Frequent attenders in primary health care

A cross-sectional study of frequent attenders’ psychosocial and family factors, chronic diseases and reasons for encounter in a Finnish health centre

Simo Jyväsjärvi

Department of Public Health Science and General Practice, University of Oulu
Health Centre of Oulainen
Unit of General Practice, University Hospital of Oulu
Department of Psychiatry, University of Oulu

Abstract

The aim of this cross-sectional controlled study was to determine frequent attenders’ chronic diseases and their reasons for encounter in primary health care. Furthermore, the study aimed to determine the associations of social, psychological and family factors with frequent attendance in a Finnish health centre.

Patients who made eight or more annual visits to physicians in the health centre during one year were defined as frequent attenders (FA). All the FAs during 1994 (N = 304) and 304 randomly selected age- and sex-matched controls constituted the study population. The data were collected from annual statistics, medical records and postal questionnaires. Over one third of the study population was interviewed. International Classification of Primary Care (ICPC) was used to determine the reasons for encounter and Symptom Checklist -36 (SCL-36) to assess the psychological distress. Toronto Alexithymia Scale -20 (TAS-20) was used as a measure of alexithymia and Whiteley Index (WI) to determine hypochondriacal beliefs.

The results showed that 4.7% of the whole population aged 15 years or older in Oulainen were FAs. They accounted for 23.5% of all visits made within the respective age group. The mean age of the FAs was 49.8 years. Over two thirds of them were female. The FAs had lower basic education and occupational status than the controls. The FAs visited physicians in the health centre mostly for reasons related to the musculoskeletal, respiratory and digestive systems. There appeared to be more chronic diseases among the FAs than among the controls. The FAs had over three times more mental disorders than the controls.

The interviewed FAs had significantly more psychological distress, somatization and hypochondriacal beliefs than the controls. The risk of frequent attendance was higher in the older family life cycle phases than in the younger family life cycle phases. Multivariate analyses showed chronic somatic disease and hypochondriacal beliefs to be risk factors for frequent attendance. Concurrence of somatization and hypochondriacal beliefs increased the risk to be a FA.

As a conclusion, the results emphasize the need to consider the FAs’ own bodily concerns expressed as hypochondriacal beliefs when managing them. Furthermore, the study implicates a need to integrate the biomedical, psychological and social dimensions in the care of FAs in primary health care.

Dedication

Non satis scire

To my family

Table of Contents

Acknowledgements

Abbreviations

List of original publications

1. Introduction

2. Review of the literature

2.1. Use of health care services

2.1.1. Theoretical aspects of use of health care services
2.1.2. Use of health care services in Finland

2.2. Frequent attenders

2.2.1. Definition
2.2.2. Prevalence of frequent attendance
2.2.3. Frequent attenders’ use of health services
2.2.4. Frequent attenders’ use of health services -related factors
2.2.5. Reasons for encounter
2.2.6. Chronic diseases of frequent attenders
2.2.7. Psychological factors related to frequent attendance
2.2.8. Social factors relating to frequent attendance
2.2.9. Family factors relating to frequent attendance

2.3. Summary of the literature

3. Objectives of the study

4. Subjects and methods

4.1. Health centre of Oulainen

4.2. Criteria for a frequent attender

4.3. Study population

4.4. Study design

4.5. Variables

4.5.1. Variables collected from medical records
4.5.2. Variables collected from annual statistics
4.5.3. Variables measured with the postal questionnaire
4.5.4. Variables measured in the personal interview and with the interview questionnaire

4.6. Statistical analyses

4.7. Approval by Ethical Committee

5.1. Prevalence and sociodemographic characteristics of frequent attenders (Paper I)

5.1.1. Prevalence of frequent attendance and use of health care services in the health centre
5.1.2. Age distribution
5.1.3. Sociodemographic background

5.2. Self-rated health and health-related quality of life

5.3. Frequent attenders’ main reasons for encounter (Paper I)

5.4. Chronic diseases of frequent attenders (Paper I)

5.5. Psychiatric symptoms and disorders assessed by the Cornell Medical Index health questionnaire (CMI)

5.6. Psychological distress, alexithymia and hypochondriacal beliefs among frequent attenders (Papers II, III)

5.6.1. Psychological distress
5.6.2. Alexithymia among frequent attenders
5.6.3. Hypochondriacal beliefs among frequent attenders

5.7. Somatization among frequent attenders (Paper III, IV)

5.8. Family-related factors and frequent attendance (Paper IV)

5.8.1. Family size and structure
5.8.2. Family life cycle
5.8.3. Marital satisfaction of frequent attenders

5.9. Results of multivariate analyses (Papers II, III, IV)

5.9.1. Factors associating with frequent attendance
5.9.2. Factors associating with frequent attenders’ somatization

6. Discussion

6.1. Subjects and methods

6.1.1. Study population
6.1.2. Design
6.1.3. Methods

6.2. Results

6.2.1. Prevalence and sociodemographic characteristics of frequent attenders (Paper I)
6.2.2. Self-rated health and health-related quality of life
6.2.3. Main reasons for encounter by frequent attenders (Paper I)
6.2.4. Chronic diseases of frequent attenders (Paper I)
6.2.5. Psychiatric symptoms and disorders assessed by the Cornell Medical Index health questionnaire (CMI)
6.2.6. Psychological distress, alexithymia, hypochondriacal beliefs and somatization among frequent attenders ( Papers II, III)
6.2.7. Family-related factors and frequent attendance (Paper IV)
6.2.8. Results of multivariate analyses
6.2.9. Gender differences among frequent attenders

