Psychosocial and health belief variables associated with frequent attendance in primary care

Determinants of Medical Care-Seeking Behavior for Musculoskeletal Conditions During US Marine Corps Training: A Thematic Analysis

CONTEXT

Musculoskeletal injuries (MSK-I) are a well-documented problem in military populations and a leading contributor to disability across military services. However, only a portion of Service members who sustain an MSK-I report it to medical providers. Although several studies have identified barriers to seeking medical care in military populations, less is known about what motivates Service members to seek care for MSK-I.

OBJECTIVE

To describe determinants of medical care-seeking behavior for MSK-I and/or musculoskeletal pain (MSK-P) in recently enlisted US Marines during military training.

DESIGN

Qualitative study.

SETTING

School of Infantry-West (SOI-W), Marine Corps Base Camp Pendleton, California.

PATIENTS OR OTHER PARTICIPANTS

A total of 1097 US Marines entering Infantry Training Battalion or Marine Combat Training at SOI-W.

DATA COLLECTION AND ANALYSIS

Participants completed written surveys at entry to (baseline) and graduation from SOI-W. Closed-ended question responses were used to calculate MSK-I/MSK-P and care-seeking frequencies. Open-ended responses describing determinants of care-seeking behavior were analyzed using inductive thematic analysis.

RESULTS

Ten percent of participants self-reported sustaining MSK-I during basic training, whereas 14% self-reported sustaining an MSK-I in SOI-W training. A greater proportion reported seeking medical care for their MSK-I/MSK-P during basic training than during SOI-W training. The thematic analysis resulted in 3 main themes that describe drivers and barriers for seeking medical care: (1) self-perceived need for medical care, (2) prioritizing military training, and (3) training-specific influences.

CONCLUSION

Understanding determinants of care-seeking behavior is valuable when designing intervention strategies to promote early MSK-I treatment. Our findings add to previous research to elucidate reasons underlying the decisions about care-seeking for MSK-I/MSK-P. Interventions, including educational strategies and direct approaches like embedding medical providers within units, to minimize barriers to seeking medical care in the military may reduce the burden of MSK-I/MSK-P on Service members throughout their military careers.

Telephone interpersonal counseling treatment for frequent attenders to primary care: Development and piloting

BACKGROUND

Frequent attenders in primary care (FAs) consume a disproportionate amount of healthcare resources and often have depression, anxiety, chronic health issues, and interpersonal problems. Despite extensive medical care, they remain dissatisfied with the care and report no improvement in quality of life.

OBJECTIVE

To pilot a Telephone-based Interpersonal Counseling intervention for Frequent Attenders (TIPC-FA) and assess its feasibility and efficacy in reducing symptoms and healthcare utilization.

METHOD

Top 10% of primary care visitors were randomly assigned to TIPC-FA, Telephone Supportive Contact (Support), or Treatment as Usual (TAU). TIPC-FA and Support groups received six telephone sessions over twelve weeks, while the TAU group was interviewed twice. Multilevel regression tested for changes over time, considering patient and counselor variance.

RESULTS

TIPC-FA and Support groups demonstrated reduced depressive symptoms, and the TIPC-FA group showed decreased somatization and anxiety. The TIPC-FA group demonstrated a trend towards less healthcare utilization than the TAU group.

CONCLUSION

This pilot study suggests that IPC via telephone outreach is a feasible approach to treating FAs, achieving a reduction in symptoms not seen in other groups. Promising reduction in healthcare utilization in the TIPC-FA group warrants further exploration in larger-scale trials.

Psychosocial characteristics and affective symptomatology associated with patient self-initiated consultations in Spanish general practice

We aimed to determine the sociodemographic and psychosocial profile, and the associated subclinical affective symptomatology of users above the 95th percentile in the distribution of patient self-initiated, face-to-face consultations. Additionally, we sought to determine the contribution of subclinical symptomatology in differentiating between the groups above or below this cut-off point. A total of 16,803 users who self-initiated at least one face-to-face consultation with a GP at any of 13 PHC practices over 1 year, were eligible. After discarding those fulfilling exclusion criteria, 129 cases and 109 controls, matched by gender and age, answered the Family APGAR, the Duke-UNC and the Goldberg Anxiety-Depression scale. Both groups did not differ significantly on any of the sociodemographic and psychosocial variables recorded showing a similar percentage distribution. However, users with high self-initiated consultation rates obtained lower scores on the affective social support subscale from the Duke-UNC. Regarding Goldberg scale, the two groups differed significantly on the likelihood of displaying depression and/or anxiety symptoms. Users with a high probability of suffering from depression and/or anxiety were more prevalent among users on the top 5% in the distribution. Altogether, results indicate that these users report a lack of affective social support and have a higher probability of suffering from subclinical depression and/or anxiety. Early detection and treatment of affective symptomatology would temperate this excess in consultation. General practitioners, social workers and psychologists could act as gatekeepers, preventing this overuse of medical services and in turn lowering economical costs, professional burnout and patients' suffering and discontent.

Children as frequent attenders in primary care: a systematic review

Background

Frequent paediatric attendances make up a large proportion of a GP's workload. Currently, there is no systematic review on frequent paediatric attendances in primary care.

Aim

To identify the sociodemographic and clinical characteristics of children who attend primary care frequently.

Design & setting

A systematic review.

Method

The electronic databases MEDLINE, Embase, and PsycINFO were searched up to January 2020, using terms relating to frequent attendance in primary care settings. Studies were eligible if they considered children frequently attending in primary care (aged 0–19 years). Relevant data were extracted and analysed by narrative synthesis.

Results

Six studies, of fair quality overall, were included in the review. Frequent attendance was associated with presence of psychosocial and mental health problems, younger age, school absence, presence of chronic conditions, and high level of anxiety in their parents.

Conclusion

Various sociodemographic and medical characteristics of children were associated with frequent attendance in primary care. Research on interventions needs to account for the social context and community characteristics. Integrating GP services with mental health and social care could potentially provide a response to medical and psychosocial needs of frequently attending children and their families.

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.

Medical Mistrust, Racism, and Delays in Preventive Health Screening Among African-American Men

The contribution of medical mistrust to healthcare utilization delays has gained increased public health attention. However, few studies examine these associations among African-American men, who delay preventive healthcare more often and report higher levels of medical mistrust than non-Hispanic White men. Additionally, studies rarely account for other factors reportedly working in tandem with medical mistrust to increase African-American men's preventive health screening delays (i.e., everyday racism and perceived racism in healthcare). We examined associations between medical mistrust, perceived racism in healthcare, everyday racism, and preventive health screening delays. Analyses were conducted using cross-sectional data from 610 African-American men aged 20 years and older recruited primarily from barbershops in four US regions (2003-2009). Independent variables were medical mistrust (MM), everyday racism (ER), and perceived racism in healthcare (PRH). Dependent variables were self-reported routine checkup, blood pressure screening, and cholesterol screening delays. Using multiple logistic regression and tests for mediation, we calculated odds ratios and 95% confidence intervals to assess associations between the independent and dependent variables. After final adjustment, African-American men with higher MM were significantly more likely to delay blood pressure screenings. Men with more frequent ER exposure were significantly more likely to delay routine checkups and blood pressure screenings. Higher levels of PRH were associated with a significant increased likelihood of delaying cholesterol screening. MM did not mediate associations between ER and screening delays. Increasing preventive health screening among African-American men requires addressing medical mistrust and racism in and outside healthcare institutions.

