Health complaints in individual visiting primary health care: population-based national electronic health records of Iran

The fundamental role of general practitioners (GPs) in the health system as well as the specialized and sub-specialized training in hospitals has made the determination of common referrals to GPs one of the priorities of educational planning in medical schools [1, 2]. However, recently there have been concerns that GPs in the early years of work are not prepared to meet the expectations of society [3]. Therefore, the social accountability of the curriculum is to direct all medical educations towards training physicians who are able to meet the health needs of the target community. Meanwhile, one of the most important policies of the World Health Organization (WHO) is to educate the medical students to serve the patients and respond to their needs [4]. The contact of medical students with patients potentially provides an opportunity to develop their clinical reasoning, communication skills, and professional attitudes [5]. On the other hand, community-based and outcome-based medical education not only have an effective role in medical professions but also improve the health status of the society [6]. One of the most important progressions in health care of each community is the electronic health record (EHR). The use of a digital version of a person's overall medical history can considerably facilitate the upgrading of health care delivery and management [7]. Also, the exploitation of EHR under medical school leadership can guarantee the increase of students' skills to access the medical history and patients' care [8]. In Iran, the integrated health system (IHS) has been designed and implemented in order to maintain, and update the information of Iranian Patients' EHRs [9]. The initial version of the online system was presented to the Iran Ministry of Health and Medical Education (IMHME) in 2015 [9, 10]. Health policymakers as well as HCPs need epidemiological information from the community, including what happens at the first level of health care (FLHC) for further planning [11]. It plays a key role in providing services in many developed countries [12]. One of the best coding systems for primary care to classify topics by subject matter is the framework of the International Classification of Primary Care 2^nd edition (ICPC-2e-English) [13]. This coding system was successfully applied to primary care in different countries such as Australia, Canada, Germany, Netherlands, and Switzerland [13, 14]. It has a biaxial structure with 17 chapters, each divided into seven components including (i) symptoms and complaints, (ii) diagnostic, screening, and preventive measures, (iii) drugs, treatments, and procedures, (iv) clinical lab tests, (v) administrative, (vi) referrals and other reasons for encounter, and (vii) diseases [15]. On the other hand, the International Classification of Diseases, version 10 (ICD-10) system is more for hospital care and does not well explain the common ill-defined reasons in primary care [16, 17]. ICPC-2e can potentially provide the classification possibility of signs and complaints, which is very appropriate to the FLHC so that it allows the multiple coding for repeated visits of a patient with each complaint until the diagnosis and subsequent follow-up [17, 18]. Although outcome-based educational concepts into the field of medical education were earlier introduced, no comprehensive effort has been made so far to determine the expected outcomes of society from trained physicians. Also, there are limited studies concerning the most common clinical complaints of patients referring to primary health care (PHC) in Iran, whereas most studies were qualitative by relying on the opinions of experts. Therefore, the present study is aimed to classify the most common complaints of referring patients to Iran's comprehensive health service centers (CHSCs) recorded in the IHS from 2015–2020. Classifying the clinical complaints and providing community health priorities at the FLHC were conducted to plan educational programs for medical students by developing strategies and policies for the improved implementation and assessment of the program in the future.

