Treatment of Chronic Diseases and Symptoms of Unknown Etiology in the General Medicine Ward of a Tertiary Comprehensive Hospital in Beijing

PANG Shu, CHEN Xiangxue, DIAO Yang, WANG Yini, JIANG Chunyan*

Department of General Practice, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China

*Corresponding author: JIANG Chunyan, Professor/Doctoral supervisor; E-mail: jchy12368@sina.com

Abstract

Background: Under the government's great emphasis on developing general practice, tertiary comprehensive hospitals have successively established general practice departments. The disciplinary characteristics of general practice confer significant advantages in the management of chronic diseases and symptoms of unknown etiology. However, the current status of admitting and managing such conditions in general medicine wards of tertiary comprehensive hospitals remains unclear.

Objective: To investigate the admission and management of chronic diseases and symptoms of unknown etiology in the general medicine ward of a tertiary comprehensive hospital, analyze existing problems, and explore directions for continuously improving management quality and efficiency.

Methods: Using the general medicine ward of Beijing Friendship Hospital, Capital Medical University as an example, we extracted clinical data of all inpatients from the electronic medical record system in February 2024, covering the period since the ward's establishment (November 2019 to January 2024). We retrospectively analyzed patients' general characteristics, admission sources, admission diagnoses, hospitalization management, discharge diagnoses, and outcomes.

Results: A total of 2,725 hospitalization episodes were included. Patient ages ranged from 12 to 95 years, with a mean age of (57.4±15.8) years; 1,400 episodes (51.38%) involved patients aged ≥60 years. The median length of stay was 7 (5, 9) days, and the median hospitalization cost was 9,053.71 (6,551.53, 12,380.82) yuan. Admissions came from general outpatient clinics in 1,724 episodes (63.27%) and from emergency departments or specialty transfers in 1,001 episodes (36.73%). The top three admission diagnoses were acute pancreatitis (9.06%), abdominal pain of unknown etiology (7.41%), and pneumonia (7.30%). Chronic diseases were present in 1,899 episodes (69.69%), multimorbidity in 1,085 episodes (39.81%), and polypharmacy in 1,016 episodes (37.18%). At admission, 1,658 episodes (60.84%) had a clear diagnosis, while 1,067 episodes (39.16%) were admitted with symptoms of unknown etiology. The top three such symptoms were abdominal pain (7.41%), dizziness (5.43%), and abdominal distension (5.03%). The five most common systems for principal discharge diagnoses were digestive (1,166 episodes, 42.79%), respiratory (334 episodes, 12.26%), endocrine (317 episodes, 11.63%), cardiovascular (279 episodes, 10.24%), and hematologic (176 episodes, 6.46%). The ten most frequent principal discharge diagnoses were acute pancreatitis (249 episodes, 9.14%), pneumonia (238 episodes, 8.73%), chronic gastritis (220 episodes, 8.07%), type 2 diabetes with chronic complications (175 episodes, 6.42%), acute cholecystitis (174 episodes, 6.39%), malignant tumors (154 episodes, 5.65%), hypertension (109 episodes, 4.00%), coronary atherosclerotic heart disease (73 episodes, 2.68%), colorectal polyps (62 episodes, 2.28%), and thyroid nodules (59 episodes, 2.17%). After treatment, 2,411 episodes (88.48%) resulted in improvement and discharge, while 96 episodes (3.52%) were transferred to specialty departments after definitive diagnosis. Hospitalization costs were higher for patients admitted with symptoms of unknown etiology compared to those with clear diagnoses at admission (P<0.05), with no significant difference in length of stay (P>0.05). Both length of stay and costs were higher for patients with chronic diseases (P<0.05) and for those with multimorbidity (P<0.05).

Conclusion: Inpatients in the general medicine ward of this Beijing tertiary comprehensive hospital covered a wide age range, with most aged ≥60 years. The disease spectrum involved common conditions across multiple systems, chronic diseases, and symptoms of unknown etiology, with frequent multimorbidity and polypharmacy, aligning with the orientation of general practice. The general practice department maintained close connections with primary care institutions and hospital emergency/specialty departments, playing an important role in tiered diagnosis and treatment and multidisciplinary management of chronic diseases and symptoms of unknown etiology. The longer stays and higher costs for patients with chronic diseases, symptoms of unknown etiology, and multimorbidity suggest that general practitioners need to continuously refine management processes and service content to improve quality.

