Tomlin J Paul1§, OD Nembhard 2 1 Department of Community Health and Psychiatry, UWI, Gibraltar Road, Mona, Kingston 7, Jamaica
2 Health Plus Associates, Elma Crescent, Kingston 20, Jamaica
§ - corresponding author
Patients’ characteristics in general practice are as critical to outcomes as are the characteristics of their disease or disorder. A full understanding of consulting patterns will contribute to improvements in practice management and quality of care. Despite the growing literature on frequent attendance in general practice, there are no studies addressing this issue in the Caribbean. No significant work has been done on consulting patterns of ambulatory care patients except for what has been gleaned from the Primary Care Operational Research studies (PRICOR) of the 1980s which took place in Jamaica (Desai P et al, 1989). But these studies focussed more on the production line type of assessments, pertinent to operations management and did not assess consulting patterns with patients’ characteristics in mind.
Patients who have above average attendance in general practice no doubt raise a number of questions in the practitioner's mind. What do these frequent visits signify? Are frequent attenders more likely to be unhealthy individuals seeking care for a number of problems, or are they persons who are in fact quite well as a result of their frequent visits? Studies have examined physician, patient and practice factors related to frequent visits. In one study in the UK, it was noted that frequent attenders were more likely to have lower educational status, were more satisfied with their practitioner, and had higher scores of anxiety and depression and lower perceived quality of life (Kersnik J et al, 2001). The frequency of chronic diseases was also a risk factor for attendance. Caribbean countries should take interest in this subject given the increasing burden of chronic diseases (diabetes and hypertension) in the population.
METHODS AND AIMS
This study is an initial examination of selected characteristics of frequent attenders attending a private group general practice. It aims to determine the sociodemographic profile of this subgroup and to ascertain the presence of the chronic diseases, diabetes and hypertension and the frequency of prescriptions for hypnotics and anxiolytics.
The study was conducted at Health Plus Associates which is a small group medical practice with a team of 4 general practitioners providing service to a Kingston suburban community and its environs since 1993. The four practitioners are all graduates of the Bachelor of Medicine, Bachelor of Surgery (MB BS) degree programme of the University of the West Indies. Patients are known to attend the group practice to see their "usual" doctor but at times may cross over to see another physician. All patients visiting are registered on a worksheet with the particular physician's name on it. These worksheets are kept to a high standard of recording as they represent a key part of the administrative management system of the group practice.
All visits for patients attending Health Plus Associates to see a selected (index) physician during 1998 were extracted from worksheets for that period. Using an excel database these visits were subsequently reduced so as to represent a frequency listing of visits for individual patients. Patients above the 96th percentile corresponding to patients with five or more visits to the index physician were selected and classified as frequent attenders. All files for patients in this group were reviewed and data extracted that were relevant to the study (age, gender, occupation, address, health insurance coverage, diagnosis and medication). The actual number of visits made by patients for 1998 was adjusted where necessary, given that patients were likely to have seen physicians other than the index physician during the study period.
The index physician had a total of 1,934 patient-visits for 1998. When these visits were collapsed to represent patients, there was a 20% reduction in the number giving a corresponding 1,224 patients. Just fewer than 7 % of these patients accounted for almost a quarter (22%) of total visits. The mean annual visit rate for the group of 1,224 patients was 1.6(SD 1.3) visits per annum. Frequent attenders as defined by this study (above the 96th percentile) consisted of a group of 39 patients (3.2% of total patients visiting for 1998). The mean annual visit rate for this sub-group after adjustment for visits to non-index physicians was 10.3(SD 4.8) visits per annum. Seventy-five percent of patients had health insurance coverage.
