Frequent attenders (FAs) represent a subgroup of patients who account for a relatively large proportion of contacts with general practitioners (GPs) and also a large number of referrals and prescriptions.1 Studies have revealed that FAs have high rates of physical disease, psychiatric illness, social difficulties, and emotional distress. They were first described in 1954 by Backett et al, who documented that most of the workload of a doctor could be attributed to a small proportion of patients.2,3

It is crucial to determine the extent of this issue and the characteristics of FAs to formulate an appropriate strategy to deal with this group of patients; however, there are no clear recommendations for researching this topic.1 The interpretation of studies on FAs is hampered by differences in the organization of health care, the settings, the definitions utilized, and the population studied.2,4

Oman, an Arab Gulf country, is facing a major challenge regarding the management of escalating health care costs, with one of the reasons being overutilization.5 In Oman, primary health care is considered one of the main pillars of the health care system, which is funded by the government through the Ministry of Health (MOH), with care provided through a network of primary health care centers (PHCs) distributed throughout the country. In 2005, approximately 10.6 million outpatient visits were made to government health institutions in Oman, with 3.27 million visits made to PHCs; visits by Omani nationals accounted for 96% of these visits.6

Since the phenomenon of FAs has not previously been explored in Oman, a pilot study was undertaken to determine the overall rates of adult patient visits to PHCs and to identify the sociodemographic variables associated with a higher number of visits.

Methods

This retrospective longitudinal study was conducted in four selected local PHCs in the A'Dakhliyah governorate of Oman in 2008. This governorate has 21 PHCs, which are distributed into several districts; the selection of the four PHCs chosen for inclusion in the study was based on convenience. The study population comprised all adults aged 18 years and above who attended four general clinics as walk-in patients; patients who attended appointment-based specialty clinics (e.g., hypertension, diabetes and antenatal clinics) were excluded. Sociodemographic data and number of visits were extracted from the electronic medical records system, and FAs were defined as those patients who made more than 12 visits per year.

The distribution was studied across gender for the total number of visits for both FA and non-FA categories, and a chi-square test was used to test the significance between gender and number of visits. The dispersion statistics divided by the degrees of freedom exceeded one, which suggested overdispersion. Since the number of visits does not have a zero count by design, a zero-truncated negative binomial regression was performed using STATA software (StataCorp, College Station, Texas) to study the sociodemographic factors which were associated with a higher number of visits.

Ethical approval for the study was obtained from the Directorate General of Health Services in the A'Dakhliyah governorate, MOH.

Results

In 2008, 12 902 adult patients visited GP clinics in the four selected PHCs resulting in 42 425 visits. The mean age of the study population was 34.0±16.0 years, and the majority were females (61.0% vs. 39.0%) [Table 1].

The number of visits made by individual patients ranged from 1 to 62; over one-third of patients made a single visit, while approximately 78.0% of patients made up to four visits. A proportionately higher number of males visited the PHCs for two or fewer visits compared to females (65.5% vs. 51.5%), but as the number of visits increased, a clear trend of an increased proportion of females compared to males was seen [Table 2].

Only 2.4% (n = 313) of subjects made more than 12 visits, representing 12.8% of total visits (n = 5449), and gender-wise analysis of FAS showed a predominance of females (3.3% vs. 1.1%). Out of the total number of visits, females and males contributed to 4505 (15.5%) and 944 visits (7.1%), respectively [Table 3]. The overall mean rate of visits per patient per year was 3.2±3.3, while the overall median number was two visits. The mean number of visits for both male and female FAs was 17.4 visits, while the median number of visits was 15 and 16 for males and females, respectively. The overall rate of visits per day was more than two-times higher for females (79.6 per day) compared to males (36.6 per day), with a nearly similar trend noted in the non-FA subgroup. However, in the FA category this was about five-times higher among females compared to males (12.3 vs. 2.6) [Table 3].

The overall and gender-wise mean and median ages were higher in the FAs group compared to the non-FAs group. Males were found to be younger (mean and median age) compared to females in both the FAs and non-FAs groups, respectively [Table 4].

