Chapter 1. Introduction

An English general practitioner called Backett and his coworkers were the first to report in 1954 that a small proportion of patients were responsible for most of the workload of a doctor (Backett et al. 1954). Since then, numerous studies have confirmed the disproportionally high use of health care by frequent attenders, also called high users or high utilizers. Frequent attenders represent about 5–15% of the population, and they use approximately 20–40% of health care services (McArdle et al. 1974, Smedby 1974, Browne et al. 1982, Westhead 1985, Larivaara 1987). They also cause a lot of costs in both primary and secondary health care (Von Korff et al. 1992, Demers 1995).

In the previous studies concerning frequent attenders, a variety of characteristics connected with frequent attendance have been identified. The findings indicate that frequent attenders comprise a highly heterogeneous group of patients with multiple and complex problems (Neal et al. 1996). Frequent attenders have high rates of somatic illnesses, mental disorders and social difficulties, often concurrently (Schrire 1986, Gill & Sharpe 1999). Frequent attendance is related to poor self-perceived health (Borgquist et al. 1993), a poor quality of life (Heywood et al. 1998) and a high number of various, often unexplained somatic symptoms (McFarland et al. 1985), and frequent attenders are more likely to seek medical help for minor symptoms (Wagner et al. 1995).

Previously, frequent use of health care services has been connected with such psychological factors as psychological distress (Katon et al. 1990, Karlsson et al. 1995a), somatization (Katon et al. 1991, Ford 1992, Portegijs et al. 1996) and hypochondriacal beliefs (Barsky et al. 1986a, Pålsson 1988). Frequent attendance associates with alexithymia, not directly but mediated by psychological distress (Joukamaa et al. 1996). The cognitive misinterpretation and amplification of bodily sensations found among hypochondriacal patients are assumed to enhance somatization (Barsky & Wyshak 1990, Hitchcock & Mathews 1992). On the other hand, alexithymia is connected with somatization (Bach & Bach 1995), hypochondriasis (Rodrigo et al. 1989) and psychological distress (Saarijärvi et al. 1993). Physicians are commonly frustrated by somatizing frequent attenders (Katon et al. 1991, Mechanic 1992), and their approach to somatizing patients’ bodily concerns is often unsatisfactory (Blackwell & DeMorgan 1996). Patients often perceive a discrepancy between their own ideas and lay beliefs about illness on the one hand and doctors’ medical explanations on the other (Salmon et al. 1999).

Although there is ample evidence of family support for the physical and mental health of individuals (Campbell 1987), few studies have examined the relationships of family structure, family interactions and marital relationship with frequent attendance, and the findings have been controversial. Only some mentions of the family life cycle of frequent attenders can be found in the previous literature (Báez et al. 1998).

In Finland, frequent attenders in primary health care have earlier been studied in a rural and an urban health centre (Larivaara 1987, Karlsson et al. 1994, Karlsson et al. 1995a, Karlsson et al. 1995b, Karlsson 1996, Joukamaa et al. 1996, Karlsson et al. 1997). These studies showed the associations of sociodemographic factors, somatic and psychiatric morbidity, psychosomatic symptoms and psychological distress with frequent attendance.

Nowadays, primary health care is facing several challenges. Insufficient resources and demands for increasing efficacy are familiar to the general practitioners (GPs) working in health centres. GPs’ profession is burdened by the stress of an increasing workload. The workload due to frequently attending patients is larger than their proportion of the visits, because GPs perceive them as demanding, difficult, and often frustrating patients with limited prospects for improvement (O’Dowd 1988, Ford 1992). Thus, more research-based knowledge is needed to find efficient approaches to the recognition and treatment of frequent attenders, who make up such a large part of GPs’ everyday work (Neal et al. 1996).

The aim of the present study was to determine the prevalence of frequent attendance, frequent attenders’ reasons for encounter and the related chronic diseases of frequent attenders in primary health care. Furthermore, the study aimed to assess the associations of certain psychological, social and family factors with frequent attendance in a Finnish health centre, in order to gain some insight into the biopsychosocial background of frequent attendance and to develop some new approaches to the management of frequent attenders in primary health care.