Keywords: General practice department; Tertiary comprehensive hospital; Inpatient; Symptoms of unknown etiology; Chronic disease; General practitioners; Beijing

Accelerating the development of general practice and training general practitioners represents a crucial task in China's current healthcare reform. The State Council has issued multiple guidelines requiring tertiary hospitals designated as residency training bases to strengthen general practice department construction according to standardized protocols [1]. The main functions of general practice departments include medical care, teaching, research, and prevention. In terms of medical care, the scope encompasses common health problems presenting as symptoms, common and frequent diseases, multi-system chronic diseases, and referrals for complex and difficult cases [2]. Chronic diseases refer to chronic non-communicable diseases. Common chronic diseases threatening residents' health include cardiovascular and cerebrovascular diseases (stroke, coronary heart disease, hypertension, heart failure, etc.), malignant tumors, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma), and diabetes [3]. General practice emphasizes person-centered, family-based care that is continuous, comprehensive, and individualized, giving it natural advantages in managing chronic diseases and symptoms of unknown etiology [4-5]. However, the development prospects and role positioning of general practice departments in general hospitals remain in the exploratory stage [6-7], with few reports on the admission of chronic diseases and symptoms of unknown etiology in general medicine wards. Understanding these admission patterns can help further explore the development prospects and role positioning of general practice departments in general hospitals. As a tertiary comprehensive hospital in Beijing, Beijing Friendship Hospital, Capital Medical University, established its general practice department and inpatient ward in November 2019. This study analyzes the diagnosis and treatment of all inpatients over the 51 months since the department's establishment, aiming to explore the current status of chronic disease and unknown etiology symptom management in general medicine wards of comprehensive hospitals, thereby providing references for role positioning and optimized construction.

1.1 Data Sources

In February 2024, we collected electronic medical record data of all patients hospitalized in the general medicine ward of Beijing Friendship Hospital, Capital Medical University between November 2019 and January 2024. This study was approved by the Institutional Review Board of Beijing Friendship Hospital, Capital Medical University (Approval No: 2024-P2-519-01).

1.2 Research Methods

We extracted and analyzed patient information including gender, age, admission source, admission diagnosis, discharge diagnosis, length of stay, outcomes, and hospitalization costs. Disease names were coded using the International Classification of Diseases 10th Revision (ICD-10) guidelines [3], with similar diagnoses merged into categories (e.g., "grade 3 hypertension" and "hypertension" were combined as "hypertension"; "gallstones with acute cholecystitis" and "acute cholecystitis" as "acute cholecystitis"; "lung cancer" and "gastric cancer" as "malignant tumors"; "chronic superficial gastritis" and "chronic atrophic gastritis" as "chronic gastritis"). Chronic disease criteria were based primarily on the WHO's "Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020" [8]. Symptoms that could not be immediately attributed to a specific disease after initial assessment were termed "symptoms of unknown etiology" for research purposes. During the study, we found that lipid results were influenced by multiple factors, many patients were diagnosed with dyslipidemia because they needed lipid-lowering drugs for secondary prevention of cardiovascular disease, many patients with joint pain or soreness were considered to have arthritis, and most patients had not received formal psychiatric diagnosis. Therefore, dyslipidemia, arthritis, and mental disorders were excluded from chronic disease analysis. Multimorbidity was defined as the coexistence of two or more chronic diseases [9]. Polypharmacy was defined as using five or more medications after discharge [10].

1.3 Statistical Methods

Data were entered using Excel and analyzed with SPSS 20.0 software. Categorical data were expressed as counts and percentages. Non-normally distributed continuous data were expressed as median (P25, P75), with between-group comparisons using Mann-Whitney U tests. P<0.05 was considered statistically significant.

