Is frequent attendance of longer duration related to less transient episodes of care? A retrospective analysis of transient and chronic episodes of care.

OBJECTIVES: Frequent attenders (FAs) suffer more and consult general practitioners (GPs) more often for chronic physical and psychiatric illnesses, social difficulties and distress than non-FAs. However, it is unclear to what extent FAs present transient episodes of care (TECs) compared with non-FAs. DESIGN: Retrospective analysis of all episodes of care (ECs) in 15 116 consultations in 1 year. Reasons for encounter (RFEs) linked to patients' problem lists were defined as chronic ECs (CECs), other episodes as TECs. SETTING: 1 Dutch urban primary healthcare centre served by 5 GPs. PARTICIPANTS: All 5712 adult patients were enlisted between 2007 and 2009. FAs were patients whose attendance rate ranked within the top decile of their sex and age group in at least one of the years between 2007 and 2009. OUTCOME MEASURES: Number of RFEs linked to TECs/CECs for non-FAs and 1-year (1yFAs), 2-year (2yFAs) and 3-year FAs (3yFAs), and the adjusted effect of frequent attendance of different duration on the number of TECs. RESULTS: The average number of RFEs linked to TECs (non-FAs 1.4; 3yFAs 7.3) and to CECs (non-FAs 0.9; 3yFAs 6.2) increased substantially with the duration of frequent attendance. The ratio of TECs to all ECs differed little for FAs (52-54%) and non-FAs (64%). Compared with non-FAs, the adjusted additional number of TECs was 3.4 (95% CI 3.2 to 3.7, 1yFAs), 6.6 (95% CI 6.1 to 7.0, 2yFAs) and 9.4 (95% CI 8.8 to 10.1, 3yFAs). CONCLUSIONS: FAs present more TECs and CECs with longer duration of frequent attendance. The constant ratio of TECs might be a sign of a low threshold for FAs to consult their GP. The large numbers of TECs in FAs might be associated with their high level of anxiety and low mastery. The consultation pattern of FAs may best be characterised by describing both TECs and CECs.

The effects of interventions on quality of life, morbidity and consultation frequency in frequent attenders in primary care: A systematic review.

BACKGROUND: Patients visiting their GPs exceptionally often (frequent attenders, FAs) have high rates of somatic disease, emotional distress, psychiatric illnesses and social problems and require a disproportionate amount of their GPs' time. OBJECTIVES: To summarize which types of FA have been studied and what the effects of interventions were on quality of life (QoL), symptom severity of underlying illness(es) and consultation frequency. To discover when patients are considered FAs. METHODS: Systematic review of RCTs using a comprehensive search (MEDLINE, PsycINFO, CINAHL and EMBASE, from 1980 to August 2015) and no language restrictions. Two investigators extracted data. Results were summarized qualitatively. RESULTS: We included 17 RCTs. Heterogeneity at the level of populations, interventions and outcomes precluded statistical pooling. In-depth analysis by GPs assessing a patient's reasons for frequent attendance decreased consultation frequency by four to six per year. A small effect on symptom severity was noted in depressed FAs, although this finding was not replicated in a recent trial. Multi-component therapy and medication in FAs with medically unexplained symptoms (MUS) improved QoL (SF36 odds ratio: 1.92; 95%CI: 1.08-3.40) and morbidity (CES-D 3.17; 95%CI: 1.27-5.08). CONCLUSION: RCTs on intervention effects in frequent attenders to primary care used different patient populations, interventions, comparators and outcome measures. Consistent evidence on the effects of particular interventions in specific patient domains is lacking. A tailored approach based on in-depth analysis among GPs of potential reasons for frequent attendance may decrease consultation frequency. Research involving the screening and treating for FAs with MUS may be useful in future trials.

Why do they keep coming back? Psychosocial etiology of persistence of frequent attendance in primary care: a prospective cohort study.

BACKGROUND: Patients who visit their General Practitioner (GP) very frequently over extended periods of time often have multimorbidity and are costly in primary and specialist healthcare. We investigated the impact of patient-level psychosocial and GP-level factors on the persistence of frequent attendance (FA) in primary care. METHODS: Two-year prospective cohort study in 623 incident adult frequent attenders (>90th attendance centile; age and sex-adjusted) in 2009. Information was collected through questionnaires (patients, GPs) and GPs' patient data. We used multilevel, ordinal logistic regression analysis, controlling for somatic illness and demographic factors with FA in 2010 and/or 2011 as the outcome. RESULTS: Other anxiety (odds ratio (OR) 2.00; 95% confidence interval from 1.29 to 3.10) over 3years and the number of life events in 3years (OR 1.06; 1.01-1.10 per event; range of 0 to 12) and, at baseline, panic disorder (OR 5.40; 1.67-17.48), other anxiety (OR 2.78; 1.04-7.46), illness behavior (OR 1.13; 1.05-1.20 per point; 28-point scale) and lack of mastery (OR 1.08; 1.01-1.15 per point; 28-point scale) were associated with persistence of FA. We found no evidence of synergistic effects of somatic, psychological and social problems. We found no strong evidence of effects of GP characteristics. CONCLUSION: Panic disorder, other anxiety, negative life events, illness behavior and lack of mastery are independently associated with persistence of frequent attendance. Effective intervention at these factors, apart from their intrinsic benefits to these patients, may reduce attendance rates, and healthcare expenditures in primary and specialist care.

