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A survey of frequent attenders at a gastroenterology clinic
Journal of Psychosomatic Research 50 (2001) 107 ± 109
Short communication
A survey of frequent attenders at a gastroenterology clinic$ Christopher Bassa,*, Gill Hydeb, Alison Bondc, Michael Sharpec a
Department of Psychological Medicine, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK b Department of Gastroenterology, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK c University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JK, UK Received 13 January 2000; accepted 18 May 2000
Abstract Objective: To examine a group of patients satisfying criteria for ``frequent attending'' as part of an audit of an outpatient gastroenterology service, and to note the prevalence of those with no conspicuous organic disease to account for their symptomatology. Methods: We used the hospital computer (Oxford Patient Administration System, OXPAS) to identify 2530 consecutive patients who were given an appointment to attend the gastroenterology clinic during an 11-month period. Patients designated ``frequent attenders'' had their notes flagged before the clinic attendance and were examined in more detail. A frequent attender was defined as a patient who had attended any hospital outpatient clinic in the three Oxford general hospitals on four or more occasions in the previous 12 months. The gastroenterologist then interviewed the patients satisfying these criteria and indicated
whether he/she was satisfied that there was no relevant organic disease to account for the symptoms. Results: Of the total 2530 patients, 762 (30%) satisfied our criteria for frequent attendance (FA). Of these, 452 (59%) had organic disease, 128 (17%) either did not attend or cancelled and 159 (21%) had no relevant organic disease. The diagnosis was uncertain in 23 patients (3%). Of patients satisfying our criteria for frequent attending, approximately 20 ± 25% had no established gastroenterological disease. Conclusions: Frequent attenders present formidable management problems for the gastroenterologist. If they can be identified by computer before the outpatient visit then assessment and management might be more appropriately supervised in designated clinics by more experienced gastroenterology staff. D 2001 Elsevier Science Inc. All rights reserved.
Keywords: Frequent attenders; Functional bowel disorders; Audit
Introduction Functional bowel disorders are common and costly to manage. In a recent study, it was estimated that the total medical care costs of patients with irritable bowel syndrome (IBS) in the United States' white population was US$8 billion [1]. It has been reported that at least one-third of all patients attending a British gastroenterology service have nonorganic disease [2], a figure which increases to one-half in patients aged 40 years or less [3]. Furthermore, there is evidence that patients with recurrent gastrointestinal symptoms who routinely seek medical help have high rates of psychiatric disorders [4]. Those with symptoms that resolve
This work was supported by a grant from Oxford Regional Health Authority. * Corresponding author. Tel.: +44-1865-220379; fax: +44-1865220373. $
or are improved by a medical intervention however do not maintain treatment-seeking behaviour. We carried out a survey of consecutive referrals to a Gastroenterology Clinic during an 11-month period (January 1994± December 1994). The survey was completed as part of a study of ``frequent attenders'' (see definition below), and our aim was to carry out a randomised control trial of psychological treatment in a group of patients with predominantly functional abdominal complaints. This will be reported elsewhere.
