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Ramos A, Pujol R, Palma C. Reducing patients' rate of frequent attendance through a training intervention for physicians. BMC MEDICAL EDUCATION 2024; 24:758. [PMID: 39004704 PMCID: PMC11247833 DOI: 10.1186/s12909-024-05748-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 07/05/2024] [Indexed: 07/16/2024]
Abstract
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.
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Affiliation(s)
- Alex Ramos
- Postgraduate and Continuing Education in Health Sciences, Faculty of Life Sciences,, Universidad Nebrija, Madrid, Spain.
- Continuing Medical Education Centre of the Official Medical College of Barcelona, Barcelona, Spain.
| | - Ramon Pujol
- Internal Medicine, Faculty of Medicine of the University of Vic-Central Catalonia, Barcelona, Spain
- Board of Directors of the Official Medical College of Barcelona, Barcelona, Spain
| | - Carol Palma
- Psychology at Blanquerna Faculty, Universitat Ramon Llull, Barcelona, Spain
- Psychologist at the Mental Health Center of the Mataró Hospital, Barcelona, Spain
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2
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Ramos-Ruiz JA, Pérez-Milena A, Noguera-Cuenca C, Rodríguez-Bayón A, Ruiz-Díaz B. Patients with severe mental illness and their carers' expectations for GPs' communication skills: a qualitative approach in Spain. BJGP Open 2024; 8:BJGPO.2023.0124. [PMID: 37931981 PMCID: PMC11169970 DOI: 10.3399/bjgpo.2023.0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/18/2023] [Accepted: 10/23/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Effective communication with GPs (General Practitioners) enables higher rates of patient satisfaction and adherence to treatment plans. People with severe mental illness (SMI) and their caregivers present unique characteristics that present difficulties in the GP-carer-patient communication process. AIM To explore the expectations of patients with SMI and their caregivers regarding GPs' communication skills in primary care consultations. DESIGN & SETTING Face-to-face interviews, using focus group methodology, which were undertaken in southern Spain. METHOD Forty-two participants took part in 21 paired semi-structured interviews with an average duration of 19±7.2 minutes. Information was audio-recorded and transcribed verbatim. Qualitative content analysis was undertaken, obtaining a codification in categories by means of triangulation. RESULTS Four themes emerged from the analysis. Theme 1 was interviewer communication characteristics. The ability of GPs to use a language that was colloquial and adapted to each person was perceived as a determinant of the quality of care provided. An empathetic attitude, low reactivity, and efficient time management were the most valued communication skills. Theme 2 was telemedicine: telephone consultation and video consultation. The telephone consultation was perceived as a useful tool to care for people with SMI. Video consultation was valued as a requirement in isolated rural areas. Theme 3 was the role of the caregiver during the clinical interview. The caregiver was considered by the patients as an ally who improves the clinical interview. Theme 4 was the perceived barriers and facilitators during the clinical interview. The continuity of care, defined by a low turnover of GPs, determined the quality perceived by those who required care. CONCLUSION Themes emerging from this study have suggested that people with SMI require an inclusive, collaborative, and personalised approach in the care they receive from the public health system. Improved communication between GPs and patients with SMI is an essential requirement for quality medical care.
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Affiliation(s)
- Juan Andrés Ramos-Ruiz
- Multiprofessional Teaching Unit of Family and Community Care Jaén North - Northeast Andalusian Healthcare Service, Andalusia, Spain
| | | | | | - Antonina Rodríguez-Bayón
- Multiprofessional Teaching Unit of Family and Community Care Jaén North - Northeast Andalusian Healthcare Service, Andalusia, Spain
| | - Beatriz Ruiz-Díaz
- El Valle Primary Care Center, Andalusian Health Service, Jaén, Spain
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3
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Baudier L, Senn N, Wild P, Cohidon C. Consultation frequency and general practitioners' and practices' characteristics. BMC PRIMARY CARE 2023; 24:39. [PMID: 36739374 PMCID: PMC9898930 DOI: 10.1186/s12875-023-01996-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 01/27/2023] [Indexed: 06/18/2023]
Abstract
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.
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Affiliation(s)
- Laura Baudier
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Nicolas Senn
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | | | - Christine Cohidon
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
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4
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Haverfield MC, Tierney A, Schwartz R, Bass MB, Brown-Johnson C, Zionts DL, Safaeinili N, Fischer M, Shaw JG, Thadaney S, Piccininni G, Lorenz KA, Asch SM, Verghese A, Zulman DM. Can Patient-Provider Interpersonal Interventions Achieve the Quadruple Aim of Healthcare? A Systematic Review. J Gen Intern Med 2020; 35:2107-2117. [PMID: 31919725 PMCID: PMC7351919 DOI: 10.1007/s11606-019-05525-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 10/16/2019] [Accepted: 10/25/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient-provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience). METHODS We sourced data from PubMed, EMBASE, and PsycInfo (January 1997-August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient-provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider-patient dyad), and quadruple aim outcomes. RESULTS Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands. DISCUSSION Simple, low-demand patient-provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes.
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Affiliation(s)
- Marie C Haverfield
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System (152-MPD), Menlo Park, CA, USA. .,Stanford University Center for Primary Care and Outcomes Research (PCOR) and Center for Health Research and Policy (CHRP), Stanford, CA, USA.
| | - Aaron Tierney
- School of Medicine, Stanford University, Stanford, CA, USA
| | - Rachel Schwartz
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System (152-MPD), Menlo Park, CA, USA.,Stanford University Center for Primary Care and Outcomes Research (PCOR) and Center for Health Research and Policy (CHRP), Stanford, CA, USA
| | | | - Cati Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Dani L Zionts
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Nadia Safaeinili
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Meredith Fischer
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Jonathan G Shaw
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Sonoo Thadaney
- School of Medicine, Stanford University, Stanford, CA, USA
| | | | - Karl A Lorenz
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System (152-MPD), Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven M Asch
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System (152-MPD), Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System (152-MPD), Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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Zulman DM, Haverfield MC, Shaw JG, Brown-Johnson CG, Schwartz R, Tierney AA, Zionts DL, Safaeinili N, Fischer M, Thadaney Israni S, Asch SM, Verghese A. Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter. JAMA 2020; 323:70-81. [PMID: 31910284 DOI: 10.1001/jama.2019.19003] [Citation(s) in RCA: 135] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction. OBJECTIVE To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients. EVIDENCE REVIEW Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (-4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their "top 5" practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes. FINDINGS The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient's story (consider life circumstances that influence the patient's health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient's emotions). CONCLUSIONS AND RELEVANCE This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.
