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

Background

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

Methods

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

Results

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

Conclusions

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

Adult frequent presentation to emergency departments and adverse childhood experiences: a scoping review

BACKGROUND

Extensive literature reports the influence of childhood adversity on adult health, however few studies have explored these life antecedents in people who frequently present to the emergency department. This review synthesizes literature exploring childhood adversity influences on emergency department presentations, if and how it is identified, and interventions addressing the health care needs of this group.

METHODS

Eight electronic databases were searched. Arksey and O'Malley's framework guided this review, and a quality appraisal was undertaken. Searches included all published studies until August 2020.

RESULTS

Twenty-one articles were included in this review. They revealed that childhood adversity is common among adults who frequently attend the emergency department. It impacts physical and psychological health into adulthood and there is no standardized approach described to documenting childhood adversity, nor any consistent intervention reported by emergency departments to address its sequelae in adulthood.

CONCLUSIONS

Several studies call for screening, intervention, and education to identify and address impacts of childhood adversity for patients who frequently present to the emergency department. However, reliable high-level studies exploring these topics specific to the emergency department are uncommon. Consequently, definitive interventions to address the healthcare needs of this group is lacking and warrants further research.

What is the prevalence of frequent attendance to emergency departments and what is the impact on emergency department utilisation? A systematic review and meta-analysis

Patients who frequently attend to emergency departments are a varying group and have complex health care needs. This systematic review and meta-analysis aimed to determine the prevalence of patients who have frequent attendance to emergency departments. A systematic review was performed in line with PRISMA guidelines. A database search was conducted, and studies were included in the final review if they analysed a population of frequent attendance. Meta-analysis was performed only on population-based studies to estimate prevalence. The search yielded 2922 nonduplicate publications, of which 27 were included in the meta-analysis. The most common definition used for frequent attendance was greater than three presentations a year. The proportion of people who frequently attended as a percentage of the total study population ranged from 0.01 to 20.9%, with emergency department presentations from frequent attenders ranging from 0.2 to 34%. When limiting the definition of frequent attendance to greater than three visits in a 12-month period, people who frequently attended contributed between 3 and 10% [pooled estimate 6%; CI 4-7%] of emergency department presentations and between 12 and 34% [pooled estimate 21%; CI 15-27%] of total emergency department presentations. Meta-analysis found substantial heterogeneity between estimates [I² > 50%]. The prevalence of frequent attendance compared to the total population of patients seeking emergency care was small, but the impact on emergency department utilisation is significant. Early identification of people attending for frequent care at an emergency department provides the opportunity to implement alternative models of care.

Perinatal outcomes of frequent attendance in midwifery care in the Netherlands: a retrospective cohort study

BACKGROUND

Over the last decade, a trend towards high utilisation of primary maternity care was observed in high-income countries. There is limited research with contradictory results regarding frequent attendance (FA) and perinatal outcomes in midwifery care. Therefore, this study examined possible associations between FA in midwifery care and obstetric interventions and perinatal outcomes.

METHODS

A retrospective cohort study was performed in a medium-sized midwifery-led care practice in an urban region in the Netherlands. Frequent attenders (FAs) were categorised using the Kotelchuck-Index Revised. Regression analyses were executed to examine the relationship between FAs and perinatal outcomes, stratified by antenatal referral to an obstetrician. Main outcomes of interest were Apgar score ≤ 7 and perinatal death, birth weight, mode of delivery, haemorrhage, place of birth, transfer during labour, and a requirement for pain relief.

RESULTS

The study included 1015 women, 239 (24%) FAs and 776 (76%) non-FAs, 538 (53%) were not referred and 447 (47%) were referred to an obstetrician. In the non-referred group, FA was significantly associated with a requirement for pain relief (OR 1.98, 95% CI 1.24-3.17) and duration of dilatation (OR 1.20, 95% CI 1.04-1.38). In the referred group, FA was significantly associated with induction of labour (OR 1.86, 95% CI 1.17-2.95), ruptured perineum (OR 0.50, 95% CI 0.27-0.95) and episiotomy (OR 0.48, 95% CI 0.24-0.95). In the non-referred and the referred group, FA was not associated with the other obstetric and neonatal outcomes. Due to small numbers, we could not measure possible associations of FA with an Apgar score ≤ 7 and perinatal death.