Method We used the Oxford Patient Administration System (OXPAS) to identify patient attendance rates. This computerised system carries basic patient data and records attendance at different outpatient clinics. All such patients, aged
0022-3999/01/$ ± see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 0 2 2 - 3 9 9 9 ( 0 0 ) 0 0 2 2 9 - 4
108
C. Bass et al. / Journal of Psychosomatic Research 50 (2001) 107±109
Table 1 Patients with unclear diagnoses (n = 23) Reason
Number
Refused to complete form Inpatient at time of assessment Moving away from area Notes missing Total
12 2 3 6 23
between 18 and 65 years, who had attended one of two gastroenterology outpatient clinics held on the same day were eligible for inclusion. The gastroenterology department provides a regional service to a population of approximately 0.5 million people. The two clinics are supervised by two consultant gastroenterologists, and are responsible for a number of trainees who work in each clinic (approximately 8 ±10 doctors service the two clinics). For the purpose of this study, a frequent attender was defined as a patient who had attended any hospital outpatient clinic in the three Oxford general hospitals on four or more occasions in the previous 12 months. All patients satisfying these criteria had their notes ``flagged'' by a member of the research team before the date of the clinic appointment. The gastroenterologist [either the consultant or specialist registrar (Year 4 or 5)] then interviewed the patient at the clinic and indicated whether he/she was satisfied that there was no relevant organic disease to account for the patient's symptoms. This decision was based on the results of investigations and clinical examination. Some of these investigations took some weeks to be completed, and so diagnostic decisions concerning certain patients were
delayed (see below). In this paper, we report the prevalence of organic and functional gastrointestinal disorders in a consecutive series of such ``frequent attenders.'' Results The OXPAS identified a total of 2530 patients who were given an appointment to attend the gastroenterology clinic during the 11-month period of the study. Of these, 762 patients (30% of the total) satisfied our criteria for frequent attendance (FA) and had their notes flagged before attending the clinic. Four hundred and twelve of these were considered by the gastroenterologist as having definite physical disease which accounted for their symptoms. A further 128 (17% of the total frequent attenders) either did not attend or cancelled (101 and 27, respectively). Examination of the notes of the remaining 222 patients revealed that: 28 had inflammatory bowel disease (IBD), 26 had IBS, and 133 had symptoms that were ``unexplained'' but probably IBS (5 of these were receiving treatment for psychiatric disorder at the time of the study). A further seven had other physical diseases, e.g. anaemia or hepatitis, and five had gastrooesophageal reflux disease (GORD). The remaining 23 patients were difficult to classify for a number of disparate reasons (see Table 1). A final flow chart of the 762 patients reveals that excluding the 128 DNAs, 452 (59%) had either organic gastrointestinal disorders (including 5 with GORD and 7
Fig. 1. Flow chart of consecutive patients attending a gastroenterology clinic in an 11-month period.
C. Bass et al. / Journal of Psychosomatic Research 50 (2001) 107±109
with other physical disease), whereas 159 of the remaining 182 had a functional bowel disorder (the remaining 23 were either moving, refused, in patients or had missing notes Ð see Fig. 1). Discussion This study has a number of limitations that need to be addressed. First, the data were collected from only two clinics, which may not have been representative of a general gastroenterology service. It is also possible that the patients in this study reflected the special interest of, or special referral pattern to, the two consultants (IBD and biliary disease). Second, the proportion of patients with functional diagnoses and organic bowel disease in any clinic sample will depend to some extent on the local follow-up practices for that clinic. We have no reason to believe that follow-up procedures were out of the ordinary for these major categories of patients. Third, we did not routinely collect information on the number and type of investigations carried out on each of the 762 patients to determine the presence of relevant organic disease. However, decisions regarding investigations were discussed with both consultants, and in cases of diagnostic uncertainty medical notes were subsequently scrutinised by a research gastroenterologist (GH) and a diagnostic category assigned. These criticisms aside, the sample represents a wide range of clinical problems attending a tertiary care University teaching hospital gastroenterology service with a catchment area serving half a million people. There are four main findings from this study, which could be regarded as an audit of an outpatient gastroenterology service. First, approximately 2500 ± 3000 patients per annum are ``booked in'' to two outpatient clinics supervised by two consultant gastroenterologists and which include between six and eight trainees. Second, one in three of these patients are ``frequent attenders'' according to our operational criteria. We have already remarked that the proportion of frequent attenders in any clinic is dependent on the follow-up practices of that clinic. Third, one in six of the patients designated frequent attenders ``did not attend'' for the index visit, and were therefore not assigned a final diagnosis. This figure is similar to the 20% of patients who fail to attend first time appointments at gastroenterology outpatient clinics referred from general practice [5]. Fourth, of the frequent attenders who were interviewed 59% had organic disease and 20 ±25% had unexplained physical symptoms or functional bowel disease. This latter
109
figure is substantially lower than usually cited for consecutive attenders at a UK district gastroenterology clinic (53% and 33%, respectively, in two recent studies [2,3]). This lower figure is probably a consequence of patients with less severe and enduring functional complaints being excluded from the requisite research criteria. An alternative, but not mutually exclusive explanation, is that a high proportion of patients with functional bowel disease failed to attend. What are the implications of these findings for the outpatient service? First, gastroenterologists should be aware that one-fifth of all frequent attenders have no organic disease, and that these patients are not only high users of medical resources but also unlikely to respond to most treatments [6,7]. Second, recent evidence suggests that outcome in these patients improves when they are seen by the same doctor throughout their outpatient consultations [8]. If such patients can be identified by computer before their outpatient appointment, then assessment and management might be more appropriately supervised in designated clinics by more experienced gastroenterology staff.