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Affiliation(s)
- Donna M Zulman
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
- VA Palo Alto Health Care System Center for Innovation to Implementation (Ci2i), Menlo Park, California
| | - Marie C Haverfield
- VA Palo Alto Health Care System Center for Innovation to Implementation (Ci2i), Menlo Park, California
- Stanford University Center for Primary Care and Outcomes Research (PCOR) and Center for Health Research and Policy (CHRP), Stanford, California
| | - Jonathan G Shaw
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Cati G Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Rachel Schwartz
- VA Palo Alto Health Care System Center for Innovation to Implementation (Ci2i), Menlo Park, California
- Stanford University Center for Primary Care and Outcomes Research (PCOR) and Center for Health Research and Policy (CHRP), Stanford, California
| | - Aaron A Tierney
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
- VA Palo Alto Health Care System Center for Innovation to Implementation (Ci2i), Menlo Park, California
| | - Dani L Zionts
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Nadia Safaeinili
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Meredith Fischer
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | | | - Steven M Asch
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
- VA Palo Alto Health Care System Center for Innovation to Implementation (Ci2i), Menlo Park, California
| | - Abraham Verghese
- Department of Medicine, Stanford University, Stanford, California
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6
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Strömbom Y, Magnusson P, Karlsson J, Fredrikson M. Health-related quality of life among frequent attenders in Swedish primary care: a cross-sectional observational study. BMJ Open 2019; 9:e026855. [PMID: 31366640 PMCID: PMC6678018 DOI: 10.1136/bmjopen-2018-026855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES The aim was to examine health-related quality of life (HRQoL), patient characteristics and reasons for visits to general practitioners (GPs) by frequent attenders (FAs) and a comparison group (CG) in primary care. METHODS Patients aged 18-64 years were eligible for the study. Medical records were scrutinised concerning reasons for visits. Questionnaires including short-form health survey (SF-36) were mailed to 331 FAs (≥5 visits at GPs during 2000) and 371 patients in a CG randomly selected from two healthcare centres and returned by 49% and 57%, respectively. FAs' SF-36 health profiles were compared both to CG and general Swedish population norms. RESULTS FAs report lower HRQoL than CG and below the general Swedish population norms in all eight SF-36 domains including both mental and physical component summary scores (MCS and PCS). Effect sizes (ESs) for differences between FAs and norms ranged from 0.79 to 1.08 for specific domains and was 0.94 for PCS and 0.71 for MCS. ESs of FAs versus CG ranged between 0.60 and 0.95 for the domains and was 0.76 for PCS and 0.49 for MCS. There were no significant differences between the FAs and CG with regard to sex, being married or cohabiting, number of children in household or educational level. FAs were more often unemployed, obese, slightly older and used complementary medicine more frequently. Except for injuries, all health complaints as classified in 10 categories were more common among FAs than CG, particularly musculoskeletal pain and psychosocial distress related to compromised HRQoL. CONCLUSION The HRQoL is compromised in FAs, both when compared with patients who do not often seek care and to general Swedish population norms. Commonly reported reasons for visiting GPs among FAs were musculoskeletal pain and psychosocial distress. Thus, perceived ill health, particularly pain and distress, seems important for high utilisation of healthcare resources.
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Affiliation(s)
- Ylva Strömbom
- Centre for Research and Development, Region Gavleborg, Gavle, Sweden
- Department of Psychology, Uppsala Universitet, Uppsala, Sweden
| | - Peter Magnusson
- Centre for Research and Development, Region Gavleborg, Gavle, Sweden
- Cardiology Research Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jan Karlsson
- University Health Care Research Center, Örebro University, Örebro, Sweden
| | - Mats Fredrikson
- Department of Psychology, Uppsala Universitet, Uppsala, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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A consultation-level intervention to improve care of frequently attending patients: a cluster randomised controlled feasibility trial. BJGP Open 2019; 3:bjgpopen18X101623. [PMID: 31049406 PMCID: PMC6480855 DOI: 10.3399/bjgpopen18x101623] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/03/2018] [Indexed: 12/26/2022] Open
Abstract
Background Frequent attenders (FAs) to primary care receive considerable NHS resources without necessarily gaining benefit, and may even be harmed. Aim To assess the feasibility of a consultation-level intervention to improve care and address service use of FAs. Design & setting A cluster randomised controlled feasibility trial was undertaken. The study used a mixed-methods process evaluation and took place in six practices in England. Method All practices screened the top 3% of all attending patients over the previous 12 months for eligibility. Following randomisation, intervention patients were matched with named GPs, trained to use the Background, Affect, Trouble, Handling, Empathy (BATHE) technique during consultations. Telephone consultations were encouraged. Feasibility outcomes assessed were recruitment, retention, data collection and completeness, implementation fidelity, and acceptability Results A total of 599/1328 (45.1%) FAs were eligible. Four practices were randomised to the intervention (n = 451) and two to usual care (n = 148). A total of 96 (23.7%) patients were recruited to complete questionnaires. Retention and completeness of data were good; for example, 76% of those agreeing to complete questionnaires did so at the 12-month assessment point. Thirty-four GPs were trained and delivered BATHE ≥1 times to 50.1% of patients (n = 577 consultations). There were minimal increases in continuity and telephone consultations. Patients were positive about the intervention, but noticed little change in their care. Despite valuing BATHE, low adherence to training was indicated and GPs used it less than anticipated. Conclusion It was feasible to identify FAs and collect trial data. GPs were keen to engage and there was evidence that the BATHE technique was taken into practice. Optimising training is likely to improve fidelity. The intervention was low cost and low risk.
