Frequent consulters in general practice: A systematic review of studies of prevalence, associations and outcome

doi:10.1016/S0022-3999(98)00118-4

Journal of Psychosomatic Research

Volume 47, Issue 2, August 1999, Pages 115-130

https://doi.org/10.1016/S0022-3999(98)00118-4 Get rights and content

Abstract

We conducted a systematic review of the observational literature on frequent consulters in general practice. Electronic searching identified 34 studies which met our inclusion criteria. Frequent consulters were identified in a wide range of primary health care settings, confirming that a small proportion of patients is responsible for a disproportionate number of consultations. A cutoff of 9-14 consultations per annum was used to define a frequent consulter in most studies. Studies have examined a variety of associated characteristics, and indicate that frequent consulters are highly heterogeneous, and have high rates of physical disease, psychiatric illness and social difficulties. Few are likely to conform to the “heartsink” stereotype. These patients are likely to have multiple, complex problems, often including chronic physical disease, with or without psychological and social problems. The natural history of frequent consulting behavior seems to be to persist in many cases. Implications for management are discussed.

Introduction

It has long been observed that the general practitioner sees a proportion of his or her registered patients particularly frequently 1, 2. Why do these patients consult their doctors more than the average? This question has been addressed by a number of investigators in different parts of the world. However, the relevant literature is widely scattered and the conclusions of these studies not easy to ascertain. We have therefore conducted a systematic review of the literature on the topic.

Early studies were 1, 2 carried out by individual primary care doctors, struck by the prominence of frequent consulters in their own practices. This is a useful approach, as it rests on personal knowledge of these patients that may go back many years. Follow-up over time is especially valuable, and is much more practicable if patients are permanently registered with a given practice (such as in the UK National Health Service, or if the practice deals with all patients from a geographically circumscribed area [29]).

Later studies have often involved researchers from other disciplines, such as liaison psychiatrists, psychologists, health services researchers, etc., coming into the general practice, and carrying out interview or questionnaire assessment. Although such research teams have not often been available to follow up patients, the advantages of this approach include more comprehensive and objective measurement of relevant characteristics of these patients.

Various terms have been used to describe the topic including frequent attender, frequent consulter, high utilizer, and heart sink patient. We have chosen to use frequent consulter as a nonpejorative term that includes consultations at home as well as at the surgery and focuses upon contact with primary care rather than overall use of health resources.

Section snippets

Method

We searched for relevant reports on the electronic databases medline, psyclit, and embase and also consulted reference lists of retrieved articles, reviews, experts in the field, and the Science Citation Index. The medline search strategy combined MeSH and free-text terms as follows (similar strategies were used for the other databases):

1.
“FAMILY-PRACTICE”/all subheadings
2.
“PHYSICIANS, -FAMILY”/all subheadings
3.
“HEALTH-SERVICES-MISUSE”/all subheadings
4.
“HEALTH-SERVICES-RESEARCH”/all subheadings
5.

Results

Thirty-four studies met the aforementioned criteria and are summarized in Table 1.

Limitations of the review process

The main limitation of the review process is that it may not have identified all relevant studies, especially those in languages other than English.

Limitations of studies reviewed

Not all of the studies included in this review used samples likely to be representative of the population concerned (these are marked in italics in Table 1); many of the remainder are small, highly selective, and therefore possibly unrepresentative. Varying case definitions (e.g., children/physical disease included/excluded) and study designs

