The effects of interventions on quality of life, morbidity and consultation frequency in frequent attenders in primary care: A systematic review

Figures & data

Figure 1. Study selection flow chart. ¹Because of time constraints, one author (DH) assessed and screened most of the articles of stage I. Discordances were solved based on consensus. ²Two studies refer to the same trial.

Table 1. Quality assessment. Notes: The best possible score per study was (9 yes, 0 unclear, 0 no). (The scores can be found in the three columns on the far right). The bottom row lists the number of studies that met the criteria for each quality criterion.

Quality criteria Authors (Ref.)	Assignment to the treatment groups random?	Treatmentallocation concealed?	Groups similar at baseline in terms of prognostic factors?	Were the eligibility criteria specified?	Outcome assessors blinded to the treatment allocation?	Was the care provider blinded?	Was the patient blinded?	Points estimates and measure of variability presented for the primary outcome measure?	Analyses included an intention to treat analysis?	Yes	Unclear	No
Rasmussen (22)	Unclear	Unclear	No	Yes	Unclear	No	No	Yes	Unclear	2	4	3
Smith (23)	Yes	Yes	Yes	Yes	Yes	No	No	Yes	Yes	7	0	2
Larisch (21)	Unclear	Unclear	Yes	Yes	No	No	No	Yes	No	3	2	4
Katon (7)	Yes	Unclear	Yes	Yes	Yes	No	No	Yes	No	5	1	3
Katzel/Simon (17,18)	Yes	Yes	Yes	Yes	Yes	No	No	Yes	Yes	7	0	2
Haas (27)	Unclear	Unclear	Yes	Yes	Unclear	No	No	Yes	Yes	4	3	2
Schilte (19)	Yes	Yes	Yes	Yes	No	No	No	Yes	No	5	0	4
van Ravesteijn (31)	Yes	Yes	Yes	Yes	Yes	No	No	Yes	Yes	7	0	2
Paterson (30)	Yes	No	No	Yes	No	No	No	Yes	Yes	4	0	5
Schreuders (24)	Yes	Yes	Yes	Yes	Unclear	No	No	Yes	No	5	1	3
Bellón (25)	Yes	Yes	Yes	Yes	Yes	No	No	Yes	Yes	7	0	2
Christensen (20)	Yes	No	Unclear	Yes	n/a	No	No	No	No	2	1	5
Gidron (28)	Unclear	Unclear	No	Yes	Yes	No	Yes	Yes	Yes	5	2	2
Olbrisch (14)	Unclear	Unclear	Yes	Yes	No	No	No	No	No	2	2	5
Berghofer (26)	Yes	Yes	Yes	Yes	No	No	No	Yes	Yes	6	0	3
Shannon (29)	Yes	Yes	Yes	Yes	Yes	No	No	Unclear	Yes	6	1	2
Beck (16)	Yes	No	No	Yes	Yes	No	No	Yes	No	4	0	5
Total	12	8	12	17	8	0	1	14	9

n/a; not applicable.

Table 2. Study characteristics and effects.