Is regular use of physiotherapy treatment associated with health locus of control and self-management competency? A study of patients with musculoskeletal disorders undergoing physiotherapy in primary health care

OBJECTIVE

To investigate the relationship between regular use of physiotherapy treatment, health locus of control and self-management competency in people with musculoskeletal disorders.

METHODS

This cross-sectional study included 507 patients between 18 and 70 years of age with musculoskeletal disorders who attended a physiotherapy clinic. The Health Education Impact Questionnaire (heiQ) was used to assess self-management competency; the Health Locus of Control Scale (HLCS) was used to assess health locus of control. Multiple linear regression analyses were performed to estimate the relationships between variables.

RESULTS

Results showed that patients who attended physiotherapy on a regular basis had lower levels of internal control than those who did not. Furthermore, regular patients reported more health-directed activities and more emotional distress than patients not attending physiotherapy on a regular basis. Finally, internal health locus of control showed statistically significant associations with all heiQ domains, indicating that a stronger internal control is associated with higher levels of self-management competency.

CONCLUSION

Our findings suggest that attending physiotherapy on a regular basis is related to self-management competency and internal health locus of control.

PRACTICAL IMPLICATIONS

A treatment aim in primary care for people with long term conditions should include development of self-management capacity.

Association between perceived stress, multimorbidity and primary care health services: a Danish population-based cohort study

OBJECTIVES

Mental stress is common in the general population. Mounting evidence suggests that mental stress is associated with multimorbidity, suboptimal care and increased mortality. Delivering healthcare in a biopsychosocial context is key for general practitioners (GPs), but it remains unclear how persons with high levels of perceived stress are managed in primary care. We aimed to describe the association between perceived stress and primary care services by focusing on mental health-related activities and markers of elective/acute care while accounting for mental-physical multimorbidity.

DESIGN

Population-based cohort study.

SETTING

Primary healthcare in Denmark.

PARTICIPANTS

118 410 participants from the Danish National Health Survey 2010 followed for 1 year. Information on perceived stress and lifestyle was obtained from a survey questionnaire. Information on multimorbidity was obtained from health registers.

OUTCOME MEASURES

General daytime consultations, out-of-hours services, mental health-related services and chronic care services in primary care obtained from health registers.

RESULTS

Perceived stress levels were associated with primary care activity in a dose-response relation when adjusted for underlying conditions, lifestyle and socioeconomic factors. In the highest stress quintile, 6.8% attended GP talk therapy (highest vs lowest quintile, adjusted incidence rate ratios (IRR): 4.96, 95% CI 4.20 to 5.86), 3.3% consulted a psychologist (IRR: 6.49, 95% CI 4.90 to 8.58), 21.5% redeemed an antidepressant prescription (IRR: 4.62, 95% CI 4.03 to 5.31), 23.8% attended annual chronic care consultations (IRR: 1.22, 95% CI 1.16 to 1.29) and 26.1% used out-of-hours services (IRR: 1.47, 95% CI 1.51 to 1.68). For those with multimorbidity, stress was associated with more out-of-hours services, but not with more chronic care services.

CONCLUSION

Persons with high stress levels generally had higher use of primary healthcare, 4-6 times higher use of mental health-related services (most often in the form of psychotropic drug prescriptions), but less timely use of chronic care services.

Association of general psychological factors with frequent attendance in primary care: a population-based cross-sectional observational study

Background

Whereas several studies have examined the association between frequent attendance in primary care and illness-specific psychological factors, little is known about the relation between frequent attendance and general psychological factors. Thus, the aim of this study was to investigate the association between being a frequent attender in primary care and general psychological factors.

Methods

Data were used from a large, population-based sample of community-dwelling individuals aged 40 and above in Germany in 2014 (n = 7,446). Positive and negative affect, life satisfaction, optimism, self-esteem, self-efficacy, and self-regulation were included as general psychological factors. The number of self-reported GP visits in the past twelve months was used to quantify frequency of attendance; individuals with more than 9 visits (highest decile) were defined as frequent attenders.

Results

Multiple logistic regressions showed that being a frequent attender was positively associated with less life satisfaction [OR: 0.79 (0.70–0.89)], higher negative affect [OR: 1.38 (1.17–1.62)], less self-efficacy [OR: 0.74 (0.63–0.86)], less self-esteem [OR: 0.65 (0.54–0.79)], less self-regulation [OR: 0.74 (0.60–0.91)], and higher perceived stress [OR: 1.46 (1.28–1.66)], after adjusting for sociodemographic factors, morbidity and lifestyle factors. However, frequent attendance was not significantly associated with positive affect and self-regulation.

Conclusions

The present study highlights the association between general psychological factors and frequent attendance. As frequent GP visits produce high health care costs and are potentially associated with increased referrals and use of secondary health care services, this knowledge might help to address these individuals with high needs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0621-5) contains supplementary material, which is available to authorized users.

Anxiety and self-management behaviour in chronic obstructive pulmonary disease: what has been learned?

A considerable amount of literature has described the prevalence of anxiety in patients with the lung condition chronic obstructive pulmonary disease (COPD). Few, if any, papers have reviewed the inter-relationship between anxiety symptoms and self-management interventions in this population. This is the aim of the current review. First, the review examines the evidence suggesting that anxiety is more common in COPD than other populations. Secondly, the focus shifts to evaluating the evidence for and against the efficacy of COPD self-management programmes. Finally this paper examines the relationship between anxiety and COPD self-management with particular reference to the benefits and possible harm of some COPD self-management goals and anxious patients.

Overutilization of ambulatory medical care in the elderly German population?--An empirical study based on national insurance claims data and a review of foreign studies

BACKGROUND

By definition, high utilizers receive a large proportion of medical services and produce relatively high costs. The authors report the results of a study on the utilization of ambulatory medical care by the elderly population in Germany in comparison to other OECD countries. Evidence points to an excessive utilization in Germany. It is important to document these utilization figures and compare them to those in other countries since the healthcare system in Germany stopped recording ambulatory healthcare utilization figures in 2008.

METHODS

The study is based on the claims data of all insurants aged ≥ 65 of a statutory health insurance company in Germany (n = 123,224). Utilization was analyzed by the number of contacts with physicians in ambulatory medical care and by the number of different practices contacted over one year. Criteria for frequent attendance were ≥ 50 contacts with practices or contacts with ≥ 10 different practices or ≥ 3 practices of the same discipline per year. Descriptive statistical analysis and logistic regression were applied. Morbidity was analyzed by prevalence and relative risk for frequent attendance for 46 chronic diseases.

