Why do they keep coming back? Psychosocial etiology of persistence of frequent attendance in primary care: A prospective cohort study
Introduction
Some patients have exceptionally high consultation rates with their General Practitioner (GP), sometimes over many years [1], [2], [3], [4], [5]. These persistent frequent attenders (FAs) often have multimorbidity and are costly in both primary and specialist healthcare [6].
Anyone may have short periods in her/his lives in which frequent help from a GP is sought or needed. However, when such periods exceed two or more consecutive years, more structural psychosocial problems are often present [1], [7], [8]. Thus, persistent frequent attendance could be seen as an easily detectable marker for underlying, often undetected and unmet, psychosocial problems or diseases. Previous work has shown that psychological distress, low physical quality of life and low educational level were associated with persistence of frequent attendance (when frequent attendance is proportional defined) [9], [10]. Studies, using a fixed cutoff definition of FA, reported contradictory results [11], [12]. Because high attendance is strongly related to age and sex, we think it makes sense to define frequent attendance proportionally as an age and sex-adjusted attendance rate [13], [14]. Such a proportional threshold definition selects the exceptionally high utilizers within each age and sex group and allows meaningful comparison between practices, periods, and countries.
However, the literature on the precise etiology of persistence of frequent attendance is equivocal [7], [11], [12], [15], [16], [17], [18]. Theoretically, within a specific healthcare setting attendance may be influenced by patient characteristics including morbidity, by GP characteristics like work style, experience, personality and professional interests and thirdly by the interpersonal dynamics between patients and their physician [19], [8], [16]. Previous work indicates that the considerable costs in primary as well as in specialist care associated with (persistent) frequent attendance may not simply be explained by the excess morbidity these patients have [6], [20]. Therefore, even fully effective treatment of clear-cut multi-morbidity, if available, cannot be expected to reduce to normal the high attendance rates and associated referral rates to specialist care. The incomplete understanding of the etiology of persistence of frequent attendance hampers the thoughtful design of preventive strategies for this persistence. Therefore we followed a cohort of incident frequent attenders over two years to investigate which and to what extent psychological and social factors and GP characteristics play a role in the etiology of persistence of frequent attendance.
Section snippets
Design
In a prospective cohort study, we followed incident FAs for two consecutive years.
Setting
Data were collected in 41 practices of GPs, participants in the GP-based continuous morbidity registration network of the Department of General Practice at the Academic Medical Center of the University of Amsterdam. The practices are located in health centres in a suburban part of Amsterdam (39 practices) and in two single-handed practices in a nearby rural area. In the GP network, electronic medical record data
The cohort of frequent attenders
Our sampling frame consisted of 44,700 patients who were enlisted with the participating GPs of whom 34,899 were 18 years or older. Of these 2311 patients fulfilled the criteria for incident FA. GPs excluded 132 patients because of illiteracy, severe mental health problems or mental retardation. Of the 2179 patients eligible for participation, 746 (34%) returned the questionnaire and of these 623 (29%) gave informed consent (Fig. 1). Compared to non-consenters, consenting individuals were older
Discussion
In a prospective cohort of incident frequent attenders, we found that anxiety (panic disorder, anxiety), negative life events in the previous year, illness behavior and lack of mastery were associated with persistent frequent attendance during one or two of the following two years. Presence of a combination of chronic somatic disease with social and/or psychological problems did not increase the probability of persistence of frequent attendance above what might be expected based on their
Conclusion
In patients who frequently attended their general practitioners for one year, panic, anxiety disorders, illness behavior, negative life events and lack of mastery over one's life were found to be associated with persistence of frequent attendance after adjustment for a large set of confounders. GPs appeared to contribute little to persistence of frequent attendance, although participating GPs may have been too similar to detect potential features of importance.
Conflicts of interests
The authors have no competing interests to report.
Funding
This study was financed by a grant from the Netherlands Organisation for Health Research and Development (ZonMw); Alledaagse ziekten no. 42011002.
Acknowledgments
We thank the GPs involved in the Network of General Practitioners of the Academic Medical Centre-University of Amsterdam (HAG-net-AMC) for their continuous efforts to keep the electronic medical records updated and their support during this study and Alice Karsten, Gerda van Zoen and Nienke Buwalda for their logistical support.
We'd like to give a special tribute for our deceased colleague, Leo Beem, for his helpful statistical work at the beginning of this project.
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