Kelly McGorm

Patients repeatedly referred to secondary care with symptoms unexplained by organic disease: prevalence, characteristics and referral pattern

BACKGROUND Patients with medically unexplained symptoms (MUS) are commonly referred to specialist clinics. Repeated referrals suggest unmet patient need and inefficient use of resources. OBJECTIVES How often does this happen, who are the patients and how are they referred? METHODS The design of the study is a case-control survey. The setting of the study is five general practices in Scotland, UK. The cases were 193 adults with three or more referrals over 5 years, at least two of which resulted in a diagnosis of MUS. The controls were (i) patients referred only once over 5 years and (ii) patients with three or more referrals with symptoms always diagnosed as medically explained. The measures of the study are SF-12 physical and mental component summaries; symptom count; and number of referrals, number of different GPs who had referred and number of specialist follow-up appointments. RESULTS A total of 1.1% [95% confidence interval (CI) 1.0-1.2%] of patients had repeated (median 3, range 2-6) referrals with MUS. Compared to infrequently referred controls, they were older and more likely to be female, living alone and unemployed. Compared to controls with medically explained symptoms, their health status was comparable or worse: odds ratio for SF-12 physical component summary<40, 1.2 (95% CI 0.72-2.0); SF-12 mental component summary<40, 1.8 (95% CI 1.1-3.0); reporting eight or more physical symptoms, 2.2 (95% CI 1.2-3.8). They were referred by more GPs and received less specialist follow-up. CONCLUSIONS A small proportion of primary care patients are repeatedly referred to specialist clinics where they receive multiple diagnoses of MUS. The needs of these patients and how they are managed merits greater attention.

Healthcare costs incurred by patients repeatedly referred to secondary medical care with medically unexplained symptoms: A cost of illness study

BACKGROUND Some patients are repeatedly referred from primary to secondary care with medically unexplained symptoms (MUS). We aimed to estimate the healthcare costs incurred by such referrals and to compare them with those incurred by other referred patients from the same defined primary care sample. METHODS Using a referral database and case note review, all adult patients aged less than 65 years, who had been referred to specialist medical services from one of five UK National Health Service primary care practices in a five-year period, were identified. They were placed in one of three groups: (i) repeatedly referred with MUS (N=276); (ii) infrequently referred (IRS, N=221), (iii) repeatedly referred with medically explained symptoms (N=230). Secondary care activities for each group (inpatient days, outpatient appointments, emergency department attendances and investigations) were identified from primary care records. The associated costs were allocated using summary data and the costs for each group compared. RESULTS Patients who had been repeatedly referred with MUS had higher mean inpatient, outpatient and emergency department costs than those infrequently referred (£3,539, 95% CI 1458 to 5621, £778 CI 705 to 852 and £99, CI 74 to 123 respectively. The mean overall costs were similar to those of patients who had been repeatedly referred with medically explained symptoms. CONCLUSIONS The repeated referral of patients with MUS to secondary medical care incurs substantial healthcare costs. An alternative form of management that reduces such referrals offers potential cost savings.

Depression and anxiety in patients repeatedly referred to secondary care with medically unexplained symptoms: a case-control study

BACKGROUND One third of referrals from primary to secondary care are for medically unexplained symptoms (MUS). We aimed to determine the association of depression and anxiety disorders with high use of specialist services by patients with MUS. We did this by comparing their prevalence in patients who had been repeatedly referred with symptoms for which they had received repeated specialist diagnoses of MUS with that in two control groups. We also determined the adequacy of treatment received. METHOD A case-control study in five general practices in Edinburgh, UK. Data collection was by case note review and questionnaire. Cases were 193 adults with three or more referrals over 5 years, at least two of which resulted in a diagnosis of MUS. Controls were: (a) patients referred only once over 5 years (n=152); (b) patients with three or more referrals for symptoms always diagnosed as medically explained (n=162). RESULTS In total, 93 (48%) of the cases met our criteria for current depression, anxiety or panic disorders. This compared with 38 (25%) and 52 (35.2%) of the control groups; odds ratios (95% confidence intervals) of 2.6 (1.6-4.1) and 1.6 (1.01-2.4), respectively. Almost half (44%) of the cases with current depression or anxiety had not received recent minimum effective therapy. CONCLUSIONS Depression, anxiety and panic disorders are common in patients repeatedly referred to hospital with MUS. Improving the recognition and treatment of these disorders in these patients has the potential to provide better, more appropriate and more cost-effective medical care.