RESULTS

Nineteen percent of the elderly were identified as high utilizers, corresponding to approximately 3.5 million elderly people in Germany. Two main types were identified. One type has many contacts with practices, belongs to the oldest age group, suffers from severe somatic diseases and multimorbidity, and/or is dependent on long-term care. The other type contacts large numbers of practices, consists of younger elderly who often suffer from psychiatric and/or psychosomatic complaints, and is less frequently multimorbid and/or nursing care dependent.

CONCLUSION

We found a very high rate of frequent attendance among the German elderly, which is unique among the OECD countries. Further research should clarify its reasons and if this degree of utilization is beneficial for elderly people.

What determines frequent attendance at out-of-hours primary care services?

BACKGROUND

A detailed description of the characteristics of frequent attenders (FAs) at primary care services is needed to devise measures to contain the phenomenon. The aim of this population-registry-based research was to sketch an overall picture of the determinants of frequent attendance at out-of-hours (OOH) services, considering patients' clinical conditions and socio-demographic features, and whether the way patients' genaral practitioners (GPs) were organized influenced their likelihood of being FAs.

METHODS

This study was a retrospective cohort study on electronic population-based records. The dataset included all OOH primary care service contacts from 1 January to 31 December 2011, linked with the mortality registry and with patients' exemption from health care charges. A FA was defined as a patient who contacted the service three or more times in 12 months. A logistic regression model was constructed to identify independent variables associated with this outcome.

RESULTS

Multivariate analysis showed that not only frailty and clinical variables such as psychiatric disease are associated with FA status, but also socio-demographic variables such as sex, age and income level. Alongside other environmental factors, the GP's gender and mode of collaboration in the provision of health services were also associated with OOH FA.

CONCLUSION

Our study demonstrates that the determinants of OOH FA include not only patients' clinical conditions, but also several socio-economic characteristics (including income level) and their GPs' organizational format.

[Would the Screening of Common Mental Disorders in Primary-Care Health Services Hyper-Frequent Patients Be Useful?]

Hyper-frequentation in health services is a problem for patients, their families and the institutions. This study is aimed at determining the frequency and characteristics of common mental disorders in hyper-frequent patients showing vague symptoms and signs at a primary healthcare service during the year 2007 in the city of Cali (Colombia).

METHODOLOGY

Cross sectional. The most frequent mental disorders in hyper-frequent patients were detected through a telephone interview which included several modules of the PRIME MD instrument.

RESULTS

In general, healthcare service hyper-frequenters are working women, 38,7-year old in average. Basically, the consultation is due to cephalalgia but they also exhibit a high prevalence of common mental disorders (somatization, depression and anxiety) not easily diagnosed by physicians in primary care. Expenses for additional health activities generated by these patients are attributed basically to medical consultation and required procedures.

CONCLUSION

Considering hyper-frequenters in health care services as a risk group in terms of common mental disorders involves screening as an efficient strategy to prevent abuse in service use and to improve satisfaction with the attention received.

Health care avoidance among people with serious psychological distress: analyses of 2007 Health Information National Trends Survey

Using data of 2007 Health Information National Trends Survey, we investigated the association between individuals' psychological distress and their reported avoidance of medical care and assessed whether people with serious psychological distress (SPD) were more likely to report psychosocial barriers to care. After controlling for demographic and health characteristics, individuals with SPD were more likely than those without SPD to report having avoided visiting a doctor even when they suspected they should (OR=1.64, 95% CI=1.08-2.48). The distressed individuals were also more likely to agree that they avoided a doctor because of fear of having a serious illness (OR=1.99, 95% CI=1.15-3.44) or thinking about dying (OR=2.15, 95% CI=1.12-4.11). Further understanding of the mechanism under which an individuals' mental health status may influence their perceived need for health and their use of medical services would improve the interface between mental health and primary care services.

Prevalence and correlates of psychopathology in children and adolescents evaluated with the strengths and difficulties questionnaire dysregulation profile in a clinical setting

BACKGROUND

The clinical presentation of children and adolescents referred to mental health services is frequently complicated by comorbid and severe affective and behavioral dysregulation. This dysregulation phenotype seems to be an indicator of overall psychopathology, symptom severity and functional impairment. Currently, this phenotype is assessed by the Child Behavior Checklist. However, the widely used Strengths and Difficulties Questionnaire (SDQ) has been recently validated to screen the Dysregulation Profile (SDQ-DP) in clinical settings. The objective of this study was to determine the prevalence and demographic, psychosocial and clinical correlates of the SDQ-DP phenotype in a Spanish clinical sample.

SAMPLING AND METHODS

In a clinical sample of 623 consecutively referred children and adolescents (4-17 years old), we compared clinical and sociodemographic correlates between subjects who met the SDQ-DP criteria (DP) and those who did not (NO_DP). Sociodemographic data, parent-rated SDQ, Children's Global Assessment Scale, Clinical Global Impression, family Apgar scale and clinical diagnoses were collected by experienced child and adolescent psychiatrists.

RESULTS

Overall in our sample, 175 subjects (28.1%) met the SDQ-DP criteria (DP group). Compared with the NO_DP group, the DP subjects had significantly higher scores on internalizing and externalizing psychopathology, problems with peers and overall problems as well as significantly lower scores on prosocial behavior. Clinical diagnoses assigned revealed that DP subjects showed significantly greater psychiatric comorbidity. DP subjects also showed significantly worse family functioning and increased symptom severity and significantly lower scores on psychosocial functioning.

CONCLUSIONS

A high prevalence of children and adolescents with the dysregulated profile, assessed by the SDQ-DP, was found in our clinical setting. The SDQ-DP may serve as an index of overall psychological severity and functional impairment. In addition, it may indicate family dysfunction. Further research is needed to validate the clinical value of SDQ-DP by examining longitudinal stability, heritability, adult outcome, risk factors and diagnostic correlates.

[Which chronic diseases are associated with frequent attending of ambulatory medical care in the elderly population in Germany? - A study based on statutory health insurance data]

BACKGROUND

Frequent attenders utilise a high proportion of medical services and therefore produce relatively high costs. Questions of utility and adequacy and, also, about the reasons for high use arise. The authors report the results of a study on the association between morbidity of the elderly and various forms of frequent attendance in ambulatory medical care in Germany.

METHODS

The study is based on claims data of all policyholders aged 65 and over of a statutory health insurance company operating nationwide in Germany in 2004 (n = 123,224). Utilisation was analysed by the number of contacts with practices of physicians working in the ambulatory medical care sector and by the number of different practices contacted. Criteria for frequent attendance were ≥ 50 contacts with practices or contacts with ≥ 10 individual practices or ≥ 3 practices of the same discipline per year. We analysed prevalences and relative risks for frequent attendance for 46 chronic diseases.

RESULTS

Frequent attendance in ambulatory medical care among the elderly is related to both severe somatic and psychic diagnoses. Five chronic diseases showed the highest relative risks for all types of frequent attendance in general: urinary incontinence, anaemia, neuropathies, renal insufficiency, and cancer. Psychic syndromes mainly led to the utilisation of many different physicians.

