Our study targeted patients aged > 60 years who attended community health service centers in Shanghai between August and December 2018. Our study enrolled 285 men and 334 men, with a mean age of 73.02 ± 8.05 years. Of these patients, 155 (25%) were FAs to a community health service center and 537 (86.8%) visited community health service center for the first consultation. We identified 10 independent risk factors of frequent attendance, including widowed status, unmarried status, the presence of > 3 chronic diseases, first consultation at a community health service center, high medical expenses, frequent attendance of the spouses, long-term medication use, the use of both traditional Chinese and Western medicine services, and depression.
In our study, FAs were defined as those with at least four visits to a primary care clinic in a month as we found the average monthly visits of patients aged > 60 years to a community health service center in Shanghai, China to be < 2. The lowest number of visits in the top 10% of the population per year was 53, 52, and 44 in 2015, 2016, and 2017, respectively, with an average of 4.14 visits per month [18]. In fact, there is currently no consensus on the definition of an FA [23]. Smits et al. [16] suggested that the proportion of FAs should be calculated based on different subgroups of at least three age categories per sex and proposed the definition of top 3% or 10% of enlisted patients in each 1-year age–sex group. A study conducted by Pasgaard et al. in a Danish population defined FAs as those with the upper quartile of the total number of measured consultations with a general practitioner over a period of 148 weeks [24]. However, these definitions might be more suitable for a retrospective study. On the other hand, Hauswaldt et al. [17] reviewed the electronic records from 123 general practice centers in Germany in a 10-year period and defined the patients with an intercontact interval of < 7 days as FAs. Thus, patients with a frequency of ≥4 visits per month can be defined as FAs. This definition is more convenient for self-assessment by older patients while participating in cross-sectional surveys on medical consultation in China. In fact, a previous cross-sectional study by Buczak-Stec et al. quantified FAs as the number of self-reported visits to general practitioners in the preceding 3 months as they found that a number of visits equal to or greater than the 90th percentile of all consultations corresponded to individuals who had ≥6 general practitioner consultations in the past 3 months in Germany [25]. To our knowledge, few studies have been conducted on FAs in China. Our definition of an FA might be of practical value in clinical practice and provide a preliminary reference for relevant studies on the use of community outpatient services in the future.
By investigating 54,849 participants aged 50–65 years in a Danish adult population, Jørgensen et al. found that FAs consulted their general practitioners 12.0 times, on average, a year [2]. Buczak-Stec et al. reported that the number of visits greater than or equal the 90th percentile of all consultations corresponded to individuals who had ≥6 general practitioner consultations in the past 3 months in Germany [25], which averages to two visits per month. The definition of FA in our study (four visits per month) is much higher than that used in other countries. This difference might have resulted from the different healthcare contexts of different countries. China reviewed its medical and health policies in 2009 to provide equal basic medical and health services to all citizens [1]. In 2011, the family doctor contract program was introduced nationwide to encourage residents to prioritize the services provided by community health service centers when visiting a doctor. In 2015, the Chinese government issued guidelines for the establishment of a hierarchical medical service system [2]. Medical institutions at all levels (third level, second level, and primary) provide services in accordance with designated functions. With the advancement of the hierarchical diagnosis and treatment system, the majority of the older patients intend to choose community health service centers for the first visit and 80–90% of health problems will be solved in primary healthcare institutions. In addition, China is committed to establishing primary healthcare services located within a 20-min walking distance in each neighborhood. Its advantages such as convenient consultation services, user-friendly family doctor contracting services, and large medical reimbursement rates have led to an increase in the frequency of patient consultations. In contrast to other countries, China has a huge population base, and its current health reform is still in its preliminary stage. The service scope of community health service centers includes the diagnosis and treatment of common diseases, dispensing, referral, chronic disease management, rehabilitation, nursing, health education, physical examination, and other required community medical services. The number of visits reported in this study also includes visits for the abovementioned services. Therefore, the patterns of attendance at primary healthcare centers in China are much higher than those in other countries.
