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

Consultation frequency and general practitioners' and practices' characteristics

BACKGROUND

High workloads generated by a few patients who consult very frequently can become huge burdens for general practitioners (GPs). Patient-related factors have been repeatedly associated with frequent consultations, but there is evidence that GPs can also influence that frequency. We investigated how patients, GPs and their practices' organisational characteristics were associated with consultation frequency.

METHODS

Data came from the SPAM Prev (Swiss Primary Health Care Active Monitoring, Prevention in primary care) national, cross-sectional survey conducted in 2015-16, including 167 GPs and 1105 patients. GPs completed an online questionnaire focused on practice organisation. Patients randomly recruited in general practices completed a questionnaire with fieldworkers. Factors predicting consultation frequency were investigated using multilevel Poisson regression models.

RESULTS

Negative associations with consultation frequency were found for females (Incidence Rate Ratio (IRR) 0.94, 95%CI [0.88-1.01]), less compliant patients (IRR 0.91, 95%CI [0.84-0.98]), high self-perceived health status (IRR 0.8, 95%CI [0.75-0.84]) and physical exercise (IRR 0.87, 95%CI [0.81-0.94]). Consultation frequencies were higher among patients with sleeping problems (IRR 1.08, 95%CI [0.96-1.23]), psychological distress (IRR 1.66, 95%CI [1.49-1.86]), chronic diseases (IRR 1.27, 95%CI [1.18-1.37]) and treatment with medication (IRR 1.24, 95%CI [1.12-1.37]). Positive associations with consultation frequency were found among GPs working longer hours (IRR 1.21, 95%CI [1.01-1.46]). Using shared medical records (IRR 0.79, 95%CI [0.67-0.92]) were negatively associated with consultation frequency.

CONCLUSION

GPs' practices' characteristics, like patients', are predictive of patients' consultation frequency, but those associations' underlying mechanisms require further qualitative investigation. These new findings could help optimise intervention strategies and reduce healthcare costs.

Unmet Healthcare Needs and Their Determining Factors among Unwell Migrants: A Comparative Study in Shanghai

The purpose of this study was to analyze the health status and unmet healthcare needs, and the impact of related factors, of unwell migrants in Shanghai. A total of 10,938 respondents, including 934 migrants and 10,004 non-migrants, were interviewed in Shanghai’s Sixth Health Service Survey. Descriptive statistics were utilized to present the prevalence of health status and unmet healthcare needs. Binary logistic regression analysis was performed to explore the relationships between predisposing factors, enabling factors, need factors, and health-related behavior and unmet healthcare needs in the Anderson health service utilization model. This study indicated the percentages of migrants having a fair or poor self-evaluated health status (21.09%) and suffering from chronic diseases (72.91%) were lower than those of non-migrants (28.34% and 88.64%, respectively). Migrants had higher percentages of unmet hospitalization needs (88.87%), unmet outpatient care needs (44.43%), and self-medication (23.98%) than those of non-migrants (86.24%, 37.95%, 17.97%, respectively). Migrants enrolled in Urban Employee Basic Medical Insurance were more likely to utilize hospitalization services (OR = 1.457) than those enrolled in other health insurances or uninsured. Need factors had impacts on unwell migrants’ unmet healthcare needs. Other factors, including age and health behavior, were also found to significantly affect unwell migrants’ unmet health service needs. Specific gaps continue to exist between unwell migrants and non-migrants regarding the accessibility of local health services. Flexible policies, such as enhancing the health awareness of migrants and eliminating obstacles for migrants to access medical services, should be implemented to provide convenient and affordable healthcare services to unwell migrants.