CONCLUSION

Frequent attendance in ambulatory medical care among the elderly is related to a large number of diseases, both somatic and psychic. Frequent attendance is a complex phenomenon which cannot be addressed by mono-dimensional approaches.

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

Different studies reveal that a large percentage of people frequently attending healthcare not only suffer from diffuse somatic symptoms but also from psychological distress and difficulties in dealing with everyday life. Even though they are not always diagnosed with psychiatric disease, questions arise about their mental health. The study aims at describing frequent attenders' conceptions of life, and as a result their health, from a cognitive perspective. A qualitative content analysis of in-depth interviews was carried out with nine service users in primary healthcare. The findings reveal that participants experience themselves as inadequate and as being a burden for others, by whom they experience rejection, in different ways. In order to take part in community with others the person develops compensatory strategies that aim at concealing their inadequacies, thus also preventing them from sharing their suffering with others. The consequence is that the persons become even more alienated as they start to relate to others through a façade and furthermore are unable to either improve their health or obtain adequate care. It can be concluded that these patients need to be taken seriously in order to prevent further psychological suffering.

Persistent frequent attenders in primary care: costs, reasons for attendance, organisation of care and potential for cognitive behavioural therapeutic intervention

BACKGROUND

The top 3% of frequent attendance in primary care is associated with 15% of all appointments in primary care, a fivefold increase in hospital expenditure, and more mental disorder and functional somatic symptoms compared to normal attendance. Although often temporary if these rates of attendance last more than two years, they may become persistent (persistent frequent or regular attendance). However, there is no long-term study of the economic impact or clinical characteristics of regular attendance in primary care. Cognitive behaviour formulation and treatment (CBT) for regular attendance as a motivated behaviour may offer an understanding of the development, maintenance and treatment of regular attendance in the context of their health problems, cognitive processes and social context.

METHODS/DESIGN

A case control design will compare the clinical characteristics, patterns of health care use and economic costs over the last 10 years of 100 regular attenders (≥30 appointments with general practitioner [GP] over 2 years) with 100 normal attenders (6-22 appointments with GP over 2 years), from purposefully selected primary care practices with differing organisation of care and patient demographics. Qualitative interviews with regular attending patients and practice staff will explore patient barriers, drivers and experiences of consultation, and organisation of care by practices with its challenges. Cognitive behaviour formulation analysed thematically will explore the development, maintenance and therapeutic opportunities for management in regular attenders. The feasibility, acceptability and utility of CBT for regular attendance will be examined.

DISCUSSION

The health care costs, clinical needs, patient motivation for consultation and organisation of care for persistent frequent or regular attendance in primary care will be explored to develop training and policies for service providers. CBT for regular attendance will be piloted with a view to developing this approach as part of a multifaceted intervention.

Frequent attendance in family practice and common mental disorders in an open access health care system

Frequent attenders in family practice are known to have higher rates of mental disorder. However little is known about specific psychiatric disorders and whether this behavior extends to specialist services, in an open access fee-for-service health care system.

METHODS

1060 patients from 46 family practices completed the Patient Health Questionnaire and the Client Service Receipt Inventory. During the consultation, family practitioners blind to the questionnaire responses rated the severity of mental health and physical disorders. The 10% of patients with the highest number of 6-month consultations in six age and sex stratified groups were defined as frequent attenders.

RESULTS

After adjustments for sociodemographic variables, physical health and other psychiatric diagnoses, patients with a somatoform disorder were more likely to be frequent attenders, with an odds ratio of 2.3 (95% CI: 1.3-3.8, p=.002).

CONCLUSION

When adjusting for confounders, among the four psychiatric diagnoses investigated only somatoform disorders remain significantly associated with frequent attendance. Physical health and chronic disease were no longer associated with frequent attendance which does not support the hypothesis that in an open access fee-for-service system, patients will consult for a wider range of health problems. Greater investigation into unexplained somatic symptoms could help reduce the frequency of attendance in both primary and secondary care, as this behaviour appears to be a general health-seeking drive than extends beyond family practice.

Recognition of anxiety disorders by the general practitioner: results from the DASMAP study

OBJECTIVES

The objectives were to determine the levels of general practitioner (GP) recognition of anxiety disorders and examine associated factors.

METHODS

An epidemiological survey was carried out in 77 primary care centers representative of Catalonia. A total of 3815 patients were assessed.

RESULTS

GPs identified 185 of the 666 individuals diagnosed as meeting the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) criteria for any anxiety disorder (sensitivity 0.28). Regarding specific anxiety disorders, panic disorder was registered in just three of the patients who, according to the SCID-I, did not meet the criteria for this condition .Generalized anxiety disorder was recorded by the GP in 46 cases, 4 of them being concordant with the SCID-I (sensitivity 0.03). The presence of comorbid hypertension was associated with an increased probability of recognition. Emotional problems as the patients' main complaint and additional appointments with a mental health specialist were associated with both adequate and erroneous recognition. Being female, having more frequent appointments with the GP and having higher levels of self-perceived stress were related to false positives. As disability increased, the probability of being erroneously detected decreased.

CONCLUSION

GPs recognized anxiety disorders in some sufferers but still failed with respect to differentiating between anxiety disorder subtypes and disability assessment.

Knowledge and health beliefs of Jamaican adolescents with sickle cell disease

BACKGROUND

The adolescent stage of life is generally perceived to be a challenging period, which may be magnified when a chronic illness such as sickle cell disease (SCD) is present. In this study, we sought to determine the knowledge and health beliefs of Jamaican adolescents with SCD as these factors may impact their self-management skills.

PROCEDURE

An interviewer-administered questionnaire was completed by 117 patients (93 SS:24 SC; 48 males:69 females) between the ages of 15 and 19 years at their routine health maintenance visit to the Sickle Cell Unit, UWI. A maximum total score of 17 could be attained for knowledge. The health belief questions were assessed using a 5-point Likert scale and correlations between knowledge and health beliefs were done. Multiple regression models were created to study the predictors of knowledge and health belief scores. The study was granted ethical approval by UWI/UHWI Ethics Committee.

RESULTS

The mean knowledge score was 64% (range 88-29%). No differences were found in the mean knowledge scores between genotypes and educational attainment but females appeared to score higher than males (P-value <0.05). Most adolescents perceived SCD to be a severe illness and thought it is important for people to know their SCD status. However, almost 30% thought their partners would be hard to convince for testing. Higher knowledge scores predicted positive health beliefs in the adolescent.

CONCLUSIONS

Whereas most adolescents were knowledgeable about how the disease was inherited and tested for, further education especially about disease and pregnancy complications is needed.

Masculinity, medical mistrust, and preventive health services delays among community-dwelling African-American men

BACKGROUND

The contribution of masculinity to men's healthcare use has gained increased public health interest; however, few studies have examined this association among African-American men, who delay healthcare more often, define masculinity differently, and report higher levels of medical mistrust than non-Hispanic White men.

OBJECTIVE

To examine associations between traditional masculinity norms, medical mistrust, and preventive health services delays.

DESIGN AND PARTICIPANTS

A cross-sectional analysis using data from 610 African-American men age 20 and older recruited primarily from barbershops in the North, South, Midwest, and West regions of the U.S. (2003-2009).