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Usability of information systems: Experiences of outpatient physicians, outpatient nurses, and open care social welfare professionals from three large cross-sectional surveys in Finland
2022, International Journal of Medical Informatics
Many European countries are integrating healthcare and social welfare services; some also include joint information systems (ISs) in this process. Despite this, large national survey studies examining and comparing the experiences of the major professional groups regarding the usability of their health (HISs) and client information systems (CISs) are lacking.
We combined the responses from three national cross-sectional surveys conducted among physicians and nurses in 2017, and social welfare professionals (SWPs) in 2019 in Finland. We selected the responses of 1,826 physicians and 774 nurses working in outpatient clinics in specialized and primary care, and 669 social workers and other SWPs working in open services. The questionnaires were adjusted from a validated instrument. In this study, we analyzed 11 usability-related statements.
The healthcare professionals (HPs) were more critical of the stability and responsiveness of their ISs than the SWPs (27–48% vs 58–65% agreed). The physicians were most dissatisfied with IS support for routine tasks (24–26% agreed). Less than half of all respondents agreed with statements concerning the ease of documentation, arrangement of fields, and terminology. While the HPs were satisfied with IS support for collaboration and information exchange between professionals in the same organization, all professional groups were dissatisfied with cross-organizational support and communication with patients and clients. Almost half of the HPs considered that HISs improve the quality of care, but 80% of the SWPs disagreed that CISs help improve the quality of services.
Overall, the physicians, nurses, and SWPs were dissatisfied with the usability of their HISs and CISs. Based on our findings, ISs should be further developed to support routine tasks, inter- and cross-organizational collaboration, and information exchange. ISs for the integration of care and services should be designed to accommodate various professional groups’ different work contexts and needs.
The effects of patient's frequency of attendance and etiology of symptoms, on the General Practitioners wellbeing
2021, Revue Europeenne de Psychologie Appliquee
Citation Excerpt :
Thereby, the negative consequences on the physicians’ wellbeing are associated to some of the patients’ characteristics, and not only to the high number of visits. Several studies show that physicians consider that many of the FAs suffer Medically Unexplained Symptoms (MUS) originated in psychological distress that may coexist with chronic illnesses, psychiatric complaints, personality disorders and/or psychosocial problems (e.g. Gill & Sharpe, 1999; Karlsson, Joukamaa, Lahti, Lehtinen, & Kokki-Saarinen, 1997; Vedsted & Christensen, 2005). In the absence of a satisfactory explanation for the motive of their medical symptoms, some of the MUS patients consult frequently, causing a partial overlap between FA and MUS.
The presence of Medically Unexplained Symptoms and a high Frequency of Attendance negatively affects the General Practitioners’ (GP) wellbeing. Although, overlapping between both phenomena is partial, with a number of frequent attenders reporting medically unexplained symptoms during consultation, there is no evidence on how GP's well-being it is affected by the specific main effects of these factors and their interaction. Evidence is also scant on the psychological processes explaining the negative impact of attendance and the etiology of symptoms on GP's wellbeing.
Drawing on the Job Demand-Control and the Conservation of Resource stress models, this paper tests the moderating effects of the GP’ perception of patient's attendance and etiology of symptoms on the relationship between patient's demands and feedback on the GP's wellbeing.
A total of 105 volunteer GPs self-reported on the study variables through an experience sampling methodology after 898 patients’ consultation. Patients attendance and etiology of symptoms were categorized according to the physician self-perception and an external criterion (organizational records).
Perception of Patients Frequent Attendance and Medically Unexplained Symptoms were positively related to physician's Emotional Exhaustion. Contrary to expected the test of the moderation effects of patients characteristics on the relation between patient's demands and feedback and the GP's emotional exhaustion were stronger for normal attenders compared with frequent attenders. An ad hoc study shows this unexplained result is related to the GP's expectations on Frequent vs. normal attenders’ behaviors. No significant results were found when the external criterion of classification was used.
Combined analysis of Frequency of Attendance and Etiology of Symptoms lead to a better understanding of the GP's decreased wellbeing. Also, the perception of the strain level (demands/positive feedback levels) associated to the consultation with different types of patients contribute to explain the consequences for the GP's wellbeing, especially when GP's expectations on patient's behaviors are violated.
La présence de symptômes médicalement inexpliqués et une fréquence de visites élevée ont un effet négatif sur le bien-être des médecins généralistes (MG). Bien que le chevauchement entre ces deux phénomènes soit partiel, un certain nombre de personnes qui consultent fréquemment signalant des symptômes médicalement inexpliqués lors de la consultation, il n’existe aucune preuve de la manière dont le bien-être du médecin généraliste est affecté par les principaux effets spécifiques de ces facteurs et leur interaction. Il existe également peu de preuves sur les processus psychologiques expliquant l’impact négatif de la fréquentation et l’étiologie des symptômes sur le bien-être du médecin généraliste.
La perception de la fréquentation des patients et les symptômes médicalement inexpliqués sont positivement liés à l'épuisement émotionnel du médecin. Contrairement aux attentes, le test des effets de la modération des caractéristiques des patients sur la relation entre les demandes et les commentaires des patients et l'épuisement émotionnel du médecin était plus fort pour les patients normaux que pour les patients fréquents. Une étude ad hoc montre que ce résultat inexpliqué est lié aux attentes du médecin généraliste concernant le comportement des patients fréquents par rapport aux patients normaux. Aucun résultat significatif n'a été trouvé lorsque le critère externe de classification a été utilisé.
Au total, 105 médecins généralistes volontaires ont participé à une étude par une méthodologie d’échantillonnage d’expérience après la consultation de 898 patients. L’assiduité des patients et l’étiologie des symptômes ont été classées selon le critère du médecin et un critère externe.
La perception de la fréquentation des patients et les symptômes médicalement inexpliqués étaient liés à l’épuisement émotionnel du médecin. Contrairement à ce qui était prévu, le test des effets de modération des caractéristiques des patients sur la relation entre les demandes des patients et le feedback qu'ils fournissent, d'une part, et l'épuisement émotionnel du médecin généraliste, d'autre part, était plus fort pour les patients à fréquence de visites normale que pour les patients à fréquence de visites élevée. Une étude ad hoc montre que ce résultat inexpliqué est lié aux attentes du médecin généraliste sur les comportements des patients fréquents par rapport aux patients normaux. Aucun résultat significatif n’a été trouvé lorsque le critère externe de classification a été utilisé.
L’analyse combinée de la fréquence de présence et de l’étiologie des symptômes permet de mieux comprendre la diminution du bien-être du médecin généraliste. De plus, la perception du niveau de stress (exigences/niveaux de rétroaction positive) associé à la consultation de différents types de patients contribue à expliquer les conséquences sur le bien-être du médecin généraliste, en particulier lorsque les attentes du médecin généraliste sur les comportements des patients sont violées.
The effects of nurse-led health coaching on health-related quality of life and clinical health outcomes among frequent attenders: A quasi-experimental study
2020, Patient Education and Counseling
Citation Excerpt :
These studies found several predictive factors for frequent attendance, including older age, female gender, lower level of education, social and economic difficulties [17,18] and stressful life events [19–24]. However, the reviews [4,6] have found that frequent attenders are in all age groups. The quality of the physician-patient relationship has not been found to be associated with frequent attendance [25].
To evaluate the effects of the nurse-led health coaching on health-related quality of life and clinical health outcomes among frequent attenders in primary healthcare.
A quasi-experimental study design. A total of 110 patients were enrolled in the study. The experimental group (n = 52) received nurse-led health coaching and the control group (n = 58) received the usual care at primary health care centres in Finland. The data were collected before the intervention and 12 months via a questionnaire of health-related quality of life and clinical health outcomes as measured by health-coaching nurses.
This study found frequent attenders have low health-related quality of life. The nurse-led health coaching showed no differences in health-related quality of life between the experimental and control groups. However, the nurse-led health coaching had statistically significant effects on the blood pressure and health-related quality of life among the experimental participants, especially in emotional role limitation and energy.
This study suggests that nurse-led health coaching may lead to an improvement in the health-related quality of life and blood pressure among frequent attenders.
The health-coaching sessions with own health-coaching nurses and action plans support the frequent attenders´ health promotion goals and implementation.
Frequent attenders in primary health care: A concept analysis
2018, International Journal of Nursing Studies
Citation Excerpt :
There is no strong and coherent evidence of the effectiveness of the studies (Smits et al., 2008; Haroun et al., 2016). Although several authors have examined the characteristics of frequent attenders (Gill and Sharpe, 1999; Vedsted and Christensen, 2005), professionals have no clear theoretical or operational definitions of this concept. This makes it difficult to identify this patient group at an early stage in primary health care.
Frequent attendance is a well-known phenomenon in health care systems. A small proportion of patients make a high rate of visits to primary health care physicians. However, due to the diversity of this phenomenon, there is no generally accepted definition of the frequent attender. The aim of this analysis was to define the concept of the frequent attender in primary health care.
A concept analysis.
The literature was searched using electronic databases (MEDLINE, CINAHL, and Scopus) and a manual search was performed for studies published from 2000 to 2016. The inclusion criteria covered frequent attenders in primary health care examined by quantitative or qualitative studies published in English or Finnish.
Walker and Avant’s (2010) strategy for concept analysis was used. Uses of the concept were studied, and attributes, antecedents, and consequences of the concepts were defined.
A total of 59 articles provided data for this concept analysis. Four defining attributes of frequent attenders were identified: the feelings of symptoms, perceived poor health status, lower quality of life and frequent visits to a primary health care provider. Antecedents included the patient’s individual characteristics, the primary health care system, and the patient-physician relationship. Consequences were divided into two categories: those for frequent attenders and those for society. Consequences for frequent attenders included: follow-up investigations and visits, social disadvantages, and economic costs. Consequences for society included: the costs to the national economy and the consumption of health care resources.
A theoretical definition and a conceptual model of the frequent attender were developed. The definition and the proposed empirical referents of all four attributes can be used to validate the presence of frequent attenders and to develop theory-based applications. Future research on frequent attenders is needed to develop and assess possible interventions.
Occupational health patients’ parallel use of primary- and secondary-care services and linkage to work disability: A follow-up study in Finland
2024, Scandinavian Journal of Public Health
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ReviewFrequent consulters in general practice: A systematic review of studies of prevalence, associations and outcome

