Frequent attenders in general practice care: A literature ... - Public Health

Public Health (2005) 119, 118–137

Frequent attenders in general practice care: A literature review with special reference to methodological considerations P. Vedsted*, M.B. Christensen The Research Unit and Department of General Practice, University of Aarhus, Vennelyst Boulevard 6, DK-8000 Aarhus C, Denmark Received 31 July 2003; received in revised form 4 March 2004; accepted 26 March 2004 Available online 13 July 2004

KEYWORDS Denmark; Family practice; Frequent attenders; Systematic review

Summary Objective. To describe the basis on which our knowledge of frequent attendance in general practice rests and to propose recommendations for further research on frequent attenders (FAs). Design. The literature review (finished February 2004) encompassed peer-reviewed articles in English describing contacts with general practice in terms of frequency. Searches were performed in the Medline, CINAHL, EMBASE, PsycINFO, Social Sciences Expanded Index and ISI Citation databases with additional searches in reference lists and the ‘related articles’ function in the ISI Citation database and Medline. Setting. General practice. Subjects. Sixty-one articles (54 studies). Measures. The articles were assessed according to the following design variables: setting; definition of FAs; sampling; sample size; control groups; study aim; study design; data sources; effect measure; and main results. Results. There was no generally accepted definition of frequent attendance. Research designs differed substantially. Eight articles gave sufficient information on all design variables. The top 10% of attenders accounted for 30 –50% of all contacts, and up to 40% of FAs were still FAs the following year. More than 50% of FAs had a physical disease, more than 50% of FAs suffered from psychological distress, social factors (low social support, unemployment, divorce) were associated with frequent attendance in more than 50% of FAs, multiproblems (physical, psychological and social) were found in one-third of FAs, and frequent attendance was associated with increasing age and female gender. Conclusion. The diversity of designs, definitions and methods in the current literature on FAs in general practice hampers comparison of their precision, validity and generalizability, and calls for cautious interpretation and adoption of a common, generally acceptable definition in future studies. Q 2004 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.

Introduction *Corresponding author. Tel.: þ45-8942-6010; fax: þ 45-86124788. E-mail address: [email protected]

Frequent attenders (FAs) account for a relatively large proportion of contacts with general

0033-3506/$ - see front matter Q 2004 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2004.03.007

Frequent attenders in general practice care

practitioners (GPs) and a large number of referrals and prescriptions. Their levels of physical, psychological and social morbidity are high. Much of the GPs’ work therefore relates to FA; a situation that has spurred interest and research in FAs in general practice. However, controversy exists regarding whether current knowledge of frequent attendance has reached a level that satisfies the clinical imperatives of general practice. Valid clinical inference based on research articles requires access to sufficient information to assess the precision, validity and generalizability of research results.1,2 The shortcomings of current research in this respect were reviewed first (unsystematically) by Schrire in 19863 and then systematically by Gill and Sharpe in 1999.4 Both reviews argued that methodological differences frustrate attempts to establish a common experiential ground within this field. However, this did not bar them from drawing specific conclusions on the basis of studies conducted in quite different settings. The methodological issues brought to light by these first reviews were explicitly addressed by Neal et al. who confirmed that FA research was fraught with methodological problems5 and called for further research into fundamental FA questions.6 However, none of these articles provided recommendations for conducting research or reviewing the research of others. The purpose of this article is to systematically review the literature on FAs in general practice in order to identify articles with pre-defined, welldescribed design variables and to try to synthesize the knowledge derived from these studies. A second aim is to propose recommendations for FA studies in general practice.

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Searches were performed with MeSH keywords and index words (text search). Firstly, a core search strategy was defined to find articles on general practice or family medicine. We searched in all subheadings and texts for combinations of the words ‘frequen*’, ‘high*’, ‘attend*’, utiliz*’, utilis*’ and ‘consult*’. This search was then constrained by the terms ‘family-practice’, ‘family-medicine’, ‘general-practice’, ‘general-medical’, ‘generalmedicine’, ‘primary-care’ and ‘primary-health’ in order to relate the study setting to general/family practice. The searches were limited to publications in English. The process of selection and discarding of articles is shown in Fig. 1. A total of 144 articles were initially selected by the authors. Of these, 51 articles were excluded as they did not deal with the subject. Thirty-two articles were excluded during assessment as they did not meet the inclusion criteria: two because the definitions of FAs were based on the thickness of the patients’ records;7,8 seven because they did not report a definition of FAs;9 – 15 four because they did not present original data (reviews);4,16 – 18 three because they sampled FAs from sub-populations (women who scored high on the General Health Questionnaire (GHQ), patients presenting with fatigue, children with psychiatric disorders);19 – 21 and 16 because the settings were not exclusively general practice and/or the contacts counted included visits to specialists, outpatient

Methods Search strategy A search in Issue 1 of the 2004 Edition of the Cochrane Library (December 2003 updates) did not identify any literature reviews of frequent attendance in general practice. A subsequent search was performed in the following databases: Medline (PubMed) 1966 to January 2004; CINAHL 1982 to January 2004; EMBASE 1974 to January 2004; PsycINFO 1967 to January 2004 and Social Sciences Index Expanded 1973 to January 2004 through the ISI Citation databases. The ‘related articles’ facility in the PubMed and the ISI Citation databases was used to expand the search.

Figure 1 Tree diagram of the selection and discarding of articles in the review.

120 visits, hospital admissions, etc.22 – 36 A fine qualitative study from the USA37 was excluded as there was no definition of the contacts counted. Following the assessment, 61 articles fulfilled the inclusion criteria: † the article presented original data in a peerreviewed journal; † the setting was general/family practice; † patients were recruited from this setting; † the number of contacts with general practice were the measure of frequency; and † an explicit, reproducible definition of FAs was made.

P. Vedsted, M.B. Christensen

of the most FAs (Table 1). Nine of these studies defined FAs as the 10% of patients with most frequent contacts. Forty-four (72%) articles used an integer threshold ranging from two to 24 contacts. The period during which contacts were counted ranged from 2 to 48 months with 45 (74%) articles using 12 months.

Counting contacts

The reference lists of included articles were scrutinized to identify non-indexed articles and articles from before the period covered by the reference databases.

Nearly all articles (60 (98%)) included surgery consultations, 16 (26%) counted telephone contacts and 27 (44%) counted home visits. Twenty-two (36%) articles had criteria for excluding contacts (Table 1), most often antenatal check-ups and administrative contacts. Problems in defining the types of contacts counted were seen in 14 (23%) articles. In 37 (61%) articles, there were problems defining the time of day during which contacts were counted.