2.1 General Characteristics

A total of 2,725 hospitalization episodes were included, involving 1,390 female patients (51.01%) and 1,335 male patients (48.99%). Ages ranged from 12 to 95 years, with a mean age of (57.4±15.8) years. Patients aged ≥60 years accounted for 1,400 episodes (51.38%), ≥65 years for 1,057 episodes (38.79%), ≥80 years for 157 episodes (5.76%), and <18 years for 14 episodes (0.51%). Length of stay ranged from 1 to 38 days, with a median of 7 (5, 9) days; 2,294 episodes (84.18%) had stays ≤10 days [TABLE:1].

The median length of stay was 7 (5, 9) days for patients with clear diagnoses at admission and 7 (5, 8) days for those admitted with symptoms of unknown etiology, with no significant difference (Z=-1.502, P=0.133). The median hospitalization cost for all discharged patients was 9,053.71 (6,551.53, 12,380.82) yuan. Patients admitted with symptoms of unknown etiology had higher median costs at 9,441.96 (7,320.17, 11,649.47) yuan compared to 8,741.03 (6,021.38, 12,809.78) yuan for those with clear diagnoses (Z=-2.79, P=0.005).

2.2 Patient Admission Sources and Outcomes

General outpatient clinics accounted for 1,724 admissions (63.27%), emergency departments for 1,000 admissions (36.70%), and specialty transfers for 1 admission (0.03%). A total of 444 episodes (16.29%) involved patients hospitalized ≥2 times in the general medicine ward. After evaluation and treatment, 2,411 episodes (88.48%) resulted in improvement and discharge; 183 episodes (6.72%) involved discharge against medical advice for personal reasons; 96 episodes (3.52%) were transferred to specialty departments after definitive diagnosis; 22 episodes (0.81%) were transferred to other hospitals or nursing facilities due to medical needs; and 11 patients (0.40%) died. Causes of death were pneumonia (6 cases), terminal malignancy (3 cases), decompensated liver cirrhosis (1 case), and septic shock from bloodstream infection due to left lower molar extraction socket infection (1 case). Two patients (0.07%) were transferred to the ICU due to acute liver failure and severe pneumonia, respectively. After discharge, 1,121 episodes (41.14%) had follow-up visits at specialty outpatient clinics, 765 episodes (28.07%) at both general and specialty clinics, 234 episodes (8.59%) at general practice clinics only, and 605 episodes (22.20%) had no follow-up at our hospital.

2.3 Admission Purposes and Diagnosis Ranking

The 2,725 hospitalization episodes included 216 disease categories. The top three admission diagnoses were acute pancreatitis (9.06%), abdominal pain of unknown etiology (7.41%), and pneumonia (7.30%). At admission, 1,658 episodes (60.84%) had clear diagnoses: 953 episodes (34.97%) for acute disease treatment after diagnosis, 570 episodes (20.92%) for chronic disease management, 134 episodes (4.92%) for elective surgery or endoscopy, and 1 episode (0.04%) for preoperative evaluation of an allogeneic hematopoietic stem cell donor. The remaining 1,067 episodes (39.16%) were admitted with symptoms of unknown etiology, with patients reporting 1-16 symptoms (mean 3.8±2.4). The top 20 admission diagnoses are shown in [TABLE:2], including 9 symptoms of unknown etiology ranked by frequency: abdominal pain, dizziness, abdominal distension, fever, chest tightness, fatigue, chest pain, dyspnea, and edema.

2.4 Discharge Diagnosis Ranking

Principal discharge diagnoses covered multiple systems. The top five systems were digestive (1,166 episodes, 42.79%), respiratory (334 episodes, 12.26%), endocrine (317 episodes, 11.63%), cardiovascular (279 episodes, 10.24%), and hematologic (176 episodes, 6.46%), totaling 2,272 episodes (83.38%). The ten most frequent principal discharge diagnoses were acute pancreatitis (249 episodes, 9.14%), pneumonia (238 episodes, 8.73%), chronic gastritis (220 episodes, 8.07%), type 2 diabetes with chronic complications (175 episodes, 6.42%), acute cholecystitis (174 episodes, 6.39%), malignant tumors (154 episodes, 5.65%), hypertension (109 episodes, 4.00%), coronary atherosclerotic heart disease (73 episodes, 2.68%), colorectal polyps (62 episodes, 2.28%), and thyroid nodules (59 episodes, 2.17%), totaling 1,513 episodes (55.52%). System distribution and composition are shown in [TABLE:3].