Growing evidence has demonstrated that need factors are the predominant determinants of frequent attendance [26, 27]. To explore the factors associated with frequent attendance in more detail, we allowed the patients to freely express themselves and provide some feedback at a suitable time during the interview. We classified and summarized the factors that influenced frequent attendance into the following aspects: poor control of chronic diseases, the convenience of community hospitals, good doctor–patient relationship, more attention to their own health, self-perceived poor health, use of the family doctor signing policy, low social support, the influence of other people’s medical behaviors, the onset of acute illness, difficulty in moving, and economic reasons. The results of the stepwise multiple logistic regression analysis performed in our study revealed that an increasing number of chronic diseases, long-term medication use, the use of both traditional Chinese and Western medicine services, and high medical expenses were significantly associated with frequent attendance of older patients aged > 60 years, which is partly consistent with the results of European studies [12, 13, 25]. An Australian study also reported that chronic health condition and medication use were associated with the FA status [28]. It is possible that more chronic diseases and an increasing need for medications drive patients to visit community health service centers more frequently in order to promote health. This indicates that people are prone to use health services more frequently when suggested by their health care providers.
In contrast to a previous study, we identified a new factor that was significantly associated with FAs. We found that patients who use both Chinese and Western medicine services are more inclined to be an FA. Traditional Chinese treatment such as acupuncture and massage can be used in conjunction with or as an alternative to Western medicine. These treatment strategies usually require professional skill and are beyond the ability of patients or their relatives. Therefore, patients who used both Chinese and Western medicine services showed a tendency to require frequent medical treatments. In addition, because FAs reportedly experience greater health anxiety than non-FAs [8], the use of both traditional Chinese and Western medicine services results from the greater health anxiety in FAs in addition to multimorbidity. Therefore, general practitioners in community health service centers should master the skills associated with traditional Chinese medicine to meet the therapeutic demands of older patients.
Frequent visits to clinics inevitably generate sizable healthcare expenses [29]. Smits et al. concluded that FAs cause exceedingly high costs in not only primary care but also specialist care [5]. Furthermore, a recent study using data from remote communities in Taiwan indicated that FAs are characterized by higher costs related to prescriptions, therapeutics, and first visit than non-FAs [30].
In addition to physical diseases, FAs are more likely to have psychiatric illnesses than the general population [31]. Depression is one of the most common mental disorders in patients who are frequent users of healthcare services [32]. There is evidence that depressive episodes are associated with frequent attendance at occupational health primary care [6]. Moreover, depression may be an important determinant of frequent attendance of older patients at healthcare centers [33]. Consistently, we found that in older patients in China, depression was an independent risk factor for frequent attendance at community health service centers. Furthermore, more depressive disorders, including dysthymia, anxiety, and somatoform disorders, have been reported in FAs than in non-FAs [8]. This suggests that general practitioners should pay more attention to older patients with concomitant depressive syndromes and provide timely and effective interventions. Cognitive behavioral therapy is able to relieve depression in FAs in primary care [34]. Further efforts are needed to develop more tailored and effective therapies against depression in FAs.
A previous study found that divorce is significantly associated with frequent attendance of FAs [23]. Conversely, another study revealed that the civil status was not associated with frequent attendance [33]. The present study identified three factors associated with the spouses of the FAs that influenced the frequent attendance of the older patients: widowed status, unmarried status, and frequent attendance of the spouses. We speculated that the high frequency of the attendance of widowed and unmarried patients might be associated with the mental and psychological state of living alone. The influence of spouses on FAs suggests that the FAs should be managed as a family unit for precise diagnosis and adequate treatment of these patients. These paradoxical results may be attributed to different definitions of FAs, limited sample size, and various analytical tools used in these studies. Further studies and more in-depth analyses are warranted to further decipher the relationships between the civil status and frequent attendance of older patients.
Our study has some limitations. This cross-sectional study explored the factors associated with frequent attendance but could not determine the presence of any causal relationship. Moreover, the sample size was small. Further thorough investigations on the FAs among older patients should be performed using a larger sample size in the future. In addition, general practitioners in community health service centers should pay close attention to the social, physical, and psychological needs of the FAs among older patients, thus developing more cost-effective health interventions for these patients.