Assessment

Sampling of FAs and control attenders

The 61 articles included in this study were assessed according to the following design variables: setting; FA definition; sampling; sample size; control groups; study aim; design; data sources; included aspects (physical, psychological, social, demographic, need, attendance) and main results.

A total of 61 articles representing 54 different studies were included in this study (Table 1). Of these, 33 articles came from the UK, five from North America and 14 from Scandinavia. Forty-seven (77%) of the articles were published after 1990.

Thirty (49%) of the articles sampled FAs from attenders and 23 (38%) from listed/registered patients (Table 2). Forty (66%) of the articles applied some type of restriction, most commonly age. Twenty-three (38%) articles included all ages, two (3%) only included children and two (3%) only included elderly patients. The lower age limit for defining adults ranged from 12 to 20 years. Nine (53%) of the studies based on a sample stated that their sample was drawn at random. In 10 (16%) articles sampled, FAs were stratified according to age and/or gender. Forty-seven (77%) of the articles used control groups. Fourteen (23%) articles matched controls with FAs according to age and gender. A total of 24 (39%) articles used either stratified sampling, frequency matching or individual matching.

Setting

Number of FAs and control attenders

The articles presented studies with participation of one to 132 practices, each with between two and 220 GPs (Table 1). Forty-two (69%) articles reported on one or two practices, 25 (41%) included less than 10 GPs, eight (13%) did not give information on the number of practices, and 26 (43%) did not state the number of GPs included. One article49 reported how many GPs were invited and how many refused to participate.

The number of FAs varied from 14 to 45 122. Twelve (20%) articles included less than 50 FAs and 11 (18%) articles included more than 500 FAs (Table 2). The studies using control groups included 14 –431 832 controls.

Results Included articles

Definition of FAs Sixteen (26%) articles defined frequent attendance in proportional terms as a percentage (range 3 – 25%)

Study designs Articles were assessed and grouped according to study design. Four articles reported a trial,45,51,58,86 one reported a qualitative study,55 48 (79%) were cross-sectional and nine (15%) were cohort studies (Table 3). None of the articles reported data appropriate to classify them specifically


121

Table 1 Publication year of the 61 articles included in this study, the number of general practitioners and practices, the definition of FAs and the included and excluded contacts. Publication year and country

GPs/practices

Threshold

Included contacts

Excluded contacts

Time

Initiation

2003, UK38 2003, Scandinavia39

14/2 7/1

$11 in 12 months 10% in 12 months

C, H C

Contacts with nurses Contacts concerning maternity or child welfare

D, O? D

P, G P, G?

2003, UK40

6/1

C, T, H

D, O?

P, G

2003, UK41 2002, UK42 2002, UK43

?/? 3/1 ?/2

.Upper quartile in 24 months $10 in 12 months $13 in 12 months 3% in 12 months

C, H C C, T, H?

D, O? D, O? D, O?

P P, G P, G

2002, Scandinavia44

220/132

10% in 12 months

C, H

D

P, G

2002, Israel45 2001, Scandinavia46

?/1 28/?

$2 in 3 months 10% in 12 months

C C, H

D, O? D

P, G? P

2001, UK47

?/6

$5 in 12 months

C, T?, H?

D, O?

P, G

2001, UK48 2001, Slovenia49

8/1 36/36

C C, T?, H?

D, O? D, O?

P, G? P, G

2001, UK50

3 (6)/1

C, H?

D, O?

P, G

2001, Netherlands51 2001, Scandinavia52 2001, Scandinavia53

?/10 6/1 ?/?

$10 in 12 months Upper quartile ($8) in 12 months $8 in year 1975 for any single diagnosis $15 in 3 years $8 in 12 months 10% in 12 months

C, T, H C, T?, H? C, T, H

D, O? D, O? D, O

P P, G P, G

2000, UK54

20/3

3% in 41 months

C, H

D, ?

P, G

2000, UK55

?/3

C

D, ?

P, G

2000, UK56

?/60

C, H

D

P, G

C, T, H C C, T?, H? C, T, H C

D, O? D D, O? O D

P, G P, G P, G P, G P, G

D, O D, D, D, D, D D, D,

P, G? P, G P, G P, G P P, G? P, G P, G P, G?

2000, 2000, 2000, 1999, 1999,

UK, Spain57 UK58 Canada59 Scandinavia60 Spain61

8/2 4/1 ?/? ?/? 5/1

Top 150 attenders in practice $12 (7 þ minor illness?) in 12 months .Mean x 2 in 12 months $11 in 12 months $6 in 12 months 10% in 12 months .Mean þ 1 SD in 12 months

1999, 1999, 1998, 1998, 1998, 1998, 1998, 1997, 1997,

Scandinavia62 Scandinavia63 UK64 UK65 Spain66 Scandinavia67 UK68 Canada69 Scandinavia70

6/1 ?/? 3/1 24/4 ?/9 6/1 ?/1 ?/? 12/2

$8 in 12 months 10% in 12 months $12/6/4 in 12 months 3% in 41 months 10% in 15 months $8 in 12 months 10% in 12 months $6 in 12 months $11 in 12 months

C, T?, H? C, T, H C, H C, H C C, T?, H? C C, T, H C

1996, Netherlands71

?/7

$12 in 36 months

C

1996, UK72 1995, Scandinavia73

?/1 4/1

$6 in 12 months $5 in 12 months

C, T?, H? C

1995, Scandinavia74

12/2

$11 in 12 months

C

1995, Scandinavia75

12/2

$11 in 12 months

C

NB: Included contacts with nurses and other staff Telephone and administrative contacts Telephone, maternity and administrative contacts NB: Included contacts with nurses

Routine examinations Telephone contacts in daytime, administrative contacts Contacts with practice nurse

Emergency room, prenatal care

Surgery consultations

Administrative and check-ups Contacts for compelling somatic reasons Child health care, pregnancy Administrative and check-ups Administrative and check-ups

O? O O? O? O? O O?

D

P, G

D, O? D

P P, G

D, O?

P, G?

D, O?

P, G?