Table 1 shows the description of clinical complaints of Iranian patients referred to CHSCs. 59% of the referring patients were women. The highest number of referrals was related to the age group of 18–59 years (56.9%), while the lowest belonged to the elderly (13.3%). Table 2 mentions priority of main complaints of population including general health issues and complaints, as well as involvements between different organs of the body. Each person had only one of these codes, and patients who had more than one complaint, the main complaint was in this list, but the rest of the complaints or requests were recorded in the list of problems in elsewhere. The most frequent referrals to the GPs present in CHSCs were for issues such as follow-ups and laboratory-clinical tests entitled “process codes (PCs)” (45.7%). Digestive (12.4%), respiratory (11.5%), and general/unspecified (9.7%) complaints were in the next ranks, respectively. Table 3 exhibits the priority of items present in PCs. The most frequent PC-related referrals to CHSCs were for reasons such as follow-up (24.1%), consult with primary care provider (18.9%), Laboratory Test and Results Exam (18.1%). The top priorities in the field of digestive complaints were teeth and gum complaints (45.6%), abdominal pains (19.6%), diarrhea (7.8%), abdominal pain epigastric (6.9%), and vomiting (5%), respectively. Most respiratory complaints included cough (40.8%) and throat symptom (30.6%). The most common general complaints were fever (66.2%), pain (general) (15.4%), weakness and fatigue (6.2%), as well as chills (4.7%), which were ranked in the fourth in the burden of referrals (Table 3). Table 4 shows the musculoskeletal (3.4%), endocrine/metabolic and nutritional (3.3%), cardiovascular (2.5%), neurological (2.3%), genital (2.1%), and skin (2%) complaints as the fifth to tenth priorities of complaints in Iranian patients referred to CHSCs. The most common reasons for referrals due to musculoskeletal complaints included back pain (38.4%), leg and knee complaints (26.9%), as well as muscle pain (6.6%). Nutritional, metabolic, and endocrine disorders with the main reasons such as weight gain (49.4%), feeding problem of adult (28.2%), and weight loss (7.4%) had the sixth rank among the referrals to the CHSCs (Table 4). Although hypertension, palpitation, hypotension, and swollen ankles were the most cardiovascular complaints in patients referred to CHSCs, 92.8% of referrals in this group were due to hypertension only. Headache (61%), dizziness (26.2%), and paralysis or numbness (8.2%) were considered to be the most common reasons for referrals with neurological complaints. According to the ICPC-2e coding system, sexual complaints of men and women were combined. Most sexual complaints are related to vaginal complaints (42.1%) and discharge (22.2%) in women and pain in testis/scrotum (0.9%) in men. Also, pruritus (26.7%), other skin complaints such as skin rash, dry skin, and cracked feet (26.3%) were the most frequent skin complaints among patients. Table 5 reveals patients' clinical complaints in the 11^th-16^th ranks including pregnancy-childbearing-family planning (1.3%), psychological (1.1%), eye (1%), urological (0.8%), ear (0.7%), and social problems (0.4%), respectively. The main corresponding disorders in these complaints were childbirth counseling in both sexes (71.5%), depression, stress, and anxiety (68.4%), itching and discharge from the eyes (71%), frequent urination and foul-smelling urine in both sexes (74.4%), earache (65.7%), and social-psychological complaints (97.8%), respectively. Figure 1 illustrates the clinical complaints of men and women referring to CHSCs. Based on sex stratification analysis, the first four clinical complaint types in men groups were PCs (42.2%), respiratory (14.2%), digestion (13.9%), and general/unspecified complaints (12.0%), whereas the corresponding data in women group were PCs (48.0%), digestive (11.4%), respiratory (9.7%), and general/unspecified (8.1%) complaints, respectively. Figure 2 depicts the prioritization of complaints of different age groups referring to CHSCs. In the age groups of 0–17 and 18–59 years, four main reasons to refer were PCs (35.3 and 49.1%), digestive (18.9 and 10.3%), respiratory (17.9 and 9.5%), and general/unspecified (15.0 and 7.7%) complaints (Fig. 2), in respective order. This order was in an agreement with the main complaints in men groups. It seems that a higher number of men in these age groups referred to CHSCs. In the age group of ≥ 60 years, PCs (53.9%), cardiovascular (10.6%), general/unspecified (6.6%), and digestive (6.5%) complaints were the top main reasons for referring to CHSCs (Fig. 2).

Awareness of community health priorities is a necessity to achieve the appropriate educational content for medical students. It is worth noting that the consequences of allocating health resources as well as diseases that can face social and economic challenges, play a role in determining the priorities of each community. These priorities are very helpful in the discussion of accountability of medical education which can well reflect the problems and needs of a society. Accordingly, the high prevalence of a disease and its high impact on the patient's life have been accepted as criteria for determining the need to learn diseases in the content of general medical education [21]. In the literature, there are diverse methods in different educational environments to achieve these priorities. At the University of Manchester, O'Neill et al. [22] earlier identified the necessary educational content in two stages using the opinions of GPs, clinical professors, health officials, and medical professionals. In the first stage, a list of clinical situations that GPs should be able to overcome alone, or with guidance, or with the help of a team was recognized. In the second stage, the educational content and the necessary skills and knowledge that GPs should have in dealing with these situations were determined with the help of all doctors and medical staff, as well as colleagues of health. At the University of Sheffield, Newble et al. [22] first prepared a list of clinical signs and symptoms of diseases using textbooks and medical school curricula in order to identify the necessary educational content. The common cases were then selected and prioritized with the opinions of university professors. Tandeter et al. [23] applied the Delphi method with the participation of 40 family physicians and medical instructors to determine the minimum content necessary for general medicine internship. After three Delphi stages, fifteen topics were identified as the most important items to be included in the curriculum. However, our studies were mainly based on the information obtained from Iran's IHS and not according to physicians' opinions.

