiences occurred in primary care and/or emergency departments.

RESULTS

The predominant aspects of frequent users' experiences were: (1) the experience of being ill and (2) the healthcare experience. The experience of being ill encompassed four central themes: physical limitations, mental suffering, impact on relationships and the role of self-management. The healthcare experience embraced the experience of accessing healthcare and the global experience of receiving care.

CONCLUSION

This synthesis sheds light on potential changes to healthcare delivery in order to improve frequent users' experiences: individualised care plans or case management interventions to support self-management of symptoms and reduce psychological distress; and giving greater importance on the patient-providers relationship as a central facet of healthcare delivery. This synthesis also highlights future research directions that would benefit frequent users.

Parents' Reported Experiences When Having a Child with Cataract-Important Aspects of Self-Management Obtained from the Paediatric Cataract Register (PECARE)

Parents are a crucial part in the care of children with pediatric cataract. The aim of this study was to explore and explain sense of coherence, family self-efficacy, perceived social support, fatigue and parent reported experiences (PREM), in order to improve clinical care. Questionnaires were sent to the parents of children registered in the Swedish national Pediatric Cataract Register, PECARE, from 2006–2019 (n = 506). The response rate was 46% (n = 231), 185 mothers and 44 fathers with a mean age of 40.39 years (SD ± 6.41 years). In total, 38% of the parents reported severe fatigue, and mothers were more burdened than fathers. Sense of coherence was strongly related to fatigue, especially among parents of children with bilateral cataract. Mental fatigue and reduced motivation explained 45% of the variation in sense of coherence. Being taken seriously by the ophthalmological clinic explained over 60% of the variation in satisfaction with care when controlled for parents’ age and gender. In conclusion, fatigue is important to take in consideration when interacting with parents of children with cataract, especially those with bilateral cataract. Being taken seriously is the key marker of satisfaction with care and support from professionals. In addition to fatigue, the parents’ age and life situation affect how they perceive their own, as well as the professionals’ effort, and should be considered when tailoring family-centered care.

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.

"No one wants you" - a qualitative study on the experiences of receiving rejection from tertiary care pain centres

Background and aims Four out of 10 referrals to tertiary care pain centres in Norway are not granted pain centre treatment, confirming earlier research on that this group of patients struggle to access the highest standard of care. Still, no study investigating how people with chronic pain experience rejections from pain centres was found. The aim of the study was therefore to investigate how people with chronic pain experience receiving a rejection from tertiary care pain centres after being referred by their general practitioners (GPs). Methods This was a qualitative study with semi-structured individual interviews with 12 persons, seven men and five women, rejected from the four different pain centres in Norway. The data were analysed thematically using systematic text condensation. Results The pain centre rejection created strong reactions, partly because the rejection was perceived as a refusal from the health care system as a whole. This was especially so because the pain centre was regarded as the last remaining treatment option, and given the rejection, they were now declined help by the experts in the field. Even though some informants had received an explanation for why they had not been granted pain centre treatment, a prominent experience was that the informants found it difficult to understand why their referral had been rejected given the severity of their pain. The incomprehensibility of the rejection together with a feeling of lack of future treatment options, increased the hopelessness and frustration of their situation and made it challenging to move on and search for help elsewhere. Conclusions The experiences with the pain centre rejections indicate that the rejection can have grave consequences for each individual in the following months. An improved system for how to handle expectations towards referrals, including prepare for the possibility of rejection and how to follow up a rejection, seems warranted. Implications Because a pain centre rejection most likely is received by persons in a vulnerable position, there should be available health care services to help them understand the rejections. And furthermore, help them to move from disappointment and hopelessness, towards an experience of empowerment and reorientation, by for instance planning further actions and interventions, and thereby, acknowledge their need for help.

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.

Psychological distress in frequent users of primary health care and emergency departments: a scoping review

INTRODUCTION

Frequent users of healthcare services are a small proportion of patients with disproportionately high healthcare usage. A wide array of factors, including psychological distress, leads to frequent use of healthcare services. There is no existing synthesis of research on frequent use and psychological distress in the general population. This scoping review aimed to compare psychological distress between frequent and non-frequent users and to examine the association between psychological distress and frequent use of healthcare services in primary care and emergency department (ED) services.

