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

Does a working day keep the doctor away? A critical review of the impact of unemployment and job insecurity on health and social care utilisation

While the negative impact of unemployment on health is relatively well established, the extent to which that impact reflects on changes in health and social care utilisation is not well understood. This paper critically reviews the direction, magnitude and drivers of the impact of unemployment and job insecurity on health and social care utilisation across different care settings. We identified 28 relevant studies, which included 79 estimates of association between unemployment/job insecurity and healthcare utilisation. Positive associations dominated mental health services (N = 8 out of 11), but not necessarily primary care (N = 25 out of 43) or hospital care (N = 5 out of 22). We conducted a meta-analysis to summarise the magnitude of the impact and found that unemployed individuals were about 30% more likely to use health services compared to those employed, although this was largely driven by mental health service use. Key driving factors included financial pressure, health insurance, social network, disposable time and depression/anxiety. This review suggests that unemployment is likely to be associated with increased mental health service use, but there is considerable uncertainty around primary and hospital care utilisation. Future work to examine the impact across other settings, including community and social care, and further explore non-health determinants of utilisation is needed. The protocol was registered in PROSPERO (CRD42020177668).

Frequent users of health services among community‐based older Australians: Characteristics and association with mortality

OBJECTIVES

To investigate characteristics of frequent users of general practice (GP; ≥21 visits in a year), medical specialist (≥10 visits), emergency department (ED; ≥2 presentations) and hospital services (≥2 overnight hospitalisations) and the association with mortality for people aged over 75 years.

METHODS

The study included residents from Central and Eastern Sydney, Australia, aged over 75 years who participated in a large community-dwelling cohort study. Demographic, social and health characteristics data were extracted from the 45 and Up Study survey. Health service (GP, medical specialist, ED and hospitalisations) use and mortality data were extracted from linked administrative data. We calculated adjusted prevalence ratios to identify independent characteristics associated with frequent users of services at baseline (approx. 2008) and adjusted hazard ratios to assess the association between frequent users of services and mortality.

RESULTS

Frequent users of services (GPs, medical specialists, EDs and hospitals) were more likely to be associated with ever having had heart disease and less likely to be associated with reporting good quality of life. Characteristics varied by service type. Frequent users of services were 1.5-2.0 times more likely to die within 7 years compared to those who were less frequent service users after controlling for all significant factors.

CONCLUSIONS

Our analysis found that frequent service users aged over 75 years had poorer quality of life, more complex health conditions and higher mortality and so their health service use was not inappropriate. However, better management of these frequent service users may lead to better health outcomes.

The Frequency of Primary Healthcare Contacts Preceding the Diagnosis of Lower-Extremity Arterial Disease: Do Women Consult General Practice Differently?

Background. Women with lower-extremity arterial disease (LEAD) are often underdiagnosed, present themselves with more advanced disease at diagnosis, and fare worse than men. Objective. To investigate to what extent potential gender differences exist in the frequency and reasons for general practitioner (GP) consultation six months prior to the diagnosis of LEAD, as potential indicators of diagnostic delay. Methods. Individuals older than 18 years diagnosed with LEAD, sampled from the Julius General Practitioner’s Network (JGPN), were included and compared with a reference population, matched (1:2.6 ratio) in terms of age, sex, and general practice. We applied a zero-inflated negative binomial (ZINB) regression model. Results. The study population comprised 4044 patients with LEAD (43.5% women) and 10,486 subjects in the reference population (46.3% women). In the LEAD cohort, the number of GP contacts was 2.70 (95% CI: 2.42, 3.02) in women and 2.54 (2.29, 2.82) in men. In the reference cohort, 1.77 (95% CI: 1.62, 1.94) in women and 1.63 (95% CI: 1.50, 1.78) in men. In the LEAD cohort, 21.9% of GP contacts occurred one month prior to diagnosis. In both cohorts and both sexes, the most common cause of consultation during the last month before the index date was cardiovascular problems. Conclusions. Six months preceding the initial diagnosis of LEAD, patients visit the GP more often than a similar population without LEAD, regardless of gender. Reported gender differences in the severity of LEAD at diagnosis do not seem to be explained by a delay in presentation to the GP.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

Background

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

Methods

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

Results

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

Conclusions

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

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

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

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

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

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

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

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

Patients with Liver Cirrhosis as Frequent Attenders of Emergency Departments

Objectives

Frequent attendance for nonemergency problems to emergency departments (EDs) contributes to ED overcrowding, resulting in medical care delays, increased medical errors, and social and economic burdens. Most studies regarding frequent attenders of EDs examine general patients without classifying certain subgroups. This study aimed to investigate patients with liver cirrhosis who present repeatedly to the ED.

Methods

This was a retrospective, observational cohort study of adult patients with a history of liver cirrhosis presenting to the ED from January 2011 to December 2015. We included patients with cirrhosis whose first ED visit occurred during the study period. We went far back for 20 years and excluded patients with any ED visits (including both cirrhosis and noncirrhosis-related ones) before the study period. We categorized frequent attenders as patients with more than 4 ED visits within 12 months after the first ED visit; infrequent attenders were those who did not meet this criterion.

Results

A total of 3513 patients with cirrhosis were included in this retrospective cohort study. Compared with the infrequent attenders, frequent attenders had a higher rate of presentations due to hepatic encephalopathy (15.2% vs 13.7%, P < 0.001) and ascites (10% vs 4%, P < 0.001) and ascites (10% vs 4%, P < 0.001) and ascites (10% vs 4%.

Conclusions

Hepatic encephalopathy and ascites account for more ED visits in frequent than in infrequent attenders. Our findings provide information for those planning outpatient support for patients with cirrhosis. Further research is warranted.

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.

Determinants of Postponed Dental Visits Due to Costs: Evidence from the Survey of Health, Ageing, and Retirement in Germany

High costs are an important reason patients postpone dental visits, which can lead to serious medical consequences. However, little is known about the determinants of postponing visits due to financial constraints longitudinally. Thus, the purpose of this study was to examine the determinants of postponing dental visits due to costs in older adults in Germany longitudinally. Data from wave 5 and 6 of the Survey of Health, Ageing, and Retirement in Europe was used. The occurrence of postponed dental visits due to costs in the last 12 months served as the outcome measure. Socioeconomic and health-related explanatory variables were included. Conditional fixed effects logistic regression models were used (n = 362). Regressions showed that the likelihood of postponing dental visits due to costs increased with lower age, less chronic disease, and lower income. The outcome measure was neither associated with marital status nor self-rated health. Identifying the factors associated with postponed dental visits due to costs might help to mitigate this challenge. In the long term, this might help to maintain the well-being of older individuals.