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Santalahti AK, Vahlberg TJ, Luutonen SH, Rautava PT. Effect of administrative information on visit rate of frequent attenders in primary health care: ten-year follow-up study. BMC FAMILY PRACTICE 2018; 19:142. [PMID: 30153800 PMCID: PMC6114713 DOI: 10.1186/s12875-018-0836-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/17/2018] [Indexed: 11/21/2022]
Abstract
Background Frequent attenders (FAs) use a disproportionately large share of the resources of general practitioners (GPs) working in primary healthcare centres. The aim of this study was to estimate the proportion of FAs among all patients in the primary health care centres of a medium-sized city in Finland, and to examine whether providing GPs with administrative information about their frequent attenders (names and numbers of visits per year) can reduce the number of FAs and the frequency of their visits. Methods Statistic data on all GP visits (n = 1.8 million) to 11 public healthcare centres in one city were collected from the electronic patient records covering the period from 2001 to 2010. A FA-patient was defined as a person who made10 or more visits to GPs during one year. The baseline situation in 2001 was compared with the situation in 2006 after administrative information had been provided three times to all GPs working in the healthcare centres. Poisson’s regression analysis was used, and FA numbers and consultation rates in the years 2002–2005 were compared with the year 2006; figures for 2006 were also compared with those for the follow-up period 2007–2010. Results During the years 2001–2006, the proportion of visits of FA-patients fell overall from 9.1 to 8.5%, a decline of 0.6% (p < 0.0001). This reduction was equivalent to an annual work load of two GPs in the study center. The proportion of visits of FA patients increased again in the follow-up period (2007–2010), when administrative information was no longer provided. Conclusion When GPs are provided with information on the number and names of their FA-patients, the annual rate of FA visits to GPs drops significantly. The method is simple and repeatable. However, without a control group of GPs who have not received such information, it is impossible to assess if the intervention was the only circumstance affecting the reduction in FA consultation rates.
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Affiliation(s)
| | - Tero J Vahlberg
- Department of Biostatistics, Faculty of Medicine, University of Turku, Turku, Finland
| | - Sinikka H Luutonen
- Department of Psychiatry, University of Turku, Turku, Finland.,Department of Psychiatry, Turku University Hospital, Turku, Finland
| | - Päivi T Rautava
- Department of Public Health, Faculty of Medicine, University of Turku, Turku, Finland.,Turku Clinical Research Centre, Turku University Hospital, Turku, Finland
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9
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Norton J, Oude Engberink A, Gandubert C, Macgregor A, David M, Mann A, Ritchie K, Ancelin ML, Capdevielle D. Frequent attendance and the concordance between PHQ screening and GP assessment in the detection of common mental disorders. J Psychosom Res 2018; 110:1-10. [PMID: 29764597 DOI: 10.1016/j.jpsychores.2018.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/03/2018] [Accepted: 04/05/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Frequent Attenders (FAs) have high rates of both common mental disorders (CMD) and physical disorders, partly justifying this service use behaviour. This study examines both case and non-case concordance between CMDs as estimated by a self-report screening questionnaire and as rated by the general practitioner (GP), in FAs compared to Other Attenders (OAs). METHODS 2275 patients of an overlapping sample of 55 GPs from 2 surveys performed 10 years apart, completed in the waiting room the Patient Health Questionnaire (PHQ) and Client Service Receipt Inventory on 6-month service use. For each patient, the GP rated mental health on a 0-4 scale, with a clear indication that scores of 2 and above referred to caseness. PHQ-CMDs included major and other depressive, anxiety, panic, and somatoform disorders, identified using the original PHQ DSM-IV criteria-based algorithms. FA was defined as the top 10% of attenders in age, sex and survey-year stratified subgroups. RESULTS FAs had higher rates of PHQ-CMDs (42% versus 23% for OAs, p < .0001). They reported more personal and social problems, disability and had higher GP-rated physical illness. Survey-day antidepressant/anxiolytic medication prescription was higher for FAs (p < .0001), with (p = .02) but also without a CMD (p < .0001). Both GP/PHQ case and non-case concordance differed between FAs and OAs, with a non-case concordance odds ratio of 0.5 (95% CI: 0.3-0.7, p = .001) for FAs compared to OAs. CONCLUSION Despite a greater likelihood of GPs detecting CMDs in FAs, our findings suggest a potential risk of 'over-detection' of patients not reaching CMD threshold criteria among FAs.
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Affiliation(s)
- J Norton
- Inserm, U1061, Montpellier, France; University of Montpellier, U1061, Montpellier, France.
| | - A Oude Engberink
- Department of General Practice, Faculty of Medicine, University of Montpellier, France
| | - C Gandubert
- Inserm, U1061, Montpellier, France; University of Montpellier, U1061, Montpellier, France
| | - A Macgregor
- University Department of Adult Psychiatry, Montpellier University Hospital, Montpellier, France
| | - M David
- Department of General Practice, Faculty of Medicine, University of Montpellier, France
| | - A Mann
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - K Ritchie
- Inserm, U1061, Montpellier, France; University of Montpellier, U1061, Montpellier, France; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - M L Ancelin
- Inserm, U1061, Montpellier, France; University of Montpellier, U1061, Montpellier, France
| | - D Capdevielle
- Inserm, U1061, Montpellier, France; University of Montpellier, U1061, Montpellier, France; University Department of Adult Psychiatry, Montpellier University Hospital, Montpellier, France
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10
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Young V, Mehl-Madrona L, Mainguy B. A Patient-Centered Approach to a Rural General Practice in Distress and the Search for a Solution. Perm J 2018; 22:17-099. [PMID: 29702050 PMCID: PMC5922810 DOI: 10.7812/tpp/17-099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT A general practice in rural UK (Cumbria) was overwhelmed by staff burnout. OBJECTIVE To present a case study for how the staff of a practice came together, used data, agreed on a plan for improvement, implemented the plan, improved subjective distress, and objectively evaluated the intervention. DESIGN We conducted an audit using the electronic health record for patients coming to the practice 5 or more times annually from 2008 to 2012 (frequent attenders). We planned an intervention to reduce utilization (frequency of visits) while still serving patients. The intervention used a genogram, psychoeducation, and up to six 30-minute sessions of solutions-focused psychotherapy, in which difficult interpersonal relationships were identified and efforts were made to resolve 1 major problem related to those relationships. MAIN OUTCOME MEASURES Quantitative data (number of visits per year) and qualitative data about the changes that resulted in the practice from the audit and the intervention. RESULTS The frequency of visits for patients with mental health conditions (41.0% of all frequent attenders in the practice) dropped significantly from 2007 to 2012 (p = 0.019; initial visits per year, 10.0, standard deviation = 2.51; final visits per year = 5.6, standard deviation = 3.8). The frequency of visits for patients without mental health diagnoses did not change. CONCLUSION Intervening with frequent attenders of primary care who have mental health conditions improved their symptoms and reduced their health care utilization, with beneficial impact on practitioners and improvement in the morale of the staff.
