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Psychosomatics 42:416-422, October 2001
© 2001 The Academy of Psychosomatic Medicine

Psychological Distress as a Predictor of Frequent Attendance in Family Practice

A Cohort Study

Peter Vedsted, M.D., Per Fink, M.D., Dr.Med.Sci., Ph.D., Frede Olesen, F.R.C.G.P., P.C.P., Dr.Med.Sci., and Povl Munk-Jørgensen, M.D., Dr.Med.Sci.

Received October 5, 2000; revised April 25, 2001; accepted May 16, 2001. From the Research Unit and Department of General Practice, University of Aarhus, Denmark; Research Unit for Functional Disorders, Aarhus University Hospital, Denmark; Institute for Basic Psychiatric Research, Department of Psychiatric Demography, Psychiatric Hospital in Aarhus, Denmark. Address correspondence to Dr. Vedsted, The Research Unit for General Practice, University of Aarhus, Vennelyst Boulevard 6, DK-8000 Aarhus C, Denmark. E-mail: pv{at}alm.au.dk


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
In cross-sectional studies, psychological distress has been associated with frequent health care utilization. However, there is a need for prospective studies to confirm these findings. This cohort study evaluated whether psychological distress predicted frequent attendance in family practice. In 1990, 185 consecutive adults who consulted their primary care physician (PCP) about an illness were rated on two psychometric scales (Hopkins Symptom Check List [SCL-8] and Whiteley-7), and their annual number of face-to-face contacts with a family practice was followed until 1996. Frequent attenders (FAs) were defined as the top 10%. A logistic regression analysis showed a significantly increased risk of becoming an FA with an increase of 1 point (odds ratio [OR] 1.17 [1.03–1.33]) on SCL and 1.28 (1.06–1.53) on Whiteley). An association was found between score and number of years as an FA (OR 1.16 [0.99–1.36] for SCL and OR 1.31 [1.05–1.65] for Whiteley). Psychological distress involved an increased risk of future frequent attendance among adult patients consulting family practice in the daytime about an illness.

Key Words: Family Practice • Health Services • Rating Scales

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The individual's response to symptoms depends on a variety of physical, psychological, and social factors. Psychological distress, for example, often prompts patients to use health services,1–13 and psychologically distressed patients account for a larger fraction (11%–79%) of frequent attenders (FAs) in family practice than other patients.14–23 Psychological distress may therefore be regarded as an important determinant of frequent attendance. However, the association between psychological distress and frequent attendance in family practice has not been studied sufficiently in prospective studies. Studies on FAs have been cross-sectional except for two23,24 which had retrospective designs, and in many of these studies methodological aspects of defining and sampling FAs have posed problems.25,26

Appropriate identification of psychological distress and frequent attendance in family practice may have implications for primary care physicians' (PCP's) clinical work. It may affect, for example, the doctor-patient relationship, workload and costs, outcome, and the ability to establish good quality care for the FA group in general2,4,20,24,27–36 and the group of somatizing FAs in particular.17,37

The aim of this study was to analyze how well two short psychologic self-rating scales (Hopkins Symptom Check List [SCL-8] and Whiteley-7) predicted frequent attendance in family practice (Figures 1 and 2). This was done in a prospective cohort study where patients were followed for 6 years after index contact.



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FIGURE 1. The Whiteley-7 Scale




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FIGURE 2. The Symptom Check List-8 Scale (SCL-8)



  METHODS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Study Population
Inclusion and assessment of psychological distress were studied in the Danish subsection of a Nordic multicenter study population.38,39 Patients who were seen by the 28 Aarhus County PCPs participating in the study during a single day in September 1990 were selected for the study. Native Danes (more than 95% of the population) age 18–65 consulting their PCP during the daytime about symptoms were included (consultations dealing with, e.g., driver's license and other certificates, pregnancy controls, and vaccinations were excluded). In all, 233 patients (67 men, 166 women) fulfilled the inclusion criteria. Thirty-eight (16%) did not wish to participate.