These findings pave the way for future researches by comparison of the results from the real society with other studies based on opinions of physicians or experts. Finley et al. [24] showed that there was not only a difference between the statements of physicians and patients but also a discrepancy in the rate of PHC referrals between developed and developing countries. Nonetheless, this difference might be useful for the development of PHC guidelines, the allocation of resources, and the design of programs and curricula. On the other hand, it should be noted that this difference may be due to a lack of information in developing countries and therefore does not reflect reality. This fact may also be due to more or less accurate estimates of physicians, as well as their mistakes in diagnosing diseases like mental disorders [24]. There was not enough information about PHC referrals in Iran. This study helps the richness of information in the region and the country. Compared to a similar survey performed in other countries, there are a number of similarities and differences [25].

In the present research, items such as follow-up and request for medical consultation, lab test, digestive complaints such as abdominal pain, and respiratory complaints like cough were identified as priorities to be considered in the educational planning. In a study on referrals to family physicians for four years at the FLSD, the most important diagnoses among patients were hypertension (11.1%), upper respiratory tract infections (URTIs, 11.0%), physical examination (8.6%), diabetes (5.3%), sinusitis (4.8%), bronchitis (4.7%), degenerative joint disease (4.0%), asthma (3.7%), otitis (3.2%), and depression (2.9%), respectively [26]. Another study investigated the time required by physicians to provide preventive services to common chronic diseases at the FLSD. The results revealed that the ten most common chronic diseases included hyperlipidemia, hypertension, depression, asthma, diabetes, arthritis, anxiety, osteoporosis, chronic obstructive pulmonary disease, and coronary artery disease, respectively. Besides, each physician should daily allocate 3.5 working hours to provide preventive services [27]. A practice-based morbidity survey in Birmingham was conducted to examine changes in disease patterns at the FLHC using two disease record systems based on ICD-9 codes. The results showed an increase in gastrointestinal disorders, malignant and benign skin tumors, hypothyroidism, and diabetes. A general decrease in the prevalence of infectious diseases (e.g., conjunctivitis, ear infections, respiratory infections, etc.), acute myocardial infarction, heart failure, and injuries were also observed. This study emphasized the prominent role of GPs in the management of non-communicable diseases [28]. The difference between this study and ours was in the coding system. The goal of our study, was problem-based coding based on ICPC-2e in line with social accountability, but diagnosed disease based on ICD was not considered. However, gastrointestinal and respiratory disorders are among priorities in our results too. To design PHC-specific guidelines in India, 17 primary care centers were asked to report the most common diseases and administered drugs in prescriptions by physicians only with clinical diagnosis. Diseases recorded in order of prevalence included URTIs (45.3%, mainly colds, and acute sore throats), lower respiratory infections (15.9%, mostly bronchitis), parasitic infections (12.6%), anemia (11.4%), dyspepsia as well as ulcer (8.8%), and urinary tract infections (6.1%) [29]. The prevalence rate of URTIs with a high frequency in colds and sore throats was consistent with the present study.

A study in Malaysia compared the incidence and referral patterns of patients according to the top ten priorities of the main complaint and diagnosis in the private and public sectors of primary care using the ICPC-2e coding system over a working week [30]. There was a significant difference in terms of age and sex between the two groups so that the patients in the public sector were older and mostly women. In the public sector, the three main complaints of the patients were respiratory, general, and cardiovascular complaints, respectively. Most patients had chronic and complex diseases such as hypertension and diabetes, as well as pregnancy complaints. In the private sector, the three main complaints of primary care clients were respiratory, general, and digestive complaints, in respective order. It seems that most of the acute patients with respiratory and fever as well as patients with better general conditions had referred to the private sector [30]. When the priorities are compared between these same studies in other countries and our study, as coding system was done on ICPC-2e, there is more similarity including the priority of respiratory, general and digestive complaints in both studies.