Accessibility of health care experienced by persons with dementia from ethnic minority groups and formal and informal caregivers: A scoping review of European literature

The number of persons with dementia from ethnic minority backgrounds is increasing. However, ethnic minority groups use health care services less frequently compared to the general population. We conducted a scoping review and used the theoretical framework developed by Levesque to provide an overview of the literature concerning access to health care for ethnic minority people with dementia and (in)formal caregivers. Studies mentioned barriers in (1) the ability to perceive a need for care in terms of health literacy, health beliefs and trust, and expectations; (2) the ability to seek care because of personal and social values and the lack of knowledge regarding health care options; and (3) lack of person-centered care as barrier to continue with professional health care. Studies also mentioned barriers experienced by professionals in (1) communication with ethnic minorities and knowledge about available resources for professionals; (2) cultural and social factors influencing the professionals' attitudes towards ethnic minorities; and (3) the appropriateness of care and lacking competencies to work with people with dementia from ethnic minority groups and informal caregivers. By addressing health literacy including knowledge about the causes of dementia, people with dementia from ethnic minorities and their informal caregivers may improve their abilities to access health care. Health care professionals need to strengthen their competencies in order to facilitate access to health care for this group.

Use of Health Services and Unmet Need among Adults of Russian, Somali, and Kurdish Origin in Finland

Equal access to health care is one of the key policy priorities in many European societies. Previous findings suggest that there may be wide differences in the use of health services between people of migrant origin and the general population. We analyzed cross-sectional data from a random sample of persons of Russian (n = 692), Somali (n = 489), and Kurdish (n = 614) origin and the Health 2011 survey data (n = 1406) representing the general population in Finland. Having at least one outpatient visit to any medical doctor during the previous 12 months was at the same level for groups of Russian and Kurdish origin, but lower for people of Somali origin, compared with the general population. Clear differences were found when examining where health care services were sought: people of migrant origin predominantly visited a doctor at municipal health centers whereas the general population also used private and occupational health care. Self-reported need for doctor's treatment was especially high among Russian women and Kurdish men and women. Compared to the general population, all migrant origin groups reported much higher levels of unmet medical need and were less satisfied with the treatment they had received. Improving basic-level health services would serve besides the population at large, the wellbeing of the population of migrant origin.

[Use of emergency rooms by so-called multiple users: results of a prospective study with special consideration of the migration status]

Fragestellung

Welche prädiktiven Faktoren lassen sich für die Gruppe der sog. Mehrfachnutzer (MFN; 4 und mehr Inanspruchnahmen einer Notaufnahme [NA] in den letzten 12 Monaten) finden? Sind Personen mit Migrationshintergrund häufiger in die Gruppe der MFN einzuordnen?

Methodik

Konsekutive Patienten, die von Juli 2017 bis Juli 2018 drei Klinik-NA in Berlin aufsuchten. Mittels Fragebogen Erfassung von Erkrankungen, Gründen für den NA-Besuch und sozioökonomischen Faktoren. Die Unterschiede zwischen Migranten (1. Generation), ihren Nachkommen (2. Generation) und Nichtmigranten wurden mithilfe der logistischen Regression bewertet.

Ergebnisse

2339 Patienten konnten in die Auswertung einbezogen werden (Rücklaufrate 56 %), davon hatten 901 einen Migrationshintergrund. Bei jungen Frauen (<30 Jahre), chronisch Kranken, Schwangeren, Patientinnen und Patienten mit starken Beschwerden und Personen mit (selbsteingeschätzter) mittlerer und schlechter „Gesundheitsqualität“ sowie solchen ohne ärztliche Zuweisung war die Chance für eine Mehrfachnutzung der NA größer.

Schlussfolgerung

MFN belasten das ohnehin zunehmende Patientenvolumen von NA. Sie stellen jedoch eine heterogene Patientengruppe dar, unter der Menschen mit Migrationshintergrund nicht häufiger vertreten sind. Weitere Untersuchungen sind erforderlich, um die Faktoren, die zu einer häufigen Inanspruchnahme führen, besser zu verstehen und wirksame Strategien zu entwickeln, um den komplexen Gesundheitsbedürfnissen von MFN gerecht zu werden.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Immigration, acculturation, and preferred help-seeking sources for depression: comparison of five ethnic groups

Background

Immigrants are more likely than the majority population to have unmet needs for public mental health services. This study aims to understand potential ethnic differences in preferred help-seeking sources for depression in Norway, and how such preferences relate to acculturation orientation.

