Consultations for injuries by frequent attenders are found to be medically appropriate from general practitioners' perspective

Frequent attenders in primary health care: a mixed-methods study of patient and staff perspectives

AIMS AND OBJECTIVE

To understand the frequent attendance phenomenon from the perspective of patients and healthcare professionals and how it can be reduced.

BACKGROUND

Frequent attenders (FAs) are characterised by the consumption of a disproportionate number of medical consultations and a high number of visits per year to primary care physicians (PCP). Although FAs constitute about 10% of all primary clinic attendees, they are responsible for ~40-50% of clinic visits, affecting the efficiency, accessibility and quality of health services provided to other patients.

DESIGN

Mixed methods (STROBE Statement: Data S1; COREQ checklist: Data S2).

METHODS

Eighteen FAs were interviewed in a qualitative approach. PCPs and nurses (n = 184) completed a cross-sectional survey.

RESULTS

FAs are driven by their personal, emotional and mental state. FAs viewed clinics as a source for information and resolving medical problems. They perceived PCPs as authoritative and knowledgeable, and nurses as treatment managers and mediators between PCPs and patients. In contrast, FAs evoked more negative emotions than positive ones among medical staff. PCPs and nurses attributed frequent visits to FAs' personal and emotional states. A model based on the findings was constructed to provide a framework for grasping frequent attendance from a sociological perspective and for planning and managing it.

CONCLUSIONS

The accessibility and availability of health services at primary clinics, and collaboration and trust in medical staff facilitate the frequent attendance phenomenon.

RELEVANCE TO CLINICAL PRACTICE

The frequent attendance phenomenon should be proactively prevented, even before patients become FA, using the model constructed, which serves as a foundation for introducing an intervention program to identify and prevent frequent attendance. PCPs and nurses working in primary care clinics should be made aware of the FA phenomenon and should be educated and given tools to deal with it within the clinic. The process should be facilitated by organisational support.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution to the design or conduct of the study, analysis or interpretation of the data, or in the preparation of the manuscript.

High cost or frequent attender - both spend resources, but are they linked to work disability? A cohort study from occupational health primary care in Finland

Background

High use of services is associated with ill health and a number of health problems, but more information is needed on whether high use of services presents a risk for future pensions or disability. We aimed to investigate if defining patients as high cost (HC) or frequent attenders (FA) was more useful in occupational health services (OHS) as a predictor of future disability pension (DP).

Methods

This cohort study used medical record data from a large OHS provider and combined it with register data from the Finnish Centre for Pensions including disability pension decisions. A total of 31,960 patients were included and odds ratios for DP were calculated. Frequent attenders (FA10) were defined as the top decile of visitors according to attendance and high cost (HC10) as the top decile according to costs accrued from service use in 2015. Those patients that were not categorized as FA nor HC, but were eligible for the study were used as the control group (non-FAHC). The outcome measure (disability pensions) was analysed for years 2016–2017.

Results

FA and HC did not significantly differ in their risk for disability pension. Both groups’ risk was higher than average users’ risk (adjusted OR 3.47 for FA10, OR 2.49 for HC10 and OR 0.33 for controls). Both HC10 and FA10 received half of their disability pensions based on musculoskeletal disorders, while for non-FAHC only 28% of pensions were granted based on these disorders. The groups overlapped by 68%.

Conclusions

High utilizers (both FA10 and HC10) have an increased likelihood of receiving a future disability pension. The chosen definition is less important than identifying these patients and directing them towards necessary rehabilitation.

Frequent attenders in the German healthcare system: determinants of high utilization of primary care services. Results from the cross-sectional German health interview and examination survey for adults (DEGS)

BACKGROUND

In Germany, patients are consulting general practitioners increasingly frequently, resulting in a high burden on the healthcare system. This study aimed to identify factors associated with frequent primary care attendance in the German healthcare system.

METHODS

The German Health Interview and Examination Survey for Adults (DEGS) is part of Germany's national health monitoring, and includes a large representative sample of the German population aged 18-79 years. We defined the 10% of participants with the highest number of general practitioner contacts in the preceding 12 months as frequent attenders of primary care services. Binary logistic regression models with average marginal effects were used to identify potential determinants for frequent use of primary care services.

RESULTS

The sample comprised 7956 participants. Significant effects on frequent use of primary care were observed for low socioeconomic status, stressful life events, factors related to medical need for care such as medically diagnosed chronic conditions and for subjective health. In the full model, the number of non-communicable diseases and subjective health status had the strongest effect on frequent primary care use. We found an interaction effect suggesting that the association between subjective health status and frequent attendance vanishes with a higher number of non-communicable diseases.

CONCLUSIONS

We observed strong associations between frequent primary care attendance and medical need for care as well as subjective health-related factors. These findings suggest that better coordination of care may be a preferred method to manage health services utilization and to avoid redundant examinations and uncoordinated clinical pathways. Further research is needed to clarify moderating and mediating factors contributing to high utilization of primary care services.