METHODS

A scoping review was performed following the five steps defined by Arksey and O'Malley. A search strategy was developed with an information specialist in five databases (Medline, PsycINFO, CINAHL, SCOPUS, and PubMed) for articles in English published between 1963 and October 2018. To be included, studies had to be quantitative, have taken place in a primary care or ED setting, have documented frequent use, and have measured psychological distress in patients. Two team members independently gathered the data for each of the included studies. Results were collated, summarized, and reported using narrative synthesis.

RESULTS

Seven studies met the inclusion criteria. Psychological distress in primary care is generally higher in frequent users, and increased psychological distress scores are associated with frequent use. Both studies set in EDs reported noteworthy findings, stating that frequent users reported higher levels of psychological distress and that psychological distress was associated with frequent use.

CONCLUSION

Psychological distress is prevalent in frequent users and has a significant association with frequent use. As such, psychological distress should be evaluated by physicians to prevent or reduce frequent use and to identify candidates for interventions.

Frequent callers in primary health care - a qualitative study with a nursing perspective

AIM

To: (a) describe how telephone nurses define a frequent caller; and (b) describe their experiences with calls from frequent callers to primary healthcare centres.

BACKGROUND

Telephone nursing has been noted to be a cost-effective method to enhance access to and use of health care. Some patients use these services extensively and are called 'frequent callers'. Little is known about this group of callers, the reasons behind these calls and telephone nurses' experiences and strategies to manage the calls.

DESIGN

Descriptive design with a qualitative inductive approach.

METHODS

Interviews were conducted with ten telephone nurses in Sweden in 2015. Qualitative content analysis was conducted.

RESULTS

A main theme was established, called 'Balancing between the experienced and assessed needs', which described the telephone nurses' experiences with calls made by frequent callers to primary healthcare centres and was further described in five categories with 15 subcategories. The categories described telephone nurses' definitions of frequent callers, telephone nurses' views of the underlying reasons for the calls, challenges related to frequent callers, experiences with an increased work load and strategies used to manage and help frequent callers.

CONCLUSION

Frequent callers were commonly encountered by telephone nurses' in this study. Their calls were experienced as complex and demanding to manage. The findings point to needs for guidelines and routines to improve the care of frequent callers. In addition, support and training in communication skills to encounter this group of callers in an optimal and safe way may be required.

Frequent attenders in general practice and immigrant status in Norway: a nationwide cross-sectional study

OBJECTIVE

To compare the likelihood of being a frequent attender (FA) to general practice among native Norwegians and immigrants, and to study socioeconomic and morbidity factors associated with being a FA for natives and immigrants.

DESIGN, SETTING AND SUBJECTS

Linked register data for all inhabitants in Norway with at least one visit to the general practitioner (GP) in 2008 (2 967 933 persons). Immigrants were grouped according to their country of origin into low- (LIC), middle- (MIC), and high-income countries (HIC). FAs were defined as patients whose attendance rate ranked in the top 10% (cut-off point > 7 visits).

MAIN OUTCOME MEASURES

FAs were compared with other GP users by means of multivariate binary logistic analyses adjusting for socioeconomic and morbidity factors.

RESULTS

Among GP users during the daytime, immigrants had a higher likelihood of being a FA compared with natives (OR (95% CI): 1.13 (1.09-1.17) and 1.15 (1.12-1.18) for HIC, 1.84 (1.78-1.89) and 1.66 (1.63-1.70) for MIC, and 1.77 (1.67-1.89) and 1.65 (1.57-1.74) for LIC for men and women respectively). Pregnancy, middle income earned in Norway, and having cardiologic and psychiatric problems were the main factors associated with being a FA. Among immigrants, labour immigrants and the elderly used GPs less often, while refugees were overrepresented among FAs. Psychiatric, gastroenterological, endocrine, and non-specific drug morbidity were relatively more prevalent among immigrant FA compared with natives.

CONCLUSION

Although immigrants account for a small percentage of all FAs, GPs and policy-makers should be aware of differences in socioeconomic and morbidity profiles to provide equality of health care.