Family Practice Vol. 16, No. 6, 586-590
© Oxford University Press 1999
Differences in diagnostic approach between family physicians and other specialists in patients with unintentional body weight loss
Department of Family Medicine, College of Medicine, National Taiwan University.
Dr Kai-Kuen Leung, Department of Family Medicine, College of Medicine, National Taiwan University, No. 1, Jen-Ai Road, Section 1, Taipei, Taiwan, R.O.C.
Lin H-W, Li C-M, Lee Y-C, Lee L-T and Leung K-K. Differences in diagnostic approach between family physicians and other specialists in patients with unintentional body weight loss. Family Practice 1999; 16: 586–590.
Received 10 February 1999; Revised 7 June 1999; Accepted 25 June 1999.
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Abstract |
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Background. Unintentional weight loss is a diagnostic dilemma with diverse diagnostic possibilities for physicians.
Objectives. Our study focused on the evaluation of differences in diagnostic approach between family physicians and physicians in other specialties.
Methods. Outpatients who visited National Taiwan University Hospital from January 1996 to December 1996 with unintentional weight loss of 5% or more within 6 months were recruited by a computer search. All data were obtained from a structured medical record audit.
Results. There was no significant difference in the utilization of common diagnostic laboratory tests between the two groups. However, other specialists ordered more carcinoembryonic antigen tests (P < 0.01) and hepatitis B antigen tests (P < 0.05), but fewer upper gastrointestinal tract barium studies (P < 0.05) than family physicians. For patients without a definite final diagnosis, the diagnostic total costs for laboratory tests and imaging studies were lower for family physicians than other specialists (P < 0.01). For patients with biomedical disorders, the diagnostic cost was not significantly different between the two groups. For patients with psychological disorders, the costs for imaging studies were lower for family physicians than for other specialists (P < 0.05) but there was no significant difference in the total costs between these two groups.
Conclusions. We conclude that the different approaches between the two groups are due to different training backgrounds and characteristics of practice. The patient-centred concepts of family physicians might be more cost-effective in dealing with undifferentiated problems.
Keywords. Cost-effectiveness, family physician, specialist, unintentional weight loss..
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Introduction |
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Unintentional weight loss is a common health problem, especially in elderly people.1 Since marked weight loss is generally viewed as a manifestation of serious underlying disease,2 it is a matter of concern for all patients who seek medical attention. Weight loss is also a diagnostic dilemma for physicians. Not all patients with unintentional weight loss have significant physical illness, and the list of possible causes of involuntary weight loss range from no apparent cause to malignancy.3–6
Because weight loss is a non-specific complaint with diverse diagnostic possibilities, patients usually undergo an extensive clinical evaluation, and sometimes hospitalization, before a diagnosis is given. In clinical practice, there are no consensus or guidelines on the diagnostic approach to patients with weight loss. Physicians rely solely on their clinical knowledge and experience in the diagnostic work-up. Previous research has found that there were wide variations in the style of evaluating and managing patients in different medical specialties.7–9 Family physicians are less aggressive, order fewer tests and procedures, and generate lower health care costs than other specialists.10 Facing a continuous increase in medical costs and cost-containment policies, provisions for cost-effective medical care are emphasized in the health care system in Taiwan as well as in other countries.
After national health insurance was implemented in Taiwan, patients were still allowed to choose primary care or other specialty care services as a source of first-contact care without any limitations. In systems such as the United States and Japan, which have traditionally allowed a free choice of physicians and unimpeded access to specialists, the benefit of a gatekeeper, a primary care source, may not be intuitively obvious. If people believe that a specialist has greater expertise and skill, they will only be satisfied with the ‘best’ care and will be dissatisfied if forced to seek care elsewhere first.
There has been no previous research comparing the implication of first-contact care between primary care physicians and specialists in this country. However, we expected to see differences in Taiwan between primary care physicians and other specialists, who have different training backgrounds and philosophies in approaching patients. This study focused on the evaluation of differences in the diagnostic approaches between family physicians and other specialists in terms of kinds and number of diagnostic tests, and the average cost for the initial diagnosis of patients with a chief complaint of unintentional weight loss.
