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