Ordering blood tests for patients with unexplained fatigue in general practice- Koch

Dolphin

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I don't find this paper that exciting but thought I'd post it so could post a nice little response I came across from a patient:

Br J Gen Pract. 2009 Apr;59(561):e93-100.

Ordering blood tests for patients with unexplained fatigue in general practice: what does it yield? Results of the VAMPIRE trial.

Koch H, van Bokhoven MA, ter Riet G, van Alphen-Jager JT, van der Weijden T, Dinant GJ, Bindels PJ.

Academic Medical Center-University of Amsterdam, Division of Clinical Methods and Public Health, Department of General Practice, Amsterdam, the Netherlands. h.koch@amc.uva.nl

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Br J Gen Pract. 2009 Apr;59(561):237-9.

BACKGROUND: Unexplained fatigue is frequently encountered in general practice. Because of the low prior probability of underlying somatic pathology, the positive predictive value of abnormal (blood) test results is limited in such patients. AIM: The study objectives were to investigate the relationship between established diagnoses and the occurrence of abnormal blood test results among patients with unexplained fatigue; to survey the effects of the postponement of test ordering on this relationship; and to explore consultation-related determinants of abnormal test results.

DESIGN OF STUDY: Cluster randomised trial.

SETTING: General practices of 91 GPs in the Netherlands.

METHOD: GPs were randomised to immediate or postponed blood-test ordering. Patients with new unexplained fatigue were included. Limited and expanded sets of blood tests were ordered either immediately or after 4 weeks. Diagnoses during the 1-year follow-up period were extracted from medical records. Two-by-two tables were generated. To establish independent determinants of abnormal test results, a multivariate logistic regression model was used.

RESULTS: Data of 325 patients were analysed (71% women; mean age 41 years). Eight per cent of patients had a somatic illness that was detectable by blood-test ordering. The number of false-positive test results increased in particular in the expanded test set. Patients rarely re-consulted after 4 weeks. Test postponement did not affect the distribution of patients over the two-by-two tables. No independent consultation-related determinants of abnormal test results were found.

CONCLUSION: Results support restricting the number of tests ordered because of the increased risk of false-positive test results from expanded test sets. Although the number of re-consulting patients was small, the data do not refute the advice to postpone blood-test ordering for medical reasons in patients with unexplained fatigue in general practice.
 

Dolphin

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Basically a diagnosis of Crohns' was missed

Basically a diagnosis of Crohns' was missed

Date: 3 April 2009

Topic: Response to: Ordering blood tests for patients with unexplained fatigue in general practice: what does it yield? Results of the VAMPIRE trial

Comments by: Jacqui Footman BA(Hons) PGCE, Information Officer, South Molton ME Support Group, North Devon


I am concerned that this article by Koch et al1 may discourage GPs from thorough testing for patients with CFS/ME. At the ME Research UK conference in 2008 Dr Gavin Spickett, consultant leading one of the NHS specialist CFS/ME services, stated that significant numbers of patients referred to the service in fact turned out to have other (more treatable) conditions.



I have a particular and personal interest in this topic in so far as I languished under a diagnosis of CFS/ME for 4 years without further medical testing. I did receive what could be considered the best NHS care currently available for CFS/ME but nevertheless in my prime at age 43 waved goodbye to a promising teaching/management career. I was subsequently found (sort of by accident) to have Crohn's disease, which had clearly gone undiagnosed for many years.



When lupus tests had come back negative, raised plasma viscosity tests had been ignored as unexplainable and few further tests done for several years. Now, some months on from an ileal resection (but after 5 years on Incapacity Benefit) I am eventually less disabled by fatigue. With testing, I recently discovered I also have osteoporosis and low Vitamin D. Many patients with chronic pain are being found to have low vitamin D, and what a simple thing to resolve once the test is done! How much better would my bone density now be if I had been tested and treated 5 years sooner?



I write to urge GPs to take testing and investigation more seriously and to avoid jumping to conclusions of somatoform illness, particularly when fatigue extends to CFS/ME, in order to help prevent further tragic and possibly avoidable losses. Most patient support groups recommend Health Canada's Clinical Guideline for help with this.2



References

1. Koch H, van Bokhoven M, ter Riet G, van Alphen-Jager JMT, van der Weijden T, Dinant G-J, Bindels P. Ordering blood tests for patients with unexplained fatigue in general practice: what does it yield? Results of the VAMPIRE trial. Br J Gen Pract 2009; 59(561):e93-e100. View abstract online.

2. Carruthers et al. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols. J Chronic Fatigue Syndrome 2003; 11(1). Overview available at http://www.mefmaction.net/Patients/Overviews/tabid/122/Default.aspx