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Methods |
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Subjects
We studied patients who visited the outpatient clinic of National Taiwan University Hospital from January 1996 to December 1996. All patients 18 years old and over with a major diagnosis of weight loss were selected by a computer search. Patients were eligible for the study if their medical records documented that they had lost 5% or more of their baseline body weight during the previous 6 months. Patients who had a known cause of weight loss prior to the index visit (such as cancer, diabetes mellitus), were actively reducing their weight, were under intentional diet modifications or were using medications which can reduce body weight (such as diuretics or amphetamines) were excluded from the study.
Medical record audit
All medical records of the initial medical consultation and subsequent visits for the evaluation and management of weight loss were reviewed by a physician with a standard chart review form. Information included the department of the initial visit, chief complaints and associated symptoms, body weight, amount and duration of weight loss, physical findings, laboratory tests, image studies, other diagnostic procedures, duration of hospitalization, final or discharge diagnosis, and duration of follow-up. The cause of weight loss was determined by a careful review of medical records and a discussion of consensus by the researchers. A patient was considered to have an identifiable cause of weight loss if the diagnostic evaluation led to a disease known to cause body weight loss (such as cancer, gastric ulcer or thyrotoxicosis), if successful treatment of a condition resulted in weight gain or if deterioration in disease status paralleled further weight loss. For those patients without a firm diagnosis, follow-up contact was made by telephone interview to obtain further health information. All statistical analyses were performed by the SPSS for Windows 7.0 with chi-square and one-way analysis of variance.
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Results |
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A total of 254 patients who met the established criteria were included in the study. One hundred and seven patients had a biomedical cause of weight loss, 30 patients had a psychological cause and 117 patients had no identifiable cause. Nearly half of the patients (129) visited a family physician and the other half (125) visited a specialist for the initial evaluation of weight loss. Of these, 111 patients visited internists, 7 patients visited surgeons, 5 patients visited neurologists and 2 patients visited oncologists. There were no statistically significant differences in age, sex, degree of weight loss, number of patients who received inpatient care and causes of weight loss between patients who visited family physicians and patients who visited other specialists (Table 1
).
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Differences in the utilization of diagnostic tests between family physicians and other specialists
There was no significant difference in the utilization of common diagnostic laboratory tests such as blood chemistry, blood glucose, electrolytes, complete blood count, stool occult blood and urinalysis between family physicians and other specialists (Table 2
). The other specialists were significantly more likely to order carcinoembryonic antigen, hepatitis B antigen and antibody tests than were family physicians (Table 3). There was no significant difference in the ordering of anti-HIV, anti-nuclear antibody or C reactive protein tests between the two groups (Table 3). Family physicians were significantly more likely to order upper gastrointestinal series (UGIS) than were other specialists (Table 4).
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Differences in the costs of initial evaluation of weight loss between family physicians and other specialists
The final diagnosis could be divided into either of the following three groups: (1) no physical or psychiatric cause found; (2) biomedical disorders; and (3) psychiatric disorders. The costs of the initial diagnostic tests among these three groups were analysed (Table 5
). For patients without a biomedical or psychiatric disorder, the costs of laboratory tests, imaging studies and other procedures were lower for family physicians than for other specialists (P < 0.01). The diagnostic costs for patients with biomedical disorders were not significantly different between family physicians and other specialists. For patients with psychological disorders, the costs for imaging studies were lower for family physicians than for other specialists (P < 0.05). However, the two groups had no significant difference in total costs.
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Discussion |
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Our study revealed that there were differences in the initial evaluation of weight loss between family physicians and other specialists. But the differences in costs between patients cared for by family physicians or other specialists could not be explained by the patients' basic characteristics and the utilization of routine laboratory tests.
The test for serum levels of CEA was ordered more frequently by other specialists than by family physicians. Tumour markers are tools for follow-up of a diagnosed malignancy, not a valid screening test.11 Other specialists seem more likely to utilize the tumour marker, CEA, for weight loss patients in the initial evaluation. From the medical records, we did not find evidence that CEA contributed to the discovery and diagnosis of malignant disease in our study.