CONCLUSION

In our study, perinatal outcomes differed by FA and antenatal referral to an obstetrician. In the non-referred group, FA was significantly associated with medical pain relief and duration of dilatation. In the referred group, FA was significantly associated with induction of labour, ruptured perineum, and episiotomy. Further research with a larger study population is needed to look for a possible association between FA and primary adverse birth outcomes such as perinatal mortality.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Analysis of factors influencing the frequency of primary care visits among diabetic patients in two provinces in China

BACKGROUND

Community health services have played an important role in the prevention and control of diabetes in China. The aims of this study were to examine the frequency of visits to community clinics for diabetic care services, to assess factors correlated with infrequent primary care visits and to identify barriers to regular follow-up visits for urban and rural patients.

METHODS

Between October 2014 and November 2014, data were collected from 17 communities in two cities and four townships located in Shandong and Jiangsu Provinces in China. A total of 1598 diabetic patients aged 18 years or older who were registered with a primary health station in local communities were selected by simple random sampling. Each participant was required to complete an interviewer-led questionnaire. Univariate and multivariate analyses were used to identify significant factors for infrequent visitor status using multivariable logistic regression analysis.

RESULTS

After being clearly informed of the study protocol, 1508/1598 (94.4%) patients agreed to participate in this survey. Among the 1508 subjects (mean age 64.4 ± 10.6), 683 (45.3%) were classified as infrequent visitors. The following were significant factors determining infrequent visitor status: urban residence, lack of health insurance, per-capita household income< 20,000 (yuan), lack of telephone follow-up and lack of household visit. From the patients' perspectives, the reasons for infrequent visits among urban patients included drug scarcity and longer travel time to clinics. For rural patients, worries about medical expenses and drug scarcity were the most common barriers to clinic visits.

CONCLUSION

Determinants of infrequent community visits in diabetes patients include urban residence, lower household income, lack of health insurance, lack of telephone follow-up and lack of household visit services. Strategies aimed at enhancing the utilization of community health care should be implemented in China.

Statistical complexity of reasons for encounter in high users of out of hours primary care: analysis of a national service

Background

Managing demand for urgent and unscheduled care is a major problem for health services globally. A particular issue is that some patients appear to make heavy use of services, including primary care out of hours. We hypothesised that greater variation (statistical complexity) in reasons for attending primary care out of hours services may be a useful marker of patients at high risk of ongoing heavy service use.

Methods

We analysed an anonymised dataset of contacts with the primary care out of hours care for Scotland in 2011. This contained 120,395 contacts from 13,981 high-using patients who made 5 or more contacts during a calendar year. We allocated the stated reason for each encounter into one of 14 categories. For each patient we calculated measures of statistical complexity of reasons for encounter including the count of different categories, Herfindahl index and statistical entropy of either the categories themselves, or the category transitions. We examined the association of these measures of statistical complexity with patient and healthcare use characteristics.

Results

The high users comprised 2.4% of adults using the service and accounted for 15% of all contacts. Statistical complexity (as entropy of categories) increased with number of contacts but was not substantially influenced by either patient age or sex. This lack of association with age was unexpected as with increasing multi-morbidity one would expect greater variability in reason for encounter. Between 5 and 10 consultations, higher entropy was associated with a reduced likelihood of further consultations. In contrast, the occurrence of one or more contacts for a mental health problem was associated with increased likelihood of further consultations.

Conclusion

Complexity of reason for encounter can be estimated in an out of hours primary care setting. Similar levels of statistical complexity are seen in younger and older adults (suggesting that it is more to do with consultation behaviour than morbidity) but it is not a predictor of ongoing high use of urgent care.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3938-z) contains supplementary material, which is available to authorized users.

Do healthcare services behave as complex systems? Analysis of patterns of attendance and implications for service delivery

BACKGROUND

The science of complex systems has been proposed as a way of understanding health services and the demand for them, but there is little quantitative evidence to support this. We analysed patterns of healthcare use in different urgent care settings to see if they showed two characteristic statistical features of complex systems: heavy-tailed distributions (including the inverse power law) and generative burst patterns.

METHODS

We conducted three linked studies. In study 1 we analysed the distribution of number of contacts per patient with an urgent care service in two settings: emergency department (ED) and primary care out-of-hours (PCOOH) services. We hypothesised that these distributions should be heavy-tailed (inverse power law or log-normal) in keeping with typical complex systems. In study 2 we analysed the distribution of bursts of contact with urgent care services by individuals: correlated bursts of activity occur in complex systems and represent a mechanism by which overall heavy-tailed distributions arise. In study 3 we replicated the approach of study 1 using data systematically identified from published sources.