Abstract

Introduction

Section snippets

Method

Results

Limitations of the review process

Limitations of studies reviewed

Gen Hosp Psychiatry

Gen Hosp Psychiatry

J Psychosom Res

The returning patienta survey of patients with high attendance rate

J Coll Gen Pract

Studies of a general practice

BMJ

The Manitoba longitudinal study on agingpreliminary findings on health care utilization by the elderly

Med Care

Characteristics of children with high and low usage of physician services

Med Care

Family health. Utilization and effects of family membership

Med-Care

Family characteristics in high and low health care utilization

Gen Hosp Psychiatry

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

Arch Gen Psychiatry

Somatizationa spectrum of severity

Am J Psychiatry

Frustrating patientsphysician and patient perspectives among distressed high users of medical services

J Gen Intern Med

A troubled youthrelations with somatization, depression and anxiety in adulthood

Fam Pract

Stability of attendance in general practice

Fam Pract

Frequent attendance in a family practice

J R Coll Gen Pract

Frequent attenders in general practicemedical, psychological and social characteristics

J R Coll Gen Pract

Frequent attenders in general practicea study from Slovenia

Scand J Prim Health Care

Prevalence and characteristics of frequent attenders in a prepaid Canadian family practice

J Fam Pract

Review
Frequent consulters in general practice: A systematic review of studies of prevalence, associations and outcome