Methods

A convenience sample of immigrants from Russia (n = 164), Poland (n = 127), Pakistan (n = 128), and Somalia (n = 114), and Norwegian students (n = 250) completed a survey. The sample was recruited from social media platforms, emails, and direct contact. The survey consisted of a vignette describing a moderately depressed person. Respondents were asked to provide advice to the person by completing a modified version of the General Help-Seeking Questionnaire. The immigrant sample also responded to questions about acculturation orientation using the Vancouver Index of Acculturation Scale.

Results

Significant differences were found in the endorsement of traditional (e.g., religious leader), informal (e.g., family), and semiformal (e.g., internet forum) help-sources between immigrant groups, and between immigrant groups and the Norwegian respondent group. Immigrants from Pakistan and Somalia endorsed traditional help sources to a greater extent than immigrants from Russia and Poland, and the Norwegian student sample. There were no ethnic differences in endorsement of formal mental help sources (e.g., a medical doctor). Maintenance of the culture of origin as the acculturation orientation was associated with preferences for traditional and informal help sources, while the adoption of mainstream culture was associated with semiformal and formal help-seeking sources.

Conclusion

Ethnic differences in help-seeking sources need to be considered when designing and implementing mental health services.

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.

Health Services Access Inequalities Between Native and Immigrant in a Southern European Region

With the economic crisis in Spain, austerity measures were applied. However, it is unknown how these measures have affected the pattern of use of health services for the immigrant population. Thus, the objective of this study was to examine the inequalities in access to different levels of health care services according to place of birth. We used data from the 2014 Foreign Immigrant Population Survey (n = 1,908) and the Basque Health Survey 2013 for the native population (n = 4,232) for adults aged 16-59 years residing in the Basque Country, Spain. Log-binomial regression was used to quantify the association between country of origin and use of different levels of care in men and in women. We found a higher probability of using general practitioner (GP) services in immigrant women (PR: 1.19; 95% CI: 1.12-1.26) and men (PR: 1.11; 95% CI: 1.01-1.23) than in natives. This was also true for emergency services with immigrant women (PR: 1.97; 95% CI: 1.43-2.69) and men (PR: 1.50; 95% CI: 1.01-2.25). However, for specialized medicine services, there was no association. This study suggests the importance of guaranteeing access to health care to the entire population. Hence policies to eliminate barriers to health care are essential to ensure health for all.

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.

Multimorbidity and immigrant status: associations with area of origin and length of residence in host country

AIM

Multimorbidity is a growing phenomenon in primary care, and knowledge of the influence of social determinants on its evolution is vital. The aim of this study was to understand the relationship between multimorbidity and immigration, taking into account length of residence in the host country and area of origin of the immigrant population.

METHODS

Cross-sectional retrospective study of all adult patients registered within the public health service of Aragon, Spain (N = 1092279; 144238 were foreign-born), based on data from the EpiChron Cohort. Age-standardized prevalence rates of multimorbidity were calculated. Different models of binary logistic regressions were conducted to study the association between multimorbidity, immigrant status and length of residence in the host country.

RESULTS

The risk of multimorbidity in foreign-borns was lower than that of native-borns [odds ratio (OR): 0.54, 95% confidence interval (CI): 0.53-0.55]. The probability of experiencing multimorbidity was lowest for Asians (OR: 0.34, 95% CI: 0.31-0.37) and Eastern Europeans (OR: 0.42, 95% CI: 0.40-0.43), and highest for Latin Americans (OR: 0.70, 95% CI: 0.68-0.72). Foreign-born immigrants residing in Aragon for ≥5 years had a higher multimorbidity risk than those residing for <5 years (OR: 2.3, 95% CI: 2.2-2.4).

