Persistent frequent attenders in primary care: costs, reasons for attendance, organisation of care and potential for cognitive behavioural therapeutic intervention

<p><b>Abstract</b></p> <p>Background</p> <p>The top 3% of frequent attendance in primary care is associated with 15% of all appointments in primary care, a fivefold increase in hospital expenditure, and more mental disorder and functional somatic symptoms compared to normal attendance. Although often temporary if these rates of attendance last more than two years, they may become persistent (persistent frequent or regular attendance). However, there is no long-term study of the economic impact or clinical characteristics of regular attendance in primary care. Cognitive behaviour formulation and treatment (CBT) for regular attendance as a motivated behaviour may offer an understanding of the development, maintenance and treatment of regular attendance in the context of their health problems, cognitive processes and social context.</p> <p>Methods/design</p> <p>A case control design will compare the clinical characteristics, patterns of health care use and economic costs over the last 10 years of 100 regular attenders (≥30 appointments with general practitioner [GP] over 2 years) with 100 normal attenders (6–22 appointments with GP over 2 years), from purposefully selected primary care practices with differing organisation of care and patient demographics. Qualitative interviews with regular attending patients and practice staff will explore patient barriers, drivers and experiences of consultation, and organisation of care by practices with its challenges. Cognitive behaviour formulation analysed thematically will explore the development, maintenance and therapeutic opportunities for management in regular attenders. The feasibility, acceptability and utility of CBT for regular attendance will be examined.</p> <p>Discussion</p> <p>The health care costs, clinical needs, patient motivation for consultation and organisation of care for persistent frequent or regular attendance in primary care will be explored to develop training and policies for service providers. CBT for regular attendance will be piloted with a view to developing this approach as part of a multifaceted intervention.</p

Who uses emergency departments inappropriately and when - a national cross-sectional study using a monitoring data system

Contains fulltext : 126219.pdf (publisher's version ) (Open Access)BACKGROUND: Increasing pressures on emergency departments (ED) are straining services and creating inefficiencies in service delivery worldwide. A potentially avoidable pressure is inappropriate attendances (IA); typically low urgency, self-referred patients better managed by other services. This study examines demographics and temporal trends associated with IA to help inform measures to address them. METHODS: Using a national ED dataset, a cross-sectional examination of ED attendances in England from April 2011 to March 2012 (n = 15,056,095) was conducted. IA were defined as patients who were self-referred; were not attending a follow-up; received no investigation and either no treatment or 'guidance/advice only'; and were discharged with either no follow-up or follow-up with primary care. Small, nationally representative areas were used to assign each attendance to a residential measure of deprivation. Multivariate analysis was used to predict relationships between IA, demographics (age, gender, deprivation) and temporal factors (day, month, hour, bank holiday, Christmas period). RESULTS: Overall, 11.7% of attendances were categorized as inappropriate. IA peaked in early childhood (adjusted odds ratio (AOR) = 1.53 for both one and two year olds), and was elevated throughout late-teens and young adulthood, with odds reducing steadily from age 27 (reference category, age 40). Both IA and appropriate attendances (AA) were most frequent in the most deprived populations. However, relative to AA, those living in the least deprived areas had the highest odds of IA (AOR = 0.89 in most deprived quintile). Odds of IA were also higher for males (AOR = 0.95 in females). Both AA and IA were highest on Mondays, whilst weekends, bank holidays and the period between 8 am and 4 pm saw more IA relative to AA. CONCLUSIONS: Prevention of IA would be best targeted at parents of young children and at older youths/young adults, and during weekends and bank holidays. Service provision focusing on access to primary care and EDs serving the most deprived communities would have the most benefit. Improvements in coverage and data quality of the national ED dataset, and the addition of an appropriateness field, would make this dataset an effective monitoring tool to evaluate interventions addressing this issue

An ELISA for detection of antibodies against influenza A nucleoprotein in humans and various animal species.

A double antibody sandwich blocking ELISA, using a monoclonal antibody (MAb) against influenza A nucleoprotein (NP) was developed to detect antibodies against influenza. Collections of serum samples were obtained from human and various animal species. All influenza A subtypes induced antibodies against hemagglutinins and NP. A close correlation between titers of the hemagglutination inhibition (HI) test and the NP-ELISA was seen. Antibodies against influenza NP were demonstrated in serum samples from humans, ferrets, swine, horses, chickens, ducks, guinea pigs, mice, and seals. The serum samples were collected at intervals during prospective epidemiological studies, from experimental and natural infections, and vaccination studies. The decline of maternal antibodies was studied in swine and horses. The NP-ELISA enables rapid serological diagnosis and is suited for influenza A antibody screening, especially in species which harbor several influenza subtypes. The HI and neuraminidase inhibition tests, however, must still be used for subtyping

The impact of disasters: long term effects on health.

Disasters occur more often since the world gets overpopulated, air traffic is busier, terrorists are operating worldwide and therefore, risks are increasing. According to the Federal Emergency Management Agency major disasters in the USA have been increasing in frequency, form fewer than 25 per year in the 1980s to more than 40 per year in the 90s. Disasters have happened throughout history. But the reaction to these events has varied according to the mood that a prevailed in society at the time. As Frank Furedi stated: "Many of our fears are not based on personal experiences. Despite an unprecedented level of personal security, fear has become an ever-expanding part of our live. Western societies are increasingly dominated by a culture of fear". Characteristic of trauma ater a disaster is perceived loss of control. The accustomed sense of security has vanished; the victim fears being struck by a new calamity. Especially after 9-11 there is a lot of attention to the aftermath of diasaters, to posttraumatic stress (disorders), medically unexplained physical symptoms (MUPS) and functional somatic syndromes (FSS). However, there is not much long-erm research on this phenomena (with a few exceptions like Three Mile Island, which was only a disaster because residents thought it was, and the Gulf war). For that reason we use in this chapter the Amsterdam air disaster as a 'casus belli'. for public health and for the authorities there are lessons to be learned, in the absence of a protocol for dealings with disasters, and in the lack of experince in dealing with man-made disasters. We pay attention to the role of the media in the aftermath of disaster as well: 'The ironic thing about the seemingly endless coverage of the 1986 Chernobyl accident - and the relatively harmless, because much diluted, radiation that then blew around the world-, is that, with few exceptions, the media have done more injury to th truth than was ever done by cover-up or whitewash. Television is the worst offendev r because the visual impact is unforgettable and any reasonable sense of proportion goes out of the window..." Earlier research showed the impact of media on consultation frequency in general practice