RESULTS

Study 1 involved data from a PCOOH service in Scotland (725,000) adults, 1.1 million contacts) and an ED in New Zealand (60,000 adults, 98,000 contacts). The total number of contacts per individual in each dataset was statistically indistinguishable from an inverse power law (p > 0.05) above 4 contacts for the PCOOH data and 3 contacts for the ED data. Study 2 found the distribution of contact bursts closely followed a heavy-tailed distribution (p < 0.008), indicating the presence of correlated bursts. Study 3 identified data from 17 studies across 8 countries and found distributions similar to study 1 in all of them.

CONCLUSIONS

Urgent healthcare use displays characteristic statistical features of large complex systems. These studies provide strong quantitative evidence that healthcare services behave as complex systems and have important implications for urgent care. Interventions to manage demand must address drivers for consultation across the whole system: focusing on only the highest users (in the tail of the distribution) will have limited impact on efficiency. Bursts of attendance - and ways to shorten them - represent promising targets for managing demand.

[Psychosocial aspects associated with excessive attendance in primary care paediatric clinics]

OBJECTIVE

Hyper-attendance is a significant problem in paediatric Primary Care clinics. The aim of our study was to analyse the level of attendance in these clinics and its relationship with certain psychosocial aspects of the families attending them.

PATIENTS AND METHODS

Observational descriptive study was conducted using questionnaires collected during a period of 6months, as well as recording the frequency of attendance in the previous 6months. A total of 346 questionnaires of children between 6months and 13years of age belonging to 2 urban Primary Care clinics in Madrid were completed. The raw data was analysed, and comparisons between groups and multivariate analysis were performed.

RESULTS

The mean number of consultations in the last 6months, of the total included in the study, was 3.06 in the Primary Care centre, and 0.77 in the emergency services. It was considered over-frequent for those who had attended the Primary Care health centre 6 or more times in this period (>p90), of which there were 33 children (9.53%). In the multivariate analysis, the variables related to being frequent users of Primary Care clinics were: the presence of high level of anxiety in the parents (OR=5.50; 95%CI: 2.49-12.17, P<.0001), and the age of the children (OR=0.73; 95%CI: 0.58-0.91, P=.005). The model presented an area under the curve of 0.761 (95%CI: 0.678-0.945, P<.0001).

CONCLUSIONS

The frequency of visits in paediatric Primary Care clinics is directly related to the high level of anxiety of the parents, and inversely to the age of the children. It would be advisable to detect and, if possible, intervene in cases of high parental anxiety in order to try to reduce the over-frequency in the paediatric primary health care.

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

[Frequent attenders in Primary Health Care Centres and frequent attenders in Emergency Departments]

Objetivo

Identificar factores predictores de hiperfrecuentación en Atención Primaria (AP) en una muestra de pacientes hiperfrecuentadores (HF) en servicios de urgencias hospitalarios (SUH).

Diseño

Estudio observacional retrospectivo multicéntrico.

Participantes

Se seleccionaron pacientes mayores de 14 años HF en el SUH entre el 1 de enero y el 31 de diciembre de 2013. Emplazamiento: se reclutaron pacientes atendidos en los SUH de 17 hospitales públicos de la Comunidad de Madrid.

Método

Se recogieron variables relativas a la visita índice del SUH. Se analizó la muestra en función de ser o no HF en AP. Se considera HF al paciente que realizó al menos 10 visitas en cada nivel asistencial durante un año.

Resultados

Se incluyeron 1.284 pacientes HF en SUH. Se analizaron 423 (32,9%) HF en AP con 16 visitas (RIC 12-25) frente a 861 (67,1%) pacientes no HF en AP con 4 visitas (RIC 2-6). Factores independientes predictores de HF en AP fueron la edad > 65 años (OR: 1,51; IC 95%: 1,07-2,13; p = 0,019), el deterioro cognitivo (OR: 1,63; IC 95%: 1,01-2,65; p = 0,049), el número de fármacos ≥3 (OR: 1,56; IC 95%: 1,06-2,30; p = 0,025) y vivir en la comunidad frente a vivir institucionalizado o en la calle (OR: 3,05; IC 95%: 1,14-8,16; p = 0,026).

Conclusiones

En una muestra de pacientes HF en los SUH, el hecho de ser mayor de 65 años, tomar 3 o más fármacos, presentar deterioro cognitivo y vivir en la comunidad se consideran factores predictores de ser HF también en AP.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical characteristics of persistent frequent attenders in primary care: case-control study

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.