MEASUREMENTS

Independent variables were endorsement of traditional masculinity norms around self-reliance, salience of traditional masculinity norms, and medical mistrust. Dependent variables were self-reported delays in three preventive health services: routine check-ups, blood pressure screenings, and cholesterol screenings. We controlled for socio-demography, healthcare access, and health status.

RESULTS

After final adjustment, men with a greater endorsement of traditional masculinity norms around self-reliance (OR: 0.77; 95% CI: 0.60-0.98) were significantly less likely to delay blood pressure screening. This relationship became non-significant when a longer BP screening delay interval was used. Higher levels of traditional masculinity identity salience were associated with a decreased likelihood of delaying cholesterol screening (OR: 0.62; 95% CI: 0.45-0.86). African-American men with higher medical mistrust were significantly more likely to delay routine check-ups (OR: 2.64; 95% CI: 1.34-5.20), blood pressure (OR: 3.03; 95% CI: 1.45-6.32), and cholesterol screenings (OR: 2.09; 95% CI: 1.03-4.23).

CONCLUSIONS

Contrary to previous research, higher traditional masculinity is associated with decreased delays in African-American men's blood pressure and cholesterol screening. Routine check-up delays are more attributable to medical mistrust. Building on African-American men's potential to frame preventive services utilization as a demonstration, as opposed to, denial of masculinity and implementing policies to reduce biases in healthcare delivery that increase mistrust, may be viable strategies to eliminate disparities in African-American male healthcare utilization.

To intend to but not being able to: frequent attenders' experiences of suffering and of their encounter with the health care system

PURPOSE

Patients who frequently consult the health care system are supposed to cause great economic costs, and they also trouble the health care staff, as it seems as if there are no interventions that will help and keep them healthy. The researcher assumes that these patients attend for a reason and that they attend frequently because they, from a holistic point of view, do not get their health care needs fulfilled. This article aims to describe how frequent attenders experience their suffering and their encounter with the health care system.

DESIGN AND METHOD

The study has an inductive hermeneutic design. Interviews with persons identified as frequent attenders were analyzed by means of a hermeneutic inquiry with three interpretive steps: naive reading, structural analysis, and critical reflection.

FINDINGS

Patients are constantly striving to be and become healthy, to be of use, and to please others. The patients do not attend until suffering is experienced as unbearable. The patients experience, however, that health care staff do not understand their situation. Patients experience feelings of mistrust and rejection, which increases suffering.

CONCLUSION

Holistic care could be a means to relieve suffering and, as a consequence, reduce attendance.

Frequent attendance in primary care: comparison and implications of different definitions

BACKGROUND

The diversity of definitions of frequent attendance in the literature hampers comparison of their precision, validity, and associated factors.

AIM

To examine different definitions of frequent attendance in order to identify the sociodemographic and clinical factors associated with frequent attendance in primary care, according to each definition.

DESIGN OF STUDY

One-phase cross-sectional study.

SETTING

Seventy-seven primary care centres in Catalonia, Spain.

METHOD

A total of 3815 primary care patients were interviewed between October 2005 and March 2006. Three definitions of frequent attendance were tested: (1) frequent attenders as the top 25% and the top 10% consulting patients; (2) frequent attenders as the top 25% and the top 10% consulting patients stratified by age and sex; and (3) frequent attenders as the top 25% and the top 10% consulting patients stratified by the presence of physical/mental conditions (patients with only mental disorders, with only chronic physical conditions, with comorbid conditions, and with no condition). Multilevel logistic regressions were used.

RESULTS

The following factors were systematically related to frequent attender status: being on sick leave, being born outside of Spain, reporting mental health problems as the main reason for consulting, and having arthritis/rheumatism, or bronchitis. Major depression was related to frequent attendance in two of the three definitions. The factor 'GP' was related to frequent attendance when the top decile cut-off point was used. The models with a 10% cut-off point were more discriminative than those with a 25% cut-off point: the area under the receiver operating characteristic curve for models with a 25% cut-off and a 10% cut-off ranged between 0.71 (95% confidence interval [CI] = 0.70 to 0.73) and 0.75 (95% CI = 0.74 to 0.77) and between 0.79 (95% CI = 0.78 to 0.81) and 0.85 (95% CI = 0.83 to 0.86), respectively.

CONCLUSION

The way frequent attendance is defined is of crucial importance. It is recommended that a more discriminative definition of frequent attendance is used (the top 10%).

Negotiations of distress between East Timorese and Vietnamese refugees and their family doctors in Melbourne

Recent critiques of depression have contested its coherence as a concept and highlighted its performance in medicalising distress. Studies of depression in a cross-cultural context have focused on language and belief systems as technical barriers to practice that need to be overcome in enacting depression work. This paper seeks to locate culture within the broader socio-structural context of depression care in general practice. The paper draws on interviews with five general practitioners (GPs), and 24 patients from Vietnamese and East Timorese backgrounds who predominantly have left their home as refugees. Each had been diagnosed with depression or prescribed antidepressants. These patients gave accounts of distress deeply embedded within, and inseparable from, lives fraught with frightening pre-migration experiences, traumatic escape and profound dislocation and alienation in their new 'home'. Fragmented lives were contrasted with the nourishing social fabric of homes left behind. GP participants were involved in a process of engaging with a profoundly communal and structural account of emotional distress while defending and drawing on an individualised notion of depression in performing their work and accounting for the pain presented to them.

General Practice Utilization After Sexual Victimization: A Case Control Study

There is a growing research literature that indicates that sexual victimization results in increased physical health problems and health service utilization. This study aimed to examine the relationship between attendance at a center for rape victims and frequency of contact with general practitioners. The study used matched case-control design, and information about general practitioner use over a 7-year period was drawn from the Danish Civil Registration System. There was a sustained increase in health care use for those who had used the center for rape victims compared to the control group.

Successful GP intervention with frequent attenders in primary care: randomised controlled trial

BACKGROUND

Frequent attenders to GP clinics can place an unnecessary burden on primary care. Interventions to reduce frequent attendance have had mixed results.

AIM

To assess the effectiveness of a GP intervention to reduce frequent-attender consultations.

DESIGN OF STUDY

Randomised controlled trial with frequent attenders divided into an intervention group and two control groups (one control group was seen by GPs also providing care to patients undergoing the intervention).

SETTING

A health centre in southern Spain.

METHOD

Six GPs and 209 randomly-selected frequent attenders participated. Three GPs were randomly allocated to perform the new intervention: of the 137 frequent attenders registered with these three GPs, 66 were randomly allocated to receive the intervention (IG) and 71 to a usual care control group (CG2). The other three GPs offered usual care to the other 72 frequent attenders (CG1). The main outcome measure was the total number of consultations 1 year post-intervention. Baseline measurements were recorded of sociodemographic characteristics, provider-user interface, chronic illnesses, and psychosocial variables. GPs allocated to the new intervention received 15 hours' training which incorporated biopsychosocial, organisational, and relational approaches. After 1 year of follow-up frequent attenders were contacted. An intention-to-treat analysis was used.