Morbidity and doctor characteristics only partly explain the substantial healthcare expenditures of frequent attenders: a record linkage study between patient data and reimbursements data.

BACKGROUND: Frequently attending patients to primary care (FA) are likely to cost more in primary care than their non-frequently attending counterparts. But how much is spent on specialist care of FAs? We describe the healthcare expenditures of frequently attending patients during 1, 2 or 3 years and test the hypothesis that additional costs can be explained by FAs' combined morbidity and primary care physicians' characteristics. METHODS: Record linkage study. Pseudonymised clinical data from the medical records of 16 531 patients from 39 general practices were linked to healthcare insurer's reimbursements data. Main outcome measures were all reimbursed primary and specialist healthcare costs between 2007 and 2009. Multilevel linear regression analysis was used to quantify the effects of the different durations of frequent attendance on three-year total healthcare expenditures in primary and specialist care, while adjusting for age, sex, morbidities and for primary care physicians characteristics. Primary care physicians' characteristics were collected through administrative data and a questionnaire. RESULTS: Unadjusted mean 3-year expenditures were 5044 and 15 824 Euros for non-FAs and three-year-FAs, respectively. After adjustment for all other included confounders, costs both in primary and specialist care remained substantially higher and increased with longer duration of frequent attendance. As compared to non-FAs, adjusted mean expenditures were 1723 and 5293 Euros higher for one-year and three-year FAs, respectively. CONCLUSIONS: FAs of primary care give rise to substantial costs not only in primary, but also in specialist care that cannot be explained by their multimorbidity. Primary care physicians' working styles appear not to explain these excess costs. The mechanisms behind this excess expenditure remain to be elucidated.

Predictability of persistent frequent attendance in primary care: a temporal and geographical validation study.

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.

Predictability of persistent frequent attendance: a historic 3-year cohort study.

BACKGROUND: Few patients who attend GP consultations frequently continue to do so long term. While transient frequent attendance may be readily explicable, persistent frequent attendance often is not. It increases GPs' workload while reducing work satisfaction. It is neither reasonable, nor efficient to target diagnostic assessment and intervention at transient frequent attenders. AIM: To develop a prediction rule for selecting persistent frequent attenders, using readily available information from GPs' electronic medical records. DESIGN OF STUDY: A historic 3-year cohort study. METHOD: Data of 28 860 adult patients from 2003 to 2005 were examined. Frequent attenders were patients whose attendance rate ranked in the (age- and sex-adjusted) top 10% during 1 year (1-year frequent attenders) or 3 years (persistent frequent attenders). Bootstrapped multivariable logistic regression analysis was used to determine which predictors contained information on persistent frequent attendance. RESULTS: Of 3045 1-year frequent attenders, 470 (15.4%) became persistent frequent attenders. The prediction rule could update this prior probability to 3.3% (lowest value) or 43.3% (highest value). However, the 10th and 90th centiles of the posterior probability distribution were 7.4% and 26.3% respectively, indicating that the model performs modestly. The area under the receiver operating characteristic curve was 0.67 (95% confidence limits 0.64 and 0.69). CONCLUSION: Among 1-year frequent attenders, six out of seven are transient frequent attenders. With the present indicators, the rule developed performs modestly in selecting those more likely to become persistent frequent attenders.

Epidemiology of frequent attenders: a 3-year historic cohort study comparing attendance, morbidity and prescriptions of one-year and persistent frequent attenders.

BACKGROUND: General Practitioners spend a disproportionate amount of time on frequent attenders. So far, trials on the effect of interventions on frequent attenders have shown negative results. However, these trials were conducted in short-term frequent attenders. It would be more reasonable to target intervention at persistent frequent attenders. Typical characteristics of persistent frequent attenders, as opposed to 1-year frequent attenders and non-frequent attenders, may generate hypotheses regarding modifiable factors on which new randomized trials may be designed. METHODS: We used the data of all 28,860 adult patients from 5 primary healthcare centers. Frequent attenders were patients whose attendance rate ranked in the (age and sex adjusted) top 10 percent during 1 year (1-year frequent attenders) or 3 years (persistent frequent attenders). All other patients on the register over the 3-year period were referred to as non-frequent attenders. The lists of medical problems coded by the GP using the International Classification of Primary Care (ICPC) were used to assess morbidity.First, we determined which proportion of 1-year frequent attenders was still a frequent attender during the next two consecutive years and calculated the GPs' workload for these patients. Second, we compared morbidity and number of prescriptions for non-frequent attenders, 1-year frequent attenders and persistent frequent attenders. RESULTS: Of all 1-year frequent attenders, 15.4% became a persistent frequent attender equal to 1.6% of all patients. The 1-year frequent attenders (3,045; 10.6%) were responsible for 39% of the face-to-face consultations; the 470 patients who would become persistent frequent attenders (1.6%) were responsible for 8% of all consultations in 2003. Persistent frequent attenders presented more social problems, more psychiatric problems and medically unexplained physical symptoms, but also more chronic somatic diseases (especially diabetes). They received more prescriptions for psychotropic medication. CONCLUSION: One out of every seven 1-year-frequent attenders (15.4%) becomes a persistent frequent attender. Compared with non-frequent attenders, and 1-year frequent attenders, persistent frequent attenders consume more health care and are diagnosed not only with more somatic diseases but especially more social problems, psychiatric problems and medically unexplained physical symptoms.