(continued on next page)

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Table 1 (continued) Publication year and country

GPs/practices

Threshold

Included contacts

1994, Australia76 1994, Scandinavia77

?/3 12/2

$7 in 6 months $11 in 12 months

C, H C

1993, UK78 1993, Slovenia79 1993, UK80 1992, UK81 1991, UK82 1990, UK83

?/1 8/1 ?/2 ?/? 3/1 ?/1

$12 in 12 months 25% in 12 months $4 in 12 months $24 in 36 months $2 in 12 months $6 in 12 months

C, H C, H C, T, H C, T, H C, H C, T?, H?

1989, UK84

?/2

$6 in 12 months

C, T?

1989, USA85

2/1

$4 in 2 months

T

1988, UK86

4/1

C, T, H

1988, UK87

?/2

.National mean x 2 in 12 months $6 in 12 months

C, T?

1986, UK88 1986, UK89 1985, UK90 1982, USA91 1982, Canada92 1974, UK93 1974, UK94 1974, UK95 1969, UK96 1966, Israel97 1954, UK98

?/1 ?/1 2/1 ?/1 4/1 2/1 4/1 6/1 2/1 2/1 2/1

$20 in 12 months $7 in 12 months 10% in 48 months $5 in 6 months $9 in 12 months 25% in 12 months $12 in 12 months $4 in 3 months $4 in 3 months $10 in 12 months $10 (20) in 12 months

C, T?, H? C C C C, T, H C, T, H C, H C C, T, H C, H C, T, H

Excluded contacts

Administrative and check-ups

Pregnancy, lifethreatening illness Family planning, administrative All non-patientinitiated calls

Family planning, administrative

All scheduled

Pregnancy Pregnancy

Time

Initiation

D, O? D, O?

P, G P, G?

D, D, D, D, O D,

P, G P, G P, G P, G P, G? P, G

O O? O? O? O?

D, O?

P, G

D, O

P

D, O

P

D, O?

P, G

D, D, D, D, D, D, D D D, D, D,

P, G? P, G? P, G P P, G P, G P, G P, G P, G P, G P, G

O? O? O? O? O O

O O? O

C, surgery consultations; T, telephone consultations; H, home visits; D, daytime; O, out of hours; P, patient initiated; G, GP initiated; ?, no exact information.

as case-control studies, although the titles or abstracts of some studies suggested that that they were case-control studies.52,62,66,67,82

Data sources and response rates Forty-one articles (67%) reported data from the patients’ records as a data source (Table 3). Thirty-two (52%) articles reported data from patient questionnaires, 23 (38%) from patient interviews and 15 (25%) used registers. In the 40 articles using interviews and/or questionnaires, 28 (70%) reported a response rate for FAs and/or controls.

Types of included variables Forty-five (74%) articles included physical variables, 39 (64%) included psychological variables, 33 (54%) included social variables, 39 (64%) included demographic variables, seven (11%) included need, and 17 (28%) included attendance. Twenty-seven (44%) articles included a combination of three aspects: physical, psychological and social variables.

The results Eight (14%) articles contained sufficient information on the assessed design variables,58,61,64,73,92,93,96,98 but a synthesis of the results was not possible because of the differences between the studies. These eight studies each drew all their patients from one practice. They used eight different thresholds for defining FAs and included a total of 1856 FAs with a minimum of 52 in one study. One study was a trial, one was a cohort study, two were cross-sectional studies with a cohort part and four studies were cross-sectional. Five studies were controlled. One article only examined adult FAs. The results of these eight articles were as follows. Attendance The proportion of contacts accounted for by FAs went from 2% using 15% of all contacts,73 5% using 21%,92 14% using 64%,96 16% using 52%,98 to 26% using 61%93 of all contacts. Among new (incident) FAs, one-third were also FAs the following year,64 and among those FAs who did not die or move,


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Table 2 Study base, sampling procedure, number of included frequent attenders (FAs) and controls, and response rates. Ref. Study base (n)

Sampling from study base

Number of FAs/controls

Control sampling/ matching

Response FAs/controls

38

Consecutive attenders in a week All FAs, divided into age and sex groups Fas who were responders to two surveys All FAs

53/87

Overall 49.5% nr

150/1,321

Other consecutive attenders/no All other listed individuals/no Other responders/? (matching in survey) Other responders/no

All FAs

107/107

All FAs, divided into sex and 10-year age bands All FAs, divided into sex and age groups Unknown, restriction as to mental and chronic illness Patients consulting 1 day in September 1990 One individual per household. NB: parents over-represented due to sampling of children Families where two or more members were FAs All FAs

?/0

Sample from other ‘patients’/age, sex nr

1500/0

nr

70.5%/nr

22/19

Randomization/no

?/?

48/137

Other patients/no

630/1913

Other sampled individuals/no

Overall 84% Overall 74%

17 (7 fam.)/?

‘Office of Health Economics’/no Non-FAs/no

39 40 41 42 43 44 45 46 47

Attenders, $66 years old (?) Listed patients (10 431) Listed patients, $18 years (8000) Two interviewed cohorts (,2000) Listed patients (5342) Attenders, 15 –75 years old (10 650) Attenders, 20 –64 years old (?) Attenders, 21 –65 years old (?) Attenders, 18 –56 years old (?) Listed households, individuals #80 years old

48

Listed patients (,12 000)

49

Consecutive adult ($18 years) attenders (60 per practice) (2160) Listed patients (7216)

50

51 52 53

Listed patients, 20–45 years (10 161) Inhabitants, $15 years (8400) Listed patients $20 years (416 172)

54 55

Listed patients (61 055?) Top 150 adult attenders in three practices (450)

56

Interviewed inhabitants (83%) (283 842) Attenders (35 500) Attenders (7200)

57 58 59 60 61 62 63

Inhabitants $12 years (?) Inhabitants $18 years (450 000) Attenders $14 years (24 000) Listed patients $16 years (6542) Attenders $18 years (101 321)

341/1025 194/544

?/?

Overall 47% Overall ,74% nr nr

? Overall 83.8%

58/58

Less than three contacts in 1975/age, sex, diagnosis

nr

81/80

Randomization

86%/84%

112/106

76%/74%

34 428/381 744

Less than eight visits/ age, sex Other listed patients/no

nr

1176/? 28/0

Other listed patients/no nr

nr 43%/ nr

13 271 (11 291)/ 270 553 (27 253) 127/175 52/52

Other inhabitants/no

?/?

