Family Practice Vol. 20, No. 4, 434-440
© Oxford University Press 2003
International Health Care Research |
Tiredness in Dutch family practice. Data on patients complaining of and/or diagnosed with ‘tiredness’
Family Physician, Haarlem and
a Department of Family Practice, Division of Clinical Methods and Public Health, Academic Medical Centre, University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands.
Correspondence to Dr IM Okkes; E-mail: i.m.okkes{at}amc.uva.nl
Kenter EGH, Okkes IM, Oskam SK and Lamberts H. Tiredness in Dutch family practice. Data on patients complaining of and/or diagnosed with ‘tiredness’. Family Practice 2003; 20: 434–440.
Received 18 September 2002; Revised 24 February 2003; Accepted 28 March 2003.
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Abstract |
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Background. Research including patients from the entire tiredness spectrum in family practice is needed.
Objectives. Our aim was to provide routine family practice data on (i) relationships between the RFE (reason for encounter) and the diagnosis ‘tiredness’; (ii) duration, number of encounters and family physician’s (FP’s) interventions in episodes of care of tiredness; and (iii) sex/age and co-morbidity of patients diagnosed with ‘tiredness’.
Methods. Routine episode of care data from the Transition Project, coded comprehensively with the International Classification of Primary Care (ICPC), were used. (i) A 16 year database (1985–2000, 58 FPs, 504 145 episodes of care, 168 550 patient years) for calculating ‘prior probabilities’ with (diagnostic) odds ratios. (ii) A ‘basic population’ extracted from that 16 year database of patients listed for an entire 4 year period (1997–2000; n = 12 292).
Results. The RFE tiredness resulted in a variety of diagnoses, but most frequently (43%) in ‘tiredness’. Most odds ratios were low or negative. Of episodes of care of tiredness, 90% started with the RFE tiredness; 72% required one encounter only, and 90% lasted <6 months. In the 4 year period, 21% of patients first presented with tiredness, and 12% were diagnosed with tiredness; both groups were skewed towards women. Average co-morbidity in tired patients (16.6) was higher than in other visiting patients (10.4), and contained more tiredness-related conditions. FPs’ interventions were mainly blood test, physical exam and advice; few referrals occurred.
Conclusions. For many diagnoses, the RFE tiredness hardly contributes to the Bayesian posterior probability. FPs react differently to the RFE tiredness in cases in which they diagnose the patient with ‘tiredness’ from how they react in other cases. The characteristics of ICPC and the Dutch health care system resulted in a full integration of tiredness as an RFE and as a freestanding episode of care in the context of family practice.
Keywords. Episode of care, family practice, probability, reason for encounter, tiredness.
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Introduction |
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Tiredness is a frequent complaint in the population, and also, though less frequently, a reason for seeing a family physician (FP).1–4 Numerous studies have been undertaken into tiredness, also based on the expectation that chronic fatigue syndrome (CFS) would prove to be an important clinical entity, with an aetiology soon to be established. At present, CFS indeed is a new nosological entity (reported prevalences between 0.04 and 2.6 per 1000), with a considerable burden of disease, but without a proven aetiology other than patients’ behavioural change.1,5–7 This behavioural change is, at the same time, the basis for the only therapies with a proven utility: cognitive behavioural therapy (CBT) and graded exercise therapy (GET).7–11 The effect in time of both is, however, limited, and patients and FPs may have views (‘attributions’) of fatigue that may be an obstacle for them to see these treatments as feasible.12–18 Also, CBT and GET may be difficult to incorporate into daily family practice, since, by definition, it is unclear for quite some time whether a patient will eventually fulfil all diagnostic criteria of CFS, including "at least 6 months of disabling tiredness".
This is also stressed in two recent important publications on CFS. Both studies cite four CFS definitions, and the conclusion is that the superiority of one over another is not well established.5,6 The many remaining questions concerning definition, pathogenesis, treatment and severity of CFS are considered to be due largely to a lack of longitudinal studies. The authors therefore call for research including people representing the entire spectrum of tiredness, looking for differences in age/ gender, co-morbidity and functional impairment.
In their excellent historical and clinical perspective on CFS in the context of other syndrome diagnoses in which tiredness plays a role (post-traumatic stress disorder, neurasthenia, depressive and anxiety disorder), Wessely et al. stress the influence of the characteristics of health care systems on the incidence and course over time of these syndromes.1 This is, in fact, particularly well illustrated by the principled and fierce debates on the existence and definition of CFS.8 In this context, family practice has a special place, being at the crossroads of health care and the social security system, where a patient’s demand for care is transformed into a diagnosis that may or may not legitimize medical interventions and sickness absenteeism. As a consequence, morbidity data from family practice are an essential source for assessing the clinical consequences of tiredness in populations. This is especially true when data on co-morbidity are available, because tiredness can occur concomitantly with a variety of conditions.1,5,6,19,20
The aim of this study was to answer some of the remaining questions on chronic fatigue and CFS, by providing routine family practice data on:
- diagnoses in patients presenting with tiredness;
- reasons for encounter resulting in the diagnosis ‘tiredness’;
- patients complaining of and/or diagnosed with tiredness: frequencies, sex/age distribution, co-morbidity and FPs’ interventions.