Subtype of FAsFirst author (year), (Ref.)	Intervention/controls	Follow-up and measurement	Effect on QoL	Effect on morbidity	Effect on consultation frequency
Older frequent attenders
Haas (2001), (27)	Type: Group 1: Health education. Group 2: Enhanced care. Controls: Usual care: up to 20 outpatient psychotherapy visits/year. Intensity: Group 1: One hour/week. Group 2: Initial evaluation, weekly visits offered. Duration: Group 1: Six weeks. Group 2: Six months.	Duration: Six months a.r. Measurement scale(s): SCL-90-R, SF-36.	Group 1: No effect. Group 2: Improvement on general (+8.74, P ≤ 0.05) and mental health (+3.74, P ≤ 0.05) on the SF36. Controls improved on the vitality scale of the SF36 (+11.19, P ≤ 0.05).	Group 1: No effect. Slight improvements in group 2 and controls.	Group 1: 11.5 visits (SD: 10.55) Group 2: 4.38 visits (SD: 2.80). Controls: 3.4 visits (SD: 1.96).
Beck (2008), (16)	Type: Group visit intervention with GP/nurse. Controls: Usual care (no change in medical care). Intensity: Monthly intervention (60–90 min). Duration: 12 months.	Duration: One year a.i. Measurement scale(s): short GDS.	n/a	No differences were observed between the groups.	The intervention group reported significantly fewer sick days or ‘same day’ internal medicine visits (0.87 versus 1.28), fewer emergency department visits (0.41) versus 0.67, P = 0.009) and fewer visits to specialists than the control patients (3.22, versus 3.95, P = 0.028). The controls made fewer visits to the nurse than the experimental patients (1.89 versus 0.63, P = 0.019).
Shannon (2008), (29)	Type: Offering FAs referrals. Controls: Usual care. Intensity: Telephone assessment, 13 follow-up calls or a one-time home visit. Duration: 12 months.	Duration: One year a.i. Measurement scale(s): n/a.	n/a	n/a	The intervention group used more GP services (OR: 2.05; P < 0.001), but numbers of hospital admissions and hospital days were less in the intervention group.
Depressed frequent attenders
Katzelnick and Simon (both published in 2001 and refer to the same RCT), (17,18)	Type: Depression management programme. Intensity: Physician education (two hours), Patient ed., eight visits with the GP. Controls: Usual care but patients were told that screening suggested depression. Duration: 12 months.	Duration: One year a.r. Measurement scale(s): HAMD, SF-20 score, calculated depression free days.	Better SF-20 scores for social function, mental health, general health perceptions (P < 0.05).	Improvement in HAMD: 13.6 versus 9.9 in controls at one year (P < 0.001). 47.4 more depression-free days (95%CI: 26.6–68.2) (229 – > 182). More costs (+$51.84 per additional depression-free day, 95%CI: $17.37–$108.47).	More attendance (+1.6 in the intervention group versus –2.0 in controls, P = 0.02).
Berghofer (2013), (26)	Type: Depression management programme. Intensity: Elements focusing on the practice, GPs and patients (who made four to eight visits). Controls: Treatment as usual for the depressed FAs by the GP. Duration: Six months.	Duration: Six months a.i. Measurement scale(s): HAMD-17, B-PHQ-9.	n/a	The HAMD-17 did not differ between the two groups. Intervention group showed 56% reduction of the baseline B-PHQ-9 sum score versus 17% in controls; P = 0.002) but the difference was not significant at 12 months.	n/a
Distressed frequent attenders
Katon (1992), (15)	Type: DIS, with psychiatrist/GP. Intensity: One 90-min interview. Controls: Usual care. Duration: Not reported.	Duration: One year a.r. Measurement scale(s): SCL-R.	n/a	No significant difference in improvement of psychopathology.	No significant differences in any utilization measure.
Frequent attenders with general mental health problems
Schreuders (2007), (24)	Type: Problem solving treatment. Intensity: Max. six sessions (total max four hours). Controls: Usual care. Duration: Not reported.	Duration: Three months a.r. Measurement scale(s): HADS, PHQ, SPSI-R, SF-36.	No effect on the SF36.	No effect on the HADS, PHQ or SPSI-R.	No differences between the groups.
Frequent attenders with medically unexplained symptoms/somatization
Schilte (2001), (19)	Type: Disclosure of emotional events. Intensity: Two to three sessions (two hours minimum, max. three hours). Controls: Usual care, nine additional practices served as an additional extra control group to test for contamination. Duration: Four weeks.	Duration: Two years a.r. Measurement scale(s): SCL-90, QoL VAS, Likert somatization scale.	No effect of the disclosure intervention on the VAS QoL scale.	No effect of the disclosure intervention on any scale.	No effect on the use of medical services.