Other attenders/age, sex ?/? FAs (randomized?)/no nr

3095/14 531 45 122/431 832

Other attenders/no Other attenders/no

89%/89% nr

Random (2018)

236/420

83%/82%

All FAs

304/304

All FAs, age and gender stratified

9623/91 698

Other attenders/age, sex (?, see abstract) Other listed patients/ age, sex Other attenders/no

All FAs who had been continuously registered with the practice from 1975 to 1995 (58 of 486) Fas with five or more somatizing symptoms (362) All FAs All FAs in daytime and out-of-hours, stratified for age, gender and attendance All FAs Regular FAs; one consultation in every 90-day period. Burst/gap FAs; 90-day period with 10 consultations and one with none All FAs (restriction as to minor illnesses) All FAs, age and sex stratified Sample from two random months (194) Random (17 626) All FAs

76(Q)/76(I)/ 74(Q)/71(I) nr


124


Table 2 (continued) Ref. Study base (n)




64 65

All FAs All FAs, time restriction

168/0 1369/42 777

nr nr Other attenders/no (continued on nrnext page)

Practice size stratified sample

102/100

Attenders with one contact/no

93%/81%

All FAs

304/304

76%/74%

In survey a 1:4 sample

95 (9)/919 (80)

Other listed patients/ age, sex Other listed patients/no

All FAs

8903(?)/36 747(?) Other inhabitants/no

42%(?)/ 42%(?) 77%/77%

Random (1000), restriction as to appointment

67/0

nr

70%/ nr

All FAs, disease restriction

80/0

nr

79%/ nr

All FAs

14/14

100%/ 100%

All FAs

179/179

Random (1000), restriction on appointment

96/466

Patients who attended on the GP’s request/ age, sex Other attenders (one to four contacts)/age, sex Other attenders/no

?/?

Random (1000), restriction on appointment

96/466

Other attenders/no

?/?

All FAs Random (1000), restriction on appointment

562/6637 96/466

Other attenders/no Other attenders/no

nr ?/?

All FAs

132/102

65%/50%

Random (623), age stratified Random (177/194)

188/320 109/23

All FAs, gender restriction

306/1585

Other attenders/age, sex Other attenders/no Non-attenders (zero contacts)/no Average attenders/no

All FAs

40/40

Sample?

90/194

Sample, gender restriction

127/215

All FAs Consecutive FAs, gender restriction

21/20 9/8

66

67 68 69 70

71

72

73

74

75

76 77

78 79 80 81

82 83 84

85 86

Attenders (6000) Listed patients (44 146) in 41 months Attenders aged 18–80 years (12 911) Listed patients $ 16 years (6642) Listed patients $ 65 years (1014) Population $16 years (46 010) Attenders with an appointment because of a complaint, age 18– 64 years (28 000) Attenders aged 20–44 years (2659) with back, neck or abdominal complaints with no serious somatic problem or psychiatric disorder (460) Attenders who the GP considered to worry excessively (?) Attenders (10 500)

Attenders with an appointment because of a complaint, aged 18–64 years (28 000) Attenders with an appointment because of a complaint, aged 18–64 years (28 000) Attenders (?) Attenders with an appointment because of a complaint, aged 18–64 years (28 000) Attenders aged 20–64 years (12 400) Listed patients (12 494) Listed patients 7–12 years (19 000) Male attenders aged 40–59 years who had an initial heart study examination (7735) Listed patients ,10 years (694) Listed patients, age 20–45 years (?) Listed non-pregnant females without severe or chronic disease, age 20–45 years (?) Attenders (?) Female patients with at least one child #7 years old


nr

nr 79%/85% 78%/78%

Other listed patients/ age, sex Infrequent attenders (one or no contacts)/no Infrequent (one contact) or non-attenders/no

?/?

Other attenders/no Randomization

nr 83%

83%/78% 73%/69%


125

Table 2 (continued) Ref. Study base (n)





87

Sample, gender restriction

117/213

Low (one contact) or non-attenders/no

73%/69%

All FAs, age stratified

40/40

?/?

All FAs, time restriction

78–92/0

Attenders with up to three contacts/age, sex nr

Sample, age and sex stratified

109/86

Other attenders/ age, sex

80%/69%

All FAs, time restriction

22/12

Other attenders/no

55%/100%

Random, stratified for attendance (600)

200/400

71%/44%

nr

88

89

90

91 92

Listed non-pregnant females without severe or chronic disease, age 20–45 years (?) Attenders (?)

Listed patients who had been on the practice list for at least 3 years (698) Listed patients $20 years, registered before 1975, complete records (4000) Attenders during 18 months aged 18 –65 years (715) Listed patients (9313)

nr

Sample, age and sex stratified All FAs, some kind of age restriction

98/284 33/0

nr

?/?

95

Listed patients (families) (3400) Adult (age?) attenders who the GP felt were FAs (11 400) Attenders aged 25–40 years (?)

Infrequent attenders (up to two contacts)/ no Other attenders/no

All FAs

23/23

68%/84%

96 97 98

Attenders (2468) Attenders (1175) Attenders (3084)

All FAs All FAs All FAs

430/0 169/0 493 (123)/0

Infrequent attenders (one contact)/age, sex nr nr nr

93 94

nr ?/nr nr

nr, not relevant; Q, questionnaire; I, interview; ?, no exact information.

44% remained FAs over the next 2 years.96 GPinitiated contacts amounted to 13%.93 Physical conditions An association was observed between the number of chronic diseases and frequent attendance (adjusted OR ¼ 1:8 (95%CI: 1.3 – 2.5)),61 and at least one major physical diagnosis was held by 43% of the FAs compared with 14% of other attenders.93 FAs had an average of 4.7 problems compared with 2.2 problems for controls.73 The studies differed regarding which physical diseases were most prevalent. One study reported back pain/arthritis (78%), headache/migraine (60%), poor circulation (42%) and bronchitis/asthma (28%) to be dominant diseases;61 another pointed to musculoskeletal (67%), respiratory (45%) and digestive (34%) disorders,73 supported by a third study that singled out musculoskeletal (14%) and respiratory (12%) disorders as particularly frequent disorders.92 A fourth study reported respiratory disorders (23%), infective disorders (11%) and, among women, pregnancy disorders (18%) as frequent disorders.96

Psychological conditions Mental health problems as measured by the GHQ-28 was shown to have the strongest association with frequent attendance (adjusted OR ¼ 3:1 (95%CI: 2.4 – 3.9)) with a prevalence of 57%.61 According to the GPs’ coding, 59% of FAs had an ICPC psychological problem/diagnosis compared with 18% of controls,73 and 27% had at least one major psychological diagnosis entered into his/her record compared with 4% of controls.93 Ten percent of FAs had emotional complaints,92 and 13% were registered as having a mental disorder.96 Multiproblem A combination of musculoskeletal, psychological and social problems was evident in 37% of the FAs but only in 4% of the controls.73 Social conditions Familiar dysfunction (adjusted OR ¼ 1:6 (95%CI: 1.2 – 2.0)) and the number of people in the household (adjusted OR ¼ 0:5 (95%CI: 0.3 –0.9)) were associated with frequent attendance.61 The proportion of FAs was highest among single people and decreased with family size.93 FAs were significantly

126

Table 3 The stated aim, assessed design, data sources and main findings of the 61 articles included in this study. Ref.

