Frequent attendance in family practice and common mental disorders in an open access health care system

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Abstract

Frequent attenders in family practice are known to have higher rates of mental disorder. However little is known about specific psychiatric disorders and whether this behavior extends to specialist services, in an open access fee-for-service health care system.

Methods

1060 patients from 46 family practices completed the Patient Health Questionnaire and the Client Service Receipt Inventory. During the consultation, family practitioners blind to the questionnaire responses rated the severity of mental health and physical disorders. The 10% of patients with the highest number of 6-month consultations in six age and sex stratified groups were defined as frequent attenders.

Results

After adjustments for sociodemographic variables, physical health and other psychiatric diagnoses, patients with a somatoform disorder were more likely to be frequent attenders, with an odds ratio of 2.3 (95% CI: 1.3–3.8, p = .002).

Conclusion

When adjusting for confounders, among the four psychiatric diagnoses investigated only somatoform disorders remain significantly associated with frequent attendance. Physical health and chronic disease were no longer associated with frequent attendance which does not support the hypothesis that in an open access fee-for-service system, patients will consult for a wider range of health problems. Greater investigation into unexplained somatic symptoms could help reduce the frequency of attendance in both primary and secondary care, as this behaviour appears to be a general health-seeking drive than extends beyond family practice.

Introduction

Frequent attendance (FA) in primary care is of particular concern as it may reflect unmet patient needs [1], can lead to ‘heartsink’ in health care providers and places a significant burden on health resources [2], [3]. The threshold for FA (number of visits or percentage with highest attendance rates) and the time range varies considerably between studies [2], [4], [5], [6], [7], leading to wide variations in rates, ranging from 2.7% of patients in a UK family practice [2] to 59.6% in Italy [8]. FA is higher in women [2], [3], [9] and in higher age groups [2], [3], leading to a consensus definition of FA as the 10% age- and sex-stratified most frequent attenders (FAs) [4], [7], [10].

FAs tend to have more socio-economic problems such as lack of social support, social isolation, and unemployment [7]. They show more family dysfunction [11], and are more likely to be divorced or widowed [7], [9]. They are clinically heterogeneous exhibiting higher rates of non disease-specific physical and chronic illness [7], [11], [12], [13]. Higher rates of FA are found in association with mental illness [11], [14], [15], [16], [17], [18], [19], the likelihood of FA increasing with anxiety disorder by a factor of 1.14 in a multi-adjusted model [19]. FAs also have higher rates of depressive symptoms [15], [16], [20], [21], as well as somatoform symptoms or disorders [20], [21], [22], [23]. Comorbid somatic and psychiatric symptoms are more frequent in FAs [24].

It is likely that the profile of FAs will vary from one health care system to another depending on the burden FA behavior places on resources. According to Anderson and Newman's model, use of health care services is a function of enabling factors such as the ease of access to and availability of other types of care, predisposing factors such as socio-demographic characteristics and beliefs and finally need, both perceived and evaluated [1]. FA has been studied mainly in gatekeeping primary care systems where FAs present a substantial burden on the clinical workload which may lead patients to withhold from visiting their FP [3], [19]. There is a gap in the literature concerning fee-for-service health care systems. Patients in such systems will have the choice of GP and between primary and secondary care, and will thereby self-select themselves for FP care rather than consulting the FP as a gateway to specialized services. It is thought that the FPs' attitude will make them less likely to withhold from consulting which will influence the type and diversity of symptoms for which they will consult.

In France, FPs are paid on a fee-for-service basis, directly by the patient. They work mainly alone with no ancillary staff. Up until 2005 they had no patient lists or gate-keeping role and patients were able to directly consult any FP or specialist as often as wanted with the same level of reimbursement by the state [25]. There were no checks or incentives from the national health system for FPs to reduce the frequency of attendance. This setting has allowed us to examine the association between frequent attendance behavior and specific common mental disorders in an open fee-for-service system, and to study whether FA is specific to family practice or whether it extends to other areas of health care which has seldom been explored before [12]. The main hypothesis is that FAs in the fee for service system will be consulting for a wider range of health conditions with a lesser prominence of mental illness than in more structured health care organizations.

Section snippets

Methods

The study was carried between October 2003 and April 2004, in a sample of FPs practicing in two urban and one semi-rural psychiatric catchment areas, in and around the city of Montpellier. The urban study area covers a population of 140,000 inhabitants with 249 FPs and the semi-rural area a population of 80,000 with 73 FPs. In order to be representative of French family practice, the sample included both randomly selected FPs with a ‘classic’ practice-style and some FPs delivering alternative

Description of the FP and patient sample

Median FP age was 45 years (range: 32–59) and similar for both sexes. Of the FPs, 56% were male; 60% had been practicing 10 years or more and 80% declared having trained in mental health in the past 3 years. Two-thirds practiced alone.

Of the 1060 patients, 61.8% were female. Median age was 42 (range: 18–93); 49.4% were married and 33.5% single; 33.5% had a high (post-school) educational level. 40.1% were working, 10.6% unemployed, 14.3% students and 35% retired. Overall, 11.3% for a somatoform

Association between psychiatric disorders and FA in family practice

Previous studies have shown in multi-adjusted analyses that psychiatric disorders have a significant influence on FA in family practice [15], [19]. Our results are in keeping with the latter with patients with a somatoform disorder being more than twice as likely as others to be FAs. However, our findings do not support the hypothesis that FAs will present for a wider range of health problems, chronic disease status and physical illness failing to reach significance in the final model.

With

Conclusion

These findings from a cross-sectional study of a large sample of French FP attenders show that even when patients have direct access to specialist services, FA in family practice remains strongly associated with common mental disorders. Among the specific diagnostic categories, somatoform disorders only predispose to higher rates of care-seeking, which might be reduced if unexplained somatic symptoms were better detected and managed. Along with improved care coordination, this could help reduce

Role of funding source

This work was supported by a grant from the French Ministry of Research as well as an unconditional grant from Lilly Pharmaceuticals.

Conflict of interest

The authors declare that there are no conflicts of interest.

Acknowledgments

Authorization to translate and use the PRIME-MD® Patient Health Questionnaire© 1999, Pfizer Inc. was kindly given by Dr. Robert L Spitzer who can be contacted for research information at [email protected]. The 46 study FPs were given 150€ for their participation. We would like to thank all the patients and FPs who participated in the study, and the research assistants who helped collect and enter the data.

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