CONCLUSION

Prevalence of multimorbidity is lower among foreign-borns as compared with native-borns, but increases rapidly with length of residence in the host country. However, the progressive development of multimorbidity among immigrants varies widely depending on area of origin. These findings provide important insight into the health care needs of specific population groups and may help minimize the negative impact of multimorbidity among the most vulnerable groups.

Reasons for attending a general emergency outpatient clinic versus a regular general practitioner - a survey among immigrant and native walk-in patients in Oslo, Norway

OBJECTIVE

To explore reasons for attending a general emergency outpatient clinic versus a regular general practitioner (RGP).

DESIGN

Cross-sectional study using a multilingual anonymous questionnaire.

SETTING

Native and immigrant walk-in patients attending a general emergency outpatient clinic in Oslo (Monday-Friday, 08:00-23:00) during 2 weeks in September 2009.

SUBJECTS

We included 1022 walk-in patients: 565 native Norwegians (55%) and 457 immigrants (45%).

MAIN OUTCOME MEASURES

Patients' reasons for attending an emergency outpatient clinic versus their RGP.

RESULTS

Among patients reporting an RGP affiliation, 49% tried to contact their RGP before this emergency encounter: 44% of native Norwegian and 58% of immigrant respondents. Immigrants from Africa [odds ratio (OR) = 2.55 (95% confidence interval [CI]: 1.46-4.46)] and Asia [OR = 2.32 (95% CI: 1.42-3.78)] were more likely to contact their RGP before attending the general emergency outpatient clinic compared with native Norwegians. The most frequent reason for attending the emergency clinic was difficulty making an immediate appointment with their RGP. A frequent reason for not contacting an RGP was lack of access: 21% of the native Norwegians versus 4% of the immigrants claimed their RGP was in another district/municipality, and 31% of the immigrants reported a lack of affiliation with the RGP scheme.

CONCLUSIONS AND IMPLICATIONS

Access to primary care provided by an RGP affects patients' use of emergency health care services. To facilitate continuity of health care, policymakers should emphasize initiatives to improve access to primary health care services. KEY POINTS Access to immediate primary health care provided by a regular general practitioner (RGP) can reduce patients' use of emergency health care services. The main reason for attending a general emergency outpatient clinic was difficulty obtaining an immediate appointment with an RGP. A frequent reason for native Norwegians attending a general emergency outpatient clinic during the daytime is having an RGP outside Oslo. Lack of affiliation with the RGP scheme is a frequent reason for attending a general emergency outpatient clinic among immigrants.

Primary healthcare usage and use of medications among immigrant children according to age of arrival to Norway: a population-based study

BACKGROUND

Morbidity, use of healthcare and medication use have been reported to vary across groups of migrants and according to the different phases of migration, but little is known about children with immigrant background. In this study, we investigate whether the immigrant children's age of arrival predicts differences in usage of primary healthcare (PHC) and in use of prescribed medication.

METHODS

This nationwide, population-based study used information for children under 18 years of age in 2008 from three linked registers in Norway. Use of medication was assessed with logistic regression analyses presented with ORs with 95% CIs.

RESULTS

Of 1 168 365 children, 119 251 had immigrant background. The mean number of PHC visits among children aged 10-18 years, was 1.19 for non-immigrants, 1.17 among second generation immigrants, 1.12, 1.05 and 0.83 among first immigrant children who were <5, 5-9 and ≥10 years at arrival in Norway, respectively. Patterns were similar for younger immigrants, and were confirmed with regression models adjusting for age and sex. First generation immigrant children used less of nearly all groups of prescribed medication compared to non-immigrants when adjusting for age and sex (overall OR 0.48 (0.47 to 0.49)), and medication was also generally less used among second generation immigrant children (overall OR 0.92 (0.91 to 0.94)).

CONCLUSIONS

Age of arrival predicted PHC usage among children among first-generation children. First-generation immigrant children, particularly those arriving later in adolescence, used PHC less than age corresponding non-immigrant children. Immigrant children used less prescribed medication compared to non-immigrants after adjustment for age and sex.

