Change of Approach in Testing for Fatigue

With fatigue complaints constituting about 3-7% of all presentations to general practitioners, NPS MedicineWise has launched a new program titled Back to basics for fatigue: a diagnostic approach to aid health professionals in understanding the limits and appropriate uses of fatigue-related tests.
Presently, 76% of GPs surveyed by NPS MedicineWise said they would often or always have patients sent for pathology tests on presentation of fatigue for the first time. There is no specific test for fatigue so investigations need to be used selectively, keeping in mind the clinical context.
The new program from NPS MedicineWise is underpinned by Therapeutic Guidelines Limited’s* Fatigue: diagnostic approach in primary care. It provides a framework for assessing, and diagnosing focusing on a comprehensive clinical history, targeted examination and judicious laboratory investigations.  While addressing more common presentations of fatigue, the program also refers to the various ‘red flags’ which may indicate more serious pathology.
NPS MedicineWise clinical advisor Dr Andrew Boyden says fatigue is common but can be difficult to define as the experience of fatigue can be different for everyone.
“Some patients refer to being ‘tired’, ‘sluggish’, ‘run-down’ or ‘lethargic’. It can be an enduring feeling of tiredness that may not be adequately relieved by rest or sleep,” says Dr Boyden. “Fatigue can often be managed by addressing a patient’s underlying causes which may be a combination of lifestyle, psychosocial and physical issues. It is also a symptom that may remain unexplained but in the vast majority of presentations is uncomplicated and self-limiting," Dr Boyden said.
Many patients expect pathology tests to be ordered by their doctors to investigate their fatigue. Fatigue was the sixth most common reason for pathology testing in 2011-12, requested in up to 70% of GP visits for fatigue with an average of four tests undertaken at a time. In a recent survey of 501 GPs, NPS MedicineWise found:

•   52% of participating GPs agreed or strongly agreed that patient expectation of a diagnosis influenced their decisions about the use of pathology tests to investigate fatigue symptoms


•  76% indicated they would always or often refer patients for pathology when they presented with fatigue for the first time with no specific features raising suspicion of an underlying condition


•  47% always or in most situations order a diagnostic test for the primary purpose of patient reassurance.

While clinicians of course will wish to exclude potential serious causes of fatigue, there are risks associated with over-testing.
“Requesting pathology when there is a low pre-test probability of disease increases the chance of a false positive result—with subsequent potential detrimental flow on effects—compared to when a higher pre-test probability of disease has been determined on the basis of clinical assessment,” Dr Boyden said.
“While serious conditions do need to be excluded, it is important to communicate with patients that they may not need pathology testing— at least in the first instance—and their fatigue may be addressed by managing lifestyle, psychosocial and physical causes. Fatigue is often not associated with underlying disease and may remain unexplained.”