Being a female significantly increased the risk of attending PHC facilities compared to being a male (relative risk (RR) 1.13; 95% confidence interval (CI): 1.10–1.20). There was a significant increase in the risk of visiting when a patient was married, divorced or widowed, compared to being single. Students were found to have a significantly lower risk of attending compared to the other three employment categories, and an illiterate patient had a nearly 1.5-times greater risk compared to a patient who had received an advanced education (p < 0.001). As age increased, the risk of making a higher number of visits per year increased significantly, especially among those aged 45 years and above (p < 0.001) [Table 5].

Discussion

Based on the mean annual consultation rates, countries are considered either low- or high-use countries. The findings of our study place Oman as a low-use country in view of the low mean rate of visits per patient per year. Large cross-country differences in mean annual consultation rates have been reported, and in high-use countries, such as Germany, Hungary, France, Belgium, and Austria, visit frequency is around 7–8 visits per year, which is twice that in low-use countries, such as Finland, Switzerland, Denmark, and the United States.7 The overall median annual consultation rates per patient in Croatia, the Netherlands, and Japan were 4.1, 5.7, and 5.6, respectively, while in Kuwait a much higher number of 16 visits has been reported.8–10 These differences could be attributed to the differences in settings and populations studied.

The finding that 2.4% of patients contributed to 12.8% of the total number of visits is consistent with previous studies that have shown that a small proportion of patients are responsible for a disproportionate number of consultations.4 In Kuwait, 5.8% of patients were classed as FAs who contributed to 19.2% of visits, while a study from Saudi Arabia noted that 27.5% of patients made 10 or more visits per year.10 Studies from Europe have reported that 4.7% of patients were responsible for 21% of consultations in the UK, 23% of patients were responsible for 60% of visits in Croatia, 24% of patients were responsible for 54.8% of visits in Slovenia, and 25% of patients were responsible for 55% of visits in Finland.10 In Oman, medical services are provided for free to all citizens, which would be expected to lead to higher utilization of health services; however, our study reveals a comparatively lower prevalence rate of FAs compared to that in other countries. Potential reasons for this finding could be the fact that our study was confined to a specific geographical region, meaning that the results are not generalizable to the whole country. There may also be an overrepresentation of young subjects in our study population (45.8% ≤ 24 years) since previous studies have shown that FAs are typically older patients.4,11,12

Being female, divorced or widowed, illiterate, and older age are significantly associated with a higher number of visits. The following reasons can explain the predominance of females: females have been found to report symptoms more frequently than males, and are more likely to be affected with illnesses because of their traditional role in caring for children.10,13,14 Females also outnumbered males by nearly five-times in our FAs group. This finding is consistent with the findings from other studies, although no significant differences between FAs and non-FAs regarding gender and marital status were noted in a Saudi Arabian study.4,15

Our study revealed that the proportion of males who visited the PHCs for one or two consultations was higher than females, and in addition, these were younger aged males. This could be attributed to the outdoor lifestyle of males, which may potentially lead to a higher prevalence of injuries in this group, thus accounting for the higher number of visits. Similar to previous studies, our patients with a low educational level utilized health services more frequently than better educated patients, which could be attributed to a lack of awareness on how to self-manage minor illnesses or injuries, and possibly a delay in seeking medical care.14 Consequently, such patients would require a higher number of visits until their medical condition resolved or improved.14

The direct relationship between number of visits and older age in our study was expected since it is recognized that as a person becomes older they are more likely to suffer from an increased number of medical conditions as part of the aging process.16 Kronfol,17 reported age to be the least important factor associated with FAs, but the associations with gender and education noted are consistent with our findings.

Our study has several limitations, the first being that the selected PHCs were in one particular region of Oman, and may not be representative of the whole country. Indeed the possibility that the A'Dhakhilyah governorate itself could be a low-use region compared to other regions cannot be ruled out. The existing health care system does not facilitate or encourage continuity of care by the same physician, as different doctors usually run general clinics and patients are seen as walk-ins rather than appointments. Therefore, it is possible that many patients were seeking continuity of care, which has been identified as an important aspect of care by Omani patients attending a private healthcare facility, and this would not have been identified in our study.18 Although previous studies have used a similar definition of FAs, this definition is still considered arbitrary since it is solely based on the number of visits.

Conclusions

The proportion of Omani FAs in primary health care is low, but the proportion of females is higher than males. The study findings have established baseline statistics, and these are vital for future studies which are required to enhance our understanding of this phenomenon and help monitor it.

Disclosure

The authors declared no conflicts of interest. No funding was received for this study.

references

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