Study aim

Design

Data sources

Aspects

Main findings

38

Establish the characteristics of older primary care FAs

Cohort crosssectional

Interview questionnaire computerized records

Psychological distress among older primary care attenders is associated with frequent attendance. NB: uses odds ratio as a measure of relative risk.

39

Compare FAs in different sex and age groups with the population according to characteristics and use of general practice

Cross-sectional

Computerized records

Physical psychological social demographic attendance Physical psychological medication certificates

40

Investigate the extent to which previous general practice use and self-assessed health status were predictors of general practice use Examine whether associations between frequent attendance and socio-economic factors remain significant after adjusting for health and social support Not stated

Historical cohort

Questionnaires computerized records

Physical psychological demographic attendance

Cross-sectional

Interview

Physical psychological demographic social

Cross-sectional


Develop a practical age and sex stratification for the definition of FAs Examine the extent to which FAs would accept and GPs recommend a special FA status consultation

Cross-sectional


Physical psychological demographic clinical explicability Attendance

Cross-sectional

Questionnaires registers

Physical psychological social

45

Examine the effect of a guided disclosure protocol of past traumas on symptoms and clinic visits

Trial

Questionnaire

Physical psychological attendance

46

Analyse how SCL-8 and Whiteley7 predicted frequent attendance Report the variables associated with higher than average attendance in a large sample of patients

Cohort

Questionnaire register

Cross-sectional

Questionnaire

Physical psychological social attendance Physical psychological social demographic

41

42

43

44

No measures of socio-economic circumstances or social support remained associated with frequent attendance when adjusted for the ill health in poorer and less well-supported groups. NB: included two cohorts 43 and 63 years old, respectively. Pooled both cohorts in the analyses. More than half of FAs had no clinically explicable reason for seeing the GP. They had high levels of kinship and received more psychiatric medications and referrals. Each sex should be considered separately. The top 3% of male patients should be stratified into two age bands (, 46 and $ 46 years) and one age band for females. 80% of FAs would accept the status consultation. This was associated with the FAs having functional symptoms. The GPs recommended the consultation to 25% of the FAs, which was associated with the FAs having social problems and functional symptoms. Compared with control FAs, intervention FAs reported lower symptom levels at 3-month follow-up. They also made half as many clinic visits at 3- and 15-month follow-ups. NB: setting may not be completely comparable with a general practice setting. Psychological distress as measured by SCL-8 and Whiteley-7 predicted frequent attendance. Attendance was strongly associated with number of medical problems and severity of physical ill health.


47

Male and female FAs represented 2.9% and 3.7% of the population. FAs accounted for 20% of referrals, 25% of visits to GPs and prescriptions and 44% of certificates of illness. Antibiotics and drugs from the neurological musculoskeletal and respiratory ATC groups were more often prescribed for FAs. More FAs had a chronic disease. Frequency of general practice use is a stronger predictor of future frequency than self-assessed health status.

Ref.

Study aim

Design

Data sources

Aspects

Main findings

48

Quantify the number of contacts with primary, secondary, community and social services of frequent attending families; examine the temporal patterns of these contacts and determine the nature of the contacts Determine the predictors of frequent attendance in general practice

Cross-sectional

Questionnaire record register

Attendance reason for encounter

Cross-sectional

Questionnaire

Physical psychological social demographic satisfaction

50

Not stated

Historical cohort

Record

Attendance physical psychological

51

Test whether a disclosure intervention improves subjective health and reduces medical consumption and sick leave in somatizing FAs in general practice Investigate the association of somatization with frequent attendance in primary health care Analyse the association between daytime attendance and out-of-hours frequent attendance

Trial

Questionnaire interview

Attendance physical psychological social

Individuals made more contacts with all health services than predicted, and less than half of these were with the GPs. 32% of contacts with staff were not reported on the patients’ diary sheets. Patterns of consulting were apparent within the families. Patients who make high use of GPs also have a large number of contacts with other health and social services. NB: sampled FAs and their families, control data not clearly defined. Well-being and age were inversely associated with frequent attendance. Patient satisfaction, quality of life, anxiety, depression and presence of chronic disease were significantly associated with frequent attendance. GP seniority, use of appointment system and distance to nearest GP were positively associated with frequent attendance. FAs are more likely to be elderly and female. Frequent attendance is of short duration for most FAs. The persistent FAs had more chronic diseases than low attenders. NB: the results were a little difficult to present. Disclosure of somatization to the FAs had no effect on healthcare use and health.

Cross-sectional

Register records questionnaire interview

Physical psychological social demographic

Cross-sectional

Register

Attendance

Determine whether FAs consult more often with some doctors, how many doctors FAs consult with and whether FAs exhibit greater continuity of care

Cross-sectional

Register

Attendance

49

52

53

54


Table 3 (continued)

One-third of FAs were somatizers but the significant association with frequent attendance disappeared when adjusting for age, gender and chronic physical illness. NB: presented as a casecontrol study. Strong association between daytime and out-of-hours frequent attendance. Daytime FAs accounted for one-third of all contacts in daytime and one-third of all contacts out-of-hours. 10% of daytime FAs accounted for 42% of all out-of-hours FAs. Considerable variation in number and proportion of consultations with FAs between individual GPs. FAs consulted with most or all GPs in a practice. FAs exhibited more continuity of care than other attenders. (continued on next page)

127

Qualitative

Interview


56

Determine the effect of a range of socio-economic features on frequent attendance

Cross-sectional

Interview

Physical Demographic Social

57

Assess whether frequent attendance is more likely to be associated with depressive symptoms than with physical health problems

Cross-sectional

Record questionnaire


58

Investigate the impact on the consultation rate of providing a detailed and accessible summary of patients’ problems including physical, social and psychological data Assess the extent to which socioeconomic barriers exist in the use of physician services