Operative deliveries in low-risk pregnancies in The Netherlands: primary versus secondary care.

BACKGROUND: In The Netherlands, 35 percent of births take place in "primary care" to women considered at low risk and during labor, approximately 30 percent are referred to "secondary care." High-risk women and some low-risk women deliver in secondary care. This study sought to compare planned place of birth and incidence of operative delivery among women at low risk of complications at the time of onset of labor. METHODS: A retrospective analysis was conducted of data about births in The Netherlands during 2003 that were recorded routinely in the Netherlands Perinatal Registry. Mode of delivery was analyzed for women classified as low risk at labor onset according to their planned place of birth (intention-to-treat analysis). The primary outcome was the rate of operative deliveries (vacuum or forceps extraction or cesarean section). RESULTS: Women at low risk who planned to give birth, and therefore labored and delivered in secondary care, had a significantly higher rate of operative deliveries than women who began labor in primary care where they intended to give birth (18% [3,558/19,850] vs 9% [7,803/87,187]) (OR 2.25, 95% CI 2.00-2.52). For cesarean section, the rates were 12 percent (2,419/19,850) versus 3 percent (2,990/87,817) (OR 3.97, 95% CI 3.15-5.01), irrespective of parity. CONCLUSIONS: The rate of operative deliveries was significantly lower for low-risk pregnant women who gave birth in a primary care setting compared with similar women who planned birth in secondary care. As with any retrospective analysis, it was not possible to eliminate bias, such as possible differences between primary and secondary care in assignment of risk status. In addition, known risk factors for interventions, technologies such as induction of labor and fetal monitoring, are only available in secondary care. These findings clearly demonstrate the need for a prospective study to examine the relationship between planned place of birth and mode of delivery and neonatal and maternal outcomes.

Interventions on frequent attenders in primary care. A systematic literature review.

OBJECTIVE: To analyse which interventions are effective in influencing morbidity, quality of life, and healthcare utilization of frequently attending patients (FAs) in primary care. METHODS: A systematic literature search was performed for articles describing interventions on FAs in primary care (Medline, Embase, and PsycINFO). Outcomes were morbidity, quality of life (QoL), and use of healthcare. Two independent assessors selected all randomized clinical trials (RCT) and assessed the quality of the selected RCTs. Results. Five primary care based RCTs were identified. Three RCTs used frequent attendance to select patients at risk of distress, major depression, and anxiety disorders. These RCTs applied psychological and psychiatric interventions and focused on undiagnosed psychiatric morbidity of FAs. Two of them found more depression-free days and a better QoL after treating major depressive disorder in FAs. No other RCT found any positive effect on morbidity or QoL. Two RCTs studied an intervention which focused on reducing frequent attendance. No intervention significantly lowered attendance. Due to the difference in study settings and the variation in methods of selecting patients, meta-analysis of the results was not possible. CONCLUSION: No study showed convincing evidence that an intervention improves QoL or morbidity of frequent attending primary care patients, although a small effect might be possible in a subgroup of depressed frequent attenders. No evidence was found that it is possible to influence healthcare utilization of FAs.

Defining frequent attendance in general practice.

BACKGROUND: General practitioners (GPs) or researchers sometimes need to identify frequent attenders (FAs) in order to screen them for unidentified problems and to test specific interventions. We wanted to assess different methods for selecting FAs to identify the most feasible and effective one for use in a general (group) practice. METHODS: In the second Dutch National Survey of General Practice, data were collected on 375 899 persons registered with 104 practices. Frequent attendance is defined as the top 3% and 10% of enlisted patients in each one-year age-sex group measured during the study year. We used these two selections as our reference standard. We also selected the top 3% and 10% FAs (90 and 97 percentile) based on four selection methods of diminishing preciseness. We compared the test characteristics of these four methods. RESULTS: Of all enlisted patients, 24 % did not consult the practice during the study year. The mean number of contacts in the top 10% FAs increased in men from 5.8 (age 15-24 years) to 17.5 (age 64-75 years) and in women from 9.7 to 19.8. In the top 3% of FAs, contacts increased in men from 9.2 to 24.5 and in women from 14 to 27.8. The selection of FAs becomes more precise when smaller age classes are used. All selection methods show acceptable results (kappa 0.849 - 0.942) except the three group method. CONCLUSION: To correctly identify frequent attenders in general practice, we recommend dividing patients into at least three age groups per sex.