Utilization of health care services by migrants in Europe-a systematic literature review

INTRODUCTION

Our study reviewed the empirical evidence on the utilization of health care services by migrants in Europe, and on differences in health service utilization between migrants and non-migrants across European countries.

SOURCES OF DATA

A systematic literature review was performed, searching the databases Medline, Cinahl and Embase and covering the period from January 2009 to April 2016. The final number of articles included was 39.

AREAS OF AGREEMENT

Utilization of accident and emergency services and hospitalizations were higher among migrants compared with non-migrants in most countries for which evidence was available. In contrast, screening and outpatient visits for specialized care were generally used less often by migrants.

AREAS OF CONTROVERSY

Utilization of general practitioner services among migrants compared with non-migrants presents a diverging picture.

GROWING POINTS

Compared with previous systematic reviews, the results indicate a clearer picture of the differences in health service utilization between migrants and non-migrants in Europe.

AREAS TIMELY FOR DEVELOPING RESEARCH

A comprehensive comparison across European countries is impossible because the number of studies is still limited. Further research should also help to identify barriers regarding the utilization of health care services by migrants.

Primary healthcare usage and morbidity among immigrant children compared with non-immigrant children: a population-based study in Norway

OBJECTIVES

Health status, disease spectrum and use of healthcare have been reported to vary across groups of migrants and according to the different phases of migration. However, most studies are conducted among adults. This study assesses usage of primary healthcare (PHC) by children with immigrant background compared with non-immigrant children in Norway and describes their relative morbidity burden.

DESIGN

Population-based retrospective cohort study.

SETTING

This study used 3 linked population-based registers in Norway for children under 18 years of age in 2008.

MAIN EXPOSURE AND OUTCOME MEASURES

Immigrants were defined as children with both parents born abroad, and further classified into first and second generation, and according to the World Bank income categories of their parents' country of origin. Usage and morbidity were assessed with negative binomial regression and logistic regression analyses, respectively. Further, population-attributable fraction analyses on PHC visits were conducted to estimate the impact on the primary health system.

PARTICIPANTS

1 168 365 children including 119 251 with immigrant background.

RESULTS

The mean number of visits to PHC for non-immigrant children was 1.40 compared with 1.19 for immigrants from high-income countries (HIC) and 1.76 for immigrants from low-income countries (LIC). Compared with non-immigrants, first generation immigrants used PHC significantly less after adjusting for age and sex (incidence risk ratio (IRR) 0.70 (HIC) to 0.93 (LIC)) while second generation immigrant children generally used PHC more (IRR 1.03 (HIC) to 1.43 (LIC)); however, the median number of visits were similar between all groups. The morbidity spectrum also varied between the groups.

CONCLUSIONS

Compared with non-immigrants, the excess number of consultations attributable to immigrant groups corresponds to around 1.3% of PHC visits among children.

Global healthcare use by immigrants in Spain according to morbidity burden, area of origin, and length of stay

BACKGROUND

The healthcare of immigrants is an important aspect of equity of care provision. Understanding how immigrants use the healthcare services based on their needs is crucial to establish effective health policy.

METHODS

This retrospective, observational study included the total population of Aragon, Spain (1,251,540 individuals, of whom 11.9 % were immigrants). Patient-level data on the use of primary, specialised, hospital, and emergency care as well as prescription drug use in 2011 were extracted from the EpiChron Cohort and compared between immigrants and nationals. Multivariable standard or zero-inflated negative binomial regression models were generated, adjusting for age, sex, length of stay, and morbidity burden.

RESULTS

The annual visit rates of immigrants were lower than those of nationals for primary care (3.3 vs 6.4), specialised care (1.3 vs 2.7), planned hospital admissions/100 individuals (1.6 vs 3.8), unplanned hospital admissions/100 individuals (2.7 vs 4.7), and emergency room visits/10 individuals (2.3 vs 2.8). Annual prescription drug costs were also lower for immigrants (€47 vs €318). These differences were only partially attenuated after adjusting for age, sex and morbidity burden.