Trial

Record

Attendance

Cross-sectional

Interview

Social Demographic Need

60

Analyse the effect of a re-organization of the out-of-hours service on Fas

Ecological

Register

Demographic attendance

61

Determine whether psychosocial factors are associated with high use and which factor possesses the strongest association? Calculate the association between frequent attendance and alexithymia, hypochondriasis and psychological distress and test the difference between genders

Cross-sectional

Record Interview

Physical Psychological Social Demographic

Cross-sectional

Record questionnaire interview


Describe the use of out-of-hours service and attendance prognosis for Fas

Cohort

Register

Demographic attendance

59

62

63

Reasons for consulting were complex. A two-part model was proposed: (1) the individual decision (perception of GP’s role, past experience, comparison with others, relation with the GP, fears, lay consulting, individual reasons and type of symptom consulting for); and (2) determinants of consulting pattern (medical reasons, experience with consultations, GP accessibility and periods of non-consulting). Men were less likely to be FAs. Divorced/widowed, low social class and unemployment was associated with FAs. NB: the study used two definitions of FAs: 12 þ and 6 þ consultations/year. Results were very similar using either definition. FAs had an OR of 27 (12– 57) to be depressive according to BDI. FAs rated their health as poorer, 39% of FAs had respiratory problems compared with 27% of non-FAs. Logistic regression showed that depressive symptoms were the major predictor of frequent attendance, but also self-reported ill health and respiratory problems were associated with frequent attendance. The intervention was a summary of the FA’s record including physical, social and psychological data given to the GP. There was no effect on consultation rate. NB: the sampling was very special and its precise effect cannot be evaluated.

FAs made up 23% of all attenders. Frequent attendance was associated with increasing age (only men), poor health status, four or more health problems and age under 12 years (only girls). Those with lower income were more likely to be FAs. A re-organization of the out-of-hours service produced a significant decrease in attendance and costs especially with respect to adult FAs. Mental health was the main factor associated with frequent attendance. Frequent attendance was also associated with perceived illness, chronic illnesses and family dysfunction. NB: defines both frequent attendance and high use. The FAs comprised 4.7% of the population and accounted for 23.5% of all visits. 68% were women. FAs had more hypochondriac attitudes, were more psychologically distressed, and somatization was more common compared with controls. Male FAs scored significantly lower on the SCL-36 scale (somatization, depression and anxiety subscales) than controls (the differences were non-significant for females). FAs made 42% of all out-of-hours contacts, 33% of FAs were also FAs the following year, 7% remained FAs for all 5 years. Age over 50 years but not sex predicted future frequent attendance


Determine why FAs consult in the patterns they do

128

55

Ref.

Study aim

Design

Data sources

Aspects

Main findings

64

Determine the prevalence and outcome of FA behaviour in relation to total practice workload

Cohort

Register

Attendance

65

Examine the consultation rates in four practices. Calculate the proportion of workload generated by Fas Assess the impact of exposure to chronic physical illness, mental disorder, life stress and sociodemographic factors on frequent attendance

Cross-sectional

Register

Demographic

Frequent attendance tends to persist through a 5-year follow-up. FAs account for a large part of the increase in workload. NB: definition of FAs was difficult to comprehend; 12 surgery consultations or six daytime home visits or four out-of-hours home visits in one calendar year excluding clinic consultations. The 1% most frequent attenders accounted for 6% of all consultations and the 3% most frequent for 15%. Females and older people were more likely to be FAs.

Cross-sectional (case-control?)

Records interview


67

Describe the proportion of FAs and the sociodemographic characteristics, morbidity and reasons for encounter

Cross-sectional

Record register questionnaire

Physical psychological social demographic attendance

68

Examine the significance of psychological health in determining frequency of attendance

Cross-sectional


Psychological

69

Examine the association between socio-economic status, need for medical care and visits to hysician Study FAs multidimensionally and group these patients in a clinically useful way

Cross-sectional

Questionnaire interview

Physical social demographic need

Cross-sectional qualitative



Examine the relation between somatization and socio-economic status, depression, anxiety and agoraphobia, consultation rate and GP’s diagnosis of psychic, social and vague somatic problems

Cross-sectional

Register questionnaire interview


66

70

71

FAs were older, less educated, more often widowed/divorced, more often housewives, pensioners and disabled than controls. No difference in social support. Multivariate analysis showed that chronic physical illness, mental disorder, exposure to mediumhigh life stress and age were associated with frequent attendance. The FAs comprised 4.7% of the population (6.8% of attenders) and accounted for 23.5% of all visits, and 68% were women. FAs had lower education, less vocational training and were more often on disability pension than controls. FAs had significantly more mental disorders and diseases of the musculoskeletal and digestive systems than controls. FAs accounted for 33% of all contacts. No difference on GHQ score and overall use of psychotropic drugs among FAs compared with non-FAs. FAs used significantly more antidepressants. The study suggested that psychiatric/psychological morbidity is not a major factor in frequent attendance among older people. Frequent attendance was significantly associated with need (number of health problems), perceived health, low income and low educational level.


Table 3 (continued)

FAs were placed in five groups: (1) physical (28%); (2) psychiatric (21%); (3) crisis (11%); (4) chronically somatizing (21%); and (5) multiproblem (19%). The groups differed in age, sex, SCL score, education and life satisfaction. The prevalence of somatization among the FAs was 45% (threshold of five complaints). A relation with age was not found. NB: the sampling of FAs was complex, making the interpretation of the results difficult.


129

Cross-sectional


Psychological demographic

79% of FAs were possibly or probably anxious and 29% depressive on the HAD scale compared with 7% and 0% of non-FAs. FAs used less normalizing attributes and FAs more often accepted a somatic reason for a common sensation.

