Physical, mental and social factors associated with frequent attendance in Danish general practice. A population-based cross-sectional study

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Abstract

Knowledge of which factors are prompting patients to seek primary care is important to the ongoing effort to improve management in general, and management of frequent attenders (FAs) in particular. We conducted a cross-sectional population-based study with the aim at examining associations between physical, mental and social factors and frequent attendance in general practice. We collected questionnaire and registry data in the County of Aarhus (630,000 inhabitants), Denmark. Half of the county general practices (132 practices, 220 GPs) were selected randomly. FAs were defined as the top 10% attenders over the past 12 months. A questionnaire including SF-36 and questions about physical and mental health and social conditions was sent to age and gender stratified samples of FAs and non-FAs from these practices. Impairments (SF-36) associated with frequent attendance were physical in 54–71% (prevalence difference (PD): 16–33%, adjusted prevalence ratio (adj. PR): 1.1–1.7), mental in 58–70% (PD: 17–25%, adj. PR:1.1–1.4) and social in 40–59% (PD: 13–28%, adj. PR:0.9–1.5). Among FAs, 46-88% had used three or more different drugs (PD: 26–39%, adj. PR:1.5–2.3) and 27–41% had been referred one or more times to outpatient specialists (PD: 4–19%, adj. PR:1.2–2.5). Although our data cannot determine the direction of causality, they clearly demonstrate that FAs carry a large burden of physical, mental and social impairments which underpins the complexity and heterogeneity of the problems which they present. The results make clear that biopsychosocial management is a core issue in FA management in general practice.

Introduction

A small group of patients, the so-called frequent attenders (FAs), account for 21–67% of all consultations in daytime general practice (Browne, Humphrey, Pallister, Browne, & Shetzer, 1982; Courtenay, Curwen, Dawe, Robinson, & Stern, 1975; Gill & Sharpe, 1999; Heywood, Blackie, Cameron, & Dowell, 1998; Karlsson, Lehtinen, & Joukamaa, 1994; Wamoscher, 1966) and receive five times more prescriptions and referrals than other patients (Heywood et al., 1998; Robinson & Granfield, 1986; Svab & Zaletel Kragelj, 1993). Knowledge of which factors are prompting patients to seek primary care is sparse, most existing studies are small and only few are populations-based and therefore potentially fraught with bias and poor precision. FA studies have used different definitions of FAs, designs and measures of determinants (Gill & Sharpe, 1999) and many have failed to distinguish between age and gender groups although it is possible that subgroups have different characteristics and needs. The quantitative and qualitative shortcomings of existing FA data could be remedied through large-scale population-based studies that incorporate valid general health measures and registry data in a stratified design.

Two persons having much the same clinical symptoms may attend quite differently (Mechanic & Volkart, 1961). A prospective descriptive study found that adults overall consulted a general practitioner (GP) 6% of the days they were having a symptom (Roghmann & Haggerty, 1972), whereas another study found that women only consulted a GP on less than 3% of such days (Banks, Beresford, Morrell, Waller, & Watkins, 1975). These observations have led to the hypothesis that differences in attendance may be rooted not only in differences in health, but also in differences in health perception and evaluation (Campbell & Roland, 1996; Hibbard & Pope, 1983; Hunt, Ford, Harkins, & Wyke, 1999; Mechanic & Volkart, 1961) and in social and health services factors (Hulka & Wheat, 1985; van de Kar, Knottnerus, Meertens, Dubois, & Kok, 1992; Wolinsky, 1978). The ‘Behavioural Model of Health Services Use’, initially developed and described by Andersen and Newman (Andersen & Newman, 1973; Andersen, 1995; Krasnik, 1996), takes many of these aspects into consideration. The model triangulates societal, health services system and individual determinants of health services utilization (Andersen & Newman, 1973). FA behaviour is a strain on general practice resources and any effort to improve intervention towards this group must be based on knowledge of the intricate interplay between all factors inducing patients to seek medical care. The Andersen-Newman model provides such a comprehensive approach and was therefore adapted to the particular needs of the present study.

The aim of this study was to examine factors associated with frequent attendance in general practice with special focus on physical, mental and social conditions.

Section snippets

The organisation of Danish general practice

The Danish GPs work as independent contractors to the National Health Service (NHS) and are partly remunerated per capita listed and partly on a fee-for-service basis (40/60%). The GPs act as gatekeepers and more than 98% of the inhabitants are registered with a GP and receive free medical care (de Fine Olivarius, Hollnagel, Krasnik, Pedersen, & Thorsen, 1997). Individuals have to consult the GP with whom they are registered. For reasons of accounting the NHS receives electronic information on

Results

Descriptive data are shown in Table 2.

Discussion

We found that FAs reported a lower physical and mental health and exhibited poorer social functioning than non-FAs. The present cross-sectional design did not, however, allow determination of the temporal relationship between these variables. Our findings are consistent with other studies where one or more physical diagnoses were held by 43% (record) (Courtenay et al., 1975), 46% (GP) (Heywood et al., 1998), 61% (record) (Báez et al., 1998) and 96% (GP/record/hospital) (Karlsson et al., 1994)

Acknowledgements

We thank Associate Professor, Morten Frydenberg, M.Sc. Ph.D., Department of Biostatistics, University of Aarhus, for the help with the statistics. We thank Mr. Jørgen N. Nielsen, the National Health Insurance, Aarhus County, for help with the data collection. We wish to thank Jakob Bue Bjørner for providing norm data. The study was supported by grants from The Municipal VAT Fund, The Lundbeck Pharma Research Fund for General Practice, The Insurance and Pension Research Fund and the Nycomed

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