Abstract
Aims and Objective
To understand the frequent attendance phenomenon from the perspective of patients and healthcare professionals and how it can be reduced.
Background
Frequent attenders (FAs) are characterised by the consumption of a disproportionate number of medical consultations and a high number of visits per year to primary care physicians (PCP). Although FAs constitute about 10% of all primary clinic attendees, they are responsible for ~40–50% of clinic visits, affecting the efficiency, accessibility and quality of health services provided to other patients.
Design
Mixed methods (STROBE Statement: Data S1; COREQ checklist: Data S2).
Methods
Eighteen FAs were interviewed in a qualitative approach. PCPs and nurses (n = 184) completed a cross-sectional survey.
Results
FAs are driven by their personal, emotional and mental state. FAs viewed clinics as a source for information and resolving medical problems. They perceived PCPs as authoritative and knowledgeable, and nurses as treatment managers and mediators between PCPs and patients. In contrast, FAs evoked more negative emotions than positive ones among medical staff. PCPs and nurses attributed frequent visits to FAs’ personal and emotional states. A model based on the findings was constructed to provide a framework for grasping frequent attendance from a sociological perspective and for planning and managing it.
Conclusions
The accessibility and availability of health services at primary clinics, and collaboration and trust in medical staff facilitate the frequent attendance phenomenon.
How to cite:
Sharabani, R., Kagan, I., & Cojocaru, S. Frequent attenders in primary health care: a mixed-methods study of patient and staff perspectives. Journal of Clinical Nursing, 32(19-20), 7135-7146. https://doi.org/10.1111/jocn.16772
References:
Bello, P. (2017). Effective communication in nursing practice: A literature review. BSc Nursing Thesis. Retrieved from: https://core.ac.uk/download/pdf/84798372.pdf
Bellón, J. Á., & Fernández-Asensio, M. E. (2002). Emotional profile of physicians who interview frequent attenders. Patient Education and Counseling, 48(1), 33–41. https://doi.org/10.1016/S0738-3991(02)00097-6
Bergh, H., Baigi, A., Fridlund, B., & Marklund, B. (2006). Life events, social support and sense of coherence among frequent attenders in primary health care. Public Health, 120(3), 229–236. https://doi.org/10.1016/j.puhe.2005.08.020
Bergh, H., Baigi, A., Mansson, J., Mattsson, B., & Marklund, B. (2007). Predictive factors for long-term sick leave and disability pension among frequent and normal attenders in primary health care over 5 years. Public Health, 121(1), 25–33. https://doi.org/10.1016/j.puhe.2006.08.018
Bergh, H., Baigi, A., & Marklund, B. (2005). Consultations for injuries by frequent attenders are found to be medically appropriate from general practitioners’ perspective. Scandinavian Journal of Public Health, 33(3), 228–232. https://doi.org/10.1080/14034940510005761
Bergh, H., & Marklund, B. (2003). Characteristics of frequent attenders in different age and sex groups in primary health care. Scandinavian Journal of Primary Health Care, 21(3), 171–177. https://doi.org/10.1080/02813430310001149
Braun-Lewensohn, O., Sagy, S., & Roth, G. (2010). Coping strategies among adolescents: Israeli Jews and Arabs facing missile attacks. Anxiety, Stress, and Coping, 23(1), 35–51. https://doi.org/10.1080/10615800802647601
Brezzi, M., Dijkstra, L., & Ruiz, V. (2011). OECD Extended Regional Typology. https://doi.org/10.1787/5kg6z83tw7f4-en
Carelli, F., Petrazzuoli, F., Daddio, F., & Sauro, A. (2003). Frequent attenders: The practitioner’s everyday life hell. British Medical Journal, 325, 323.
Carney, T. A., Guy, S., & Jeffrey, G. (2001). Frequent attenders in general practice: a retrospective 20-year follow-up study. British Journal of General Practice, 51(468), 567–569. https://www.ncbi.nlm.nih.gov/pubmed/11462318
Clarfield, A. M., Manor, O., Nun, G. B., Shvarts, S., Azzam, Z. S., Afek, A., Basis, F., & Israeli, A. (2017). Health and health care in Israel: An introduction. Lancet, 389(10088), 2503–2513. https://doi.org/10.1016/s0140-6736(17)30636-0
Committee for Strengthening the Public Health System Report. (2014). Retrieved from Jerusalem
Creswell, J. W. (2014). Research design: Qualitative, quantitative, and mixed methods approaches ( 4th ed.). Sage.