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Affiliation(s)
- Venetia Young
- Senior Research Assistant in General Practice Research at the Coyote Institute in Orono, ME, and a General Practitioner in Penrith, UK.
| | - Lewis Mehl-Madrona
- Faculty Physician at the Eastern Maine Medical Center Family Medicine Residency in Bangor and Associate Professor of Family Medicine at the University of New England in Augusta, ME. He is also affiliated with the Coyote Institute in Orono, ME.
| | - Barbara Mainguy
- is a Psychotherapist and Reiki Practitioner. She is the Education Director at the Coyote Institute in Orono, ME.
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Loftus A, McCauley F, McCarron M. Impact of social prescribing on general practice workload and polypharmacy. Public Health 2017; 148:96-101. [DOI: 10.1016/j.puhe.2017.03.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 03/23/2017] [Accepted: 03/24/2017] [Indexed: 11/26/2022]
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Hajek A, Bock JO, König HH. Association of general psychological factors with frequent attendance in primary care: a population-based cross-sectional observational study. BMC FAMILY PRACTICE 2017; 18:48. [PMID: 28340559 PMCID: PMC5366110 DOI: 10.1186/s12875-017-0621-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 03/20/2017] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- André Hajek
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Jens-Oliver Bock
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Cognitive behaviour therapy for long-term frequent attenders in primary care: a feasibility case series and treatment development study. Br J Gen Pract 2016; 66:e729-36. [PMID: 27432609 DOI: 10.3399/bjgp16x686569] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/20/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Most frequent attendance in primary care is temporary. Long-term frequent attendance may be suitable for psychological intervention to address health management and service use. AIM To explore the feasibility and acceptability of cognitive behaviour therapy (CBT) for long-term frequent attendance in primary care and obtain preliminary evidence regarding clinical and cost effectiveness. DESIGN AND SETTING A CBT case series was carried out in five GP practices in the East Midlands. METHOD Frequent attenders (FAs) were identified from case notes and invited by their practice for assessment, then offered CBT. Feasibility and acceptability were assessed by CBT session attendance and thematic analysis of semi-structured questionnaires. Clinical and cost effectiveness was assessed by primary care use and clinically important change on a range of health and quality of life instruments. RESULTS Of 462 FAs invited to interview, 87 (19%) consented to assessment. Thirty-two (7%) undertook CBT over a median of 3 months. Twenty-four (75%) attended at least six sessions. Eighteen FAs (86%, n = 21) reported overall satisfaction with treatment. Patients reported valuing listening without judgement alongside support to develop coping strategies. Thirteen (54%, n = 24), achieved clinically important improvement on the SF-36 Mental-Component Scale at 6-month follow-up and improved quality of life, but no improvement on other outcomes. Primary care use reduced from a median of eight contacts in 3 months at baseline (n = 32) to three contacts in 3 months at 1 year (n = 18). CONCLUSION CBT appears feasible and acceptable to a subset of long-term FAs in primary care who halved their primary care use. With improved recruitment strategies, this approach could contribute to decreasing GP workload and merits larger-scale evaluation.
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Parejo Maestre N, Lendínez-de la Cruz J, Bermúdez-Torres F, Gónzalez-Contero L, Gutierrez-Espinosa de los Monteros M, Espejo-Almazán María T. Prevalencia y factores asociados a la hiperfrecuentación en la consulta de medicina de familia. Semergen 2016; 42:216-24. [DOI: 10.1016/j.semerg.2015.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 03/03/2015] [Accepted: 05/13/2015] [Indexed: 10/23/2022]
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Haroun D, Smits F, van Etten-Jamaludin F, Schene A, van Weert H, ter Riet G. The effects of interventions on quality of life, morbidity and consultation frequency in frequent attenders in primary care: A systematic review. Eur J Gen Pract 2016; 22:71-82. [DOI: 10.3109/13814788.2016.1161751] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Dany Haroun
- Department of General Practice, University of Amsterdam, Amsterdam, The Netherlands
| | - Frans Smits
- Department of General Practice, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Aart Schene
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Psychiatry, Academic Medical Center, Amsterdam, The Netherlands
| | - Henk van Weert
- Department of General Practice, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerben ter Riet
- Department of General Practice, University of Amsterdam, Amsterdam, The Netherlands
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van den Bussche H, Kaduszkiewicz H, Schäfer I, Koller D, Hansen H, Scherer M, Schön G. 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. BMC Health Serv Res 2016; 16:129. [PMID: 27074709 PMCID: PMC4831189 DOI: 10.1186/s12913-016-1357-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 03/21/2016] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Hendrik van den Bussche
- Institute of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Hanna Kaduszkiewicz
- Institute of General Practice, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Ingmar Schäfer
- Institute of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Daniela Koller
- Department of Health Services Management, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Heike Hansen
- Institute of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Martin Scherer
- Institute of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
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Hastings A, Fowler J, Morriss R, Scanlan M, Smart D, Valand R, Waseem Shahzad M. The development of a short course for general practitioners in the management of patients with medically unexplained symptoms (MUS). EDUCATION FOR PRIMARY CARE 2016; 27:53-6. [PMID: 26862800 DOI: 10.1080/14739879.2015.1119978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Adrian Hastings
- a Department of Medical and Social Care Education , University of Leicester , Leicester , UK
| | - John Fowler
- b Independent Researcher and Education Consultant , Leicester , UK
| | | | | | - David Smart
- e General Practitioner Partner , Northampton , UK
| | - Reena Valand
- f Innovation and Improvement, Health Education , East Midlands , UK
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Patel S, Kai J, Atha C, Avery A, Guo B, James M, Malins S, Sampson C, Stubley M, Morriss R. Clinical characteristics of persistent frequent attenders in primary care: case-control study. Fam Pract 2015; 32:624-30. [PMID: 26450918 PMCID: PMC5926457 DOI: 10.1093/fampra/cmv076] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Most frequent attendance in primary care is temporary, but persistent frequent attendance is expensive and may be suitable for psychological intervention. To plan appropriate intervention and service delivery, there is a need for research involving standardized psychiatric interviews with assessment of physical health and health status. OBJECTIVE To compare the mental and physical health characteristics and health status of persistent frequent attenders (FAs) in primary care, currently and over the preceding 2 years, with normal attenders (NAs) matched by age, gender and general practice. METHODS Case-control study of 71 FAs (30 or more GP or practice nurse consultations in 2 years) and 71 NAs, drawn from five primary care practices, employing standardized psychiatric interview, quality of life, health anxiety and primary care electronic record review over the preceding 2 years. RESULTS Compared to NAs, FAs were more likely to report a lower quality of life (P < 0.001), be unmarried (P = 0.03) and have no educational qualifications (P = 0.009) but did not differ in employment status. FAs experienced greater health anxiety (P < 0.001), morbid obesity (P = 0.02), pain (P < 0.001) and long-term pathological and ill-defined physical conditions (P < 0.001). FAs had more depression including dysthymia, anxiety and somatoform disorders (all P < 0.001). CONCLUSIONS Persistent frequent attendance in primary care was associated with poor quality of life and high clinical complexity characterized by diverse and often persistent physical and mental multimorbidity. A brokerage model with GPs working in close liaison with skilled psychological therapists is required to manage such persistent complexity.
