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Open Access Study protocol

Persistent frequent attenders in primary care: costs, reasons for attendance, organisation of care and potential for cognitive behavioural therapeutic intervention

Richard Morriss1*, Joe Kai2, Christopher Atha3, Anthony Avery2, Sara Bayes4, Matthew Franklin5, Tracey George4, Marilyn James6, Samuel Malins7, Ruth McDonald8, Shireen Patel9, Michelle Stubley4 and Min Yang10

Author Affiliations

1 Psychiatry and Community Mental Health, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom

2 Primary Care, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom

3 Research Cognitive Therapist, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom

4 CLAHRC NDL, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom

5 Division for Social Research in Medicines and Health, The School of Pharmacy, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom

6 Economics of Health and Social Policy, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom

7 Nottinghamshire Healthcare NHS Trust, 3 Oxford Street, Nottingham, United Kingdom

8 Professor of Healthcare Innovation and Learning, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom

9 University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom

10 Medical Statistics, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom

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BMC Family Practice 2012, 13:39  doi:10.1186/1471-2296-13-39

Published: 20 May 2012

Abstract

Background

The top 3% of frequent attendance in primary care is associated with 15% of all appointments in primary care, a fivefold increase in hospital expenditure, and more mental disorder and functional somatic symptoms compared to normal attendance. Although often temporary if these rates of attendance last more than two years, they may become persistent (persistent frequent or regular attendance). However, there is no long-term study of the economic impact or clinical characteristics of regular attendance in primary care. Cognitive behaviour formulation and treatment (CBT) for regular attendance as a motivated behaviour may offer an understanding of the development, maintenance and treatment of regular attendance in the context of their health problems, cognitive processes and social context.

Methods/design

A case control design will compare the clinical characteristics, patterns of health care use and economic costs over the last 10 years of 100 regular attenders (≥30 appointments with general practitioner [GP] over 2 years) with 100 normal attenders (6–22 appointments with GP over 2 years), from purposefully selected primary care practices with differing organisation of care and patient demographics. Qualitative interviews with regular attending patients and practice staff will explore patient barriers, drivers and experiences of consultation, and organisation of care by practices with its challenges. Cognitive behaviour formulation analysed thematically will explore the development, maintenance and therapeutic opportunities for management in regular attenders. The feasibility, acceptability and utility of CBT for regular attendance will be examined.

Discussion

The health care costs, clinical needs, patient motivation for consultation and organisation of care for persistent frequent or regular attendance in primary care will be explored to develop training and policies for service providers. CBT for regular attendance will be piloted with a view to developing this approach as part of a multifaceted intervention.

Keywords:
High utilisers of care; Primary care; Cognitive behavior therapy; Hypochondriasis; Somatoform disorders; Health care economics and organizations