A Framework for Understanding Visits by Frequent Attenders in Family Practice

We reported the number of visits in each category to provide a general impression of the variation of visit types among frequent attenders and how it differed from the non-frequent attender group. Given the qualitative study design and data collection methods, the distribution of visit types may not accurately represent all frequent attender visits to the physician practices in this study and may not be generalizable to other clinical settings.

For some patients frequent attendance is appropriate, and a one-size-fits-all approach to reducing frequent attendance is unlikely to be effective. In his qualitative study of the management styles of 2 experienced family physicians, Miller20 described a visit typology that included routine, drama, and ceremony visits. He observed that visits with frequent attenders were often “maintenance ceremonies” with a prescribed repetitive format guided by a skilled physician. The “ritual” or “tango” visit types described in our study were the most obvious instances of “maintenance ceremonies” that were based on a high level of familiarity between patient and physician. The ceremonies in such visits may not be based on published medical guidelines or outcomes studies but are likely, in some instances, to represent an effective and appropriate therapeutic response by a physician who has developed an intimate understanding of the complex medical and psychosocial needs of a patient. In other cases such a visit pattern may be an inappropriate pattern of care that allows the familiar routines to take the place of consideration of different diagnostic or therapeutic directions.

Conclusions

Our study provides a foundation for further understanding the variation in family practice patient encounters and holds implications for a number of other issues that require further study. Any evaluation of the appropriateness of outpatient utilization patterns should recognize the wide range of encounter types that may not be apparent from studies of administrative databases. Interventions designed to reduce “inappropriate” utilization also should consider such factors. Our study also provides a basis for teaching students and physicians how to understand and manage the complexities and variation of outpatient primary care encounters. By categorizing and reflecting on the pattern of visit types over time for particular patients, physicians may gain insight into how best to care for “difficult” frequent attenders.

Acknowledgments

Our study was supported by a grant from the Agency for Healthcare Research and Quality (R01 HS08776), a grant from the Health Resources and Services Administration (5D32HP10231), and a Family Practice Research Center grant from the American Academy of Family Physicians. We are grateful to the physicians, staff, and patients from the 18 practices, without whose participation this study would not have been possible. The authors also wish to thank Kurt C. Stange, MD, PhD, who provided helpful comments on earlier drafts of this paper.