The male: female ratio was 1:8.3 with men accounting for 10.8 percent of frequent attenders. The age range was from 1 to 81 years, but there was only one patient who was under the age of 18 years. The mean age was 39.9 yrs (SD 20.2). Approximately 60 percent of frequent attenders were in very close proximity to the practice living in the same or adjacent geographical zone. Fifty-four percent of patients held professional office-based jobs with a tendency for these to be in the accounting or banking sector. Only seven frequent attenders (18 %) had a diagnosis of diabetes or hypertension recorded in their records up to the time of their visits in 1998. Nearly half (48.6%) of frequent attenders had a prescription for a hypnotic or anxiolytic drug at least once during their visits in 1998. Antidepressants were only prescribed on one occasion.
This study provides a first look at the profile of frequent attenders in a small group practice and it must be noted however that there is no comparison group. However the study raises a number of hypotheses requiring further exploration and provides some initial insights about the potential nature of this interesting sub-group of patients called frequent attenders.
The sub-group is predominantly female (89.2 %) which is not surprising. Women are known generally to be more likely to visit physicians than men (Woodwell DA, 1999), so the likelihood that they will be in a FAs sub-group will be high. Despite a small sub-group of older individuals in the sub-group, the majority of individuals are adults in the late 20's to 40's age group. There is a surprising low prevalence of chronic diseases (diabetes and hypertension) among these FAs given the general community prevalence. This however is consistent with the younger age profile of the group where these conditions are not in a particularly high prevalence. But based on the assumption that chronic disease patients are likely to make more visits to the doctor, one would expect a higher proportion of such patients. Self-selection could also be operating here with this practice clientele.
There are no established data regarding prescriptions for anxiolytics and hypnotics in general practice in the Caribbean with which to compare the data from this study. However it is fair to say that a near 50 percent "ever-prescribed" prevalence for anxiolytics/hypnotics is somewhat high in this patient sub-group. If the assumption is that this level of prescribing is not the norm for low attenders, then it is more likely to be associated with frequent attendance. Somatization has been seen as a problem with FAs. Hypochondriacal beliefs and psychiatric comorbidity were connected with frequent attenders' somatization in one study (Jyvasjarvi S et al, 2001). Hypochondriacal beliefs explained somatizers' frequent attendance and there was a significant interaction effect between somatization and hypochondriacal beliefs when explaining frequent attendance. These might be factors operating in this study contributing to the apparent high level of anxiolytic/hypnotic prescriptions.
Overall in this study, the profile of the frequent attender is that of a young to middle aged adult female, professional or semi-professional who lives in close proximity to the medical facility without substantial chronic disease but more likely to be experiencing symptoms requiring anxiolytics and hypnotics. Of course one will have to consider the role of physician factors in a larger study. Are there considerations about physicians which perpetuate frequent attendance? Consulting style and prescribing habits may be all important here. Neal et al notes that there is considerable variation in the numbers and proportions of consultations with frequent attenders between individual doctors (Neal RD et al, 2000). But the reasons why some doctors have more consultations with frequent attenders are unclear. Kersnick et al showed that the factors influencing frequent visits were more attributable to patient factors than physician factors (Kersnik J et al, 2001). Through multivariate modeling it was shown that 16.9% of the variation was attributed to patient characteristics and 3.1% to GP characteristics. Some doctors may actively encourage frequent attendance. While many frequent attenders have clear allegiances to one doctor, many also consult widely with a large number of doctors (Neal RD et al, 2000).
A follow-up to this study will be to include a comparison group so as to look at the strength of association of various factors that are thought to be linked with frequent attendance and tracking of high and low attenders over time. In addition, future studies should include a qualitative angle so the nature of the consultation can be assessed. Smucker et al have identified different encounter types such as: simple medical, ritual visit, complicated medical, the tango, simple frustration, psychosocial disconnect, medical disharmony, and the heartsink visit (Smucker DR et al, 2001). Different visit types can have implications for return visits as it relates to physician's comfort levels and patient's satisfaction.
Frequent attenders in this practice tend to be adult to middle aged professional or semi-professional women, living within close proximity to the medical centre and likely to be covered by health insurance. Diabetes and hypertension are not in high prevalence in this group but there is an apparent excess of prescriptions for anxiolytics and hypnotics suggesting psychological related disorders
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