A New Approach to Frequent Attenders

Naomi Stanton, Adarsh Shetty & Paul Davies


Cwm Taf University Health Board


AIM:

Patients who attend the GP repeatedly (Frequent Attenders) place a significant and disproportionate burden on GP services. We aim to audit factors associated with persistent Frequent Attendance, before designing and piloting a multidisciplinary approach incorporating cognitive behavioural therapy and community assets to improve management within a primary care setting.


CONTEXT:

Frequent Attender (FA) describes a patient who presents to healthcare services repeatedly, and more often than the general population. Chronic physical illness, especially hypertension, musculoskeletal pain and gastrointestinal upset is correlated with frequent attendance. Psychological morbidity (depression, anxiety and somatisation) is strongly associated. Social factors - being elderly, female, having lower education and socioeconomic background and having a high body mass index (BMI) are all associated.


A recent feasibility study of CBT in primary care targeting FAs concluded that joint working between a GP and therapist could create greater capacity in primary care (halving consultation rates at one year with no increase in secondary care consultations) and support GPs in managing FAs. Patient satisfaction was good.


PLANNING & DEVELOPMENT:

A literature review was conducted of:

  1. Factors associated with FAs;

  2. Interventions to improve quality of life outcomes. An audit within a pilot practice of factors associated with FA was conducted including co-morbidities, reasons for presentation, repeat medications used, etc and compared to the literature. A multidisciplinary intervention to devise a novel approach to managing FAs involving CBT and linking into community assets via a community care co-ordinator is currently in development.


RESULTS:

During audit, 101 adults were defined as FAs: Number of consultations: The median number was 17. The overall range was 15-34 over one year.

  • Ages: The median age was 63 years. The overall range was 19-94 years old;

  • Gender: 64 (63%) of the study sample were female;

  • BMI: The median BMI was 29.9. The overall range was 18.8-51.6;

  • Co-morbidities and medications: 58 (57%) of patients had a past medical history of psychiatric conditions including depression and anxiety or were under secondary care with psychiatric conditions. The mean number of medications per patient was 6. The most common repeat medications were Proton Pump Inhibitors (PPIs), antidepressants/anxiolytics (excluding benzodiazipines) and analgesics including opioids.


There was a mean of 3 co-morbidities per patient (the most common co-morbidities were depression/ anxiety, then hypertension arthritis/chronic pain and asthma/COPD).


There was a familial component, with family members exhibiting similar presentation patterns. There was also an association with high use of services such as the GP Out of Hours service and the Accident & Emergency departments.


NEXT STEPS:

Patients have been identified and will be invited shortly. The intervention is currently being refined.



Acknowledgment: Medical student Bradley Dawes, who assisted with data collection of audit and literature search


FIT WITH PRUDENT HEALTH:

  • The British Journal of General Practice (BJGP) study estimates that if the reduction in service use demonstrated in its study was replicated and maintained, engaging only a small proportion of long-term FAs would lead to cost-effective capacity generation within primary care;

  • The intervention aims to improve quality of life, rationalise medication use and use community assets and social prescribing as an alternative to the current pattern of contact / support.



Part of cohort Bevan Exemplar Projects 2016-17