RESULTS

A multilevel model was built with three factors: time, patient, and doctor. After adjusting for covariates, the mean number of visits at 1 year in IG was 13.10 (95% confidence interval [CI]=11.39 to 14.94); in the CG1 group was 19.37 (95% CI=17.31 to 21.55); and in the CG2 group this was 16.72 (95% CI=4.84 to 18.72).

CONCLUSION

The new intervention with GPs resulted in a significant and relevant reduction in frequent-attender consultations. Although further trials are needed, this intervention is recommended to GPs interested in reducing consultations by their frequent attenders.

Frequent consulting and multiple morbidity: a qualitative comparison of 'high' and 'low' consulters of GPs

BACKGROUND

Frequent consulting is associated with multiple and complex social and health conditions. It is not known how the impact of multiple conditions, the ability to self-manage and patient perception of the GP consultation combines to influence consulting frequency.

OBJECTIVE

To investigate reasons for frequent consultation among people with multiple morbidity but contrasting consulting rates.

METHODS

Qualitative study with in-depth interviews in the west of Scotland. Participants were 23 men and women aged about 50 years with four or more chronic illnesses; 11 reported consulting seven or more times in the last year [the frequent consulters (FCs)] and 12, three or fewer times [the less frequent consulters (LFCs)]. The main outcome measures were the participants' accounts of their symptoms, self-management strategies and reasons for consulting a GP.

RESULTS

All participants used multiple self-management strategies. FCs described: more disruptive symptoms, which were resistant to self-management strategies; less access to fewer treatments and resources and more medical monitoring, for unstable conditions and drug regimens. The LFCs reported: less severe and more containable symptoms; accessing more efficacious self-management strategies and infrequent GP monitoring for stable conditions and routine drug regimens. All participants conveyed consulting as a 'last resort'. However, the GP was seen as 'ally', for the FCs, and as 'innocent bystander', for the LFCs.

CONCLUSIONS

This qualitative investigation into the combined significance of multiple morbidities and self-management on the GP consultation suggests that current models of self-management might have limited potential to reduce utilization rates among this vulnerable group. Severity of symptoms, stability of condition and complexity of drug regimens combine to influence the availability of effective resources and influence frequency of GP consultations.

Self-efficacy, social support and service integration at medical cannabis facilities in the San Francisco Bay area of California

In an effort to examine and possibly utilise the community-based, bottom-up service design of medical cannabis facilities in the San Francisco Bay area of California, 130 adults who had received medical cannabis recommendations from a physician were surveyed at seven facilities to describe the social service aspects of these unique, community-based programmes. This study used an unselected consecutive sample and cross-sectional survey design that included primary data collection at the medical cannabis facilities themselves. In this exploratory study, individual level data were collected on patient demographics and reported patient satisfaction as gathered by the Patient Satisfaction Questionnaire III. Surveys were filled out on site. In the case of a refusal, the next person was asked. The refusal rate varied depending on the study site and ranged between 25% and 60%, depending on the facility and the day of sampling. Organisational-level data, such as operating characteristics and products offered, created a backdrop for further examination into the social services offered by these facilities and the attempts made by this largely unregulated healthcare system to create a community-based environment of social support for chronically ill people. Informal assessment suggests that chronic pain is the most common malady for which medical cannabis is used. Descriptive statistics were generated to examine sample- and site-related differences. Results show that medical cannabis patients have created a system of dispensing medical cannabis that also includes services such as counselling, entertainment and support groups - all important components of coping with chronic illness. Furthermore, patients tend to be male, over 35, identify with more than one ethnicity, and earn less than US$20 000 annually. Levels of satisfaction with facility care were fairly high, and higher than nationally reported satisfaction with health care in the USA. Facilities tended to follow a social model of cannabis care, including allowing patients to use medicine on site and offering social services. This approach has implications for the creation and maintenance of a continuum of care among bottom-up social and health services agencies.

With an attack I associate it more with going into hospital: understandings of asthma and psychosocial stressors; are they related to use of services?

Asthma is still a major cause of morbidity and mortality. Patients who use hospital services frequently tend to have more severe asthma and lack formal support. Attitudes to self-management also tend to differ and qualitative studies of frequent attenders have identified differing views of the appropriateness of service use between patients and their physicians. We undertook a qualitative study of patients with severe asthma admitted and not admitted to hospital in a 12-month period in the UK. The aim of the study was to investigate the relationship between perception of life events, psychosocial factors, coping and asthma admission in these two groups of patients. We interviewed 50 patients (aged 16 and over) admitted to two large teaching hospitals in London with asthma exacerbations, 25 patients with similar levels of asthma severity (step 3 or higher of the British Thoracic Society guidelines) sampled in General Practice and 19 general practitioners (GPs). Data were analysed using an adapted framework analysis. Patients admitted to hospital reported high levels of psychosocial problems and life events but tended to make few connections between these and their asthma attacks or their ability to manage their asthma. Patients reporting frequent hospital use tended to value professionals working in hospitals while reporting poor relationships with GPs; views that appeared related to delays in seeking help from primary care. Among GPs, knowledge of patients having attended hospital was generally poor, although they appeared more aware of those who were high users of General Practice (whether they were high attenders at hospital or not). GPs perceived stressful life events in patients with asthma to compound existing dispositions and be related to poor control and poor adherence. These findings suggest that vulnerable patient groups often face poor material circumstances and chaotic lives, impacting on their capacity to manage their illness and on their ability to derive benefit from primary care. Policy interventions aimed at reducing 'unnecessary' admissions will need to be tailored to the psychosocial circumstances and health beliefs of vulnerable patient groups.

Cigarette smoking, socioeconomic status, and psychosocial factors: examining a conceptual framework

Inequalities in cigarette smoking prevalence exist, with smokers more likely to be poor and less educated. Higher socioeconomic status (SES) is associated with higher quit rates. The overall relationship between low SES and poor health, as measured by morbidity and mortality, is well established. However, research indicates that inequalities in health are not explained by SES alone; other variables, such as psychosocial factors, may play a significant role. Williams has developed a conceptual framework to examine relationships among SES, psychosocial factors, and medical care related to health outcomes. According to Williams, the interrelationships among these factors have yet to be determined. As such, the pathways among the variables within psychosocial factors are explored and the authors discuss application to public health nursing practice and areas for future research. Further understanding of these relationships in the context of smoking may inform prevention and cessation strategies.

[Motives that condition use of the health services by over-users: study with focus groups]

BACKGROUND

Much is known about the profile of over-users and the cost of their demands, but their personal views about the reasons for their behaviour have been little examined.

AIMS

To identify the reasons over-users give for their behaviour.

DESIGN

Qualitative analysis of transcriptions of video-recorded focus group meetings.

SETTING

Two urban primary care clinics of the Andalusian Health Service in Seville, Spain.

PARTICIPANTS

Twelve women and 15 men; 9 between 45 and 65 years old and 18 over 65. Average of 55 attendances at the health centre (HC) during the previous year. Group meetings were held in Seville between November 26, 2003 and December 12, 2003.