In a consistent survey with the present study, Salvi et al. [31] assessed the health profile of all Indian patients throughout the country in all age groups at PHC level. The most common complaints in the general classification were fever (35.5%), headache-body pain (19.5%), loss of appetite (10.2%), and injuries (3.1%), respectively. In our study, fever, pain, and fatigue were also the first three priorities. In the different classification in different organs, the most common reasons for referrals were respiratory symptoms (50.6%), gastrointestinal (25.0%), blood (12.5%), cutaneous (9.0%), and endocrine (6.6%), respectively [31]. In our study, gastrointestinal and respiratory symptoms were in second and third ranks of clinical complaints after PCs.

The demographic composition in the present study is closer to the demographic composition of Iran population in the same period. According to official statistics, 22%, 20% and 40% of the Iranian population were ≤ 20, 21–59 and 60 years old and above, respectively [32]. Interestingly, compared to other groups, there was almost a higher rate of visits among the elder people, which is probably due to the proximity of these centers to the place of residence and the lower cost of services for the elderlies. In addition, women more than men referred to CHSCs. Most of the women referred are under 60 years old. The potential reason for the frequent visits of women is the high prevalence of genital problems, pregnancy, childbearing and family planning in health centers. This statistic is consistent with other studies [33].

The second and third priorities between them were different so that respiratory complaints were more common in men than women. Since these sex groups are different in biology, social roles, and responsibilities are different, due to different risk factors and needs, they will experience various morbidity and mortality. It will be important for policymakers to address these differences for population planning. Studies from different countries showed that health services and health costs were higher in women than men. Here, the burden of diseases should be considered as a significant component for using PHC services between the sexes. A retrospective descriptive study on 79,809 adults referred to PHC using health details in the EHR showed that the use of health services as a result of the higher disease incidence was more in women than men in all age groups. However, there was no significant difference between the two sexes in the use of services and the number of visits after being assigned to the age and burden of infection [34]. A retrospective study in the UK reviewed the non-emergency counseling of GPs and nurses working in the NHS system over a period of 7 years using data recorded in the EHR. Results showed that the number of patients, counseling, and its duration during this period was increased. The highest counseling rate in the age group of 0–4 and ≥ 85 years was observed. Similar to our results, women in all age groups referred more than men [35]. Salvi et al. [31] reported that men in all age groups and geographies referred more compared to women. They explained that this difference may be a result of the sex preference of men in Indian societies. As women and the elder people have the maximum need for health services, fewer reports in this study clearly showed the social inequality in India.

In our study, the first five complaints of Iranian patients were requests, gastrointestinal, respiratory, general, and musculoskeletal, respectively. However, these priorities in clinical complaints are different in other world’s countries due to the discrepancy in health systems, cultural differences, and the burden of disease. For example, pregnancy and family planning, blood/immunity complaints (e.g., HIV), as well as unknown general and neurological causes in South Africa were more prevalent among referrals. However, the same pattern was detected when the 52 most common symptoms/complaints in the Netherlands, Poland, Japan and the United States were compared to the 56 most common causes in South Africa. But, psychological complaints such as depression, anxiety, and sleep disorders beside common complaints in older people (e.g., vision and hearing complaints) were more in these countries compared to the South African. Complaints that appear on the South African list, possibly reflect the burden of HIV/AIDS and tuberculosis (e.g., weight loss, sweating, appetite loss, abnormal sputum, respiratory pain, and dysphagia), and sexually transmitted infections (e.g., genital/pelvic and vaginal pains). In addition, eye-ear infections (e.g., eye pain and discharge, redness of the eyes, and ear discharge), and trauma/injuries were very rare. This fact may indicate different disease loads in these areas [33].

The present study showed that items such as disease follow-up, consultation request, lab test, and digestive (e.g., abdominal pain) and respiratory (e.g., cough) complaints were identified as priorities to be considered in the educational content. Most patients for the mentioned priorities referred to CHSCs for treatment at the first level of health care. However, medical students spent most of their time in clinical education to learn approaches to refer patient with specified and defined diagnosis, while they did not experience visiting new patients with different signs and symptoms to find diagnose in the FLHC. This study in parallel with the assessment of health needs in Iran's healthcare centers indicates a necessity to partially modify the national pattern of patients' clinical complaints based on their recorded medical profile in the first level of health care. Accordingly, it would contribute to preparing a more comprehensive framework for medical education, educational planning and policy-making, curriculum development, and educational content. Given that the provision of health services in Iran is in line with the needs of society and reflects the socio-economic equality and proportional distribution of government subsidies, a newly developed approach can significantly improve the efficiency of the national programs, guidelines, and policies implemented in PHC for preventive cares.