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Br J Gen Pract. 2010 April 1; 60(573): 293–294.
PMCID: PMC2845493

Persistent frequent attenders

Frans Smits
Department of General Practice, Academic Medical Centre, University of Amsterdam, Meibergdreef 15, 1105AZ Amsterdam, The Netherlands. E-mail: ln.ollehc@stims.m.t.f
Henk Brouwer
Department of General Practice, University of Amsterdam

We read with great interest the article by Luciano et al about frequent attendance in the BJGP.1

The authors state that ‘neither definition (has taken) into account that certain patients need to make more consultations than others,’ and therefore, they study a two-stage approach in that they define frequent attenders according to four clinical profiles and to the top 25 and 10% top attenders.

Obviously sick patients will make more appointments with their GP and frequent attendance is linked to (multi-)morbidity. Therefore, we think that, from a clinical perspective of a GP, thinking in strict profiles of frequent attenders denies the complexity of consulting behaviour. Our research group prefers to analyse frequent attendance as a clinical risk phenomenon: consulting exceptionally more than your peers may be a sign for GPs that a mismatch exists between the needs of these patients and the actual care delivered by the GP; a sign that there are undiscovered and unmet (medical) problems. In this perspective it makes sense to only select the top attenders stratified by age and sex (method 2 in this article).

Taking a certain number of consultations as a criterion will result in a selection of relatively many older women and diminishes the number of exceptional consulters among the young.2 Selecting 25% of your practice is too much to be of any practical usefulness in this concept. Therefore, we think that defining frequent attenders as a (10%) proportional part of all enlisted patients is the best method to select the exceptional attenders in all age and sex categories. Also, this method makes it possible to compare between countries and different practices.2,3

Most 1-year frequent attenders have good reasons to consult more often because of intercurrent disease or other (medical, social, or psychological) problems. Therefore, most frequent attendance is temporary. Only a minority persist in frequent attendance.4 Moreover, persistent frequent attenders have more (multi-) morbidity, compared with 1-year frequent attenders, and their consulting behaviour is, by definition, not determined only by intercurrent illnesses.4

Therefore, we stated in a paper in this Journal that for GPs persistent frequent attending is of more importance and clinical usefulness than short-term frequent attending.5

Unfortunately, the authors did not raise this issue in their paper.


1. Luciano JV, Fernandez A, Pinto-Meza A, et al. Frequent attendance in primary care: comparison and implications of different definitions. Br J Gen Pract. 2010;60(571):95–100. [PMC free article] [PubMed]
2. Smits FT, Mohrs JJ, Beem EE, et al. Defining frequent attendance in general practice. BMC Fam Pract. 2008;9:21. [PMC free article] [PubMed]
3. Vedsted P, Christensen MB. Frequent attenders in general practice care: a literature review with special reference to methodological considerations. Public Health. 2005;119(2):118–137. [PubMed]
4. Smits FT, Brouwer HJ, Ter RG, van Weert HH. Epidemiology of frequent attenders: a 3-year historic cohort study comparing attendance, morbidity and prescriptions of one-year and persistent frequent attenders. BMC Public Health. 2009;9:36. [PMC free article] [PubMed]
5. Smits FTM, Brouwer HJ, ter Riet G, van Weert HC. Predictability of persistent frequent attendance. A historic 3-year cohort study. Br J Gen Pract. 2009;59(59):e44–50. [PMC free article] [PubMed]

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