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Methods |
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General description of the data
Since 1985, the members of the Transition Project of the Amsterdam University Department of Family Practice have been contributing to the episode-oriented epidemiology of family practice. In the Dutch health care system, all inhabitants are listed (registered) with an FP, and cannot, in principle, seek specialist care without their FP’s referral. Therefore, Dutch FPs document a close approximation of all episodes of care in the population.3,4
FPs participated for at least 1 year; the registration period ranged from 1 to 10 years (mean 2.4). The unit of data collection was the episode of care: "a health problem in an individual from the first encounter until the completion of the last encounter for it with a health care provider". For all episodes of care, the patient’s reason(s) for encounter (RFE), the diagnosis (episode title) and the FP’s intervention(s) were coded with the International Classification of Primary Care (ICPC), the classification designated by the World Organization of Family Doctors (WONCA) as the ordering principle of the family practice domain.21 Also, for each episode of care, FPs indicated its status: ‘new’ (start) or ‘old’ (follow-up). Obviously, episodes of care only reflect problems that led to a demand for care (consulting the FP), and the episode of illness (the patient’s illness experience) may last considerably longer than the episode of care, both before and after. The episode title (the diagnosis) could be modified; if that occurred, the final diagnosis was used in the analysis. The average yearly practice population served as the denominator.
Between 1985 and 2000, 58 FPs routinely coded data on 504 145 episodes of care in 168 550 patient years. Until 1995, coding occurred on self-copying encounter forms, for all face-to-face encounters. Since 1995, an electronic patient record (EPR), Transhis, has replaced this system and was used (1995–2000) by 10 FPs in five practices with a total listed population of 21 003 patients (80 244 patient years), for all direct and indirect encounters. The 1985–1995 reference database is available in Dutch on a CD-ROM attached to a family practice textbook.22 Both databases include, in a 1 year observation period, all combinations of RFEs, diagnoses and interventions for 14 standard sex/age groups, at the start of episodes and during follow-up, and co-morbidity data.
Data use and analysis
Data analysis occurred in conformity with the structure of encounters in episodes of care described in ICPC-2, and the definitions of the International Glossary for General/Family Practice were followed.23–25
Because of the need for a large database for the analysis of diagnoses resulting from the complaint tiredness, we used the 16 year database (1985–2000) for the calculation of ‘prior probabilities’ for the total population and for seven standard age groups, with 95% confidence intervals. In order to allow a better assessment of the data’s clinical utility, we added incidences standardized for the 2000 Dutch population. Also, we calculated positive and negative likelihood ratios, combined in (diagnostic) odds ratios. [We could calculate these Bayesian prior probabilities, because the population of 168 550 ‘patients’ (years) allowed the determination of 1 year incidences of RFEs and episodes of care]. Also in this 16 year database, the distribution of RFEs that led to an episode of care of tiredness was established.
Reliable information on episode duration, interventions and co-morbidity required long-term data, that were also free from the potential bias caused by patients joining or leaving the practice. Therefore, from the original database, a 4 year period (1997–2000) was selected (annual average of 17 850), from which we extracted a ‘basic population’ by excluding newborns, newly listed patients and patients who died or left the practice. The resulting database (n = 12 292) had, consequently, a well-defined denominator of patients listed for the full 4 year period. Age was calculated as that in the middle of the 4 year period.
We calculated frequency and sex/age distributions of the RFE tiredness at the start of episodes, of new episodes of care of tiredness, and of the interventions linked to both. For each new tiredness episode, the duration and number of encounters were established. Finally, we established aggregated co-morbidity in patients with a new tiredness episode by ICPC chapter (i.e. by body system/problem area), and prevalences of potentially tiredness-related conditions in the co-morbidity of tired and non-tired visiting patients.
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Results |
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The distribution of probabilities of diagnoses for patients starting an episode with the RFE tiredness is presented as a percentage for the 40 most frequent diagnoses (Table 1
; standard sex/age distribution not shown). The RFE tiredness resulted in a wide range of diagnostic labels, but by far most frequently (43%) in the diagnosis tiredness; for several diagnoses, major age differences existed.3 Most odds ratios (last column) were low or even negative; they were only 
2 for the symptom diagnosis tiredness (as high as 228!), viral disease not otherwise classified (NOS), infectious disease NOS, anaemia, infectious mononucleosis, depressive disorder and mental disorder NOS.