Larisch (2005), (21)	Type: GP education about somatization Intensity: 12 h GP education, six 20 min. consultations for FAs. Controls: Also received the same number of consultations but were treated as usual. Duration: 12 weeks.	Duration: Six months a.i. Measurement scale(s): n/a.	n/a	n/a	No effect on GP consultations.
Smith (2006), (23)	Type: Multi-step intervention. Intensity: Minimum of twelve 20-min. visits by nurse practitioners. Controls: Usual care. Duration: 12 months.	Duration: One year a.i. Measurement scale(s): SF36, CES-D, PSC, SSAS.	Improvement in treatment group: (SF36): 48 (49%). Improvement in control group: 34 (33.3%) OR: 1.92; 95%CI: 1.08–3.40. Number needed to treat =6.	Slightly less depressive symptomatology (measured with the CES-D) in the treatment group (inter-group difference 1.44 (95%CI: –1.23–4.11))	n/a
Rasmussen (2006), (22)	Type: GP education. Intensity: One hour-long health enhancement consult. Controls: Usual care. Duration: Not reported.	Duration: One year a.i. Measurement scale(s): SF12.	At four weeks, the intervention group showed a higher percentage change for mental function score (+7.2% versus –10.1%, P = 0.02), but no statistically significant changes were found at 6 or 12 months.	n/a	At six months, the intervention group had made 2.5 more visits to the GP compared with controls (P = 0.04,) but no significant difference was found after 12 months.
Paterson (2011), (30)	Type: Acupuncture Intensity: 12 sessions, average of 60 min/session. Controls: Usual care, but received the intervention after 26 weeks. Duration: Six months.	Duration: One year a.r. Measurement scale(s): MYMOP, W-BQ12, EuroQoL-5D, PEI.	EuroQoL-5D changes between the groups were not statistically significant.	The adjusted mean difference of the MYMOP between the groups in favour of acupuncture was 0.6 (95%CI: 0–1.1), P = 0.05 and P = 0.12 after adjusting for missing data. The W-BQ12 improved by a mean of 4.4 points compared to the control group (95%CI: 1.6–7.2, P = 0.002).	There was no statistically significant difference in number of GP consultations.
Van Ravesteijn (2013), (31)	Type: MBCT and enhanced usual care (= usual care and the initial psychiatric assessment, diagnosis was shared with the GP). Intensity: Eight 2.5-h sessions, plus instructions to practice six days a week (45 min/day). Controls: Enhanced usual care. Duration: Not reported.	Duration: Nine months a.i. Measurement scale(s): SF-6D, EuroQol 5D scale.	EuroQoL-5D changes between the groups were not statistically significant. The MBCT group reported a greater improvement in mental functioning at the end of treatment (adjusted mean difference, 3.9; 95%CI: 0.24–7.6), but this difference was not maintained at nine months.	n/a	Healthcare use did not differ significantly between the two groups.
No specific subgroup
Olbrisch (1981), (14)	Type: Brief educational programme. Intensity: A one-hour educational session. Controls: Screening and evaluation. They also selected another control group that was never contacted for the initial recruitment phase. Duration: Not reported.	Duration: One year a.i. Measurement scale(s): n/a.	n/a	n/a	The intervention group showed reduced consultations at the university health centre for a short but imprecisely reported period of time with this effect dissipating over time.
Gidron (2002), (28)	Type: Guided disclosure programme. Intensity: 15 min per day Controls: Wrote about ‘neutral topics’, without emphasizing any emotionality. Duration: three consecutive days.	Duration: Between 10 and 20 months (mean 15.2) a.r. Measurement scale(s): Hopkins symptom checklist	n/a	Lower symptom levels in the intervention group at three months (2.3 versus 5.2, P < 0.05). Baseline symptom levels were significantly different. After controlling statistically for these differences the intervention group still visited less frequently than controls (P < 0.05).	The intervention group showed a reduction in clinic visits at three-month follow-up and also after 15 months (5.1 versus. 9.7, P < 0.01).
Christensen (2004), (20)	Type: Status consultation Intensity: Five education sessions for GPs. Controls: No status consultation. Duration: Not specified	Duration: One year a.r. Measurement scale(s): n/a.	n/a	n/a	There was no statistically significant difference in GP consultations.
Bellón (2008), (25)	Type: 7 hypothesis + team Intensity: 15-h education to GPs, who held structured meetings about FAs. Controls: Two control groups were used. Group 1 (C1) received usual care by the GPs that also intervened. Group 2 (C2) received usual care by different GPs. Duration: Three days of education, 5–35-min meetings per FA.	Duration: One year a.i. Measurement scale(s): n/a.	n/a	n/a	The intervention was effective at decreasing the number of consultations in comparison to both control groups (C1 & C2); adjusted means: IG-C1: 7.04 (95%CI: 3.63–10.45); IG-C2: 4.13, 95%CI: 0.76–7.50).

