Beilby, Justin

Gialamas, Angela

Henning, Rhys

Marley, John E

Pratt, Nicole L

Roddick, John Francis

English

Flinders Academic Commons

Archived at the Flinders Academic Commons:  http://dspace.flinders.edu.au/dspace/  This is the publisher’s copyrighted version of this article.  The original can be found at: http://www.racgp.org.au/afp/200308/20030805gialamas.pdf © 2003 Australian Family Physician www.afp.org.au Copyright to Australian Family Physician. Reproduced with permission. Permission to reproduce must be sought from the publisher, The Royal Australian College of General Practitioners. Reprinted from Australian Family Physician Vol. 32, No. 8, August 2003 • 663Although tiredness is a commonsymptom among patients in generalpractice, it is rarely associated with seriousdisease.1–3 It is the seventeenth most fre-quent reason for a patient to consult anAustralian general practitioner4 and thefourth most common problem associatedwith pathology testing. The rate of orderingincreased from 300 test orders per 100 prob-lems in 1998–1999 to 355 in 2001–2002.4–7Nevertheless, tiredness does not rankamong the GP reported 30 most commonlymanaged problems in general practice.4–7The diagnostic challenge for the GP is todetect physical causes and serious diseasewithout excessive medical investigation. Tiredness can indicate a number ofphysical or psychological disorders. Almostany medical condition can cause tiredness.Psychosocial illnesses are the mostcommon causes.8–11 About half of consulta-tions with Australian GPs for tirednessresult in a pathology test (the mostcommon being a full blood examination).12Yet confirmation of diagnosis is rare.13–15There is limited Australian researchabout the appropriateness of pathologytests for tiredness, or the impact investi-gations have on patient management. InBritain, 33% of patients with tirednesshad one or more abnormal result from apathology test, but only 9% were clini-cally important.13We aimed to describe the use ofpathology ordering in patients who presentto the Australian GP with tiredness.MethodsWe retrospectively examined case notesaudited over seven years (1 April 1994 to25 April 2001) of patients enrolled in sixgeneral practices in South Australia,Western Australia, Victoria and theAustralian Capital Territory with com-puterised medical record systems. Clinicalinformation from participating practiceshas been consolidated into a comput-erised database (Medic-GP) of all patientclinical encounters including consultation,pathology investigations, diagnosticimaging and medications prescribed.16Anonymity of patient records was pre-served because patient names werereplaced by record numbers. Patients inthe Medic-GP database are representa-Investigating tiredness in Australian general practiceDo pathology tests help in diagnosis?Angela Gialamas, Justin J Beilby, Nicole L Pratt, Rhys Henning, John E Marley, John F RoddickAngela Gialamas, BHSc, is Project Officer, Department of General Practice, The University of Adelaide, South Australia.Justin J Beilby, MBBS, MD, FRACGP, is Professor of General Practice, Department of General Practice, The University of Adelaide, South Australia.Nicole L Pratt, BSc, is a statistician, Department of General Practice, The University of Adelaide, South Australia.Rhys Henning, MBBS, FRACGP, is General Practitioner Consultant, Rhylyn Pty Ltd.John E Marley, MD, MBChB, DA, FRACGP, FACRRM, is Pro Vice-Chancellor, The University of Newcastle, New SouthWales.John F Roddick, BSc, PhD, FACS, is Professor of Informatics and Engineering, Flinders University, South Australia.INTRODUCTION Tiredness is a common presentation in general practice for which pathology tests are commonlyordered. Our aim was to study their utilisation for tiredness.METHODS We examined an integrated database which contains the medical records for 58 139 patients and their 696518 associated general practitioner encounters. Three hundred and forty-two patients and their 1652 associatedencounters were randomly selected out of 12 291 patients and their 26 748 associated encounters that had mentionedtiredness (or a synonym). RESULTS One hundred and eighty-one patients (53%) had at least one pathology test ordered at any time in their episodeof care. Patients over 60 years of age, patients who consulted their GP more than once and patients without comorbiditywere more likely to have a pathology test ordered. Only 12 patients (3%) had a significant clinical diagnosis based onan abnormal pathology test. CONCLUSION Pathology testing for patients presenting with tiredness is high. Most tests do not yield a significant clinical diagnosis. 