الفهرس 
LITERATURE REVIEWOnly 14 pages are availabe for public view
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Abstract
At a Primary Care level, it has been observed that a small number of patients is responsible for a high percentage of the GP working time, defined as “frequent attenders”. Frequent attenders (FA) in primary care is of particular concern as it may reflect unmet patient needs, can lead to “heartsink” in health care providers and places a significant burden on health resources. FAs are responsible for a great number of prescriptions and referrals to other levels of medical care. These patients therefore impact a significant economic, human and social burden on society. It is estimated that more than 50% of frequent attenders present a physical disorder and that about 33% present a combination of physical, mental and social problems. The threshold for FA (number of visits or percentage with highest attendance rates) and the time range varies considerably between studies, leading to wide variations in rates. The reasons that motivate an individual to frequently attend a Health Centre may be related to individual, morbid and sociodemographic factors and also with the Health system itself. “Frequent attender” characterization has become a major concern, as it will enable GPs to optimize healthcare and management of consulting time allocation. Also it will allow policy makers to plan interventions to reduce costs and improve the quality of care provided to such group of patients.
This study aims:
1. To determine the frequency of annual general practice consultations and the extent of the frequent attendance phenomenon in HIO comprehensive clinics in Alexandria.
2. To identify variables associated with frequent attendance.
3. To compare the pattern of use of health insurance services among frequent and infrequent attenders.
The study was conducted at the six Health Insurance Organization comprehensive clinics at Alexandria (Louran, Gleem, Alexandria, Noukrashy, Mina Elbasal and Elnasr Elshamla). The study included two designs; the cross-sectional design to determine the prevalence of FAs in which the sample consisted of the electronic database of GP visits of the selected HIO clinics during 2013; the case-control design to determine predictors of FAs in which the sample consisted of 120 cases (FAs ≥ 20 GP visits during 2014) and 120 controls (IFAs ≤ 5 GP visits during 2014) and allocated proportionally among six study clinics based on total number of beneficiaries affiliated to each district.
As regards data collection, data was collected using;
Record reviewing was used for reviewing GP visits of one calendar year (2013) from the computerized database; to identify the proportion of frequent attenders to the selected clinics during 2013.
Booklet reviewing using a sheet for abstracting the following data of HIO services utilization during 2014 from the patient’s booklet; number and dates of all GP, specialist and consultant visits, reason of last GP visit, number and diagnoses of chronic diseases that the patient has, number and types of medications refill, number and types of laboratory tests and radiological investigations, number and reasons of emergency room (ER) visits, number of home visits, and number of visits and days for sickness leave. In addition, abstracting data of number, reason and length of stay of HIO hospital admissions during the last 5 years (from 2010 to 2014).
Charlson comorbidity index CCI was calculated using patients’ diagnoses abstracted from patients’ booklets by matching these diagnoses with the ICD-10 codes of each of the 19 chronic conditions of the charlson Index.
Patient interviewing which includes eight main sections. The first section includes structured interview schedule for assessing sociodemograhic, physical and mental health characteristics, treatment compliance, and social support among FAs and IFAs. The second section is the Self-administered Comorbidity Questionnaire (SAQ) including 15 chronic conditions for assessing patients’ comorbidity. The third section is The Illness Attitude Scales (IAS) includes 27 questions for assessing patients’ illness behavior and health anxiety. The fourth section is the 7-item Paerlin- Schooler mastery Scale for assessing patients’ health mastery. The fifth section is the Life Event Questionnaire (LEQ) including 27 questions for assessing patients’ negative life events during the last 12 months. The sixth section is the Patient Health Questionnaire (PHQ) for assessing diagnosis of depression, panic and generalized anxiety disorder encountered among FAs and IFAs. The seventh section is the Short Form Health Survey (SF-12) for assessing patients’ perceived health status. The eighth section and the last section is The General Practice Assessment Questionnaire (GPAQ) includes 8 communication questions aiming to assess satisfaction of patients with GP visits and one question for assessing overall satisfaction with care provided at HIO clinics.
