Introduction
In different Countries and different Healthcare Systems, GP workload is
significantly burdened by a minority of patients seeing their GP a lot
more often than their peers (1).
Those are patients are generally well-known to their family physician as
subjects that make the ”heart sink” and therefore were initially called
by O’Dowd “heartsink patients” (2).
But when, more precisely, a patient “becomes” a high user or frequent
attender ”?
Even if the phenomenon is not new, we do not have data to define
quantitatively this “entity” and we ignore if the prevalence of FAs as
increased over time, or if it hasn’t (3,4).
We do not have precise data about the average duration of their GP
encounters, which could well differ from the standards 10 minutes, hence
likewise affecting the burden on GP time.
To describe those patients, we still often reference to a work published
in 1988. It is believed that Tom O’Dowd then coined the term
”heartsink”, to describe ”The feeling experienced (by the family doctor)
when their names (of patients) appear in the list of the morning
appointments. ” (1)
Further work has been done to define the reasons behind the frequent GP
visits. In 1988, O’Dowd acknowledged that the medical experience was
subjective, but perceived that the problem and its solution resided both
in the patient.
A systematic review from Gill and Sharpe on prevalence, associations and
clinical outcomes, and subsequent observations from other Authors, have
shown that FAs have high rates of physical illnesses, psychiatric
illnesses, social difficulties and emotional distress (3,5).
Frequent attendance in General Practice is also considered an indicator
of behaviour of inappropriate use of other health services, in
particular emergency departments and Secondary Care services (6,7,8).
Evidence of the effect of (mainly psychiatric) interventions on the rate
of frequency and morbidity of
FAs have shown conflicting results (9,10). In a review of the
interventions on FAs, it was found that
the high frequency can be a sign of a major depressive disorder and that
its treatment can improve the depressive symptoms, but there is no
evidence that it is thereby possible to influence the use of the
services (11).
The interpretation of the studies on FAs is hampered by differences in
Healthcare Systems and in the definition of FA (12).
It has been shown that age and sex are highly associated to the number
of GP visits and that the identification of FAs without adjustment by
age and sex leads predominantly to the selection of older women (13).
After reviewing the literature on high users, Vedsted suggested that the
FA should be described as a subject that falls at the top 10% of the
practice population stratified by age and gender (4).
Vedsted, suggested to arbitrarily fix a threshold in the distribution of
the frequency of consultation, such that they are considered FAs all
those who go above the percentage or percentile set as threshold.
However, this choice is associated with various problems of practicality
with one key disadvantage that is of failing to identify a number of
variabilities in relation Health Care System, for instances.
In this work, we checked the frequency GP encounters, both in office and
at patient’s domicile, over the course of 12 months, in both sexes, and
in all age bands.
We then looked at the number of visits over the course of a year above
which such number increases rapidly, isolating a limited group of
patients to whom was associated an extremely high number of GP
encounters.
Doing so, we aimed to clarify if and where the proportional threshold
value and the absolute threshold value may converge.
We believe that they do converge and that this number can be identified
as the most useful threshold value for the definition FA.
Method
In the context of a General Practice medium density urban setting, we
collected data on 9651 people registered with 4 different GPs.
Unlike most previous studies on FAs, we have not ruled out children and
the most elderly.
In fact, several studies have only used data from patients aged 15 to 74
years.
For all patients registered during the 12 months prior to the audit
date, we only counted the GP face to face consultations, either at the
Surgery or at home of the patient. We have calculated the contact
frequencies of all patients for each combination of age and gender. The
top 5% of patients in terms of frequency of yearly encounters has been
defined using the concept of proportional threshold.
Results
The characteristics of the population studied is graphically represented
in figure 1, they are the following:
Mother population: Patients currently registered
Last Search: 01-mar-2018
Relative Date: 01-Mar-2018
Population count: 9651
Males: 4540
Females: 5111