664 • Reprinted from Australian Family Physician Vol. 32, No. 8, August 2003tive of Australian general practice atten-dees, both by age and sex.17We searched the Medic-GP databasefor all patient visits using the key terms:tiredness, fatigue, weariness, weakness,lethargy or malaise, and individuallychecked them. Patients under five yearsof age were excluded. Trained data entry staff coded the rel-evant details (such as patientcomorbidities, other symptoms, pathologyinvestigations) using a controlled vocabu-lary list, to an episode of care (defined asthe period surrounding all care from startof the tiredness to its finish, or the end ofthe relevant care).18 Of the 58 139 patients included on thedatabase there were 12 291 patients withthe mention of at least one of the specifiedproblems. The prevalence of tiredness was21% of all patients included on the data-base. All records mentioning tiredness,fatigue, weariness, weakness, lethargy ormalaise were randomly sorted. We aimedto select 300 patients from the databasepresenting to their GP with tiredness.Previous studies of similar size were able todescribe the patient group and find statisti-cally and practically importantassociations.13–15 A random number genera-tor was used to select 345 patients and their1656 associated GP encounters for the casenote review but of these, three did not havesex specified in their case notes. As sex isan important factor when considering themanagement of tiredness these threepatients were excluded from all analysesand this paper reports on 342 patients andtheir 1652 associated GP encounters.Discrete variables were comparedusing the Pearson x2 test. We used logis-tic regression to determine the possiblepredictors of a patient having a pathologytest ordered (age, sex, number of visitsand whether there were any comorbidi-ties associated with the patient). ResultsTwo hundred and twenty (64%) werefemale; the mean age was 44 years (range6–90 years). The mean number of consul-tations for all patients with tiredness was4.8 (SD: 9.8), (range from 1–74 consulta-tions) and 189 patients (55%) consultingonce for tiredness. Female patients con-sulted the GP significantly morefrequently (p=0.014) (Table 1). Thoseover 60 years of age consulted the GPwith tiredness significantly more thanyounger patients (p=0.009). There were 161 (47%) patients whohad no pathology ordered at any time;181 (53%) who had at least one. At leastone pathology test was ordered for 125(57%) females compared to 56 (46%)males (p=0.053). Patients Ž60 years weresignificantly more likely to have a pathol-ogy test ordered (p<0.001), and to havetheir first pathology test on a visit otherthan their first visit, than those aged30–59 and Ž29 years (p=0.002). Most, 121 (67%) patients, had apathology test ordered in the first visit, 25(14%) not until a second visit, 8 (4%) at athird visit, and 27 (15%) after that. SexTable 2. Association between age, sex, number of visits and comorbidity, of patients with tiredness havinga pathology test ordered n % Total *Adjusted 95% CI Unadjusted 95% CIodds ratio odds ratioSex Female 220 64 342 1.1 0.7 1.9 1.5 0.9 2.4Male 122 36 – – – – – – –Age <29 years 92 27 342 – – – – – –30–59 years 163 48 – 2.4 1.3 4.3 2.0 1.1 3.3>60 years 87 25 – 2.8 1.4 5.5 2.9 1.6 5.4Number of visits 1 visit 189 55 342 7.2 4.2 12.5 5.0 3.1 8.0>2 visits 153 45 – – – – – – –Comorbidities No 87 25 342 4.0 2.2 2.3 1.7 1.1 2.9Yes 255 75 – – – – – – –* Adjusted for sex, age, number of visits and comorbiditiesTable 1. Frequency of consultation for tiredness by sex Number of visits to the GP Female Male Total1 visit 109 (49%) 80 (65%) 189 (55%)2–4 visits 70 (32%) 29 (24%) 99 (29%)Ž5 visits 41 (19%) 13 (11%) 54 (16%)Total 220 (100%) 122 (100%) 342 (100%)Reprinted from Australian Family Physician Vol. 32, No. 8, August 2003 • 665(38, 68% males compared to 83, 66%females) had no significant effect onhaving a test ordered at the first visit. Logistic regression for independentpredictors showed that patients aged over60 years of age were 2.8 times more likelyto have a pathology test compared toyounger patients; those who consulted theGP more than once were 7.2 times morelikely to have a pathology test, and thosewithout a comorbidity were 4.0 times morelikely to have a pathology test (Table 2). There were 1183 pathology testsordered. Most patients had between oneand six tests (Table 3). Table 3. Type of pathology tests orderedPathology test n % n abnormal pathology resulting in significant clinical diagnosisFull blood examination 316 26.7% 4Urea, electrolytes and creatinine 214 18.1% 4Thyroid function test 139 11.7% 2Liver function test 129 10.9% 2Blood glucose test 109 9.2% 2Erythrocyte sedimentation rate 103 8.7% 0Iron studies 85 7.2% 2B12 54 4.6% 0Folate 34 2.9% 0Total 1183 100% 16Table 4. Number of tests performed per patient that were normal or abnormal by typed test Number of abnormal tests for each patientTyped test Number of times tests 0 1 2 3 4 Totalperformed per patient n n n n n nFull blood examination 1 217 18 – – – 2352 8 9 4 213 1 3 4 1 – 94 – – 1 2 – 3Urea, electrolytes, 1 136 14 – – – 150creatinine 2 1 3 11 – – 153 – 2 2 6 – 104 – – – – 1 1Thyroid function test* 1 109 6 – – – 1152 7 – – – – 73 – – 1 1 – 24 1 – – – – 1Liver function test 1 97 5 – – – 1022 2 2 2 – – 63 1 1 1 2 – 5Erythrocyte 1 64 39 – – – 103sedimentation rateIron studies 1 45 9 – – – 542 4 3 1 – – 83 1 – 4 – – 5Blood glucose 1 96 7 – – – 1032 2 1 – – – 3B12 1 54 – – – – 54Folate 1 34 – – – – 34Total 880 122 31 12 1 1046* Note: Eight patients had an abnormal thyroid function test, but only two patients had a new and active diagnosis of thyroid disease. (The other sixhad a past history of thyroid disease being monitored by the GP) 666 • Reprinted from Australian Family Physician Vol. 32, No. 8, August 2003Of the 1183 pathology tests orderedthere were only 1046 corresponding testresults recorded. The laboratory recordsof 137 tests were incomplete, and there-fore could not be coded; 880 (84%) testswere normal with only 166 (16%) deemedabnormal (Table 4). Only 12 patients (4%of 342 patients sampled) had a significantclinical diagnosis made because of anabnormal pathology test, two of whichwere separate diagnoses (renal failureand diabetes mellitus, nephropathy andhepatitis). Overall the diagnoses based onan abnormal pathology test includedanaemia (3), diabetes mellitus (2), renalfailure (2), glandular fever (1), goiter (1),hepatitis (1), HIV infection (1),hypokalaemia (1), hypothyroidism (1),and nephropathy (1). Of patients who hadno pathology ordered, 16 (5%) had a sig-nificant clinical diagnosis identified, and51 (15%) had no clinical diagnosis identi-fied in their episode of care.DiscussionWas the sample representative? The GPswere self selected and providing patientmedical records for more than 10 years. It seems unlikely that information biascould have influenced the results. We showed that the majority ofpatients have a pathology test ordered onthe first visit to the GP, although only asmall number have a new diagnosisderived from an abnormal pathology test.Those with no pathology ordered were aslikely to be given a new diagnosis as thosewho had pathology ordered. Our findings confirm previous workelsewhere.13–15 The three most likely diag-noses seem to be anaemia, diabetesmellitus and hypothyroidism; and themost useful pathology tests are the fullblood examination, blood glucose test andthe urea, electrolytes and creatinine test.We could identify no Australian guide-lines for investigating tiredness in generalpractice. The Dutch College of GeneralPractitioners recommends postponingblood tests for patients presenting withvague medical conditions for one month.19More research to elucidate the