Hepatitis B antigen and antibody tests were more frequently ordered by other specialists than family physicians. Hepatitis B is a disease with high prevalence in Taiwan, and the positive predictive value may be higher than in other areas.12 But no definitive evidence revealed a correlation between weight loss and hepatitis B infection. There was only one case of body weight loss associated with chronic hepatitis B in our study. In addition, hepatitis B infection is a significant risk factor for hepatocellular carcinoma in Taiwan.12 Physicians may suspect that weight loss is caused by hepatocellular carcinoma, so they often order tests for serum hepatitis B antigen and antibody. There were five cases with a final diagnosis of hepatocellular carcinoma in our study, but the serum hepatitis B antigen and antibody tests did not contribute to the diagnosis. The diagnosis was suggested by clinical symptoms and signs. So it does not seem cost-effective or reasonable to use hepatitis B serology tests as a screening test for weight loss.
Imaging studies were used similarly in the two groups, except that family physicians ordered upper gastrointestinal series more often. We suspect that several factors caused this result. First, panendoscopy is so invasive that some patients fear this procedure. Family physicians choose non-invasive procedures more often if there are alternative choices and patients request it. Secondly, the cost of an upper gastrointestinal series (equivalent to US$38.00) is cheaper than a panendoscopy (equivalent to US$57.00). So family physicians tended to choose a cheaper and less-invasive procedure in the initial evaluation of weight loss.
For patients without a specific diagnosis, our study revealed that the costs of laboratory tests, imaging tests and total tests were lower for patients of family physicians than for patients of other specialists. But there was no difference for patients with biomedical disorders and patients with psychiatric disorders, except for the cost of imaging studies. We suspect that the differences in patient management between family physicians and other specialists mainly come from the training background and characteristics of practice. Family physicians seemed to spend less money than other specialists in the evaluation of patients with no apparent diagnosis or with a psychiatric diagnosis. As family physicians usually see patients in the early undifferentiated stage of disease, they have more expertise and sensitivity in detecting serious problems than do other specialists. For patients whose problems could not be elucidated during the first visit, family physicians often scheduled follow-up visits and used the time as a diagnostic aid rather than ordering a lot of tests.13 Moreover, family physicians have more training in dealing with psychosocial problems than other specialists. This may give family physicians more confidence and skill in the evaluation of patients without an obvious diagnosis.
Weight loss is an undifferentiated problem, and the literature reveals that about 40% of poorly defined problems arise from stress in an individual's family or environment.14 Discussion, support and reassurance are often the preferred therapies. This practice style explains why family physicians are less precise about diagnosis and tend to use fewer tests and procedures than other specialists. However, other specialists, who mainly focus on disease, organ-systems or investigative procedures, see illness at a more advanced stage and generally do not deal with problems beyond the realm of their discipline. Our study revealed that the diagnostic approach for patients with biomedical diseases was quite similar for family physicians and other specialists. The diagnostic costs for patients with psychiatric disease were lower for family physicians than for other specialists. Unfortunately, this difference did not reach statistical significance. We expect to see a difference in studies with a larger sample size. Our study revealed that more imaging studies were ordered by other specialists. We reviewed the charts and found one patient who was eventually diagnosed with hypochondriasis who received a chest film, abdominal sonography and a lower gastrointestinal series in the initial evaluation. Two others with neurotic depression had computer tomography, panendoscopy and abdominal sonography. This diagnostic approach was not seen with family physicians. Bio-psychosocial concerns are emphasized in the training programme of family medicine, so family physicians may pay more attention to psychosocial problems when they make a diagnosis. However, physical disease is the major concern for other specialists, so they may focus on a physical disorder when they make a diagnosis.
There were some limitations in our study. First, we didn't know the characteristics of the physicians, such as specialty training, age or experience. These characteristics are factors contributing to medical outcome. Secondly, the sample size of the group with a psychological cause was small and this may explain why there was no significant difference in the diagnostic costs for patients with a psychological cause. Thirdly, the patients were all from a teaching hospital and may not represent the general population. We did not know whether the patients visiting a teaching hospital had more severe physical problems or were more anxious about their health. Whether family physicians and other specialists were cost-effective in their management is another unanswered question.
This study suggests that family physicians ordered fewer diagnostic tests than other specialists for patients with weight loss with no definite final diagnosis. This study reveals that using patient-centred concepts in medical education may help physicians more effectively differentiate undifferentiated problems. Patient-centred concepts may also lead to more cost-effective methods of dealing with undifferentiated problems. We believe that the results of this study can be applied to countries where primary care physicians are trained with the same philosophies.
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Acknowledgments |
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The authors would like to thank Dr Wei-Chu Chie for her critiques of earlier revisions of this paper.
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References |
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