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Affiliation(s)
- Shireen Patel
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | - Joe Kai
- Division of Primary Care and
| | - Christopher Atha
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | | | - Boliang Guo
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | - Marilyn James
- Health Economics, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Samuel Malins
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | - Christopher Sampson
- Health Economics, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Michelle Stubley
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | - Richard Morriss
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands,
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Stone L. Managing the consultation with patients with medically unexplained symptoms: a grounded theory study of supervisors and registrars in general practice. BMC FAMILY PRACTICE 2014; 15:192. [PMID: 25477194 PMCID: PMC4266896 DOI: 10.1186/s12875-014-0192-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 11/10/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with medically unexplained symptoms (MUS) commonly present in general practice. They often experience significant disability and have difficulty accessing appropriate care. Many feel frustrated and helpless. Doctors also describe feeling frustrated and helpless when managing these patients. These shared negative feelings can have a detrimental effect on the therapeutic relationship and on clinical outcomes. The aim of this study was to explore how novice and experienced GPs manage patients with MUS and how these skills are taught and learned in GP training. METHODS A constructivist grounded theory study with 24 general practice registrars and supervisors in GP training practices across Australia. RESULTS Registrars lacked a framework for managing patients with MUS. Some described negative feelings towards patients that were uncomfortable and confronting. Registrars also were uncertain about their clinical role: where their professional responsibilities began and ended. Supervisors utilised a range of strategies to address the practical, interpersonal and therapeutic challenges associated with the care of these patients. CONCLUSIONS Negative feelings and a lack of diagnostic language and frameworks may prevent registrars from managing these patients effectively. Some of these negative feelings, such as frustration, shame and helplessness, are shared between doctors and patients. Registrars need assistance to identify and manage these difficult feelings so that consultations are more effective. The care of these patients also raises issues of professional identity, roles and responsibilities. Supervisors can assist their registrars by proactively sharing models of the consultation, strategies for managing their own feelings and frustrations, and ways of understanding and managing the therapeutic relationship in this difficult area of practice.
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Affiliation(s)
- Louise Stone
- Centre for Values, Ethics and the Law in Medicine, University of Sydney, Level 1 Medical Foundation Building, 92-94 Parramatta Road, Camperdown, NSW, 2041, Australia.
- Academic Unit of General Practice, Australian National University Medical School, College of Medicine, Biology and Environment, Australian National University, Canberra ACT, 0200, Australia.
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Tricco AC, Antony J, Ivers NM, Ashoor HM, Khan PA, Blondal E, Ghassemi M, MacDonald H, Chen MH, Ezer LK, Straus SE. Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis. CMAJ 2014; 186:E568-78. [PMID: 25225226 DOI: 10.1503/cmaj.140289] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Frequent users of health care services are a relatively small group of patients who account for a disproportionately large amount of health care utilization. We conducted a meta-analysis of the effectiveness of interventions to improve the coordination of care to reduce health care utilization in this patient group. METHODS We searched MEDLINE, Embase and the Cochrane Library from inception until May 2014 for randomized clinical trials (RCTs) assessing quality improvement strategies for the coordination of care of frequent users of the health care system. Articles were screened, and data abstracted and appraised for quality by 2 reviewers, independently. Random effects meta-analyses were conducted. RESULTS We identified 36 RCTs and 14 companion reports (total 7494 patients). Significantly fewer patients in the intervention group than in the control group were admitted to hospital (relative risk [RR] 0.81, 95% confidence interval [CI] 0.72-0.91). In subgroup analyses, a similar effect was observed among patients with chronic medical conditions other than mental illness, but not among patients with mental illness. In addition, significantly fewer patients 65 years and older in the intervention group than in the control group visited emergency departments (RR 0.69, 95% CI 0.54-0.89). INTERPRETATION We found that quality improvement strategies for coordination of care reduced hospital admissions among patients with chronic conditions other than mental illness and reduced emergency department visits among older patients. Our results may help clinicians and policy-makers reduce utilization through the use of strategies that target the system (team changes, case management) and the patient (promotion of self-management).
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Affiliation(s)
- Andrea C Tricco
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Jesmin Antony
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Noah M Ivers
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Huda M Ashoor
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Paul A Khan
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Erik Blondal
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Marco Ghassemi
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Heather MacDonald
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Maggie H Chen
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Lianne Kark Ezer
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont.
