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

Abstract

Patients with medically unexplained symptoms (MUS) are commonly referred to specialist clinics. Repeated referrals suggest unmet patient need and inefficient use of resources. How often does this happen, who are the patients and how are they referred? 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. 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. 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.