a.r.: after randomization; a.i.: after intervention; n/a: not applicable; FAs: frequent attenders; OR: odds ratio; 95%CI: 95% confidence interval; SD: standard deviation; GP: general practitioner; QoL: quality of life; VAS: visual analogue scale; SCL-90(-R): symptom checklist-90(-revised); GDS: geriatric depression scale; HAM-D-(17): Hamilton depression rating scale (17); B-PHQ-9: brief psychiatric health questionnaire; PHQ: psychiatric health questionnaire; DIS: diagnostic interview schedule; HADS: hospital anxiety and depression scale; SPSI-R: social problem-solving inventory—revised; PSC: psychosomatic symptom checklist; SSAS: Spielberger state anxiety scale; MYMOP: measure yourself medical outcome profile; W-BQ12: well-being questionnaire 12; EuroQoL-5D: European quality of life-5 dimensions; PEI: patient enablement instrument; MBCT: mindfulness based cognitive therapy; Likert scale: a 5-point scale to asses somatization; SF-(12) (36) (20) (6D): short form 12; 20; 36. Functional health and well-being from the patient’s point of view; CES-D: Centre for Epidemiologic Studies depression scale.

Rasmussen NH, Furst JW, Swenson-Dravis DM, et al. Innovative reflecting interview: effect on high-utilizing patients with medically unexplained symptoms. Dis Manag. 2006;9:349–359.

 PubMedGoogle Scholar

Smith RC, Lyles JS, Gardiner JC, et al. Primary care clinicians treat patients with medically unexplained symptoms: a randomized controlled trial. J Gen Intern Med. 2006;21:671–677.

 PubMed Web of Science ®Google Scholar

Larisch A, Fisch V, Fritzsche K. Cost-effectiveness of psychosocial interventions for somatising patients by the general practitioner. Z Klin Psychol Psychother. 34:282–290.

 Web of Science ®Google Scholar

Katon W, Von KM, Lin E, et al. Distressed high utilizers of medical care. DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry 1990;12:355–362.

 PubMed Web of Science ®Google Scholar

Katzelnick DJ, Simon GE, Pearson SD, et al. Randomized trial of a depression management program in high utilizers of medical care. Arch Fam Med. 2000;9:345.

 PubMedGoogle Scholar

Simon GE, Manning WG, Katzelnick DJ, et al. Cost effectiveness of systematic depression treatment for high utilizers of general medical care. Arch Gen Psychiatry 2001;58:181–187.

 PubMed Web of Science ®Google Scholar

Haas LJ, Spendlove DC, Silver MP. Expanding mental health services to older high utilizing HMO patients: a pilot study. J Clin Psychol Med Settings 2001;8:189–197.

 Web of Science ®Google Scholar

Schilte AF, Portegijs PJ, Blankenstein AH, et al. Randomised controlled trial of disclosure of emotionally important events in somatisation in primary care. Br Med J. 2001;323:86.

 PubMed Web of Science ®Google Scholar

van Ravesteijn H, Lucassen P, Bor H, et al. Mindfulness-based cognitive therapy for patients with medically unexplained symptoms: a randomized controlled trial. Psychother Psychosom. 2013;82:299–310.

 PubMed Web of Science ®Google Scholar

Paterson C, Taylor RS, Griffiths P, et al. Acupuncture for ‘frequent attenders’ with medically unexplained symptoms: a randomised controlled trial (CACTUS study). Br J Gen Pract. 2011;61:e295–305.

 Google Scholar

Schreuders B, van Marwijk H, Smit J, et al. Primary care patients with mental health problems: outcome of a randomised clinical trial. Br J Gen Pract. 2007;57:886.

 PubMed Web of Science ®Google Scholar

Bellón JA, Rodríguez-Bayón A, de Dios Luna J, et al. Successful GP intervention with frequent attenders in primary care: randomised controlled trial. Br J Gen Pract. 2008;58:324.

 PubMed Web of Science ®Google Scholar

Christensen MB, Christensen B, Mortensen JT, et al. Intervention among frequent attenders of the out-of-hours service: a stratified cluster randomized controlled trial. Scand J Prim Health Care 2004;22:180–186.

 PubMed Web of Science ®Google Scholar

Gidron Y, Duncan E, Lazar A, et al. Effects of guided written disclosure of stressful experiences on clinic visits and symptoms in frequent clinic attenders. Fam Pract. 2002;19:161–166.

 PubMed Web of Science ®Google Scholar

Olbrisch ME. Evaluation of a stress management program for high utilizers of a prepaid university health service. Med Care 1981;19:153–159.

 PubMed Web of Science ®Google Scholar

Berghöfer A, Hartwich A, Bauer M, et al. Efficacy of a systematic depression management program in high utilizers of primary care: a randomized trial. BMC Health Serv Res. 2012;12:298.

 PubMed Web of Science ®Google Scholar

Shannon GR, Wilber KH, Allen D. Reductions in costly healthcare service utilization: findings from the care advocate program. J Am Geriatr Soc. 2006;54:1102–1107.

 PubMed Web of Science ®Google Scholar

Beck A, Scott J, Williams P, et al. A randomized trial of group outpatient visits for chronically ill older HMO members: the Cooperative Health Care Clinic. Gen Hosp Psychiatry 1990;12:355–362.

 PubMed Web of Science ®Google Scholar

Katon W, Von Korff M, Lin E, et al. Randomized trial of psychiatric consultation with distressed high utilizers. Gen Hosp Psychiatry 1992;14:86–98.

 PubMed Web of Science ®Google Scholar