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Hauswaldt J, Himmel W, Hummers-Pradier E. The inter-contact interval: a new measure to define frequent attenders in primary care. BMC FAMILY PRACTICE 2013; 14:162. [PMID: 24152427 PMCID: PMC3834877 DOI: 10.1186/1471-2296-14-162] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 10/10/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND Frequent attenders receive much attention in primary care research. Defining frequent attendance is crucial for an adequate view on this group of demanding patients. We aimed to develop a purely contact-based definition of "frequent attendance" and to apply it to real patients. METHODS From electronic records of 123 general practices in Germany, patients' inter-contact intervals (ICI) between two consecutive doctor-patient-contacts were calculated in this retrospective observational study. ICI less than 7 days were labelled "frequent attendance", patients with 60% or more of such intervals "frequent attenders (new view)". In contrast, patients having at least 24 contacts per calendar year were considered "frequent attenders (traditional view)". Both groups were analysed in their diseases and demands, using multiple logistic regression. RESULTS A total of 177,057 patients with at least 3 ICI in 1996 until 2006 yielded 4,408,033 ICI. One third were "short" ICI (less than 7 days), resulting in 19,759 (11.2%) frequent attenders (new). In contrast, 22,921 (12.9%) patients were frequent attenders (traditional). Compared to non-frequent attenders, frequent attenders (new) were more likely to have pneumonia (OR 1.66), stroke (OR 1.49), dementia (OR 1.46), or severe substance abuse (OR 1.44), also to need home visits or emergency attention. Frequent attenders (traditional) were more likely to have dementia (OR 2.76) or stroke (OR 2.06), and by far to need home visits (OR 5.43; all p < 0.001). CONCLUSIONS A new measure, the interval in days of two consecutive face-to-face contacts (ICI), widens our perspective on frequent attenders in general practice. In many cases, their consultation behaviour and need for medical services seem to follow "disease logic".
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Affiliation(s)
- Johannes Hauswaldt
- Department of General Practice/Family Medicine, University Medical Centre, Georg-August-University, Humboldtallee 38, 37073 Göttingen, Germany.
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Smits FT, Brouwer HJ, Zwinderman AH, van den Akker M, van Steenkiste B, Mohrs J, Schene AH, van Weert HC, ter Riet G. Predictability of persistent frequent attendance in primary care: a temporal and geographical validation study. PLoS One 2013; 8:e73125. [PMID: 24039870 PMCID: PMC3764153 DOI: 10.1371/journal.pone.0073125] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 07/17/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Frequent attenders are patients who visit their general practitioner exceptionally frequently. Frequent attendance is usually transitory, but some frequent attenders become persistent. Clinically, prediction of persistent frequent attendance is useful to target treatment at underlying diseases or problems. Scientifically it is useful for the selection of high-risk populations for trials. We previously developed a model to predict which frequent attenders become persistent. AIM To validate an existing prediction model for persistent frequent attendance that uses information solely from General Practitioners' electronic medical records. METHODS We applied the existing model (N = 3,045, 2003-2005) to a later time frame (2009-2011) in the original derivation network (N = 4,032, temporal validation) and to patients of another network (SMILE; 2007-2009, N = 5,462, temporal and geographical validation). Model improvement was studied by adding three new predictors (presence of medically unexplained problems, prescriptions of psychoactive drugs and antibiotics). Finally, we derived a model on the three data sets combined (N = 12,539). We expressed discrimination using histograms of the predicted values and the concordance-statistic (c-statistic) and calibration using the calibration slope (1 = ideal) and Hosmer-Lemeshow tests. RESULTS The existing model (c-statistic 0.67) discriminated moderately with predicted values between 7.5 and 50 percent and c-statistics of 0.62 and 0.63, for validation in the original network and SMILE network, respectively. Calibration (0.99 originally) was better in SMILE than in the original network (slopes 0.84 and 0.65, respectively). Adding information on the three new predictors did not importantly improve the model (c-statistics 0.64 and 0.63, respectively). Performance of the model based on the combined data was similar (c-statistic 0.65). CONCLUSION This external validation study showed that persistent frequent attenders can be prospectively identified moderately well using data solely from patients' electronic medical records.
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Affiliation(s)
- Frans T. Smits
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk J. Brouwer
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Aeilko H. Zwinderman
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marjan van den Akker
- Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Department of General Practice, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Ben van Steenkiste
- Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Jacob Mohrs
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Aart H. Schene
- Department of Psychiatry, Academic Medical Center; University of Amsterdam, Amsterdam, The Netherlands
| | - Henk C. van Weert
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerben ter Riet
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Crone DM, O'Connell EE, Tyson PJ, Clark-Stone F, Opher S, James DVB. 'Art Lift' intervention to improve mental well-being: an observational study from U.K. general practice. Int J Ment Health Nurs 2013; 22:279-86. [PMID: 22897659 DOI: 10.1111/j.1447-0349.2012.00862.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Arts for health interventions are emerging as an alternative option to medical management of mental health problems and well-being. This study investigated process and outcomes of an art intervention on patients referred by primary care professionals, including associations between patient characteristics (e.g., sex), progress through the intervention (e.g., attendance), and changes in mental well-being. Referral criteria included people with anxiety, depression, or stress; low self-esteem, confidence, or overall well-being; and chronic illness or pain. The study took place in U.K.-based general practitioner practices, with a total of 202 patients referred to a 10-week intervention. Patient sociodemographic information was recorded at baseline, and patient progress assessed throughout the intervention. Significant improvement in well-being was revealed for the 7-item (t = -6.049, d.f. = 83, P < 0.001, two-tailed) and 14-item (t = -6.961, d.f. = 83, P < 0.001, two-tailed) scales. Of referred patients, 77.7% attended and 49.5% completed. Most patients were female, and from a range of socioeconomic groups, and those who completed were significantly older (t = -2.258, d.f. = 145, P = 0.025, two-tailed). Findings reveal that this art intervention was effective in the promotion of well-being and in targeting women, older people, and people from lower socioeconomic groups.
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Affiliation(s)
- Diane M Crone
- Faculty of Applied Sciences, University of Gloucestershire, UK.
