Developing a clinical prediction rule for repeated consultations with functional somatic symptoms in primary care: a cohort study

Abstract

ObjectivesPatients who present in primary care with chronic functional somatic symptoms (FSS) have reduced quality of life and increased health care costs. Recognising these early is a challenge. The aim is to develop and internally validate a clinical prediction rule for repeated consultations with FSS.Design and settingRecords from the longitudinal population-based (‘Lifelines’) cohort study were linked to electronic health records from general practitioners (GPs).ParticipantsWe included patients consulting a GP with FSS within 1 year after baseline assessment in the Lifelines cohort.Outcome measuresThe outcome is repeated consultations with FSS, defined as ≥3 extra consultations for FSS within 1 year after the first consultation. Multivariable logistic regression, with bootstrapping for internal validation, was used to develop a risk prediction model from 14 literature-based predictors. Model discrimination, calibration and diagnostic accuracy were assessed.Results18 810 participants were identified by database linkage, of whom 2650 consulted a GP with FSS and 297 (11%) had ≥3 extra consultations. In the final multivariable model, older age, female sex, lack of healthy activity, presence of generalised anxiety disorder and higher number of GP consultations in the last year predicted repeated consultations. Discrimination after internal validation was 0.64 with a calibration slope of 0.95. The positive predictive value of patients with high scores on the model was 0.37 (0.29–0.47).ConclusionsSeveral theoretically suggested predisposing and precipitating predictors, including neuroticism and stressful life events, surprisingly failed to contribute to our final model. Moreover, this model mostly included general predictors of increased risk of repeated consultations among patients with FSS. The model discrimination and positive predictive values were insufficient and preclude clinical implementation.

Patients’ Characteristics and General Practitioners’ Management of Patients with Symptom Diagnoses

“…Our findings that persistent symptoms were more prevalent in females, older patients, patients with more comorbidities, patients who experienced abuse and with coexisting psychological symptoms correspond to other studies. 14,15,21,32,[34][35][36][37] In addition, in line with previous studies, patients with persistent symptoms had a lower socioeconomic status including lower rates of employment, 14,32 more coexisting social problems, 37 and a lower level of education. 21,32,37 In line with previous literature, we found that GPs prescribed medical prescriptions and referrals significantly more often when the symptoms were persistent.…”

The Predictors of Somatic Symptoms in a Population Sample: The Lifelines Cohort Study

“…Although a strong association between multiple somatic symptoms and mental disorder has been demonstrated previously in some studies in primary care attenders, these have generally been selected samples of patients with preexisting persistent symptoms, whereas the current study included a population-based sample, in which most participants did not have multiple somatic symptoms or preexisting mental disorders (25). A study of established cases of FSSs in the same data set as the current study found that among participants with two or more FSSs (who would have a high number of somatic symptoms), 15% had anxiety disorder and 29% had a mood disorder; that is, the majority of individuals with multiple somatic syndromes/symptoms did not have a mental disorder (31).…”

“…In particular, many studies have not controlled adequately for general medical disorders, which form an important predictor or correlate of multiple somatic symptoms (1,3,20,21). Clinicians, especially in primary care, are concerned to understand better the predictors of persistent somatic symptoms because these are associated with repeated consultations and a poor outcome (22)(23)(24)(25).…”