title: Persistent frequent attenders in primary care: costs, reasons for attendance, organisation of care and potential for cognitive behavioural therapeutic intervention.
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
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Psychiatry and Community Mental Health, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom. richard.morriss@nottingham.ac.uk
authors.forename: Richard
authors.initials: R
authors.lastname: Morriss
authors.forename: Joe
authors.initials: J
authors.lastname: Kai
authors.forename: Christopher
authors.initials: C
authors.lastname: Atha
authors.forename: Anthony
authors.initials: A
authors.lastname: Avery
authors.forename: Sara
authors.initials: S
authors.lastname: Bayes
authors.forename: Matthew
authors.initials: M
authors.lastname: Franklin
authors.forename: Tracey
authors.initials: T
authors.lastname: George
authors.forename: Marilyn
authors.initials: M
authors.lastname: James
authors.forename: Samuel
authors.initials: S
authors.lastname: Malins
authors.forename: Ruth
authors.initials: R
authors.lastname: McDonald
authors.forename: Shireen
authors.initials: S
authors.lastname: Patel
authors.forename: Michelle
authors.initials: M
authors.lastname: Stubley
authors.forename: Min
authors.initials: M
authors.lastname: Yang
mesh_terms: D000293:Adolescent; D000328:Adult; D016022:Case-Control Studies; D015928:Cognitive Behavioral Therapy; D039721:Diagnostic and Statistical Manual of Mental Disorders; D004739:England; D005240:Feasibility Studies; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data* / Q000639:trends; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000523:psychology / Q000706:statistics & numerical data; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D001523:Mental Disorders / Q000175:diagnosis* / Q000628:therapy; D016134:Organizational Policy; D010342:Patient Acceptance of Health Care / Q000523:psychology; D010865:Pilot Projects; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care / Q000191:economics / Q000706:statistics & numerical data* / Q000639:trends; D011594:Psychometrics; D036301:Qualitative Research; D012017:Referral and Consultation / Q000191:economics / Q000706:statistics & numerical data; D013001:Somatoform Disorders / Q000175:diagnosis / Q000628:therapy