Cross-sectional

Record register


Cross-sectional


75

Investigate whether psychiatric morbidity among FAs differs from that of other patients

Cross-sectional


Physical psychological social demographic demand Physical psychological demand

76

Examine the stability of attendance patterns

Cohort

Record (Register)

Physical social demographic

77

Investigate FAs by comparing them with other patients

Cross-sectional



78

Define and identify frequent attenders and characterize their attributes and use of services

Cross-sectional



79

Find differences between frequent and infrequent attenders Determine the frequency and nature of psychiatric disorders among child FAs

Cross-sectional

Record

Physical demographic

Cross-sectional


Physical psychological demographic

Determine whether high consulters were in need of more effective health promotion and illness prevention Identify reasons why some children receive more out-of-hours visits than most others

Cross-sectional

Record register questionnaire

Physical

1.7% of the population were FAs and used 15% of the contacts. More women than men were FAs. More female FAs than controls were divorced. Two-thirds of FAs had psychological, social or musculoskeletal problems. FAs had a significantly higher SCL-25 score than controls. The GPs rated the FAs to be more psychiatrically distressed than controls (57% of FAs). No difference in demand for psychiatric help. FAs had a significantly higher SCL-25 score than controls. The GPs rated the FAs to be more psychiatrically distressed than controls. Depression and anxiety were the most common clinical entities. No difference in demand for psychiatric help. 22% of the initial FAs were also FAs in the second period. 66% of high-to-high were women. High-to-high had more chronic diseases (inclusive mental) than controls. FAs tended to have lower vocational training level and to live alone. Significantly more often FAs received disability pension and significantly more often had somatic diagnoses than controls. Frequent attendance was not associated with age, sex or basic education. 86% of FAs were female vs 52% of the practice population. FAs were referred, received prescriptions and consulted five times as often as controls. 94% of FAs vs 39% of controls had a chronic health problem. 52% of FAs vs 29% of controls were depressed according to GHQ-28. FAs had significantly more diagnoses of cancer, mental, endocrine, respiratory, skin and gastrointestinal diseases than controls. 21% of listed patients were FAs and used 51% of all contacts in the age group. 29% of FAs had a psychiatric disorder compared with 9% of controls. 31% of mentally disordered and 3% of nondisordered FAs had seen a psychiatrist. 4% were FAs and accounted for 22% of all consultations. FAs had more cardiorespiratory diseases (50% vs 27%) and risk factors (less healthy lifestyle, 61% vs 47%) than controls.

Cross-sectional

Record interview

Physical social

73

74

80

81

82

6% of children were FAs and used 74% of contacts. Mothers of FAs were more often divorced, received income support and had a lower educational level than controls.


Test whether FAs were more likely to make somatic attributions and less likely to make normalizing. Whether FAs had greater difficulty in finding reasons why attribution might be wrong Describe sociodemographic data, attendance patterns and characteristics of FAs’ problems Measure the level of distress among Fas

130

72

Ref.

Study aim

Design

Data sources

Aspects

Main findings

83

Explore the variables associated with consultation and help-seeking behaviour for minor illnesses

Cross-sectional



84

Elucidate the relationship between distress, expressed beliefs about autonomy and the frequency of consulting Test whether patients who often call the physician are different from those who only occasionally call

Cross-sectional



FAs had a significantly higher GHQ score than controls. FAs had more somatic diseases than controls. 32% of female FAs had a psychiatric diagnosis compared with 11% of male FAs. No association with social problems. Younger females with somatic symptoms and minor psychiatric disorder were most likely to be FAs. FAs had higher scores on the ’powerful others’ health locus of control scale and greater psychological distress than controls.

Cross-sectional

Register

Physical demographic need

See whether attendance rate and requests for medical support changed after attending a discussion group on children’s behavioural problems Identify factors associated with attendance rate and identify subjects for a prospective study Interested in the type and number of symptoms, recent life experiences and coping with symptoms and troubles among Fas

Trial

Record (?)

Attendance

Cross-sectional



Cross-sectional cohort

Record interview


Cohort

Record

Attendance

Cross-sectional

Record interview questionnaire


85

86

87

88

89

90

Test whether individuals’ attendance patterns have no stability over time Compare a range of social, medical and psychological characteristics of FAs with controls

6% of patients were FAs and accounted for 21.2% of all calls. FAs had more chronic diseases than controls. The calls from FAs had a higher rate of psychological content. No difference in the GP assessed necessity of the calls. NB: the mean age of the controls was remarkably low (14.7 compared with 31.2 for the FAs). The use of general practice fell significantly in the intervention group during the first 6 months after the intervention. NB: the mothers’ and their children’s attendance rates were summed.


Table 3 (continued)

FAs had more illness during the past 12 months, higher GHQ scores, more psychiatric diagnosis and were prescribed more psychotropic drugs than controls. FAs did not have significantly more social problems than controls. FAs took more medicine of all types than controls. FAs reported significantly more symptoms and sought significantly more often help (59% vs18% of symptoms) than controls. FAs reported significantly more often days with negative mood than controls. FAs and non-FAs had similar life events, but FAs coped less well with them. 10% of practice population was non-attenders in all 3 years. The individual patients were likely to have the same number of visits the next year. NB: the paper defines FAs in the result section. FAs scored significantly higher on Eysenck personality questionnaire and on the GHQ than controls. 60 –65% of FAs had positive GHQ or former psychiatric distress (15 –27% for controls). 44 –51% of FAs had bad physical health (9 –10% for controls). FAs were significantly more often divorced/separated than controls. (continued on next page)

131

Test whether FAs report higher anxiety levels, less control of healthcare issues, fewer social supports and a higher number of life events Explore prevalence and characteristics of FAs

Cross-sectional



FAs were older and less educated than controls. FAs rated the seriousness of their illness higher.

Cross-sectional



93

Identify FAs and study them


Record


94

Not explicitly stated

Cross-sectional


Physical social demographic

95

Identify differences between FAs and non-FAs regarding attitudes and reasons for consulting Identify Fas and ex amine differences in the results of treating FAs with psychiatric vs other reasons for consulting Not explicitly stated

Cross-sectional


Psychological

4.5% of listed patients were FAs and accounted for 21% of all contacts. FAs rated their health significantly lower than controls, although 83% of FAs rated it as good. FAs had significantly lower self-esteem, reported higher degree of emotional distress and took more medicine than controls. FAs had poorer social function, lower income and were more often unemployed than controls. 26% of listed patients were FAs and accounted for 61% of all contacts. 43% of FAs had more serious somatic diseases and 27% had more serious psychiatric diseases than the controls (14% and 4% in controls). NB: sampled families instead of individuals. A small biased trial was conducted but is not reported here. Unemployment, loneliness and housing problems were more often found among FAs than among controls. NB: selection of FAs was not clearly defined. FAs scored significantly higher on GHQ than controls. FAs were probably more likely to adapt the ‘sick role’ than controls.


Record


Cross-sectional

?