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

OBJECTIVES

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

SETTING AND PARTICIPANTS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Frequent attenders in occupational health primary care: A cross-sectional study

Aims: This study characterizes frequent attenders in primary care provided by occupational health services (OHS) in Finland. Methods: This is a nationwide cross-sectional study using medical record data from an OHS provider in 2015. Frequent attenders were defined as persons who were within the top decile of annual visits to healthcare professionals (frequent attender 10%, FA10) at any of the OHS’s 37 stations. FA10s within this study consulted the OHS primary care unit eight or more times during 2015. We used logistic regression to analyse factors associated with frequent attendance in OHS primary care. The independent variables were age, gender, employer size and industry, health professionals visited and diagnoses given during visits to the OHS. The dependent variable was belonging to the FA10 group. Results: Altogether 31,960 patients met the inclusion criteria and were included in the study. The FA10 group included 3617 patients, who conducted 36% of visits to healthcare professionals. The findings indicate that working within the manufacturing industry, health and social services, or public administration, and being employed in medium or large companies, are associated with frequent attendance. Frequent attendance was also associated with being female, diagnoses of the musculoskeletal system, or mental and behavioral disorders. In particular, depressive episodes and anxiety were associated with FA10s. Conclusions:This research characterized FA10 clients at a Finnish OHS. Illnesses of the musculoskeletal system and mental and behavioral disorders were accentuated among FA10s. The stability of the FA10 group, along with their sickness absences and work disabilities, should be investigated further.

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

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

Frequent attenders in late life in primary care: a systematic review of European studies

Background

High utilization of health care services is a costly phenomenon commonly observed in primary care practices. However, while frequent attendance in primary care has been broadly studied across age groups, aspects of high utilization by elderly patients have not been investigated in detail. The aim of this paper is to provide a systematic review of frequent attendance in primary care among elderly people.

Methods

We searched five databases (PubMed, PsycINFO, Web of Science, PubPsych, and Cochrane Library) for published papers addressing frequent attendance in primary health care among elderly individuals. Quality of studies was assessed using established criteria for evaluating methodological quality.

Results

Ten studies met inclusion criteria and were included for detailed analysis. The average number of patients frequently utilizing primary care services varied across studies from 10% to 33% of the elderly samples and subsamples. The definition of frequent attendance across studies differed substantially. The most consistent associations between frequent attendance and old age were found for presence and severity of physical illness. Results on mental disorders and frequent attendance were heterogeneous. Only a few studies have assessed frequent attendance in association with factors such as drug use, social support or sociodemographic aspects; however results were inconsistent.

Conclusions

Severe ill health and the need for treatment serve as the main drivers of frequent attendance in older adults. As results were scarce and divergent, future studies are needed to provide more information on this topic. Since prior studies have offered only a snapshot of this service use behaviour, a longitudinal approach would be preferable in the future.

Electronic supplementary material

The online version of this article (10.1186/s12875-017-0700-7) contains supplementary material, which is available to authorized users.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Socio-demographic and clinical characteristics of re-presentation to an Australian inner-city emergency department: implications for service delivery

Background

People who have complex health care needs frequently access emergency departments for treatment of acute illness and injury. In particular, evidence suggests that those who are homeless, or suffer mental illness, or have a history of substance misuse, are often repeat users of emergency departments. The aim of this study was to describe the socio-demographic and clinical characteristics of emergency department re-presentations. Re-presentation was defined as a return visit to the same emergency department within 28 days of discharge from hospital.

Methods

A retrospective cohort study was conducted of emergency department presentations occurring over a 24-month period to an Australian inner-city hospital. Characteristics were examined for their influence on the binary outcome of re-presentation within 28 days of discharge using logistic regression with the variable patient fitted as a random effect.

Results

From 64,147 presentations to the emergency department the re-presentation rate was 18.0% (n = 11,559) of visits and 14.4% (5,894/40,942) of all patients. Median time to re-presentation was 6 days, with more than half occurring within one week of discharge (60.8%; n = 6,873), and more than three-quarters within two weeks (80.9%; n = 9,151). The odds of re-presentation increased three-fold for people who were homeless compared to those living in stable accommodation (adjusted OR 3.09; 95% CI, 2.83 to 3.36). Similarly, the odds of re-presentation were significantly higher for patients receiving a government pension compared to those who did not (adjusted OR 1.73; 95% CI, 1.63 to 1.84), patients who left part-way through treatment compared to those who completed treatment and were discharged home (adjusted OR 1.64; 95% CI, 1.36 to 1.99), and those discharged to a residential-care facility compared to those who were discharged home (adjusted OR 1.46: 95% CI, 1.03 to 2.06).

Conclusion

Emergency department re-presentation rates cluster around one week after discharge and rapidly decrease thereafter. Housing status and being a recipient of a government pension are the most significant risk factors. Early identification and appropriate referrals for those patients who are at risk of emergency department re-presentation will assist in the development of targeted strategies to improve health service delivery to this vulnerable group.