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The distribution of RFEs at the start of episodes of tiredness (n = 4971) shows that 89.4% began with the complaint tiredness, and 8.5% with a request for a blood test (data not shown). Here, the influence of age was rather limited.
The basic population contained data on 12 292 patients, 49 168 patient years and 125 781 episodes of care. In the 4 year period, 21% started a new episode of care with the RFE tiredness, and 12% were diagnosed with tiredness; both groups were skewed towards women (Table 2). Some patients started more than one episode with the RFE tiredness (2583 RFEs by 2018 patients), and some had more than one tiredness episode (1499 episodes in 1309 patients).
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The main interventions in episodes of tiredness were a blood test (often at the start), physical exam and advice; only a few referrals to a specialist occurred (Table 3
). The interventions linked to tiredness as an RFE differ from those linked to the episode: with the exception of a blood test at the start, almost all rates are higher for the RFE, especially for physical examination, medication at the start and referral to a specialist during follow-up. Table 4 shows that >90% of the tiredness episodes of care lasted <6 months, while 72% consisted of one encounter only.
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Patients with a new episode of tiredness had a wide variety of other diagnoses (Table 5
). Their average co-morbidity (total number of other episodes of care) in the 4 year observation period was 16.6, which is high compared with co-morbidity in the rest of the visiting basic population (10.4). Table 6 shows that the rates of potentially tiredness-related co-morbid conditions were approximately twice as high in the tired as in the rest of the visiting population (n = 10 222) for all conditions except malignancies and hypertension.
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Discussion |
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Of patients first presenting with tiredness, 43% are diagnosed with ‘tiredness’ (odds ratio 228). The wide variety of other resulting health problems illustrates that a patient presenting with tiredness may seem, indeed, "like opening up Pandora’s box".16 For a substantial number of diagnoses, the RFE tiredness does not contribute to posterior probabilities, when, in conformity with Bayes’ theorem, the prior distribution of the diagnosis in the population is taken into account (odds ratios
1). The diagnostic label of an episode of care could be modified at any time, and the last diagnosis was the final episode title. Therefore, the 1499 episodes represent cases in which—after all opportunities for modification, such as a blood test or a referral—no other diagnosis was found, and the tiredness was not attributed to another condition. The sex differences for both the RFE and the episode of care of tiredness are impressive. In agreement with other studies, we found that tiredness in family practice is skewed towards women.1,5,6 The literature is less unequivocal as to the effect of age.26 In this study, we found the highest rates in women aged 15–24 and >75 years; in fact, in these groups, tiredness as an RFE at the start of an episode occurred in 36 and 48%, respectively. Not surprisingly, episodes of tiredness often start with patients complaining of it. The relatively frequent requests for a blood test at the start of these episodes probably reflect blood tests with no abnormal findings.
It is an interesting finding that FPs immediately at the start of the episode react differently to the RFE tiredness in cases in which they diagnose the patient with ‘tiredness’: they do more blood tests, fewer physical exams and prescribe less, which would seem to indicate that they, from the start, see these cases as different. They seem to consider a simple blood test a cheap and harmless way to exclude various diseases, and to respond to explicit and implicit patients’ wishes. This response to tiredness has been described previously, and seems to be in line with recent advice.6,12
As a consequence of this approach or otherwise, the large majority of episodes of care of tiredness require one encounter only, and only 8.3% of episodes last >6 months (chronic fatigue). Of course, this does not imply that the complaints have disappeared, or even decreased. Apparently, most patients did not pursue their tiredness as a freestanding medical problem, even though they had every opportunity to do so in the context of their co-morbidity (on average, 16.6 other episodes of care in 4 years). Many medical problems in their co-morbidity are known to be a potential explanation for tiredness (e.g. depression, anxiety, sleeping problems). Both questions raised here (how do tired patients’ complaints develop over time, and what part of their co-morbidity could explain their tiredness) deserve further attention.
It can be concluded that the characteristics of the ICPC, and the Dutch health care system do accommodate a morbidity pattern where tiredness as an RFE and as a freestanding episode of care have been integrated. Clearly, the position of tiredness may be different, for example, in developing countries, where tiredness will be addressed primarily as a symptom of infectious, parasitic or nutritional diseases, and where tiredness as a freestanding episode would hardly result in social advantage or financial compensation. Also, in countries with a non-western culture (e.g. Japan), tiredness does not seem to fit the health care system.4 Nosological diagnoses often reflect a society’s culture rather than an underlying objective pathology.1 This is not to say, however, that complaints of tired patients should be disposed of as a mere cultural phenomenon not to be taken seriously: these patients might well suffer from major limitations in function, also in the context of their large co-morbidity.
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References |
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