Frequent Fliers
Frequent Fliers
Abstract & Commentary
By Allan J. Wilke, MD, Residency Program Director, Associate Professor of Family Medicine, University of Alabama at Birmingham School of Medicine—Huntsville Regional Medical Campus, Huntsville. Dr. Wilke reports no financial relationship to this field of study.
Synopsis: A very small group of patients consume a significant portion of outpatient primary care physician time.
Source: Naessens JM, et al. Predicting persistently high primary care use. Ann Fam Med. 2005;3:324-330.
As physicians caring for patients in ambulatory settings, we all have people who seek our attention more frequently than others. Of course, these visits consume a great deal of our time, and we sometimes wonder if it is time well spent. Naessens et al sought to characterize these patients and to devise a prediction tool to identify individuals likely to use our services at higher rates than average. The study was conducted from 1997 through 1999 in a smallish Midwestern city, among a group of 58,000 continuously insured individuals in a fee-for-service health plan that did not require co-pays or referrals for specially care. After excluding patients who did not give permission for examination of their medical records, 54,074 charts were available for study. The authors used the following definitions:
- Primary care visits were ones made to family physicians, general internists, general pediatricians, or obstetricians.
- A patient was classified as a high primary care user (HPCU) if he or she made 10 or more visits to primary care annually.
- Patients who made more than 10 visits in 2 consecutive years were termed persistently HPCUs (PHPCUs). The visits were sorted into ambulatory diagnosis groups (ADGs).
The most frequent diagnoses were: routine child health examination, otitis media, acute upper respiratory infection, acute pharyngitis, hypertension, gynecologic examination, medical examination (administrative), asthma, pregnancy, dermatitis, depressive disorder, heart valve replacement status, deep phlebitis, and atrial fibrillation.
In 1997 there were 987 HPCUs (1.8%), who accounted for 18% of all primary care visits; this group of patients was used to develop a tool to predict who would be a HPCU in 1998. Compared to the people who weren't HPCUs, these patients were more likely to be female (83.2% vs 53.0%), adults (86.0% vs 69.8%), and employed (61.9% vs 36.1%). By 1998, 58 HPCUs from 1997 were no longer in the plan, leaving 929. There were a total of 1,110 HPCUs in 1998. Of these, 173 were also HPCUs in 1997, and, thus, PHPCUs. Compared to non-PHPCUs, PHPCUs were more likely male (28.9% vs 13.9%) and pediatric (18.5% vs 13.5%). There were 4 ADGs which identified individuals at significantly increased risk of being a PHPCU. They were: ADG 11 (chronic medical-unstable), ADG 23 (psychosocial: time limited, minor), ADG 26 (signs/symptoms, minor), and ADG 30 (see and reassure). A fifth ADG, 33 (pregnancy), was negatively associated with being a PHPCU. The authors used these 5 ADGs to devise a clinical prediction tool that assigned a score of +1 (ADGs 23 and 26), +2 (ADGs 11 and 30), or -4 (ADG 33) to the patients visits. A score of ≥ 1 identified patients with future high use the next year (sensitivity 80.3%, specificity 62.7%). The model did not identify as well HPCUs who were persistently high uses over all 3 years of the study.
Commentary
Many of us (especially if we've practiced hospital medicine) became familiar with DRGs (Diagnostic Related Groups) in the mid-1980s. ADGs are a similar concept applied to the outpatient setting. They are part of the Adjusted Clinical Group (ACG) case-mix system. International Classification of Diseases (ICD-9) codes are grouped into ADGs, based on clinical and expected utilization criteria: clinical similarity; likelihood of persistence or recurrence of the condition over time; likelihood that the patient will return for a repeat visit/continued treatment; likelihood of specialty consultation or referral; expected need and cost of diagnostic and therapeutic procedures for the condition; expected need for a required hospitalization; likelihood of associated disability; and likelihood of associated decreased life expectancy. The presence of 3 or more ADGs is a crude measure of significant morbidity burden.1 To confuse matters further, ADG now stands for Aggregated Diagnostic Groups. It gets worse: ADGs are derived from ACGs (Adjusted Clinical Groups, née Ambulatory Care Groups). Blame all of this on the Johns Hopkins Bloomberg School of Public Health.2
Physicians are not likely to use ADGs any more than they use DRGs, so applying this clinical prediction tool to your patient list isn't going to happen. That in of itself does not invalidate the findings of this study. It does allow us to think about our "frequent fliers." They present with chronic, unstable diseases (think uncompensated congestive heart disease), low-level, short-term psychosocial problems (acute stress reaction), minor signs and symptoms (dyspepsia), or see-and-reassure concerns (benign nevi). This raises some uncomfortable questions. Are our patients with chronic, unstable diseases in frequently because we aren't providing them the best possible care? Should they be in a disease management program? Are our patients with minor, time-limited problems using these ailments as "the tickets" into our offices, when what they really need is attention to their psychosocial needs? Should they be referred for counseling or to support groups if we can't/won't delve into these concerns? If you do not practice in an area where patients have the insurance coverage that these folks had, finding the proper resources may not be easy.
This is not the first attempt to identify potential "over-users" of health care. An earlier study3 found that gender, total number of visits, and percent of visits with "somatization potential" helped to distinguish chronic somatizing patients from other high utilizing patients. Naessens and colleagues characterizes these patients as "overserviced, but underserved."
Who has the problem here? A companion article in the Annals of Family Medicine4 looked at frequent flying from the patients' perspective. It showed that patients who attend frequently do not have the ability "to reassure themselves that they are not ill" and do not share with physicians the same criteria for what constitutes "frequent." This leads to frustrations on both sides. The authors recommend that since frequent attendees need "consistent acknowledgement and legitimization of their perceived unique suffering," we need to be more aware of their perceptions and expectations.
References
1. www.umanitoba.ca/centres/mchp/concept/thesaurus/thesaurus_A.html#ADG. Accessed 01/06.
2. www.acg.jhsph.edu/html/AboutACGs.htm. Accessed 01/06.
3. Smith RC, et al. Screening for high utilizing somatizing patients using a prediction rule derived from the management information system of an HMO: a preliminary study. Med Care. 2001;39:968-978.
4. Hodgson P, et al. Stories from frequent attenders: a qualitative study in primary care. Ann Fam Med. 2005;3:318-323.
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