What is new?
Key findingDiagnostic labels applied in family practice can indicate the severity of physical health within categories of cardiovascular disease and musculoskeletal disorder.
What this adds to what was known?Although diagnostic variability has been shown to exist in family practice, our results support the concept that groups of consulters with the same diagnostic label as recorded in clinical encounters could be grouped into exclusive measures of severity.
What is the implication, what should change now?Our findings show the usefulness of routinely collected morbidity data as implicit indicators of severity. This method shows the potential for epidemiological construction of populations using morbidity data, the clinical implication supporting the potential for testing this method in clinical decision-making research.
A visit to family practice is marked by the application of a label summarizing the main presenting complaint. This label, usually attributed by the family practitioner (FP), determines the course of health care management or treatment [1]. For example, routine chronic disease clinics that monitor individual patients with conditions, such as diabetes [2] and ischemic heart disease [3], have their respective labels that provide key signposts for the health care management pathway of the patient [4].
The presenting complaint of the patient can fall within a wide spectrum of health, including nonspecific and self-limiting symptoms such as pain or infections or specific disorders such as anxiety or depression. Complaints can also relate to specific chronic conditions, including a number of potentially interlinking diseases affecting the same system (e.g., cardiovascular), a series of unrelated disorders (musculoskeletal), or spectrums which can include both disease and disorder.
The variation in the use of labels [5] can be dependent on both patient-related [6] and clinician-related [7] factors. Patients may present at different points as a result of changes in their health and clinical histories that may be specific or complex. Clinician choices can relate to (1) integration of complex information from a variety of sources, (2) imperfect or incomplete information, (3) the presence of uncertainty, and (4) complex interactions between the clinician and the patient [8]. In the end, the final choice of label at one time point could therefore relate to any stage along a disease or disorder spectrum (between onset and end stage). These labels in themselves will be either a “working diagnosis” (e.g., symptom-related only) or a definitive “diagnostic label” based on a combination of clinical assessment and further information, such as investigation. However, whether the choice of this label within the same spectrum of “diagnostic” possibilities reflects the severity as measured by health is unknown.
Chronic disease or disorder spectrums may comprise symptoms and pathologies that are related or unrelated to each other [9]. For example, in musculoskeletal disorders, diagnostic labels can range from pain symptoms that are regional [10] or widespread [11] to pathology that is localized such as osteoarthritis [12] or to more systemic conditions such as rheumatoid arthritis [13]. Notably the pain symptoms could either be self-limiting [14] or be part of an established chronic disease such as osteoarthritis [15]. In contrast, within cardiovascular diseases, current evidence has more clearly focused on a linked pathway in relation to development of this disease spectrum [16], [17]. Therefore, hypertension may be a preceding risk factor to myocardial infarction, which in turn can progress to end-stage heart failure in some individuals [18]. Yet, even within this spectrum, it is not clear as to how the stages of disease development can affect the patient population and whether this reflects the associated severity of general health [19].
From this current perspective of clinical encounters in family practice, we have taken two examples of chronic illness spectrums to identify two distinct questions: (1) do different labels that form the stages of a disease spectrum, that is, cardiovascular disease, reflect the associated health severity of the corresponding patient group, and (2) do different labels that form the stages of a disorder spectrum, that is, musculoskeletal disorder, also reflect the associated health severity of the corresponding patient group.