Psychological Rating
The patients completed a 25-item version of the SCL (Hopkins Symptom Check List) self-rating questionnaire in the PCP's waiting room prior to the consultation. All patients with a score of >=1.55 on the SCL-25, as well as a corresponding number of randomly selected patients with a score<1.55, were selected for a PSE-10 (Present State Examination) interview.40 These patients also completed the Whiteley-7 questionnaire immediately after the PSE interview. The SCL-8 includes the eight questions from the SCL-25 measuring depression and anxiety and has been validated in a Nordic setting.38 The Whiteley-7 index41–44 measures somatization (illness worrying and conviction). We used the 8-item version of the SCL because it is shorter and thus more appropriate in the clinical setting. The answers to each SCL-8 question were dichotomized (0 or 1). For each individual, total scores were calculated from both scales. In a primary care population, sensitivity and specificity for SCL-8 (cutoff point 1/ 2) have been shown to be 0.62 and 0.8138 and for Whiteley-7 (cutoff point 0/1) 0.71 and 0.62 (at least one DSM-IV somatoform disorder).41

Data
In Denmark, PCPs act as gatekeepers, and 98% of the inhabitants have free access to family practice care. For accounting reasons, the Public Health Insurance in Aarhus County receives information on all contacts with the PCPs. This highly reliable database allows contacts to be traced to the individual user via the personal identification number (civil registration number).45 We obtained data for all eligible patients for each of the 5 years 1992–1996. Contacts included all face-to-face surgery consultations and home visits in the daytime (8:00 AM to 4:00 PM, Monday to Friday). The year 1991 was excluded from the follow-up to minimize Hawthorne bias due to the questionnaires and interviews. Patients were not informed about the focus on frequent attendance. There was no disclosure of the rating results to the PCPs. The study was approved by the Danish Data Protection Agency and the Scientific Ethics Committee in the County of Aarhus.

Definition of FAs
FAs were defined as the 10% most frequent attenders (of either sex) within three age groups (18–34, 35–49, and 50–65) within a calendar year (12 months). Thresholds for inclusion as an FA were calculated on the basis of all individuals in the County of Aarhus (general population of 630,000) age 18–65 who had contacted a PCP. These thresholds were then applied to the study population. The thresholds in the three age strata were >=5, >=6, and >=8 face-to-face consultations for men and >=9, >=8, and >=9 face-to-face consultations for women. Age was calculated at the time of inclusion.

Analysis
Separate analyses were done for both psychological scales. All analyses were performed for men, for women, and for all patients. If a patient died or moved out of the county during the follow-up, he or she was excluded at the beginning of the calendar year. The starting time was set at January 1992. We estimated the association between score and risk of becoming an FA during the study period. Odds ratios (OR) were calculated using a logistic regression taking into account the correlation between recurrent events (generalized estimating equation, GEE). The appropriateness of a linear model was tested with the likelihood-ratio {chi}2statistics (LR-test). To account for residual confounding, we included age in the regression analyses. We also included the year of observation as an independent variable to adjust for the possible effect of time since psychological rating. The model was checked for additional interaction among the explanatory variables.

The association between score on the psychological scales and number of years as an FA was determined by an ordered logistic regression analysis. Only patients with full follow-up (1992–1996) were included in this analysis.46,47

Weighting the Whiteley Sample
The Whiteley-7 population had an overrepresentation of the patients with a score of >=1.55 on the SCL-25 according to the sampling of patients that completed the Whiteley-7. To adjust for the different probabilities to be sampled, patients were weighted with the inverse of the probability of being selected to fill in the Whiteley-7 (probability-weighted random sampling). This was done separately for men and women.

Statistics
Baseline comparisons between FAs and non-FAs were made with the Mann-Whitney test and the {chi}2-test. Probabilities of 5% or less were regarded as significant. Stata 6 was used for the analyses.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Four of the 195 patients who entered the study in 1990 moved out of the county, and another four died before the follow-up or in the first follow-up year (1992). Two individuals could not be traced because of incorrect civil registration numbers. This brought the total number of patients entering the follow-up period down to 185 (94.9%), of whom 181 (97.8%) could be followed for 3 years, 175 (94.6%) for 4 years, 171 (92.4%) for 5 years, and 168 (90.8%) for 6 years after the index contact. Table 1 shows the characteristics of the included patients for each rating scale at the time of index contact. No statistically significant differences were found between FAs and non-FAs (Table 2). A total of 36 patients (20.3%) entering the study in 1992 scored 2 or more on SCL-8, and 45 (48.9%) scored 1 or more on Whiteley-7 (Table 3).