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Hauswaldt J, Hummers-Pradier E, Junius-Walker U. Health service use among patients with chronic or multiple illnesses, and frequent attenders: secondary analysis of routine primary care data from 1996 to 2006. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:814-20. [PMID: 23248711 PMCID: PMC3521193 DOI: 10.3238/arztebl.2012.0814] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 07/20/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Little or no longitudinal data have been available to date on the utilization of primary care physicians' services, particularly by chronically ill and multimorbid patients and by those who see their primary care physician often ("frequent attenders"). METHODS We collected anonymous data on 305 896 patients from 155 primary care practices over the period 1996-2006 and analyzed them with descriptive statistics, correlations, and multiple logistic regression. RESULTS Over the period of the study, patients visited their primary care physicians about 7 times per year on average. Frequent attendance, defined as 24 or more contacts per year, was not strongly associated with chronic illness or multimorbidity (r=0.19 and r=0.24, respectively) but was found to be linked to time-consuming medical services, such as detailed counseling (adjusted odds ratio [OR], 5.8) and house calls (OR, 3.5). Chronically ill patients utilized their primary care physicians' services less than we had expected. Chronic illness and multimorbidity were more common with increasing age; also correlated with age were the utilization of medical services, the number of visits to the primary care physician, and the number of visits to the primary care physician among frequent attenders. DISCUSSION Although in Germany visits to physicians of all types (both primary care physicians and specialists) in private practice became more frequent in total over the period of this study, visits to primary care physicians alone did not. Frequent attenders do not necessarily have chronic illness or multimorbidity but seem to constitute a particularly problematic group. Chronic illness is not a predictor for greater utilization of primary care physicians' services.
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Affiliation(s)
- Johannes Hauswaldt
- Department of General Practice at the University Medical Centre Göttingen, Humboldtallee 38, Göttingen, Germany.
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Morriss R, Kai J, Atha C, Avery A, Bayes S, Franklin M, George T, James M, Malins S, McDonald R, Patel S, Stubley M, Yang M. Persistent frequent attenders in primary care: costs, reasons for attendance, organisation of care and potential for cognitive behavioural therapeutic intervention. BMC FAMILY PRACTICE 2012; 13:39. [PMID: 22607525 PMCID: PMC3390898 DOI: 10.1186/1471-2296-13-39] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 05/20/2012] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Richard Morriss
- Psychiatry and Community Mental Health, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom.
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Self-care in primary care: findings from a longitudinal comparison study. Prim Health Care Res Dev 2012; 14:29-39. [PMID: 22717510 DOI: 10.1017/s1463423612000199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AIM To examine the effects of self-care training workshops for primary healthcare workers on frequently attending patients. BACKGROUND Interventions to promote self-care in frequent users of primary care services have had mixed results. This paper reports an evaluation of a self-care initiative that aimed to develop a practice-based strategy to support self-care. METHODS A 12-month longitudinal-matched comparison study was carried out in seven intervention and four comparison practices. The intervention was a multidisciplinary training package delivered to Primary Care Trusts (PCTs) and practice staff in three workshops, over a three- to six-month period. Twenty-one managers, health professionals and other staff from participating practices and PCTs and 1454 patients were involved in the study. 'Frequently attending' patients were defined as having visited the practice more than eight times in the previous year, and were identified from practice registers and recruited by letter. Three sets of data were obtained: psychometric scores and other data from structured questionnaires; routinely collected data on use of healthcare services; and self-care beliefs and behaviour from qualitative interviews. Findings Study recruitment rate was 20% and retention rate 75%. Of those recruited 66% were female and the majority (94.8%) were White. There was poor uptake of the training programme within the participating practices, with few changes agreed or implemented. Few healthcare professionals consented to take part in the evaluation. No significant changes were seen in patients' use of health services, psychometric scores or self-care beliefs or behaviour. CONCLUSION The initiative did not show any effects during its pilot phase. Uptake and implementation were adversely affected by competing pressures for time and resources in primary care, coupled with a lack of engagement from primary health care professionals.
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Norton J, David M, de Roquefeuil G, Boulenger JP, Car J, Ritchie K, Mann A. Frequent attendance in family practice and common mental disorders in an open access health care system. J Psychosom Res 2012; 72:413-8. [PMID: 22656435 DOI: 10.1016/j.jpsychores.2012.02.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 02/23/2012] [Accepted: 02/24/2012] [Indexed: 11/19/2022]
Abstract
UNLABELLED 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.
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Rodríguez García LC, Ferrándiz Santos J, González JJ, Mora Navarro G, García Álvarez G, Alonso Salazar MT. [Organizational procedures and health care management. A point of view from primary care centres]. Aten Primaria 2011; 43:409-16. [PMID: 21334768 PMCID: PMC7025045 DOI: 10.1016/j.aprim.2010.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 07/09/2010] [Accepted: 07/28/2010] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE We aimed to know how the directive teams perceive the implementation of organizational procedures in relation with the health care management in the primary care setting. DESIGN Multicentre cross-sectional descriptive study. SETTING Area 11 Madrid Primary Care Service, Spain. PARTICIPANTS All directive teams of primary care centres (PCC) (n=38). MEASUREMENTS Data were collected with a self-administered semiestructured questionnaire which included 21 main questions about procedures and use of internal organizational measures relating to the health care management in PCC, grouped in five sections: predictable and non predictable consultations(clinical and administrative), clinical schedules and office management. RESULTS 100% response rate. 69% of PCC use internal procedures and computerized applications for the renewal of medical chronic prescriptions and 55% for temporary disability. 71% show nurse involvement in terms of dispensing medical prescriptions during clinical consultations. 42% keep on performing administrative procedures of specialized care. 21% don't get compliance with routine control of programs and in 29% of consultations duplicity of visits among medicine and nursing are expected. 97% follow a specific process for urgent attention. 84% request subsequent appointment in the previous clinical consultation. 29% have open schedules availables for 6 months. CONCLUSIONS A wide variability of the implementation of organizational procedures in PCC was observed. Further research is needed to determine whether any organizational and professional changes could contribute to improve efficiency and patient satisfaction.
