title: Why do they keep coming back? Psychosocial etiology of persistence of frequent attendance in primary care: a prospective cohort study.
abstract: BACKGROUND
  Patients who visit their General Practitioner (GP) very frequently over extended periods of time often have multimorbidity and are costly in primary and specialist healthcare. We investigated the impact of patient-level psychosocial and GP-level factors on the persistence of frequent attendance (FA) in primary care.
  
  
  METHODS
  Two-year prospective cohort study in 623 incident adult frequent attenders (>90th attendance centile; age and sex-adjusted) in 2009. Information was collected through questionnaires (patients, GPs) and GPs' patient data. We used multilevel, ordinal logistic regression analysis, controlling for somatic illness and demographic factors with FA in 2010 and/or 2011 as the outcome.
  
  
  RESULTS
  Other anxiety (odds ratio (OR) 2.00; 95% confidence interval from 1.29 to 3.10) over 3years and the number of life events in 3years (OR 1.06; 1.01-1.10 per event; range of 0 to 12) and, at baseline, panic disorder (OR 5.40; 1.67-17.48), other anxiety (OR 2.78; 1.04-7.46), illness behavior (OR 1.13; 1.05-1.20 per point; 28-point scale) and lack of mastery (OR 1.08; 1.01-1.15 per point; 28-point scale) were associated with persistence of FA. We found no evidence of synergistic effects of somatic, psychological and social problems. We found no strong evidence of effects of GP characteristics.
  
  
  CONCLUSIONS
  Panic disorder, other anxiety, negative life events, illness behavior and lack of mastery are independently associated with persistence of frequent attendance. Effective intervention at these factors, apart from their intrinsic benefits to these patients, may reduce attendance rates, and healthcare expenditures in primary and specialist care.
authors.affiliation: Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands. Electronic address: f.t.smits@amc.uva.nl.
authors.forename: Frans T
authors.initials: FT
authors.lastname: Smits
authors.affiliation: Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands.
authors.forename: Henk J
authors.initials: HJ
authors.lastname: Brouwer
authors.affiliation: Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands.
authors.forename: Aeilko H
authors.initials: AH
authors.lastname: Zwinderman
authors.affiliation: Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands.
authors.forename: Jacob
authors.initials: J
authors.lastname: Mohrs
authors.affiliation: Department of Psychiatry, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands; Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands.
authors.forename: Aart H
authors.initials: AH
authors.lastname: Schene
authors.affiliation: Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands.
authors.forename: Henk C P M
authors.initials: HC
authors.lastname: van Weert
authors.affiliation: Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands.
authors.forename: Gerben
authors.initials: G
authors.lastname: ter Riet
mesh_terms: D000328:Adult; D001007:Anxiety / Q000453:epidemiology; D001008:Anxiety Disorders / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008016:Life Change Events; D016015:Logistic Models; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology*; D008875:Middle Aged; D016017:Odds Ratio; D016584:Panic Disorder / Q000453:epidemiology; D011320:Primary Health Care / Q000706:statistics & numerical data*; D011446:Prospective Studies; D011795:Surveys and Questionnaires; D013997:Time Factors
keywords: (persistent) Frequent attender; Anxiety disorders; Cohort study; Depressive disorder; Etiology; General Practitioner