predic-tors of patients with important medicalproblems is required to begin the processof defining appropriate guidelines anddecision support tools for the problem oftiredness in Australian general practice.AcknowledgmentsThanks to both Heather McElroy whoprovided statistical advice and comment andGillian Laven in the Department of GeneralPractice, The University of Adelaide whoprovided editorial comment. Thanks to theparticipating GPs and the CommonwealthDepartment of Health and Aged Care for thefinancial support. Ethics approval wasobtained from the University of Adelaide.Conflict of interest: none declared.References1. De Rijik A, Schreurs K G, Bensing J.General practitioners’ attributions offatigue. Soc Sci Med 1998; 47:487–496.2. Murtagh J. Making fatigue less tiresome.Med J Aust 1996; 164:580–581.3. Ridsdale L. Tired all the time. BMJ 1991;303:1490–1491.4. Britt H, Miller GC, Knox S, et al. Generalpractice activity in Australia 2001-2002.Canberra: Australian Institute of Healthand Welfare, 2002.5. Britt H, Sayer G P, Miller G C, et al.General practice activity in Australia1998-1999. Canberra: Australian Instituteof Health and Welfare, 1999.6. Brit t  H, Miller G C, Charles J ,  et al.General practice activity in Australia1999-2000. Canberra: Australian Instituteof Health and Welfare, 2000.7. Britt H, Miller G C, Knox S, et al. Generalpractice activity in Australia 2000-2001.Canberra: Australian Institute of Healthand Welfare, 2001.8. David A, Pelosi A, McDonald E, et al.Tired, weak or in need of rest: fatigueamong general practice attenders. BMJ1990; 301:1199–1202.9. Knottnerus J, Knipschild P G, van Wersch JW J, Sijstermanns A H J. Unexplainedfatigue and hemoglobin: A primary carestudy. Can Fam Physician 1986;32:1601–1604.10. Llewelyn M. Assessing the fatigued patient.Br J Hosp Med 1996; 55:125–129.11. Ridsdale L, Evans A, Jerrett W, Mandalia S,Osler K, Vora H. Patients who consult withtiredness: Frequency of consultation, per-ceived causes of t iredness and itsassociation with psychological distress. BrJ Gen Pract 1994; 44:413–416.12. Britt H, Miller G C, McGeechan K, SayerG P. Pathology ordering by general practi-tioners in Australia 1998. AIHW Cat. No.GEP 4. Canberra: Department of Healthand Aged Care, 1999. 13. Ridsdale L, Evans A, Jerrett W, Mandalia S,Osler K, Vora H. Patients with fatigue ingeneral practice: A prospective study. BMJ1993; 307:103–106.14. Jerrett W. Lethargy in general practice. ThePractitioner 1981; 225:731–737.15. Morrison J. Fatigue as a presenting com-plaint in family practice. J Fam Pract 1980;10:795–801.16. Beilby J J ,  Marley J E, Walker D C,Duszynski K M. Medic-GP: An example ofan observational, pharmacoepidemiologi-cal database. Pharmacoepidemiol Drug Saf2001; 9:S34.17. Beilby J J ,  Marley J E, Walker D C,Chamberlain N L, Burke M. Effect ofchanges in antibiotic prescribing onpatient outcomes in a community setting:a natural experiment in Australia. ClinInfect Dis 2002; 34:55–64.18. Lamberts H, Hofmans-Okkkes I. Episode ofcare: A core concept in family practice. JFam Pract 1996; 42:161–167.19. Dinant G J, van Wijk M A M, Janssens H JE M, et al. NHG-standaard bloedonder-zoek. Algemene principes en uitvoering ineigen beheer. (Dutch College of GeneralPractitioners guidelines for blood tests.General principles and testing in ownpractice.) Huisarts Wet 1994; 37:202–211. Implications of this studyfor general practice• Most use of pathology isunproductive.• There are no guidelines about itsbest approach to investigation inAustralian general practice.• Only 5% of patients with tirednesshave a clinical diagnosis derivedfrom an abnormal pathology test.• The most useful pathology tests are:– full blood examination– blood glucose test– urea, electrolytes and creatininetest.CorrespondenceEmail: angela.gialamas@adelaide.edu.auAFP

Investigating tiredness in Australian general
            practice. Do pathology tests help in diagnosis?

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Investigating tiredness in Australian general practice. Do pathology tests help in diagnosis?

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