6.3. Strengths and limitations of the study

7. Conclusions

8. Implications

9.1. Study population and study design
9.2. Methods
9.3. Results
9.4. Conclusions

1. Hill’s classification of the phases of family life cycle (Hill 1970)

List of Tables
1. Synonyms for frequent attender.
2. Review of the previous studies of frequent attenders. Study populations, definitions of FA, key questions and main results.
3. Health-related quality of life among frequent attenders and controls by gender. Nottingham Health Profile (NHP) dimensions (means (SD)).
4. Psychiatric symptoms and disorders as assessed by the Cornell Medical Index (CMI) questionnaire among frequent attenders and controls by gender. Values are numbers (percentages).
5. Alexithymia (TAS-20 total score, TAS-20 factors), hypochondriacal beliefs (Whiteley Index) and psychological distress (SCL-36 and SCL-36 factors) among frequent attenders and controls by gender (means (SD)).
6. Proportions of psychologically distressed, somatizing, alexithymic and hypochondriacal patients among frequent attenders and controls by gender.
7. Association of various psychosocial and health factors with frequent attendance. Frequent attendance as the dependent variable and psychosocial factors as covariates one by one, adjusted for age and sex. The odds ratios (OR) and 95% conficence intervals (CI) are from logistic regression analyses, without and after adjusting for chronic somatic disease (method: Enter).
8. Association of various psychosocial and health factors with somatization among frequent attenders. Dichotomized somatization variable as the dependent variable and psychosocial and health factors as covariates one by one, adjusted for age and sex. The odds ratios (OR) and 95% conficence intervals (CI) are from logistic regression analyses (method: Enter).

List of Figures
1. Reasons for encounter with GPs classified by the International Classification of Primary Care (ICPC) chapter codes (%). Sorted by frequent attenders’ reasons for encounter. Symbols: *** = Difference between the study groups highly significant (P < 0.001). P-values by McNemar’s tests for matched pairs.
2. The proportions of the eleven most frequently diagnosed chronic diseases according to the International Classification of Diseases 9^th Revision (ICD-9) diagnostic categories among frequent attenders and controls (%). Sorted by the proportions of chronic diseases among frequent attenders. Symbols: *** = Difference between the study groups highly significant (P < 0.001). P-values by McNemar’s tests for matched pairs.
3. Boxplots of hypochondriacal beliefs (Whiteley Index sum score, WI) among frequent attenders and controls by gender. The horizontal line in the middle of the box is the median value of WI and the lower (upper) boundary indicates the 25^th (75^th) percentile. The boxplot also displays outliers; cases with values more than 1.5 box length from the upper (lower) edge of the box are designated with a circle. The highest and lowest observed values that are not outliers are also shown. Lines have been drawn from the ends of the boxes to those values. The difference between male frequent attenders and controls is significant (P < 0.001). The difference between male and female frequent attenders is significant (P < 0.001). P-values by Mann-Whitney U tests.
4. Boxplots of hypochondriacal beliefs (Whiteley Index sum score, WI) among somatizing and non-somatizing frequent attenders (FA) by gender. The horizontal line in the middle of the box is the median value of WI and the lower (upper) boundary indicates the 25^th (75^th) percentile. The boxplot also displays outliers; cases with values more than 1.5 box length from the upper (lower) edge of the box are designated with a circle. The largest and smallest observed values that are not outliers are also shown. Lines have been drawn from the ends of the box to those values. The difference between somatizing and nonsomatizing male FAs is significant (P = 0.011) and that between the respective female groups is also significant (P = 0.001). The difference between somatizing male and female FAs is significant (P = 0.006). P-values by Mann-Whitney U tests.
5. Boxplots of Marital Communication Inventory (MCI) sum scores among somatizing and non-somatizing frequent attenders by gender. The horizontal line in the middle of the box is the median value of MCI and the lower (upper) boundary indicates the 25^th (75^th) percentile. The boxplot also displays outliers and extreme values; cases with values more than 1.5 (3.0) box length from the upper (lower) edge of the box are designated with a circle (asterix), respectively. The highest and lowest observed values that are not outliers are also shown. Lines have been drawn from the ends of the box to those values. The difference between somatizing female and male FAs is significant (P = 0.027). P-value by Mann-Whitney U tests.
6. Numbers of frequent attenders and controls at the various family life cycle phases. P-values by chi-square tests.

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