Elsevier

Public Health

Volume 119, Issue 2, February 2005, Pages 118-137
Public Health

Frequent attenders in general practice care: A literature review with special reference to methodological considerations

https://doi.org/10.1016/j.puhe.2004.03.007Get rights and content

Abstract

Objective. To describe the basis on which our knowledge of frequent attendance in general practice rests and to propose recommendations for further research on frequent attenders (FAs).

Design. The literature review (finished February 2004) encompassed peer-reviewed articles in English describing contacts with general practice in terms of frequency. Searches were performed in the Medline, CINAHL, EMBASE, PsycINFO, Social Sciences Expanded Index and ISI Citation databases with additional searches in reference lists and the ‘related articles’ function in the ISI Citation database and Medline.

Setting. General practice.

Subjects. Sixty-one articles (54 studies).

Measures. The articles were assessed according to the following design variables: setting; definition of FAs; sampling; sample size; control groups; study aim; study design; data sources; effect measure; and main results.

Results. There was no generally accepted definition of frequent attendance. Research designs differed substantially. Eight articles gave sufficient information on all design variables. The top 10% of attenders accounted for 30–50% of all contacts, and up to 40% of FAs were still FAs the following year. More than 50% of FAs had a physical disease, more than 50% of FAs suffered from psychological distress, social factors (low social support, unemployment, divorce) were associated with frequent attendance in more than 50% of FAs, multiproblems (physical, psychological and social) were found in one-third of FAs, and frequent attendance was associated with increasing age and female gender.

Conclusion. The diversity of designs, definitions and methods in the current literature on FAs in general practice hampers comparison of their precision, validity and generalizability, and calls for cautious interpretation and adoption of a common, generally acceptable definition in future studies.

Introduction

Frequent attenders (FAs) account for a relatively large proportion of contacts with general practitioners (GPs) and a large number of referrals and prescriptions. Their levels of physical, psychological and social morbidity are high. Much of the GPs' work therefore relates to FA; a situation that has spurred interest and research in FAs in general practice. However, controversy exists regarding whether current knowledge of frequent attendance has reached a level that satisfies the clinical imperatives of general practice.

Valid clinical inference based on research articles requires access to sufficient information to assess the precision, validity and generalizability of research results.1., 2. The shortcomings of current research in this respect were reviewed first (unsystematically) by Schrire in 19863 and then systematically by Gill and Sharpe in 1999.4 Both reviews argued that methodological differences frustrate attempts to establish a common experiential ground within this field. However, this did not bar them from drawing specific conclusions on the basis of studies conducted in quite different settings. The methodological issues brought to light by these first reviews were explicitly addressed by Neal et al. who confirmed that FA research was fraught with methodological problems5 and called for further research into fundamental FA questions.6 However, none of these articles provided recommendations for conducting research or reviewing the research of others.

The purpose of this article is to systematically review the literature on FAs in general practice in order to identify articles with pre-defined, well-described design variables and to try to synthesize the knowledge derived from these studies. A second aim is to propose recommendations for FA studies in general practice.

Section snippets

Search strategy

A search in Issue 1 of the 2004 Edition of the Cochrane Library (December 2003 updates) did not identify any literature reviews of frequent attendance in general practice. A subsequent search was performed in the following databases: Medline (PubMed) 1966 to January 2004; CINAHL 1982 to January 2004; EMBASE 1974 to January 2004; PsycINFO 1967 to January 2004 and Social Sciences Index Expanded 1973 to January 2004 through the ISI Citation databases. The ‘related articles’ facility in the PubMed

Included articles

A total of 61 articles representing 54 different studies were included in this study (Table 1). Of these, 33 articles came from the UK, five from North America and 14 from Scandinavia. Forty-seven (77%) of the articles were published after 1990.

Setting

The articles presented studies with participation of one to 132 practices, each with between two and 220 GPs (Table 1). Forty-two (69%) articles reported on one or two practices, 25 (41%) included less than 10 GPs, eight (13%) did not give information on

Discussion

This systematic review identified 61 articles presenting 54 studies with FAs in a general practice setting. Research designs differed substantially, and only eight articles gave sufficient information on a pre-defined number of design variables to allow evaluation of the precision, validity and generalizability of their results. The FA research performed to date in this field has given insufficient attention to the implications of definitions and sampling, and most high-quality studies have

Acknowledgements

This study received financial support from The Municipal VAT Fund, The Insurance and Pension Research Fund and The Danish National Research Foundation for Primary Care. We thank Professor Henrik Toft Sørensen and Dr Per Fink and Professor Frede Olesen for their help and contribution.

References (101)

  • H. Karlsson et al.

    Psychiatric morbidity among frequent attender patients in primary care

    Gen Hosp Psychiatr

    (1995)
  • R.H. Corney

    Sex differences in general practice attendance and help seeking for minor illness

    J Psychosom Res

    (1990)
  • J.O. Robinson et al.

    The frequent consulter in primary medical care

    J Psychosom Res

    (1986)
  • J.E. Hood et al.

