Mental disorders, chronic conditions and psychological factors: a path analysis model for healthcare consumption in general practice

Reducing patients' rate of frequent attendance through a training intervention for physicians

BACKGROUND

Frequent attendance is a common issue for primary care health centres. The phenomenon affects the quality of care, increases doctors' workloads and can lead to burnout.This study presents the results of an educational intervention for primary care physicians, aimed at helping them to decrease the prevalence rate of excessive attendance by patients at their centres.

METHODS

A training programme was carried out for 11 primary care doctors in Barcelona who had patient lists totalling 20,064 patients. The goal of the training was to provide the participating physicians with techniques to curb frequent attendance. Additionally, the programme sought to offer them strategies to prevent professional burnout and tools to better organize their everyday medical practice. The study used a quasi-experimental design for an evaluation of an educational intervention, featuring a pre-test assessment (before the training programme) and a post-test assessment (after the training programme), as well as comparison with a control group that did not undergo the training. The study assessed the effects of the programme on the rates of frequent attendance of patients served by the participating physicians. These rates were compared with those registered by the patients seen by the control group physicians over the same period.

RESULTS

Among the group of physicians who received the training, the mean prevalence of patients who qualified as frequent attenders decreased from 22% prior to the training programme to 8% after completion of the programme. In other words, 14% of patients (2,809) limited the frequency of their visits to primary care physicians after their physicians had completed the training programme. Meanwhile, the study recorded an average decrease of 3.1 visits per year by the patients of the physicians who had undergone the training. Statistically significant differences between this group and the control group were observed.

CONCLUSIONS

The educational intervention proved effective at helping primary care physicians to decrease their patients' rates of frequent attendance. It also contributes to the impact research of continuing education on doctors and their patients. We need to increase primary care spending from the current 14% to the 25%, to address this problem, among others.

Evaluating the Change Process of a Brief Cognitive Behavior Therapy Workshop for Psychological Distress Among Primary Care Self-Referrals in Selangor, Malaysia

Despite the high prevalence of psychological distress in primary care, only a limited number of individuals can benefit from early and evidenced-based psychological approach. Barriers to help-seeking attributable to stigma, lack of proper care pathway to evidence-based psychological interventions, and a high volume of primary care attendees are among the factors that contribute to the inadequate psychological treatments. This study examined the implementation of a change process using a brief cognitive behavioral therapy (b-CBT) workshop as a potential approach in managing psychological distress among 73 primary care self-referrals using purposive sampling. One-way repeated-measures multivariate analysis of variance (ANOVA) was used to analyze changes in psychological distress within a non-randomized quasi-experimental study. Results revealed significant differences in psychological distress using Depression, Anxiety, and Stress Scale-21 items at three time points (pre-intervention, post-intervention, and 1-month follow-up). Implementation of the b-CBT workshop showed positive changes for psychological distress, suggesting the possibility of integrating brief, non-stigmatized, and evidence-based psychological approach at the primary care level. However, the self-referral characteristics of the attendees remain unknown. Factors such as potential feasibility, participant's usability and satisfaction, and implementation of b-CBT workshop to improve psychological distress are discussed in this study.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Changes of perceived control after kidney transplantation: a prospective study

AIMS

The aim of this study was to determine if kidney transplantation is associated with increases of perceived control and how changes of perceived control affect the course of psychological distress until 1 year after transplantation.

BACKGROUND

Low levels of perceived control are associated with reduced well-being among dialysis patients.

DESIGN

Prospective longitudinal cohort study.

METHODS

Perceived control (Mastery Scale) and psychological distress (GHQ-12) were prospectively assessed before (T0; n = 470) and three (T1; n = 197), six (T2; n = 210) and twelve (T3; n = 183) months after transplantation. Differences between T1 and T0 perceived control were used to stratify the sample into three groups (control gain, stable control and control loss). Socio-demographic and clinical variables, including complications, were examined as potential correlates and the course of psychological was distress compared across groups. Data were collected between July 2008 - July 2013.

RESULTS

Perceived control showed a small increase overall, with 35·1%, 50·0% and 14·9% reporting gain, stable level and loss respectively. Patients with secondary schooling were overrepresented in the control loss group. The course of psychological distress varied across perceived control change groups, with patients in the control gain group experiencing a significant reduction in psychological distress.

CONCLUSION

A considerable number of patients report increased levels of perceived control after transplantation that are associated with a subsequent decrease in psychological distress. Results emphasize the importance of perceived control and could inform interventions to facilitate well-being after kidney transplantation.