A framework for understanding visits by frequent attenders in family practice

OBJECTIVE Our purpose was to develop a typology of outpatient Visits betwee n family physicians and adult "frequent attender" patients. STUDY DESIGN This was a cross-sectional observational study using qualitati ve analysis of family physician Visits. Three family physician researchers reviewed detailed field notes for each patient based on direct observation of a single office Visit to determine major themes and characteristics of p hysician-patient encounters. POPULATION Non-pregnant adults in the top 5% for visit frequency, and age- and sex-matched non-frequent attenders were identified from among 1194 adul t patients in 18 Midwestern family practice offices as part of The Preventi on and Competing Demands in Primary Care Study. RESULTS Visits by 62 patients who had made at least 25 visits in the previo us 2 years were selected (frequent attender visits). Three major dimensions emerged to distinguish different encounter types: (1) biomedical complexit y, (2) psychosocial complexity, and (3) the degree of dissonance between th e patient and the physician. These 3 dimensions were used in a descriptive framework to characterize visit types as: simple medical, ritual visit, com plicated medical, die tango, simple frustration, psychosocial disconnect, m edical disharmony, and the heartsink visit. CONCLUSIONS The discovery of a wide variation of encounter types among adul t frequent attenders and the resulting descriptive framework laid a foundat ion for defining the appropriateness of outpatient health care utilization, for designing interventions to reduce inappropriate utilization, and for e ducating physicians regarding effective management of frequent-attender pat ients.