    A comparative study of frequent and infrequent attenders at a general practice

    Int J Nurs Stud

    (1974)
  • K.J. Rothman et al.

    Modern Epidemiology

    (1998)
  • R.H. Fletcher et al.

    Clinical epidemiology

    (1996)
  • S. Schrire

    Frequent attenders—a review

    Fam Pract

    (1986)
  • R.D. Neal

    Frequent attenders

    Fam Pract

    (1995)
  • R. Neal et al.

    Frequent attenders: who needs treatment?

    Br J Gen Pract

    (1996)
  • D.M. Goodridge

    An analysis of fat folders

    J R Coll Gen Pract

    (1982)
  • J.F. Buckmaster

    The thick-file patient in England

    NZ Med J

    (1973)
  • L.E. Mehl-Madrona

    Frequent users of rural primary care: comparisons with randomly selected users

    J Am Board Fam Pract

    (1998)
  • L. Borgquist et al.

    Perceived health and high consumers of care: a study of mental health problems in a Swedish primary health care district

    Psychol Med

    (1993)
  • G.R. Parkerson et al.

    A telephone needs assessment for potential high utilizers

    Fam Med

    (2001)
  • A. Matalon et al.

    A short-term intervention in a multidisciplinary referral clinic for primary care frequent attenders: description of the model, patient characteristics and their use of medical resources

    Fam Pract

    (2002)
  • A. Ellaway et al.

    Someone to talk to? The role of loneliness as a factor in the frequency of GP consultations

    Br J Gen Pract

    (1999)
  • M.A. Leach

    Childhood consultation rates in general practice—factors associated with the variations in attendance; a review

    J R Army Med Corps

    (1993)
  • N. Crossley et al.

    A frequent attender

    Practitioner

    (1995)
  • W.J. Katon et al.

    Panic disorder: relationship to high medical utilization

    Am J Med

    (1992)
  • J. Murray et al.

    General practice attendance in women with psychosocial problems

    Soc Psychiatr Psychiatr Epidemiol

    (1988)
  • L. Ridsdale et al.

    Tiredness as a ticket of entry. The role of patients beliefs and psychological symptoms in explaining frequent attendance. General practice fatigue group

    Scand J Prim Health Care

    (1999)
  • M.E. Garralda et al.

    Children with psychiatric disorders who are frequent attenders to primary care

    Eur Child Adolesc Psychiatr

    (1999)
  • L.J. Haas et al.

    Psychopathology and emotional distress among older high-utilizing health maintenance organization patients

    J Gerontol A Biol Sci Med Sci

    (1999)
  • D.J. Katzelnick et al.

    Randomized trial of a depression management program in high utilizers of medical care

    Arch Fam Med

    (2000)
  • M. Joukamaa et al.

    Alexithymia and psychological distress among frequent attendance patients in health care

    Psychother Psychosom

    (1996)
  • W.J. Katon

    The development of a randomized trial of consultation-liaison psychiatry trial in distressed high utilizers of primary care

    Psychiatr Med

    (1991)
  • E.H. Lin et al.

    Frustrating patients: physician and patient perspectives among distressed high users of medical services

    J Gen Intern Med

    (1991)
  • P.M. Densen et al.

    Concerning high and low utilizers of service in a medical care plan, and the persistence of utilization levels over a three year period

    Milbank Mem Fund Q

    (1959)
  • B.H. McFarland et al.

    Utilization patterns among long-term enrollees in a prepaid group practice health maintenance organization

    Med Care

    (1985)
  • M. VonKorff et al.

    Disability and depression among high utilizers of health care. A longitudinal analysis

    Arch Gen Psychiatr

    (1992)
  • W. Katon et al.

    Somatization: a spectrum of severity

    Am J Psychiatr

    (1991)
  • D.K. Freeborn et al.

    Consistently high users of medical care among the elderly

    Med Care

    (1990)
  • T.S. Nighswander

    High utilizers of ambulatory care services: 6-year followup at Alaska Native Medical Center

    Public Health Rep

    (1984)
  • F. Lefevre et al.

    Screening for undetected mental disorders in high utilizers of primary care services

    J Gen Intern Med

    (1999)
  • S.D. Pearson et al.

    Depression among high utilizers of medical care

    J Gen Intern Med

    (1999)
  • D.R. Smucker et al.

    A framework for understanding visits by frequent attenders in family practice

    J Fam Pract

    (2001)
  • B. Sheehan et al.

    Somatization among older primary care attenders

    Psychol Med

    (2003)
  • H. Bergh et al.

    Characteristics of frequent attenders in different age and sex groups in primary health care

    Scand J Prim Health Care

    (2003)
  • K. Jordan et al.

    Previous consultation and self reported health status as predictors of future demand for primary care

    J Epidemiol Commun Health

    (2003)
  • S. Wyke et al.

    Frequent attendance, socioeconomic status and burden of ill health. An investigation in the West of Scotland

    Eur J Gen Pract

    (2003)
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