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

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Abstract

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.

Introduction

Many patients attending medical services have symptoms which cannot be adequately explained by organic disease, so-called medically unexplained symptoms (MUS) [1], [2]. This clinical description includes a range of symptom syndromes such as irritable bowel syndrome, fibromyalgia, and non-cardiac chest pain and tension type headache [3], [4], [5], [6]. Patients with MUS may be high users of medical services [7], [8], [9], [10], [11]: whilst some are high users of primary care [12], the greatest costs are incurred by those who are high users of secondary care. One cause of a high use of secondary care is the repeated referral to specialists by their primary care doctor [13]. Patients with MUS are however unlikely to benefit from such repeated referral as secondary care medical services are designed primarily to identify and treat disease whereas the patients with MUS: (a) are likely to have already had many previous negative investigations and are unlikely to be reassured by more tests [14] and (b) have symptoms that are more likely to be relieved by addressing causes other than disease, such as depression and anxiety [15].

The decision of the primary care doctor to refer a patient to secondary care is a critical and potentially modifiable step in increasing the costs of care. That is why this study focuses on referrals. Alternatives to repeated referral such as enhanced assessment and better treatment of depression and anxiety in primary care could potentially be more effective and cost-effective [16]. Therefore knowledge of the secondary care costs incurred by repeated referral indicates the potential savings that could be achieved by such an alternative management strategy.

We have reported elsewhere our findings on a novel sample of patients selected from a defined primary care population as having been repeatedly referred to secondary care (defined as at least three times in five years) where they had received repeated diagnoses of MUS. We found the prevalence of such patients to be approximately 1% (1.1%, 95%CI 1.0–1.2) of 26,252 patients aged between 18 and 65 years who were registered at one of five primary care practices [13]. Approximately half of these patients had an anxiety or depressive disorder [15].

In this paper we use data obtained from this sample together with standard cost estimates to estimate the costs incurred in the secondary care of such patients. In order to aid interpretation of these costs we compared them to those incurred by: (a) patients who had been infrequently referred; (b) patients who had been repeatedly referred for symptoms that the specialist had concluded were symptoms of disease (medically explained symptoms). The infrequently referred comparison group provides an indication of the savings that could be made by reducing the number of referrals. The repeated referral for medically explained symptoms (MES) comparison group provides an estimate of the costs of care of patients similarly frequently referred but with needs better served by disease focused secondary care.

Section snippets

Methods

The study was based in five National Health Service general primary care practices in Edinburgh, UK. The practices comprised 30 primary care doctors and 39,562 registered patients. Data collection took place between March 2003 and October 2005.

Participants

14,034 patients, representing 53% of the practices' population aged between 18 and 64, were identified in the hospital activity database as having had at least one referral to specialist medical care over the five-year study period. Fig. 1 shows the numbers at each stage of recruitment of the samples. 718 patients met our inclusion criteria for referrals for symptoms; of these 267 had been repeatedly referred for MUS; 221 had been infrequently referred and 230 had been repeatedly referred for

Main findings

This study examined referrals from primary to secondary medical care from a defined primary care population and found that the repeated referral of patients with symptoms deemed by the assessing specialist to be MUS incurs substantial costs. These costs are, not surprisingly, much higher than those incurred by patients who were infrequently referred; the difference allows an estimate of the maximum cost saving that could be made if the patients with MUS were only referred once. The overall cost

Conclusions

The repeated referral of patients with MUS from primary care to medical specialists generates high healthcare costs and is of dubious benefit to patients. There is consequently an urgent need to develop and evaluate potentially more cost-effective methods of identifying assessing and treating this important group of patients including the better assessment and treatment of depression and anxiety. This study quantifies the potential maximum savings that could be made.

Competing interests

All authors declare that they have no competing interests.

Acknowledgements

We wish to thank the staff of ISD for their collaboration, and the primary care staff and patients who took part in this study. We are grateful to Dr Andrew Walker for his advice on the design of the study. This work was supported by the Chief Scientist Office of the Scottish Government Health Directorate [CZH/4/37]; the funder had no involvement in the conduct or reporting of the study.

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