CONCLUSION

In a universal coverage health system offering broad legal access to immigrants, the global use of healthcare services was lower for immigrants than for nationals. These differences may be explained in part by the healthy migration effect, but also reveal possible inequalities in healthcare provision that warrant further investigation.

Multimorbidity and Its Patterns according to Immigrant Origin. A Nationwide Register-Based Study in Norway

INTRODUCTION

As the flows of immigrant populations increase worldwide, their heterogeneity becomes apparent with respect to the differences in the prevalence of chronic physical and mental disease. Multimorbidity provides a new framework in understanding chronic diseases holistically as the consequence of environmental, social, and personal risks that contribute to increased vulnerability to a wide variety of illnesses. There is a lack of studies on multimorbidity among immigrants compared to native-born populations.

METHODOLOGY

This nationwide multi-register study in Norway enabled us i) to study the associations between multimorbidity and immigrant origin, accounting for other known risk factors for multimorbidity such as gender, age and socioeconomic levels using logistic regression analyses, and ii) to identify patterns of multimorbidity in Norway for immigrants and Norwegian-born by means of exploratory factor analysis technique.

RESULTS

Multimorbidity rates were lower for immigrants compared to Norwegian-born individuals, with unadjusted odds ratios (OR) and 95% confidence intervals 0.38 (0.37-0.39) for Eastern Europe, 0.58 (0.57-0.59) for Asia, Africa and Latin America, and 0.67 (0.66-0.68) for Western Europe and North America. Results remained significant after adjusting for socioeconomic factors. Similar multimorbidity disease patterns were observed among Norwegian-born and immigrants, in particular between Norwegian-born and those from Western European and North American countries. However, the complexity of patterns that emerged for the other immigrant groups was greater. Despite differences observed in the development of patterns with age, such as ischemic heart disease among immigrant women, we were unable to detect the systematic development of the multimorbidity patterns among immigrants at younger ages.

CONCLUSIONS

Our study confirms that migrants have lower multimorbidity levels compared to Norwegian-born. The greater complexity of multimorbidity patterns for some immigrant groups requires further investigation. Health care policies and practice will require a holistic approach for specific population groups in order to meet their health needs and to curb and prevent diseases.

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.

Multimorbidity among registered immigrants in Norway: the role of reason for migration and length of stay

OBJECTIVES

International migration is rapidly increasing worldwide. However, the health status of migrants differs across groups. Information regarding health at arrival and subsequent periodic follow-up in the host country is necessary to develop equitable health care to immigrants. The objective of this study was to determine the impact of the length of stay in Norway and other sociodemographic variables on the prevalence of multimorbidity across immigrant groups (refugees, labour immigrants, family reunification immigrants and education immigrants).

METHODS

This is a register-based study merging data from the National Population Register and the Norwegian Health Economics Administration database. Sociodemographic variables and multimorbidity across the immigrant groups were compared using Persons' chi-square test and anova as appropriate. Several binary logistic regression models were conducted.

RESULTS

Multimorbidity was significantly lower among labour immigrants (OR (95% CI) 0.23 (0.21-0.26) and 0.45 (0.40-0.50) for men and women, respectively) and education immigrants (OR (95% CI) 0.40 (0.32-0.50) and 0.38 (0.33-0.43)) and higher among refugees (OR (95% CI) 1.67 (1.57-1.78) and 1.83 (1.75-1.92)), compared to family reunification immigrants. For all groups, multimorbidity doubled after a five-year stay in Norway. Effect modifications between multimorbidity and sociodemographic characteristics across the different reasons for migration were observed.

CONCLUSIONS

Multimorbidity was highest among refugees at arrival but increased rapidly among labour immigrants, especially females. Health providers need to ensure tailor-made preventive and management strategies that take into account pre-migration and post-migration experiences for immigrants in order to address their needs.