Filc, D., Rasooly, A., & Davidovitch, N. (2020). From public vs. private to public/private mix in healthcare: Lessons from the Israeli and the Spanish cases. Israel Journal of Health Policy Research, 9(1), 31. https://doi.org/10.1186/s13584-020-00391-4
Groode, J., Cohen, A. D., Vardy, D. A., & Dreiher, J. (2008). Factors associated with frequent attendance in a Bedouin primary care setting. Harefuah, 147(12), 966-970, 1030. https://www.ncbi.nlm.nih.gov/pubmed/19260591
Hajek, A., Kretzler, B., & König, H.-H. (2021). Determinants of frequent attendance in primary care. A systematic review of longitudinal studies. Frontiers in Medicine, 8, 595674. https://www.frontiersin.org/articles/10.3389/fmed.2021.595674
Hammerman, O., Halperin, D., Tsalihin, D., Greenberg, D., Kushnir, T., & Ezra, Y. (2021). Characteristics and economic burden of frequent attenders with medically unexplained symptoms in primary care in Israel. European Journal of General Practice, 27(1), 294–302. https://doi.org/10.1080/13814788.2021.1985997
Heywood, P. L., Blackie, G. C., Cameron, I. H., & Dowell, A. C. (1998). An assessment of the attributes of frequent attenders to general practice. Family Practice, 15(3), 198–204. https://doi.org/10.1093/fampra/15.3.198
Hodgson, P., Smith, P., Brown, T., & Dowrick, C. (2005). Stories from frequent attenders: a qualitative study in primary care. Annals of Family Medicine, 3(4), 318–323. https://doi.org/10.1370/afm.311
Huhtakangas, M., Tuomikoski, A.-M., Kyngäs, H., & Kanste, O. (2021). Frequent attenders’ experiences of encounters with healthcare personnel: A systematic review of qualitative studies. Nursing & Health Sciences, 23(1), 53–68. https://doi.org/10.1111/nhs.12784
Jacob, R., Wong, M. L., Hayhurst, C., Watson, P., & Morrison, C. (2016). Designing services for frequent attenders to the emergency department: a characterisation of this population to inform service design. Clinical Medicine (London), 16(4), 325–329. https://doi.org/10.7861/clinmedicine.16-4-325
Kivela, K., Elo, S., & Kaariainen, M. (2018). Frequent attenders in primary health care: A concept analysis. International Journal of Nursing Studies, 86, 115–124. https://doi.org/10.1016/j.ijnurstu.2018.06.003
Kontopantelis, E., Panagioti, M., Farragher, T., Munford, L. A., Parisi, R., Planner, C., Spooner, S., Tse, A., Ashcroft, D. M., & Esmail, A. (2021). Consultation patterns and frequent attenders in UK primary care from 2000 to 2019: a retrospective cohort analysis of consultation events across 845 general practices. BMJ Open, 11(12), e054666. https://doi.org/10.1136/bmjopen-2021-054666
Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nursing, 20(1), 158. https://doi.org/10.1186/s12912-021-00684-2
Lin, E. H. B., Katon, W., Von Korff, M., Bush, T., Lipscomb, P., Russo, J., & Wagner, E. (1991). Frustrating patients. Journal of General Internal Medicine, 6(3), 241–246. https://doi.org/10.1007/BF02598969
McCabe, C. (2004). Nurse–patient communication: An exploration of patients’ experiences. Journal of Clinical Nursing, 13(1), 41–49. https://doi.org/10.1111/j.1365-2702.2004.00817.x
Neal, R. D., Heywood, P. L., Morley, S., Clayden, A. D., & Dowell, A. C. (1998). Frequency of patients’ consulting in general practice and workload generated by frequent attenders: Comparisons between practices. British Journal of General Practice, 48(426), 895–898. https://www.ncbi.nlm.nih.gov/pubmed/9604412
Nyman, J., & Jäppinen, P. H. (2015). Heavy users of health station outpatient care. Journal of Social Medicine, 52(1), 4–19.
Patel, S., Kai, J., Atha, C., Avery, A., Guo, B., James, M., Malins, S., Sampson, C., Stubley, M., & Morriss, R. (2015). Clinical characteristics of persistent frequent attenders in primary care: Case-control study. Family Practice, 32(6), 624–630. https://doi.org/10.1093/fampra/cmv076
Pino-Moya, E., Ortega-Moreno, M., Gómez-Salgado, J., & Ruiz-Frutos, C. (2018). Determining factors for the increase in self-referrals to the emergency department of a rural hospital in Huelva (Spain). PLoS One, 13(11), e0207199. https://doi.org/10.1371/journal.pone.0207199
Polit, D. F., & Beck, C. T. (2017). Nursing Research: Generating and Assessing Evidence for Nursing Practice ( 10th ed.), Philadelphia: Wolters Kluwer Health.