Acknowledgments We thank Professor D. Jewell and Dr. R. Chapman for allowing us to study their patients.
References [1] Longstreth GE. Irritable bowel syndrome: a multibillion-dollar problem. Gastroenterology 1995;109:2029 ± 31. [2] Hamilton J, Campos R, Creed F. Anxiety, depression and management of medically unexplained symptoms in medical clinics. J R Coll Physicians 1996;30:18 ± 20. [3] Holmes KM, Salter RH, Cole TP, Girdword TG. A profile of district hospital gastroenterology. J R Coll Physicians 1996;21:111 ± 4. [4] North CB, Alpers DH, Thompson DJ, Spitznagel EL. Gastrointestinal symptoms and psychiatric disorders in the general population. Dig Dis Sci 1996;41:633 ± 40. [5] Lloyd M, Bradford C, Webb S. Non-attendance at outpatient clinics: is it related to the referral process? Fam Pract 1993;10:111 ± 7. [6] Guthrie EA, Creed FH, Whorwell PJ, Tomenson B. Outpatients with irritable bowel syndrome: a comparison of first time and chronic attenders. Gut 1992;33:362 ± 3. [7] Bass C, Bond A, Gill D, Sharpe M. Frequent attenders without organic disease in a gastroenterology clinic. Patient characteristics and health care use. Gen Hosp Psychiatry 1999;21:30 ± 8. [8] Van Dulmen AM, Fennis JF, Mokkink HG, Van der Velden HG, Bleijenberg G. Persisting improvement in complaint-related cognitions initiated during medical consultations in functional abdominal complaints. Psychol Med 1997;27:725 ± 9.
Short communication
A survey of frequent attenders at a gastroenterology clinic$ Christopher Bassa,*, Gill Hydeb, Alison Bondc, Michael Sharpec a
Department of Psychological Medicine, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK b Department of Gastroenterology, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK c University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JK, UK Received 13 January 2000; accepted 18 May 2000
Abstract Objective: To examine a group of patients satisfying criteria for ``frequent attending'' as part of an audit of an outpatient gastroenterology service, and to note the prevalence of those with no conspicuous organic disease to account for their symptomatology. Methods: We used the hospital computer (Oxford Patient Administration System, OXPAS) to identify 2530 consecutive patients who were given an appointment to attend the gastroenterology clinic during an 11-month period. Patients designated ``frequent attenders'' had their notes flagged before the clinic attendance and were examined in more detail. A frequent attender was defined as a patient who had attended any hospital outpatient clinic in the three Oxford general hospitals on four or more occasions in the previous 12 months. The gastroenterologist then interviewed the patients satisfying these criteria and indicated
whether he/she was satisfied that there was no relevant organic disease to account for the symptoms. Results: Of the total 2530 patients, 762 (30%) satisfied our criteria for frequent attendance (FA). Of these, 452 (59%) had organic disease, 128 (17%) either did not attend or cancelled and 159 (21%) had no relevant organic disease. The diagnosis was uncertain in 23 patients (3%). Of patients satisfying our criteria for frequent attending, approximately 20 ± 25% had no established gastroenterological disease. Conclusions: Frequent attenders present formidable management problems for the gastroenterologist. If they can be identified by computer before the outpatient visit then assessment and management might be more appropriately supervised in designated clinics by more experienced gastroenterology staff. D 2001 Elsevier Science Inc. All rights reserved.
