Identifying chronic widespread pain in primary care: a medical record database study

Abstract

Chronic widespread pain (CWP) is common and associated with poor health. In general practice no morbidity code for CWP exists. By identifying patients in medical records consulting regularly over five years with multiple individual regional (axial, upper limb, lower limb) problems, a previous study identified patients in one practice with features consistent with CWP. This suggests patients regularly consult for regional pains without being recognised, or managed, as having a generalised condition. The original criteria for identifying these recurrent regional consulters (RRCs) had limitations including a restricted set of musculoskeletal morbidity codes.

This thesis aimed to develop the existing RRC definition, determine characteristics of RRCs, and assess the extent of unrecognised CWP in primary care. The study was set in: i) a general practice database; ii) a cohort with linked self-reported health and medical records. RRCs were identified using different code lists, over altered timeframes, and with a varied number of recorded body regions. Three-quarters of RRCs were not recorded with a generalised pain code related to CWP (e.g. fibromyalgia) and are therefore potentially unrecognised as having a generalised pain condition. Recorded prevalence of recognised CWP was lower than community CWP prevalence, suggesting CWP is under-recognised in primary care.

The new approach to identifying RRCs, using all regional musculoskeletal Read codes and identifying patients prospectively between three and five years from an index musculoskeletal consultation, identified more patients earlier, and returned patients with features consistent with self-reporting of CWP (e.g. increased somatic symptoms, frequent consultation, worse general health). However, RRC prevalence overestimated CWP prevalence and not all RRCs self-reported CWP, suggesting the RRC criteria identified a heterogeneous group of frequent consulters sharing features with CWP, including those less severely affected who do not necessarily fit established CWP criteria. They nonetheless lie on the spectrum of polysymptomatic distress characteristic of CWP.