METHODS

Inductive analysis of focus group interview transcriptions.

RESULTS

Most over-users attend their HC because of perception of problems (psychological, physical) and their belief that they will find effective help from the health services. Factors such as their relationships with health staff or organisation of care are perceived as barriers or facilitators of health service use. Low family and social support are perceived as important factors in seeking help in primary care.

CONCLUSIONS

Health services should bear in mind these motives of over-users, on designing and introducing support systems to manage demand more rationally and effectively. These systems could be based on new technology (internet and telephone information and consulting) and the cooperation of other professionals, such as pharmacists or nurses.

[Validation of a scale to measure ill-treatment of women]

OBJECTIVES

To analyse the validity of content and of structure and the reliability of a questionnaire designed to measure ill-treatment (IT) of women by their partners.

DESIGN

Descriptive, transversal, multi-centre study.

SETTING

Four urban health centres in Granada, Spain.

PARTICIPANTS

Three hundred and ninety one women of 14 and over who consulted in primary care and had a stable partner for at least 3 months.

MAIN MEASUREMENTS

Questionnaire by means of interviews between December 2000 and May 2001, with 10 Likert-like questions on physical, psychological, and sexual mistreatment, social and demographic questions and various health indicators. We analysed content validity by means of exploratory factorial analysis, reliability of alpha-Cronbach factors and of corrected scale-item correlation coefficients, and structure validity.

RESULTS

We obtained 2 empirical IT factors that did not correspond to the theoretical dimensions of physical, psychological, and sexual mistreatment and explained 64.21% of variance. The first included all the questions on psychological abuse, one on physical abuse and the sexual abuse dimension. The second covered the remaining questions on physical IT and "breaking things in the home". The factors gave reliability coefficients of 0.8688 and 0.7072. Comparison by means of extreme groups technique showed that the questionnaire's structure is valid.

CONCLUSION

We found this was a reliable and valid questionnaire for evaluating ill-treatment of women. Its use, particularly in primary care, could help expand and deepen understanding of the problem.

Frequent users of Massachusetts emergency departments: a statewide analysis

STUDY OBJECTIVE

We describe the epidemiology of frequent users of emergency departments (EDs), using a statewide dataset derived from linked ED, observation stay, and inpatient hospital discharge databases.

METHODS

Unique patient identifiers were used to link visits across databases, encompassing all ED visits regardless of disposition. Individuals with 5 or more visits during a year were considered frequent users and were compared with infrequent users, as well as nonusers, using descriptive statistics.

RESULTS

Only 1% of Massachusetts residents were frequent users, but they made 17.6% of all ED visits in fiscal year 2003; 57.8% of residents used multiple EDs. Compared with infrequent users, frequent users were more likely to die at their last visit (2.6% of frequent users versus 1.1% of infrequent users), were hospitalized at higher rates (18.8% versus 14.2% of visits), and were transported more frequently by ambulance (18.6% versus 12.1% of visits). Two percent of the uninsured individuals were frequent users compared with 2.1% of Medicaid enrollees, 2.0% of Medicare enrollees, and 0.4% of privately insured individuals. Only 15% of frequent users were uninsured. Frequent ED use is typically temporary; just 28.4% of frequent users in fiscal year 2002 remained frequent users in fiscal year 2003.

CONCLUSION

Uninsured individuals are no more likely than publicly insured individuals to be ED frequent users and compose only 15% of them. Frequent users tend to be sicker than infrequent users, but most use the ED at high rates temporarily and visit the ED less frequently or not at all the following year.

Views on respiratory tract symptoms and antibiotics of Dutch general practitioners, practice staff and patients

OBJECTIVES

To explore views on respiratory tract symptoms (cough, sore throat and earache) and antibiotics of GPs, practice staff, and patients.

METHODS

In a nationwide study, 181 GPs, 204 practice staff members and 1250 patients from 90 practices participated by answering 14 items relating to views on respiratory tract symptoms and antibiotics in a written questionnaire. Differences in means were compared.

RESULTS

Patients more than GPs endorsed the seriousness of respiratory tract symptoms, the need to consult a GP, the need to prescribe antibiotics, and the ability of antibiotics to speed up recovery. GPs were more than patients convinced of the self-limiting character of respiratory tract symptoms and of the fact that antibiotics have side effects. Practice staff took a middle ground in most of these views.

CONCLUSIONS

Differences between GPs, practice staff and patients must be taken into account when exploring patients' complaints and advising on treatment. Education and knowledge programmes for practice staff might be advocated.

Depression and frequent attendance in elderly primary care patients

OBJECTIVE

The aim of this study is to investigate the association between depression and frequent attendance in elderly primary care patients. Moreover, we compare the prevalence and clinical characteristics of frequent attenders (FAs) in the elderly and the nonelderly patients.

METHODS

This nationwide, cross-sectional, two-phase epidemiological study involved 191 primary care physicians (PCPs) and 1896 patients aged 14 and over. We consider FAs those subjects attending PCP practice more than once a month in the last 6 months. Screening for psychiatric disorders was conducted by using the General Health Questionnaire-12. Subsequently, probable cases were assessed by the PCPs with the WHO ICD-10 Checklist for Depression.

RESULTS

Prevalence value of frequent attendance was 22.4% in the elderly. Depression was associated with frequent attendance in the elderly even after controlling for physical illness and unexplained somatic complaints. The risk for being an FA was more than twofold in the elderly than in the nonelderly (cOR=2.58; 95% confidence interval, 1.97-3.37). Considering subjects without medical illness, depression increased the risk of being an FA fivefold among the elderly and threefold among the nonelderly.

CONCLUSION

Frequent attendance in primary care is associated with depressive disorder in the elderly. Depression seems to play a more important role in determining frequent attendance in the elderly patients in respect to the nonelderly.

Rural/urban differences in accounts of patients' initial decisions to consult primary care

In the UK, patients in urban areas consult primary health care more than rural patients for both trivial and serious conditions. This study, involving focus groups and interviews, examined rural/urban differences in accounts of patients' intentions around initial decisions to consult general practice. Findings suggest 'relationships' between doctors and patients and easier access to appointments could affect consulting in rural areas, while decision-making for urban patients tended to be more consumerist. Perceptions about access to different health services meant rural patients' decision-making in out-of-hours emergencies was complex. Rural/urban differences in demand could be affected by change in UK primary care provision.

The patients' illness perceptions and the use of primary health care

OBJECTIVE

To investigate if primary care patients' perceptions of a current health problem were associated with use of health care.

METHOD

One thousand seven hundred eighty-five patients presenting a new health problem to 1 of 38 physicians from 28 general practices in Aarhus County, Denmark. Patients completed a questionnaire on their illness perceptions and emotional distress before the consultation. The physicians completed a questionnaire for each patient on diagnostics and prognostics. Register data on primary health care utilization 3 years before and 2 years after baseline were obtained. Odds ratios were estimated to examine associations between previous health care use and illness perceptions. Linear regression analysis was performed to examine if illness perceptions predicted later health care use.