2.5 Chronic Diseases and Multimorbidity

Among all patient diagnoses, common chronic diseases included hypertension (1,221 episodes, 44.81%), diabetes (832 episodes, 30.53%), chronic obstructive pulmonary disease/emphysema/chronic bronchitis (413 episodes, 15.16%), coronary heart disease (351 episodes, 12.88%), malignant tumors (328 episodes, 12.04%), stroke (325 episodes, 11.93%), heart failure (242 episodes, 8.88%), and asthma (82 episodes, 3.01%). No chronic diseases were present in 826 episodes (30.31%), while 1,899 episodes (69.69%) had at least one chronic disease, and 1,085 episodes (39.81%) had multimorbidity (≥2 chronic diseases). Patients with any chronic disease had longer median stays (7 [5, 9] vs. 6 [4, 8] days, Z=-6.90, P<0.001) and higher median costs (9,438.53 [6,940.29, 12,785.25] vs. 8,145.74 [5,701.94, 11,129.46] yuan, Z=-7.32, P<0.001) than those without chronic diseases. Similarly, patients with multimorbidity had longer stays (7 [6, 10] vs. 6 [4, 8] days, Z=-8.57, P<0.001) and higher costs (9,890.24 [7,313.59, 13,673.80] vs. 8,528.54 [6,006.63, 11,391.72] yuan, Z=-8.81, P<0.001) than those without multimorbidity.

2.6 Polypharmacy

Excluding 11 episodes (0.40%) where only self-prepared medications were recorded without details, among the remaining 2,714 episodes, 444 episodes (16.36%) required no medication after discharge, while 1,016 episodes (37.18%) required ≥5 medications, including many elderly patients ≥60 years.

2.7 Discharge Diagnoses for Patients with Symptoms of Unknown Etiology

Most patients admitted with symptoms of unknown etiology had their etiology clarified during hospitalization, though some remained undiagnosed. Among 767 episodes admitted with the top nine symptoms (abdominal pain, dizziness, abdominal distension, fever, chest tightness, fatigue, chest pain, dyspnea, and edema), 696 episodes (90.7%) received definitive ICD-10 diagnoses explaining their symptoms, while 71 episodes (9.3%) remained undiagnosed at discharge. Primary explanatory diagnoses are shown in [TABLE:4].

3.1 Broad Age Range and Disease Spectrum Align with General Practice Development

The study hospital's general medicine ward served patients with balanced gender distribution and wide age range, with over half aged ≥60 years, consistent with reported data from other provinces [7,11-12]. This demonstrates that general practitioners serve nearly all age groups. With 16.29% of patients hospitalized multiple times in the ward and 28.07% attending both general and specialty follow-up clinics (plus 8.59% attending only general practice clinics), the continuity-of-care characteristic of general practice is evident. Inpatient diseases included common conditions across systems, chronic diseases, and symptoms of unknown etiology. The broad disease spectrum of principal discharge diagnoses, involving multiple systems and organs, reflects the comprehensive, continuous, and holistic nature of general practice and aligns with its development direction.

3.2 Close Integration with Primary Care and Hospital Emergency/Specialty Departments Facilitates Tiered Diagnosis and Treatment

Emergency department admissions accounted for 36.70% of cases, indicating that general medicine wards can alleviate emergency department pressure and compensate for their limitations. Most inpatients presented with chronic diseases or symptoms of unknown etiology, often referred from primary care institutions. After diagnosis and treatment, most were discharged back to primary care. Only 3.52% required transfer to specialty departments after diagnosis, and 0.81% needed transfer to other hospitals or facilities, demonstrating that general practitioners could resolve most health problems for common and frequent diseases, while appropriately referring those needing specialized care. Therefore, general practice departments in tertiary hospitals play important roles in implementing tiered diagnosis and treatment, rationally allocating medical resources, and improving service efficiency and quality [13]. Analysis of admission sources and outcomes also shows frequent interaction, close integration, and complementary functions between general practice and emergency/specialty departments [14], enabling effective resource utilization and providing continuous, comprehensive, and accessible healthcare for patients with chronic diseases and symptoms of unknown etiology.