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Gili M, Sesé A, Bauza N, Serrano MJ, Salvador-Carulla L, Molina R, Roca M. Mental disorders, chronic conditions and psychological factors: a path analysis model for healthcare consumption in general practice. Int Rev Psychiatry 2011; 23:20-7. [PMID: 21338294 DOI: 10.3109/09540261.2010.544646] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To explore potential individual determinants of healthcare utilization in primary care (PC) using a structural equation modelling approach. Atotal of 638 patients from five PC units were randomly selected. Mental disorders, psychological distress and other psychological factors were assessed with the 28-item General Health Questionnaire (GHQ-28) and the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Medical records and ICD-10 diagnosis were used to measure somatic morbidity. There is a negative relationship between the presence of mental disorders and psychological well-being (-0.74), and a negative relationship with use of health services (-0.25). Age has a positive and significant relationship with the presence of chronic diseases (0.49), which has a positive and significant relationship with limitation of daily activities (0.18). This limitation has a positive relationship with poor perception of health (0.57) and with psychological well-being (0.03). Findings confirm the existence of specific pathways in PC health use. Health service use depends on the patient's psychological well-being and on the presence of chronic medical conditions. Healthcare professionals need to pay attention to the comorbidity of mental disorders and chronic medical conditions in order to identify frequent attenders and to decrease the inappropriate use of healthcare services.
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Affiliation(s)
- Margalida Gili
- Institut Universitari d'Investigació en Ciències de la Salut, Department of Psychology, University of the Balearic Islands, Red de Investigación en Actividades Preventivas y Promoción de Salud Palma de Mallorca, Balearic Islands, Spain.
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How usual is usual care in pragmatic intervention studies in primary care? An overview of recent trials. Br J Gen Pract 2010; 60:e305-18. [PMID: 20594432 DOI: 10.3399/bjgp10x514819] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Because pragmatic trials are performed to determine if an intervention can improve current practice, they often have a control group receiving 'usual care'. The behaviour of caregivers and patients in this control group should be influenced by the actions of researchers as little as possible. Guidelines for describing the composition and management of a usual care control group are lacking. AIM To explore the variety of approaches to the usual care concept in pragmatic trials, and evaluate the influence of the study design on the behaviour of caregivers and patients in a usual care control group. DESIGN OF STUDY Review of 73 pragmatic trials in primary care with a usual care control group published between January 2005 and December 2009 in the British Medical Journal, the British Journal of General Practice, and Family Practice. Outcome measures were: description of the factors influencing caregiver and patients in a usual care control group related to an individual randomised design versus cluster randomisation. RESULTS In total, 38 individually randomised trials and 35 cluster randomised trials were included. In most trials, caregivers had the freedom to treat control patients according to their own insight; in two studies, treatment options were restricted. Although possible influences on the behaviour of control caregivers and control patients were more often identified in individually randomised trials, these influences were also present in cluster randomised trials. The description of instructions and information provided to the control group was often insufficient, which made evaluation of the trials difficult. CONCLUSION Researchers in primary care medicine should carefully consider the design of a usual care control group, especially with regard to minimising the risk of study-induced behavioural change. It is recommended that an adequate description of the information is provided to control caregivers and control patients. A proposal is made for an extension to the CONSORT statement that requires authors to specify details of the usual care control group.
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Frequent attendance in primary care: comparison and implications of different definitions. Br J Gen Pract 2010; 60:49-55. [PMID: 20132693 DOI: 10.3399/bjgp10x483139] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
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%).
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More randomised controlled trials on frequent attendance. Br J Gen Pract 2010; 60:373. [DOI: 10.3399/bjgp10x501912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Calderón-Larrañaga A, Abrams C, Poblador-Plou B, Weiner JP, Prados-Torres A. Applying diagnosis and pharmacy-based risk models to predict pharmacy use in Aragon, Spain: the impact of a local calibration. BMC Health Serv Res 2010; 10:22. [PMID: 20092654 PMCID: PMC2828433 DOI: 10.1186/1472-6963-10-22] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Accepted: 01/21/2010] [Indexed: 11/23/2022] Open
Abstract
Background In the financing of a national health system, where pharmaceutical spending is one of the main cost containment targets, predicting pharmacy costs for individuals and populations is essential for budget planning and care management. Although most efforts have focused on risk adjustment applying diagnostic data, the reliability of this information source has been questioned in the primary care setting. We sought to assess the usefulness of incorporating pharmacy data into claims-based predictive models (PMs). Developed primarily for the U.S. health care setting, a secondary objective was to evaluate the benefit of a local calibration in order to adapt the PMs to the Spanish health care system. Methods The population was drawn from patients within the primary care setting of Aragon, Spain (n = 84,152). Diagnostic, medication and prior cost data were used to develop PMs based on the Johns Hopkins ACG methodology. Model performance was assessed through r-squared statistics and predictive ratios. The capacity to identify future high-cost patients was examined through c-statistic, sensitivity and specificity parameters. Results The PMs based on pharmacy data had a higher capacity to predict future pharmacy expenses and to identify potential high-cost patients than the models based on diagnostic data alone and a capacity almost as high as that of the combined diagnosis-pharmacy-based PM. PMs provided considerably better predictions when calibrated to Spanish data. Conclusion Understandably, pharmacy spending is more predictable using pharmacy-based risk markers compared with diagnosis-based risk markers. Pharmacy-based PMs can assist plan administrators and medical directors in planning the health budget and identifying high-cost-risk patients amenable to care management programs.
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Bellón Saameño JA. [De-bureaucratization of clinics. To where?]. Aten Primaria 2009; 41:429-30. [PMID: 19539405 DOI: 10.1016/j.aprim.2009.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Revised: 05/19/2009] [Accepted: 05/21/2009] [Indexed: 11/28/2022] Open
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Bosch Fontcuberta JM. Encuentros difíciles médico-paciente: ¿un problema inevitable? Aten Primaria 2009; 41:15-7. [DOI: 10.1016/j.aprim.2008.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Accepted: 09/08/2008] [Indexed: 11/28/2022] Open
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Bellón Saameño JA, Rodríguez Bayón A. [What can really be done to reduce the number of clinic visits by the frequent-user patient?]. Aten Primaria 2008; 40:591-3. [PMID: 19100143 DOI: 10.1016/s0212-6567(08)75689-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Juan Angel Bellón Saameño
- Centro de Salud El Palo, Málaga, Profesor Asociado del Departamento de Medicina Preventiva de la Universidad de Málaga, Unidad de Investigación del Distrito Málaga, España, Grupo SAMSERAP de la redIAPP (RD06/0018/0039)
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