RESULTS

Previous use: Higher use was associated with psychosocial, stress, and lifestyle attributions. Accident/chance attributions were associated with higher use for patients with a chronic disorder but with lower use for patients without a chronic disorder. A strong illness identity (number of self-reported symptoms), illness worry, a long timeline perspective, a belief that the symptoms would have serious consequences, and all emotional distress variables were associated with higher use. Use during follow-up: Infection/lowered immunity attributions were associated with higher use for patients with a chronic disorder, whereas psychosocial and lifestyle attributions were associated with higher use for all patients. Illness worry and all emotional distress variables predicted higher health care use. A strong illness identity, a long timeline perspective, a belief in serious consequences, and stress and accident/chance attributions were among the strongest predictors of health care use in a multivariate model including all variables.

CONCLUSIONS

Patients' perceptions of a current health problem are associated with health care use and may offer an obvious starting point for a biopsychosocial approach in primary care.

The influence of complaint symptoms on health care utilisation, medicine use, and sickness absence. A comparison between retrospective and prospective utilisation

OBJECTIVE

The main aim was to examine the impact of reported individual symptoms on health care utilisation (HCU) in a primary health care practice population and to evaluate the impact of these symptoms on utilisation over time.

METHOD

The study was performed in 1055 out of 1442 consecutive adult patients visiting a Swedish health care centre. Logistic regression analyses were applied to assess the relationships between symptoms and HCU outcomes.

RESULTS

Each of the 30 symptoms was related to consultations with GPs and a provider of alternative medicine, use of medications and herbals, and sickness absence. Depression and tension groups were the strongest predictors of utilisation. Multisymptomatics had higher OR for most of the outcome variables than those with no symptoms.

CONCLUSION

The results of this study show a linear correlation between the numbers of symptoms and increasing GP consultations, medicine use and sickness absences days, and this persisted during the years 2001 and 2002.

Stories from frequent attenders: a qualitative study in primary care

PURPOSE

Patients who make frequent office visits (frequent attenders) in primary care are often considered a major burden on resources, yet we know little about their perceptions and expectations. We wanted to explore how these patients viewed their rates of consultation, what they expected from the consultation, and how they perceived their relationship with the primary health care team.

METHODS

Using a qualitative study design, we undertook in-depth semi-structured interviews with frequent attenders at 4 primary care practices of the Mersey Primary Care R&D Consortium in the North West of England. Participants were identified on the basis of office visits at least twice the mean standardized rate for 1 year and a medical assessment that these visits had no important clinical outcome. Interviews with 30 patients aged 24 to 81 years (18 men) were audiotaped and transcribed, and the text was methodically coded; data were analyzed by generating common themes.

RESULTS

Participants were unable or unwilling to quantify their consultation rates. Despite the assertion by many participants that family doctors are caring, authority figures, there was an underlying tension between such perceptions and the apparent medical mismanagement of symptoms. Their expectations of the consultation were complex and included the presentation of old and new symptoms implicitly embedded within an illness framework. Gaining access to family doctors was generally perceived as problematic.

CONCLUSION

The criteria held by family doctors and researchers regarding the appropriate rate of consultations in primary care may not be shared by patients who attend frequently. Such patients require family doctors to acknowledge their symptoms and to provide reassurance.

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.

Multiple medically unexplained physical symptoms and health care utilization: outcome of psychological intervention and patient-related predictors of change

OBJECTIVES

To test the effect of psychological intervention on multiple medically unexplained physical symptoms, psychological symptoms, and health care utilization in addition to medical care as usual. To identify patient-related predictors of change in symptoms and care utilization.

METHODS

In a randomized controlled trial, subjects were assigned to one of two conditions: psychological intervention by a qualified therapist plus care as usual by a general practitioner (GP) or care as usual only. Participants (N=98) were administered a standardized interview and several outcome measures at intake and after 6 months and 12 months after intake. GPs rated medically unexplained and explained symptoms and consultations over a period of 1 1/2 years.

RESULTS

ANOVAs for repeated measures showed that self-reported and GP-registered unexplained physical symptoms decreased from pretest to posttest to follow-up. Psychological symptoms and consultations decreased from pretest to posttest. GP-registered explained symptoms did not decrease. However, intervention and control groups did not differ in symptom reduction. Path analysis revealed two paths to a decrease in self-reported unexplained physical symptoms: from more negative affectivity via more psychological attribution and more pretreatment anxiety, and from more somatic attribution via more psychological attribution and more pretreatment anxiety.

CONCLUSION

Intervention and control groups did not differ in symptom reduction. Reduction of self-reported medically unexplained symptoms was well predicted by patient-related symptom perception variables, whereas the prediction of change in registered symptoms and consultations requires a different model.

Determinants of complaint symptoms in a Swedish health care practice--results of a questionnaire survey

OBJECTIVE

The aim of this study was to identify predictors of complaint symptoms in an adult general practice population.

METHOD

The study was performed in 1055 out of 1442 consecutive adult patients visiting a Swedish health care centre. The relationship between complaint symptoms and sociodemographic characteristics, perceived health, and chronic disease was assessed using multiple regression analysis.

RESULTS

Gender and perceived health were related to all symptom categories independently of each other, and when the effects of various symptom categories were taken into account in the regression analysis, the depression and tension symptom categories could predict about 50% of the explanation.

CONCLUSION

The results of this study suggest that psychiatric symptoms, particularly depression and tension symptoms, interact and have an impact on somatic symptom reporting in addition to sociodemographic characteristics, perceived health, and chronic disease, which have impact on only some symptom categories.

Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics

STUDY OBJECTIVE

We describe, in comparison with a control group, frequent attenders to an emergency department in terms of their general health service use and their clinical, psychological, and social profiles.

METHODS

One hundred frequent attenders (those who had made > or =4 visits in the previous year) and 100 nonfrequent attenders matched for sex, age, and triage category were interviewed in the ED. Data were gathered on health service use, mental health (by using the General Health Questionnaire-12 item), and perceived social support (by using the Multidimensional Scale of Perceived Social Support). Patients' general practitioners were contacted to validate attendance data. Medical charts were searched for evidence of psychological problems and alcohol or drug abuse.

RESULTS

In the overall sample of 200 patients, 32% were female, and the mean age was 55 years (SD 20). Frequent attenders had made more visits to their general practitioner in the past year compared with control patients (median 12 versus 3 visits); a higher proportion of frequent attenders had used public health nursing services, community welfare services, social work services, addiction counseling, and psychiatric services in the past year. Frequent attenders had made more other hospital visits and had spent more nights in the hospital than control patients. General Health Questionnaire-12 item scores were higher for frequent attenders than control patients, indicating poorer mental health. Frequent attenders had lower levels of perceived social support.

CONCLUSION

Frequent attenders to the ED are also heavy users of general practice services, other primary care services, and other hospital services. General Medical Services-eligible patients (84% of frequent attenders) frequently attend the ED, even though they have free access to primary care. Frequent attenders are a psychosocially vulnerable group, and service providers and policy makers need to take account of this vulnerable patient profile as they endeavor to meet their service needs.