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TABLE 1. Characteristics of the study population (N=185) included in the study in 1992




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TABLE 2. Characteristics of the frequent attenders (FAs) and non-FAs included in the study in 1992 (N=185)




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TABLE 3. Number of frequent attenders (FAs) and non-FAs included in the study in 1992 according to a score on SCL-8 and Whiteley-7



Logistic regression analysis (Table 4) showed that all patients were facing a statistically significantly increased risk of falling into the frequent attendance category during the follow-up years with an increase of 1 on the SCL-8 or the Whiteley-7 scale. There was no statistical difference between the ORs for men and women (SCL-8: relative difference in ORs=1.12, [95% CI=0.87–1.46]; Whiteley-7: relative difference in ORs=0.65 [95% CI=0.38–1.12]). Patients scoring 1 or more on Whiteley-7 had a statistically significantly increased OR of becoming an FA at least once. This was especially true for women.


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TABLE 4. Odds ratios (OR) of becoming a frequent attender (FA) during the study period if the psychological distress score increased by one on the Symptom Check List-8 (SCL-8) and Whiteley-7



Ordered logistic regression analysis for both scales (Table 5) showed an increased OR of becoming an FA once more if the score rose by 1. For Whiteley-7, this increase was statistically significantly higher than 1. It should be noted that only 20 men were included in the analysis of Whiteley-7.


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TABLE 5. Odds ratios (OR) of becoming a frequent attender (FA) one more time during the study period if the psychological distress score on either Symptom Check List-8 (SCL-8) or Whiteley-7 increased by 1




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
This prospective study demonstrates that psychological distress places the distressed patient at a higher risk of becoming an FA than a nondistressed patient. Thus, this study extends the current knowledge based on cross-sectional studies with prospective data: the higher the score on a brief self-rating scale, the greater the likelihood of future frequent attendance. Moreover, the study also demonstrates that frequent attendance in family practice rooted in psychological distress is probably more persistent with a higher degree of psychological distress. In contrast to patients scoring 2 or more on SCL-8, patients scoring 1 or more on Whiteley-7 had a statistically significantly increased risk of becoming FAs. This indicates that Whiteley-7 may be the more useful rating scale in predicting frequent attendance.

PCPs should accordingly pay attention to the patient's level of psychological distress—especially somatization—and the associated propensity of the patient to become an FA. Assessing a patient's level of psychological distress could provide the PCP with a reinforced basis for estimating the risk of frequent attendance and, if relevant, for considering prevention.

In this study, the ORs for men were consistently lower than those for women. This may indicate that men and women differ in their response to psychological distress as far as attendance patterns are concerned. Unfortunately, the sample size precluded a further exploration of this.

Validity, Statistical Precision, and Potential Biases
One limitation of the analyses lies in the recurrent events. In this study we used the GEE, which takes into account the correlation between the repeated measures for each patient. We also corrected for different patterns of frequent attendance by including the year variable in the logistic regression. With respect to both regression analyses, we assumed a linear tendency of the coefficients for each of the scale scores. However, as Table 2 demonstrates, the material in this study does not hold enough statistical power to evaluate this assumption.

This study sampled consecutive adult patients who consulted their PCP on one specific day about symptoms. The thresholds for FAs were adapted from the whole adult county population. Moreover, the sample of patients who completed the Whiteley-7 questionnaire was weighted to represent the whole study population. The sampling could be problematic because there is a stronger probability for the most persistent FAs to be sampled. The ideal sample would only include patients who had never been FAs at all. The small number of patients represents a weakness as it lowers the statistical precision.

The FAs did not differ statistically significantly from the non-FAs on a set of factors known to be associated with health care utilization.1,11,48–53 The introduced bias in the non-stratified analysis can therefore be assumed to be relatively small, but it indeed stresses the need for an appropriate, larger study using stratified analysis. In this study, information on scores was treated as cutoff points, reflecting the use of such scales in the clinical setting. A larger study is necessary to provide exact risk estimates for clinical use.

Conclusions and Implications
This study shows a causal relationship between psychological distress and frequent attendance. Moreover, there may be a positive association between the severity of psychological distress and the persistence of frequent attendance. This applies in particular to somatization as measured by Whiteley-7, indicating that Whiteley-7 may be the more useful scale in predicting frequent attendance. It seems likely that the use of the two brief self-rating scales could enable PCPs to assess the risk of a patient becoming an FA.


  ACKNOWLEDGMENTS

 
This study was supported by grants from The General Practitioners Foundation for Education and Development and The Municipal VAT Fund.

The authors thank Mr. Jørgen N. Nielsen, National Health Insurance, Aarhus County, for help with the data collection. The authors thank Research Fellow Eva Ørnbøl, M.Sc., and Associate Professor, Morten Frydenberg, M.Sc., Ph.D., Department of Biostatistics, University of Aarhus, for their help with the statistics and the interpretation of the regression analyses.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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