Keywords: Frequent attenders; Functional bowel disorders; Audit
Introduction Functional bowel disorders are common and costly to manage. In a recent study, it was estimated that the total medical care costs of patients with irritable bowel syndrome (IBS) in the United States' white population was US$8 billion [1]. It has been reported that at least one-third of all patients attending a British gastroenterology service have nonorganic disease [2], a figure which increases to one-half in patients aged 40 years or less [3]. Furthermore, there is evidence that patients with recurrent gastrointestinal symptoms who routinely seek medical help have high rates of psychiatric disorders [4]. Those with symptoms that resolve
This work was supported by a grant from Oxford Regional Health Authority. * Corresponding author. Tel.: +44-1865-220379; fax: +44-1865220373. $
or are improved by a medical intervention however do not maintain treatment-seeking behaviour. We carried out a survey of consecutive referrals to a Gastroenterology Clinic during an 11-month period (January 1994± December 1994). The survey was completed as part of a study of ``frequent attenders'' (see definition below), and our aim was to carry out a randomised control trial of psychological treatment in a group of patients with predominantly functional abdominal complaints. This will be reported elsewhere.
Method We used the Oxford Patient Administration System (OXPAS) to identify patient attendance rates. This computerised system carries basic patient data and records attendance at different outpatient clinics. All such patients, aged
0022-3999/01/$ ± see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 0 2 2 - 3 9 9 9 ( 0 0 ) 0 0 2 2 9 - 4
108
C. Bass et al. / Journal of Psychosomatic Research 50 (2001) 107±109
Table 1 Patients with unclear diagnoses (n = 23) Reason
Number
Refused to complete form Inpatient at time of assessment Moving away from area Notes missing Total
12 2 3 6 23
between 18 and 65 years, who had attended one of two gastroenterology outpatient clinics held on the same day were eligible for inclusion. The gastroenterology department provides a regional service to a population of approximately 0.5 million people. The two clinics are supervised by two consultant gastroenterologists, and are responsible for a number of trainees who work in each clinic (approximately 8 ±10 doctors service the two clinics). For the purpose of this study, a frequent attender was defined as a patient who had attended any hospital outpatient clinic in the three Oxford general hospitals on four or more occasions in the previous 12 months. All patients satisfying these criteria had their notes ``flagged'' by a member of the research team before the date of the clinic appointment. The gastroenterologist [either the consultant or specialist registrar (Year 4 or 5)] then interviewed the patient at the clinic and indicated whether he/she was satisfied that there was no relevant organic disease to account for the patient's symptoms. This decision was based on the results of investigations and clinical examination. Some of these investigations took some weeks to be completed, and so diagnostic decisions concerning certain patients were
delayed (see below). In this paper, we report the prevalence of organic and functional gastrointestinal disorders in a consecutive series of such ``frequent attenders.'' Results The OXPAS identified a total of 2530 patients who were given an appointment to attend the gastroenterology clinic during the 11-month period of the study. Of these, 762 patients (30% of the total) satisfied our criteria for frequent attendance (FA) and had their notes flagged before attending the clinic. Four hundred and twelve of these were considered by the gastroenterologist as having definite physical disease which accounted for their symptoms. A further 128 (17% of the total frequent attenders) either did not attend or cancelled (101 and 27, respectively). Examination of the notes of the remaining 222 patients revealed that: 28 had inflammatory bowel disease (IBD), 26 had IBS, and 133 had symptoms that were ``unexplained'' but probably IBS (5 of these were receiving treatment for psychiatric disorder at the time of the study). A further seven had other physical diseases, e.g. anaemia or hepatitis, and five had gastrooesophageal reflux disease (GORD). The remaining 23 patients were difficult to classify for a number of disparate reasons (see Table 1). A final flow chart of the 762 patients reveals that excluding the 128 DNAs, 452 (59%) had either organic gastrointestinal disorders (including 5 with GORD and 7
Fig. 1. Flow chart of consecutive patients attending a gastroenterology clinic in an 11-month period.