Statistical analysis of data was done using SPSS version 20 and suitable statistical methods were used. All statistical analyses were performed using 5% level of significance. The following tests of significance were used: independent sample t-test, Mann-Whitney U test, chi-square and multiple logestic regression analysis.
The study reveals the following findings:
A. The extent of the frequent attendance phenomenon in HIO comprehensive clinics in Alexandria
A very high GP attendance rate in Louran HIO clinic (54.7%); a total number of 36,587 patients made 133,868 GP visits during 2013.
The prevalence of frequent attenders (FAs) in the present study was 0.5% of patients who were responsible for 3.3% of the total number of visits; in other words 190 FAs made 4,425 visits during 2013.
During 2013, the top 10% of attenders to GP made about 33% of GP visits and the top 3% of attenders made about 14% of GP visits.
The phenomenon of frequent attendance was found in HIO comprehensive clinic in Egypt as in most other countries.
B. Pattern of utilization of HIO services among FAs and IFAs
A very high pattern of utilization of all HIO services by FAs.
For FAs, attendance rate was higher for GP than specialist and consultant, whereas for IFAs, it was higher for specialist than GP.
FAs made five times the laboratory visits of IFAs and four times the radiological visits of IFAs.
FAs had significantly higher number of hospital admissions and longer length of stay during the past 5 years.
FAs had more visits for sick leave and took more days of sick leaves during 2014.
FAs made more medication refill visits and they needed medication refill for nearly 5 times the types of drugs that IFAs needed prescription refill for them.
C. Assessment of comorbidity among FAs
The six most common chronic diseases among FAs in the present study were osteoarthritis, hypertension, DM, diabetic peripheral neuritis, COPD and chronic gastritis.
FAs had significantly higher charlson comorbidity index and self-administered comorbidity questionnaire scores than IFAs.
Medication refill was the most common cause of the last GP visit and for the current GP visit by FAs.
D. Characteristics of FAs in HIO clinics
The majority of FAs were elderly, 60 years or above (83.3%) and they included more widowed/divorced, more early-retired and more disability pensioners.
FAs had significantly poor structural and functional social support.
FAs having an already diagnosed psychiatric disease were significantly more than those of IFAs.
FAs had high satisfaction scores with GP visits and highly satisfied with the services provided at health insurance clinics.
Approximately 32% of FAs had major depression disorder (MDD), and 9.2% of FAs had severe depression, while 11.7% of FAs suffered from panic disorder and 15% of FAs had generalized anxiety disorder.
FAs had low perceived health status as shown by SF-12 scores.
FAs had a significantly high number of negative life events during the past 12 months and the two most common negative life events were long term or severe physical illness (yourself) and financial worries.
FAs had low health locus of control and more somatization tendency and maladaptive illness behavior.
After adjusting for confounders by multiple logestic regression analysis, patients with comorbidity, polypharmacy, high illness attitude (health anxiety/ somatoform disorder and illness behavior) and poor social support (being alone against their will) were at high risk of being FAs to GP in HIO comprehensive clinics.
Based on the study findings, the following recommendations were suggested:
1. Improving accuracy of Health Insurance database and accuracy of data entry to the electronic databases of HIO clinic in order to allow annual determination of attendance rates and identification of frequent attenders in HIO clinics and their costs, also to allow international comparison of their prevalence and workload between different systems and across time.
2. Development of electronic system that makes it more feasible for HIO to annually detect and monitor attendance rate and also to label extreme FAs in the computerized database by a flag to deal with them individually.
3. Emphasizing the Importance of accurate and complete physicians’ registration in patient’s booklet.
4. Targeting, adequate detection and management of the predictors of FAs for better quality of life of these patients and reducing their attendance rates, workload and costs.
5. Improving management of chronic diseases in Health Insurance clinics.
6. Making files by HIO medical committee for chronic patients who need drug refill for more than 3 types of prescriptions to allow those patients to receive their drugs at once in only one GP visit.
7. Promote the role of the GP in detection and treatment of some underlying psychological problems as undetected somatization tendency or inappropriate illness behavior.
8. Promote the role of the GP in recognizing the social factors associated with frequent attendance, and in initiation and stimulation of relevant care from, for example, the social authorities.