Frequent Attenders Clinical Trial
Official title:
Effectiveness of the "7H" Intervention to Reduce Frequent Attendance in Primary Care: Cluster Randomised Controlled Trial. The "7H" Study
The main objective is to measure the effectiveness of a new intervention to decrease use of
services of primary care frequent attenders (FA).Among the secondary objectives are to
evaluate the cost-effectiveness and cost utility of the new intervention compared with usual
care.
METHODS: There will be a randomized controlled trial with cluster assignment. It will take
place in the field of primary care in the city of Malaga.It will be evaluated a new
multicomponent intervention called "7H" (7 Hypothesis). This intervention will be applied on
the FA by their family doctors in the intervention group. In the control group will be
developed usual cares.
The main outcome is the total of visits of FA at 12 months of the follow-up. The secondary
outcomes include changes happened in biopsychosocial health, satisfaction, and quality of
life measurements. The investigators will assess the dependent and independents (from FA,
general practitioner [GP] and health centres) variables at baseline, and 12 months. At
baseline it will be include a random sample of 450 FA (225 for each arm), belonging to 30
family doctors of 10 health centres. It will be performed linear regression multilevel
models with 4 levels (time, patient, doctor and health centre) to evaluate the effectiveness
of the intervention. . Moreover will be undertaken multivariate gamma and quantile
regressions to assess the cost-effectiveness and cost-utility respectively of the new
intervention versus usual cares, estimating their standard errors by bootstrap calculations.
The "7H" intervention
1. Hypothesis generation: analysis of available informationGPs analyze all the available
information about possible reasons for frequent attendance from clinical charts using a
standardized questionnaire designed to facilitate analysis of this information. This
questionnaire prompts analysis of the following: (1) category of visits and their
frequencies; (2) type of frequent attender according to the first point; (3) family and
personal history, and biopsychosocial problem list that needed follow-up; (4) searching
for common factors for frequent attendance from the previous points; (5) feelings and
thoughts questionnaires, 'In most interviews with this patient I think ...' (11 items),
'I feel ...' (13 items); (6) rethinking issues of GP capacity (and processes) to
resolve the frequent attendance in this patient; and (7) analyzing the different
professionals who intervened in patient care and their contribution to resolving or
continuing frequent attendance.Finally, GPs indicate the type of hypothesis from a list
of seven that they believe made the patient a frequent attender: biological,
psychological, social, family, cultural, administrative-organizational, or related to
the doctor-patient relationship.
2. Hypothesis confirmation: the decision to accept or refute each hypothesis is based on
the GP's interpretation of the data (cognitive component) and the self-perception about
feeling sure (emotional component). When necessary, the GPs can try out the hypothesis
with one or more of the following strategies: another interview with the
patient,biological and psychosocial tests, and/or asking for the opinion of other
professionals.
3. Planning: the GP makes plans for each frequent attender based on the confirmed
hypothesis and available resources. There are many possible plans, examples of which
include: making longer intervals between medical revisits for stable chronic patients,
and asking for collaboration with nurses; looking for possible causes of the unstable
physical chronic illness and intervening accordingly; scheduling an interview to search
for a psychological, family or/and, social diagnosis; suppressing unnecessary
face-to-face medical revisits for repeat prescriptions in stable chronic patients, and
asking the health centre administrative staff for collaboration; asking the social
worker at the health centre for help; referring to community resources if necessary;
and being more realistic about the type of doctor-patient relationship expected. These
plans are then commented on at the group meeting, after which the GP negotiates the
plan with the frequent attender. The GP should never suggest to the patient: 'You have
to attend less frequently'. This would be too aggressive and the patient might react
with anger or guilt. It is better to offer a search for solutions to the patient's
health problem from both points of view.
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Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Investigator), Primary Purpose: Health Services Research