Physical demographic

Cross-sectional

Record

Demographic Need

92

96

97

98

Describe some quantitative aspects of the doctor’s job

132

91

13.9% of listed males were FAs and accounted for 64% of all contacts. 21% of listed females were FAs and used 69% of all contacts. Frequent attendance was mainly due to respiratory disorders, psychoneurotic disorders or pregnancy. 14.4% of listed population (10.5% of males and 18.7% of females) were FAs and accounted for 48.8% of all contacts. FAs were more likely to be female and elderly than controls. 16% of listed individuals were FAs and accounted for 52% of all contacts. FAs were more likely to be female and elderly than controls. NB: this study did not explicitly use terms like frequent attenders, etc.


FAs, Frequent attenders; GHQ, General health questionnaire; BDI, Beck Depression Inventory; HAD, Hospital Anxiety and Depression scale; SCL, Symptom Check List.


more often unemployed (39% vs 27%) and single (22% vs 15%) than controls.92 Among female FAs, 25% were divorced, compared with 9% of controls.73 In total, 66% of FAs had a social problem, compared with 25% of controls.73 Demographic conditions Women accounted for 54 –75% of all FAs.61,64,73,93,98 However, gender was not a predictor of persistent FA status.64 Age was also associated with FA status. Hence, one study showed that most FAs (65%) were 25 – 64 years old,73 whereas another study found that 29% of all FAs were aged 65 years or older.98

Discussion This systematic review identified 61 articles presenting 54 studies with FAs in a general practice setting. Research designs differed substantially, and only eight articles gave sufficient information on a pre-defined number of design variables to allow evaluation of the precision, validity and generalizability of their results. The FA research performed to date in this field has given insufficient attention to the implications of definitions and sampling, and most high-quality studies have only included a small number of FAs and GPs. Thus, this review not only justifies further research, but sets out some criteria for approaching such research. In general, the studies showed that the top 10% of attenders accounted for 30 – 50% of all contacts, that up to 50% of the FAs had a physical disease, that over half of the FAs had some kind of psychological distress, that social factors were associated with frequent attendance, and that multiproblems could be found in one-third of the FAs.

Recommendations We found no generally accepted definition of frequent attendance in general practice. This review allows us to propose recommendations for future studies. Tables 4 and 5 can act as a starting point in reaching an agreed definition of what design variables should be included in future research and as checklists for reviewing FA articles. The adoption of a common, transparent and operational definition of FAs will help general practice profit from the results of future research on FAs (Table 4). The definition must include an exact description of the contacts counted, the period of counting, the threshold used and the denominator (population, listed patients or

133

Table 4 Important elements in the definition of frequent attenders. Contacts counted

A comprehensive description must be offered to distinguish between daytime and out-of-hours contacts, between face-to-face contacts (surgery, home visits) and telephone contacts, between patient- and GP-initiated contacts and to establish whether any contacts have been excluded (administrative consultations, preventive consultations e.g. child immunization, antenatal care, etc.). Time counting The period for counting the contacts has to be known. Threshold Three types can be used; proportional (%, percentile), absolute ðnÞ and parametric (mean SD). The proportional threshold makes comparisons between different periods, practices, regions and countries meaningful. The absolute and parametric thresholds will depend on differences in organizational, cultural and health service set-ups. Denominator To be considered together with the threshold. The threshold can be applied among attenders or all listed patients/inhabitants (including zero users).

attenders). It may not be possible to have the same definition in many different healthcare systems. However, it should be possible to define restrictions and to describe the setting and population so that precision, validity and generalizability can be evaluated. Finally, the design problems in extant research fall into multiple categories (Table 5) and should be duly considered in future studies. In particular, the control groups were sampled very differently. Some attenders were only one contact from becoming FAs. The growing body of epidemiological, methodological knowledge about research design may also provide answers to issues raised by some researchers, e.g. which control groups should be used.5,6

Strengths and weaknesses of this review The present review was more comprehensive and less burdened by selection bias than previous reviews.3,4 A strength of the present study lies in its focus on general practice settings. We used explicit inclusion and exclusion criteria to ensure a homogenous setting and the ability to generalize from the results.1 This focus was not maintained in the systematic review of the topic by Gill and Sharpe4 published in 1999. We therefore, excluded 16 of their 34 articles. The inclusion of articles as the only source of research data and the exclusion

134

Table 5 General methodological considerations raised by this review. Setting

The setting should be well defined, uniform and restricted to general/family practice to increase generalizability Sampling The populations studied should be defined with study base size of GPs, practices and patients. The sampling procedure (e.g. probability, random, stratified, clusters) must be stated. Design The actual design (experimental, cohort, cross-sectional, case-control cohort) must be stated. The design must refer to the research question, sampling, use of controls, data collection and analysis. Controls The different designs (e.g. case-control, intervention) should determine how to include controls from the study base. The denominator should be defined (zero users). Data sources The data sources should be well described and their validity should be evaluated. Precision Based on e.g. sample-size calculations of an appropriate number of practices/GPs/patients should be included. Stratified sampling, enlarging samples and matching can increase the statistical precision. These strategies should be included in selected analyses. Bias The use of bias control (e.g. randomization, restriction, matching, stratification) should be included in the design if necessary. Potential biases should be stated, especially those emerging from response rates, possible confounders and data collection. Analysis How the analyses connect to the aim, design and bias of the study should be stated. Due to the risk of confounding in this research area, multivariate statistical procedures should be preferred in addition to other analyses.

of literature in languages other than English may, however, imply that relevant publications may have been missed. The strictness of the criteria used to assess the articles could, however, have introduced information bias and reduced precision. It is indeed possible that the studies were in fact appropriately designed, but the authors did not include the information about design. The results of the present study must be interpreted with a high level of caution as most of the articles reviewed here included FAs from only one or two practices, which involves a concomitant risk of biased and clustered sampling.1,2 Moreover, random sampling was sparse, and even if a few articles resorted to stratified sampling, matching and restriction, which can increase the statistical precision and provide confounder control,1,99 any statistical analysis of the results must be thorough and meticulous, particularly as most articles analysed all FAs as one group although they had


obtained an age- and gender-stratified sample. It follows that some of the articles reported analyses that did not perfectly match the stated research design in the article. Most articles used patients’ records for data collection, even if the validity of written consultation data has been questioned,100 as is also the case with patients’ self-reported attendance.101 This review also proves that the concept of frequent attendance is guided by occasional definitions based on statistical information and medical data on patients rather than on data on the GPs, the healthcare system and its organization, and sociological literature.

Acknowledgements This study received financial support from The Municipal VAT Fund, The Insurance and Pension Research Fund and The Danish National Research Foundation for Primary Care. We thank Professor Henrik Toft Sørensen and Dr Per Fink and Professor Frede Olesen for their help and contribution.

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