C. Bass et al. / Journal of Psychosomatic Research 50 (2001) 107±109
with other physical disease), whereas 159 of the remaining 182 had a functional bowel disorder (the remaining 23 were either moving, refused, in patients or had missing notes Ð see Fig. 1). Discussion This study has a number of limitations that need to be addressed. First, the data were collected from only two clinics, which may not have been representative of a general gastroenterology service. It is also possible that the patients in this study reflected the special interest of, or special referral pattern to, the two consultants (IBD and biliary disease). Second, the proportion of patients with functional diagnoses and organic bowel disease in any clinic sample will depend to some extent on the local follow-up practices for that clinic. We have no reason to believe that follow-up procedures were out of the ordinary for these major categories of patients. Third, we did not routinely collect information on the number and type of investigations carried out on each of the 762 patients to determine the presence of relevant organic disease. However, decisions regarding investigations were discussed with both consultants, and in cases of diagnostic uncertainty medical notes were subsequently scrutinised by a research gastroenterologist (GH) and a diagnostic category assigned. These criticisms aside, the sample represents a wide range of clinical problems attending a tertiary care University teaching hospital gastroenterology service with a catchment area serving half a million people. There are four main findings from this study, which could be regarded as an audit of an outpatient gastroenterology service. First, approximately 2500 ± 3000 patients per annum are ``booked in'' to two outpatient clinics supervised by two consultant gastroenterologists and which include between six and eight trainees. Second, one in three of these patients are ``frequent attenders'' according to our operational criteria. We have already remarked that the proportion of frequent attenders in any clinic is dependent on the follow-up practices of that clinic. Third, one in six of the patients designated frequent attenders ``did not attend'' for the index visit, and were therefore not assigned a final diagnosis. This figure is similar to the 20% of patients who fail to attend first time appointments at gastroenterology outpatient clinics referred from general practice [5]. Fourth, of the frequent attenders who were interviewed 59% had organic disease and 20 ±25% had unexplained physical symptoms or functional bowel disease. This latter
109
figure is substantially lower than usually cited for consecutive attenders at a UK district gastroenterology clinic (53% and 33%, respectively, in two recent studies [2,3]). This lower figure is probably a consequence of patients with less severe and enduring functional complaints being excluded from the requisite research criteria. An alternative, but not mutually exclusive explanation, is that a high proportion of patients with functional bowel disease failed to attend. What are the implications of these findings for the outpatient service? First, gastroenterologists should be aware that one-fifth of all frequent attenders have no organic disease, and that these patients are not only high users of medical resources but also unlikely to respond to most treatments [6,7]. Second, recent evidence suggests that outcome in these patients improves when they are seen by the same doctor throughout their outpatient consultations [8]. If such patients can be identified by computer before their outpatient appointment, then assessment and management might be more appropriately supervised in designated clinics by more experienced gastroenterology staff.
Acknowledgments We thank Professor D. Jewell and Dr. R. Chapman for allowing us to study their patients.
References [1] Longstreth GE. Irritable bowel syndrome: a multibillion-dollar problem. Gastroenterology 1995;109:2029 ± 31. [2] Hamilton J, Campos R, Creed F. Anxiety, depression and management of medically unexplained symptoms in medical clinics. J R Coll Physicians 1996;30:18 ± 20. [3] Holmes KM, Salter RH, Cole TP, Girdword TG. A profile of district hospital gastroenterology. J R Coll Physicians 1996;21:111 ± 4. [4] North CB, Alpers DH, Thompson DJ, Spitznagel EL. Gastrointestinal symptoms and psychiatric disorders in the general population. Dig Dis Sci 1996;41:633 ± 40. [5] Lloyd M, Bradford C, Webb S. Non-attendance at outpatient clinics: is it related to the referral process? Fam Pract 1993;10:111 ± 7. [6] Guthrie EA, Creed FH, Whorwell PJ, Tomenson B. Outpatients with irritable bowel syndrome: a comparison of first time and chronic attenders. Gut 1992;33:362 ± 3. [7] Bass C, Bond A, Gill D, Sharpe M. Frequent attenders without organic disease in a gastroenterology clinic. Patient characteristics and health care use. Gen Hosp Psychiatry 1999;21:30 ± 8. [8] Van Dulmen AM, Fennis JF, Mokkink HG, Van der Velden HG, Bleijenberg G. Persisting improvement in complaint-related cognitions initiated during medical consultations in functional abdominal complaints. Psychol Med 1997;27:725 ± 9.