Use of emergency care services by immigrants—a survey of walk-in patients who attended the Oslo Accident and Emergency Outpatient Clinic

BACKGROUND

The Oslo Accident and Emergency Outpatient Clinic (OAEOC) experienced a 5-6% annual increase in patient visits between 2005 and 2011, which was significantly higher than the 2-3% annual increase among registered Oslo residents. This study explored immigrant walk-in patients' use of both the general emergency and trauma clinics of the OAEOC and their concomitant use of regular general practitioners (RGPs) in Oslo.

METHODS

A cross-sectional survey of walk-in patients attending the OAEOC during 2 weeks in September 2009. We analysed demographic data, patients' self-reported affiliation with the RGP scheme, self-reported number of OAEOC and RGP consultations during the preceding 12 months. The first approach used Poisson regression models to study visit frequency. The second approach compared the proportions of first- and second-generation immigrants and those from the four most frequently represented countries (Sweden, Pakistan, Somalia and Poland) among the patient population, with their respective proportions within the general Oslo population.

RESULTS

The analysis included 3864 patients: 1821 attended the Department of Emergency General Practice ("general emergency clinic"); 2043 attended the Section for Orthopaedic Emergency ("trauma clinic"). Both first- and second-generation immigrants reported a significantly higher OAEOC visit frequency compared with Norwegians. Norwegians, representing 73% of the city population accounted for 65% of OAEOC visits. In contrast, first- and second-generation immigrants made up 27% of the city population but accounted for 35% of OAEOC visits. This proportional increase in use was primarily observed in the general emergency clinic (42% of visits). Their proportional use of the trauma clinic (29%) was similar to their proportion in the city. Among first-generation immigrants only 71% were affiliated with the RGP system, in contrast to 96% of Norwegians. Similar finding were obtained when immigrants were grouped by nationality. Compared to Norwegians, immigrants from Sweden, Pakistan and Somalia reported using the OAEOC significantly more often. Immigrants from Sweden, Poland and Somalia were over-represented at both clinics. The least frequent RGP affiliation was among immigrants from Sweden (32%) and Poland (65%).

CONCLUSIONS

In Norway, immigrant subgroups use emergency health care services in different ways. Understanding these patterns of health-seeking behaviour may be important when designing emergency health services.

Longitudinal cohort study describing persistent frequent attenders in Australian primary healthcare

OBJECTIVES

To describe patterns of frequent attendance in Australian primary care, and identify the prospective risk factors for persistent frequent attendance.

DESIGN, SETTING AND PARTICIPANTS

This study draws on data from the Personality and Total Health (PATH) Through Life Project, a representative community cohort study of residents from the Canberra region of Australia. Participants were assessed on 3 occasions over 8 years. The survey assessed respondents' experience of chronic physical conditions, self-reported health, symptoms of common mental disorders, personality, life events, sociodemographic characteristics and self-reported medication use. A balanced sample was used in analysis, comprising 1734 respondents with 3 waves of data. The survey data for each respondent were individually linked to their administrative health service use data which were used to generate an objective measure of general practitioner (GP) consultations in the 12 months surrounding their interview date.

MAIN OUTCOME MEASURES

Respondents in the (approximate) highest decile of attenders on number of GP consultations over a 12-month period at each time point were defined as frequent attenders (FAs).

RESULTS

Baseline FAs (8.4%) were responsible for 33.4% of baseline consultations, while persistent FAs (3.6%) for 15.5% of all consultations over the 3 occasions. While there was considerable movement between FA status over time, consistency was greater than expected by chance alone. While there were many factors that differentiated non-FAs from FAs in general, persistent frequent attendance was specifically associated with gender, baseline reports of depression, self-reported physical conditions and disability, and medication use.

CONCLUSIONS

The degree of persistence in GP consultations was limited. The findings of this study contribute to our understanding of the risk factors that predict subsequent persistent frequent attendance in primary care. However, further detailed investigation of longitudinal patterns of frequent attendance and consideration of time-varying determinants of frequent attendance is required.