Review article
Prognosis of fatigue. A systematic review

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Abstract

Objective

The objective of the study was to summarize evidence on the course and prognostic factors of fatigue in primary care patients and in the community.

Methods

Two reviewers independently screened identified citations, discussed eligible studies, and assessed methodological quality of selected studies. Data concerning study population, duration of follow-up, measurement of fatigue, outcome, and prognostic factors were extracted. Studies with populations selected by a specific disease or postpartum condition were excluded.

Results

We selected 21 articles reporting on 11 (partly) primary care cohorts and six community cohorts. Follow-up was up to 1 year in primary care and up to 4 years in the community, and in most studies that presented duration of fatigue, participants were chronically fatigued. Because of wide heterogeneity of studies, a qualitative analysis was performed. Recovery of fatigue varied widely, but no differences were found between settings. Sufficient evidence for an association with recovery was found for lower severity of fatigue, and limited evidence was found for good self-reported health, mental health, and psychological attributions. A major deficit in methodological quality of most studies was a potential bias due to low or selective response or loss to follow-up.

Conclusion

Most studies on fatigue included patients with long symptom duration at baseline, making it difficult to study prognosis early in the course of fatigue. To provide clear evidence on prognosis in fatigued persons, prognostic studies should use an optimal design including selection of an inception cohort with limited duration of fatigue at baseline, a sufficient sample size, and information on rates and selectivity of response and loss to follow-up.

Introduction

Fatigue is common in the community and a frequently presented symptom in primary care. The 2-week prevalence in a community-based sample of 12,672 people was 36% [1]; in primary care, the annual incidence of fatigue presented as a symptom ranges from 1.5% to 2.6% [1], [2], [3], while a prevalence of 25% has been reported [4].

Fatigue is an intriguing phenomenon, which occurs in a variety of diseases and is seldom explained by a specific condition. When presented in primary care, general practitioners (GPs) focus on co-occurring symptoms and mostly adhere to a wait-and-see policy. However, identification of patients with a poor prognosis who need special attention is important. Therefore, information about prognostic factors is needed in order to better predict the course of fatigue in relevant subgroups of patients and subsequently facilitate management decisions.

Reviews on the prognosis of fatigue have focused mainly on selected patients, notably the chronic fatigue syndrome (CFS) [5], rather than fatigue as a common symptom in primary care or the general population. Joyce et al. [6] reviewed the literature on fatigue in 1996 in a wide variety of patient populations, but the majority of studies was hospital-based. They report on 10 studies of fatigue presented in primary care, which showed a wide variety in outcome, with recovery or improvement ranging from 22% to 97%. Limited evidence was presented on fatigue in the community. However, a major limitation of the review is that methodological quality of the studies was not taken into account.

The aim of this study was to perform a systematic review of the literature on the course of fatigue and to identify indicators of outcome in fatigued patients in primary care and in the community. Including community studies may provide more evidence on prognostic factors since we do not expect predictors of outcome to be much different in patients visiting the GP or not. As to the course, however, we expect that there is a difference between both populations, either in favor of consulting patients because of attention and management of their problem or in favor of those not visiting the GP because their fatigue might be less severe.

Section snippets

Identification and selection

Studies were identified by systematic searches of Medline (1966–October 2006), Psycinfo (1967–October 2006), and Embase (1966–October 2006). The search strategy consisted of key words and medical subject headings relating to fatigue, setting (general practice or community), and journal titles for general practice (Medline). Studies in English, Dutch, German, and French were included. Additionally, a Dutch journal for research in primary care (Huisarts en Wetenschap) was searched using the

Selection of studies

The search resulted in 3162 citations, of which 71 papers were retrieved after screening of title and abstract (Fig. 1). Twenty of these met our selection criteria. The main reason for exclusion at this stage was a cross-sectional design. One additional paper was identified by checking references of selected papers. Finally, 21 papers were included reporting on 17 studies. Four studies reported on primary care attenders presenting with symptoms of fatigue, and six reported on patients visiting

Main results

In primary care, only 4 out of 10 studies included a population of patients visiting their GP for fatigue. Recovery rates differed widely in studies concerning primary care attenders, whereas studies among patients presenting with fatigue and in the community showed a recovery rate ranging from 35% to 55%. Most studies showing lowest recovery rates (22–23%) had small sample sizes. Four studies, of which only one was conducted in primary care, reported a reasonable sample size and showed no

Acknowledgments

The authors would like to thank Ingrid Riphagen, Medical Information Specialist (Library VU University Medical Centre, Amsterdam) for her help with the search of the literature.

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