A cognitive analytic framework for understanding and managing problematic frequent attendance in primary care

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Aim To develop and demonstrate the use of a systematic approach to identifying and managing problematic frequent attendance in primary care.

Study type Phase I: development of intervention.

Setting Two urban primary care practices.

Method Patients were identified whose attendance at the practice was inappropriately frequent, using a statistical method adjusting for age and sex and an operational definition of 'problematic' attendance. Three in-depth interviews were conducted with a subsample of nine patients from these lists, to build up a profile of patterns of and reasons for inappropriate frequent attendance. Focus groups with members of the primary care teams were conducted to explore attitudes to and management of frequent attendance. A cognitive-analytic framework was applied to these qualitative data to identify 'reciprocal roles' in doctor–patient interaction for these patients. On this basis, a training and consultation intervention was developed which aimed to alert practitioners to these patterns in order to alter their reciprocating role behaviour.

Results Three 'procedural sequences' were identified that characterise unhelpful but self-maintaining patterns of consulting. Feedback from the teams receiving the training intervention was positive, reporting increased understanding, team co-operation and changes in practice.

Conclusion Frequent attending can be understood as part of a pattern of interpersonal relating which unwittingly maintains or encourages the behaviour. After a brief training intervention, this framework can be used by primary care staff to become alert to these patterns and to understand and manage frequent attendance. The effectiveness of this intervention in reducing consultation rates requires formal evaluation through a phase II cluster randomised trial.


Document Type: Research Article

Publication date: September 1, 2004

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