3.3 High Prevalence of Chronic Diseases, Multimorbidity, and Polypharmacy

Among inpatients, 69.69% had at least one common chronic disease, 39.81% had multimorbidity, and 37.18% had polypharmacy. Patients with chronic diseases had longer stays and higher costs than those without; similarly, patients with multimorbidity had longer stays and higher costs than those without. Analysis of self-paid direct economic burden for Chinese inpatients with four chronic disease categories (cancer, diabetes, cardiovascular/cerebrovascular, and chronic respiratory diseases) in 2013 showed heavy economic burden and long stays, with higher economic risk for low-income and surgical patients [15]. The substantial economic burden of chronic diseases on the nation compels general practitioners to continuously improve chronic disease management capabilities and explore more efficient management models [16]. It also suggests that general practitioners must emphasize prevention, actively control disease progression and complications, and serve as "gatekeepers" for residents' health and medical expenditures. Polypharmacy is a common clinical problem, and general practitioners have important responsibilities to review medications promptly, supplement necessary drugs, eliminate unnecessary ones, and consider non-pharmacological treatments to improve medication safety [17].

3.4 High Proportion of Patients with Symptoms of Unknown Etiology Highlights General Practice Advantages

Analysis of admission purposes and diagnoses showed 39.16% of patients were admitted with symptoms of unknown etiology, consistent with reported rates of 48.2%-84.2% in tertiary hospital general medicine wards [12,14]. The hospitalization goal for these patients was etiological clarification, with primarily symptomatic and supportive treatment. Despite lower medication costs, their average hospitalization costs were similar to patients with clear diagnoses, indicating substantial resource and financial consumption during diagnostic workup. Reportedly, healthcare consumption for these patients is about double that of the general population [18], with US patients with medically unexplained symptoms consuming $256 billion annually [19]. Under the Diagnosis-Related Group (DRG) payment system, symptoms of unknown etiology put general medicine wards at a disadvantage [12]. While most patients had their etiology clarified during hospitalization, some remained undiagnosed. Managing symptoms of unknown etiology requires a "bio-psycho-social medical model" and comprehensive analysis from family, psychological, and social perspectives, fully embodying general practice's person-centered philosophy [4]. The complex diagnostic process benefits from general practitioners' holistic and comprehensive thinking to explore disease causes and treatments, giving general practice natural advantages in managing symptom-based health problems [20].

This study analyzed chronic diseases and symptoms of unknown etiology in a Beijing tertiary comprehensive hospital's general medicine ward, providing data support for promoting management of these characteristic clinical issues in similar settings. Since its establishment, the study hospital's general practice department has served a broad population with diverse diseases, including common conditions across systems, chronic diseases, symptoms of unknown etiology, and multimorbidity, aligning with general practice orientation. Analysis of admission sources and outcomes demonstrates close connections with primary care institutions and hospital emergency/specialty departments, highlighting its importance in tiered diagnosis and treatment and multidisciplinary management. The findings of longer stays and higher costs for patients with chronic diseases, symptoms of unknown etiology, and multimorbidity suggest that general practitioners must continuously refine management processes and service content to improve quality.

Limitations: This single-center study included a limited number of cases from a newly established ward. The retrospective design precluded regular follow-up of discharged patients, including whether chronic disease patients were transferred to primary care for continuous management or the outcomes of patients with symptoms of unknown etiology. Future multicenter studies with larger samples and long-term follow-up are needed.

Author Contributions: PANG Shu conceived and designed the study, implemented the research, and drafted the manuscript. PANG Shu, CHEN Xiangxue, and DIAO Yang collected and organized data and performed statistical analysis and interpretation. WANG Yini and JIANG Chunyan proposed the main research objectives and revised the manuscript. JIANG Chunyan was responsible for quality control and review and takes overall responsibility for the article.

Conflict of Interest: The authors declare no conflict of interest.

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(Received: September 30, 2024; Revised: December 30, 2024) (Edited by: WANG Fengwei)