Pymont, C., & Butterworth, P. (2015). Longitudinal cohort study describing persistent frequent attenders in Australian primary healthcare. BMJ Open, 5(10), e008975. https://doi.org/10.1136/bmjopen-2015-008975
Reho, T., Atkins, S., Talola, N., Sumanen, M., Viljamaa, M., & Uitti, J. (2018). Comparing occasional and persistent frequent attenders in occupational health primary care – a longitudinal study. BMC Public Health, 18(1), 1291. https://doi.org/10.1186/s12889-018-6217-8
Reho, T. T. M. (2020). Frequent attenders of occupational health primary care and work disability. Tampere University.
Reho, T. T. M., Atkins, S. A., Talola, N., Sumanen, M. P. T., Viljamaa, M., & Uitti, J. (2019). Occasional and persistent frequent attenders and sickness absences in occupational health primary care: a longitudinal study in Finland. BMJ Open, 9(2), e024980. https://doi.org/10.1136/bmjopen-2018-024980
Rosen, B., Waitzberg, R., & Merkur, S. (2015). Israel: Health system review. Health Systems in Transition, 17(6), 1–212.
Sabar Ben-Yehoshua, N., & Dushnik, L. (2006). Ethical issues in action research. In D. Levy (Ed.), Philosophical and methodological associations between action research and the qualitative research paradigm. Tel Aviv.
Sandvik, H., Hetlevik, O., Blinkenberg, J., & Hunskaar, S. (2021). Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway. British Journal of General Practice., 72, e84–e90. https://doi.org/10.3399/BJGP.2021.0340
Scaife, B., Gill, P. S., Heywood, P. L., & Neal, R. D. (2000). Socio-economic characteristics of adult frequent attenders in general practice: Secondary analysis of data. Family Practice, 17(4), 298–304. https://doi.org/10.1093/fampra/17.4.298
Shkedi, A. (2003). Words That Try to Touch: Qualitative Research—Theory and Application. Tel-Aviv: Ramot.
Shum, C., Humphreys, A., Wheeler, D., Cochrane, M.-A., Skoda, S., & Clement, S. (2000). Nurse management of patients with minor illnesses in general practice: Multicentre, randomised controlled trial. BMJ, 320(7241), 1038–1043. https://doi.org/10.1136/bmj.320.7241.1038
Smits, F. T., Brouwer, H. J., ter Riet, G., & van Weert, H. C. (2009). Epidemiology of frequent attenders: a 3-year historic cohort study comparing attendance, morbidity and prescriptions of one-year and persistent frequent attenders. BMC Public Health, 9, 36. https://doi.org/10.1186/1471-2458-9-36
Smits, F. T., Brouwer, H. J., van Weert, H. C., Schene, A. H., & ter Riet, G. (2009). Predictability of persistent frequent attendance: a historic 3-year cohort study. British Journal of General Practice, 59(559), e44–e50. https://doi.org/10.3399/bjgp09X395120
Smits, F. T., Brouwer, H. J., Zwinderman, A. H., Mohrs, J., Schene, A. H., van Weert, H. C., & ter Riet, G. (2014). Why do they keep coming back? Psychosocial etiology of persistence of frequent attendance in primary care: a prospective cohort study. Journal of Psychosomatic Research, 77(6), 492–503. https://doi.org/10.1016/j.jpsychores.2014.08.003
Vedsted, P., & Christensen, M. B. (2005). Frequent attenders in general practice care: a literature review with special reference to methodological considerations. Public Health, 119(2), 118–137. https://doi.org/10.1016/j.puhe.2004.03.007
Wagner, E. H. (1998). Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice, 1(1), 2–4. https://www.ncbi.nlm.nih.gov/pubmed/10345255
Wagner, E. H., Glasgow, R. E., Davis, C., Bonomi, A. E., Provost, L., McCulloch, D., Carver, P., & Sixta, C. (2001). Quality improvement in chronic illness care: a collaborative approach. Joint Commission Journal on Quality Improvement, 27(2), 63–80. https://doi.org/10.1016/s1070-3241(01)27007-2
Williams, S. J. (2005). Parsons revisited: From the sick role to…? Health (London, England), 9(2), 123–144. https://doi.org/10.1177/1363459305050582