ORIGINAL ARTICLE

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A COMPARISON OF MORBIDITY PATTERNS IN PUBLIC AND PRIVATE PRIMARY CARE CLINICS IN MALAYSIA

Table 4: Distribution of patient reasons for encounter, by ICPC-2 chapter and most frequent individual reasons for encounter within chapter*

		Overall			Public Clinics			Private Clinics
		n	% age of total RFE n=7281	Rate/100 encounter n=4262	n	% age of total RFE n=5865	Rate/100 encounter n=3474	n	% age of total RFE n=1415	Rate/100 encounter n=788
Respiratory		1584	21.8	37.2	1179	20.0	33.9	412	29.1	52.3
R05	Cough	651	8.9	15.3	477	8.1	13.7	174	12.3	22.1
R07	Sneezing/Nasal congestion	327	4.5	7.7	245	4.2	7.1	82	5.8	10.4
R21	Throat symptom/ Complaint	195	2.7	4.6	111	1.9	3.2	84	5.9	10.7
R74	Upper respiratory infection, Acute	96	1.3	2.3	79	1.3	2.3	17	1.2	2.2
R80	Influenza	74	1.0	1.7	63	1.1	1.8	11	0.8	1.4
R02	Shortness of breath, Dyspnoea	70	1.0	1.6	51	0.9	1.5	19	1.3	2.4
General and unspecified		1259	17.3	29.5	936	16.0	26.9	322	22.8	40.9
A03	Fever	678	9.3	15.9	480	8.2	13.8	198	14.0	25.1
A30	Check up complete	73	1.0	1.7	60	1.0	1.7	13	0.9	1.6
A80	Trauma/Injury, NOS	71	1.0	1.7	61	1.0	1.8	10	0.7	1.3
A01	Pain, General/ Multiple sites	53	0.7	1.2	30	0.5	0.9	23	1.6	2.9
A27	Fear of other disease, NOS	51	0.7	1.2	36	0.6	1.0	15	1.1	1.9
A11	Chest pain NOS	37	0.5	0.9	30	0.5	0.9	7	0.5	0.9
A04	Weakness/ tiredness general				27	0.5	0.8
A62	General administrative procedure							8	0.6	1.0
Cardiovascular		946	13.0	22.2	871	14.9	25.1	75	5.3	9.5
K63	Encounter, follow-up cardiovascular	688	9.4	16.1	644	11.0	18.5	44	3.1	5.6
K50	Medication; renew; cardiovascular	74	1.0	1.7	70	1.2	2.0
K25	Fear of hypertension							11	0.8	1.4
Endocrine		719	9.9	16.9	683	11.6	19.7	36	2.5	4.6
T63	Encounter, follow-up endocrine/ metabolic	543	7.5	12.7	528	9.0	15.2	15	1.1	1.9
T60	Test result, endocrine/ metabolisme	44	0.6	1.0	42	0.7	1.2
Digestive		535	7.4	12.6	373	6.4	10.7	162	11.5	20.6
D01	Pain/Cramps, Abdominal general	95	1.3	2.2	60	1.0	1.7	35	2.5	4.4
D11	Diarrhoea	86	1.2	2.0	58	1.0	1.7	28	2.0	3.6
D02	Pain, Abdominal epigastric	70	1.0	1.6	52	0.9	1.5	18	1.3	2.3
D10	Vomiting	69	0.9	1.6	40	0.7	1.2	29	2.0	3.7
D09	Nausea							8	0.6	1.0
Pregnancy		470	6.5	11.0	429	7.3	12.3	41	2.9	5.2
W30	Check up; antenatal	313	4.3	7.3	295	5.0	8.5	18	1.3	2.3
W41	Postnatal examination	38	0.5	0.9	34	0.6	1.0			0.0
Musculoskeletal		427	5.9	10.0	351	6.0	10.1	76	5.37	9.6
L02	Back symptom/ Complaint	60	0.8	1.4	47	0.8	1.4	13	0.9	1.6
L15	Knee symptom/ Complaint	58	0.8	1.4	49	0.8	1.4	9	0.6	1.1
L14	Leg/Thigh symptom/ Complaint	36	0.5	0.8	28	0.5	0.8	8	0.6	1.0
L17	Ankle symptom/ Complaint	34	0.5	0.8	30	0.5	0.9
L01	Neck symptom/ Complaint							7	0.5	0.9
Neurological		359	4.9	8.4	273	4.7	7.9	86	6.1	10.9
N01	Headache	196	2.7	4.6	141	2.4	4.1	55	3.9	7.0
N17	Vertigo/Dizziness	92	1.3	2.2	73	1.2	2.1	19	1.3	2.4
Skin		346	4.8	8.1	264	4.5	7.6	82	5.8	10.4
S02	Pruritus	102	1.4	2.4	80	1.4	2.3	22	1.6	2.8
S06	Rash localized	56	0.8	1.3	36	0.6	1.0	20	1.4	2.5
Eye		177	2.4	4.2	147	2.5	4.2	30	2.1	3.8
F02	Red eye	39	0.5	0.9	34	0.6	1.0
Urology		116	1.6	2.7	97	1.7	2.8	19	1.3	2.4
U01	Dysuria/Painful urination	42	0.6	1.0	34	0.6	1.0	8	0.6	1.0
U02	Urinary frequency /Urgency	33	0.5	0.8	28	0.5	0.8
Female genital system		113	1.6	2.7	87	1.5	2.5	26	1.8	3.3
Psychiatry		83	1.1	1.9	60	1.0	1.7	23	1.6	2.9
P50	Medication; renew; psychological							10	0.7	1.3
P06	Sleep disturbance							7	0.5	0.9
Ear		59	0.8	1.4	40	0.7	1.2	19	1.3	2.4
Blood		51	0.7	1.2	50	0.9	1.4	1	0.1	0.1
Social problems		19	0.3	0.4	17	0.3	0.5	2	0.1	0.3
Male genital system		17	0.2	0.4	14	0.2	0.4	3	0.1	0.4

*Only morbidities with a rate of ≥ 0.5 percentage of total RFE are included

Table 5: Ten most frequent patient reasons for encounter (RFE) in public and private clinics

Public				Private
ICPC-2 code	Description	N=5865 n (%)	Rate per 100 encounters (Total=3474)	ICPC-2 code	Description	N=1415 n (%)	Rate per 100 encounters (Total=788)
K63	Encounter, follow up cardiovascular	644 (11.0)	18.5	A03	Fever	198 (14.0)	25.1
T63	Encounter, follow up endocrine/ metabolic	528 (9.0)	15.2	R05	Cough	174 (12.3)	22.1
A03	Fever	480 (8.2)	13.8	R21	Throat symptom/ Complaint	84 (5.9)	10.7
R05	Cough	477 (8.1)	13.7	R07	Sneezing/Nasal congestion	82 (5.8)	10.4
W30	Check up; antenatal	295 (5.0)	8.5	N01	Headache	55 (3.9)	7.0
R07	Sneezing/Nasal congestion	245 (4.2)	7.1	K63	Encounter, follow up cardiovascular	44 (3.1)	5.6
N01	Headache	141 (2.4)	4.1	D01	Pain/Cramps, Abdominal general	35 (2.5)	4.4
R21	Throat symptom/ Complaint	111 (1.9)	3.2	D10	Vomiting	29 (2.0)	3.7
S02	Pruritus	80 (1.4)	2.3	D11	Diarrhoea	28 (2.0)	3.6
R74	Upper respiratory infection, Acute	79 (1.3)	2.3	A01	Pain, General/ Multiple sites	23 (1.6)	2.9

The percentage of acute cases seen in private clinics was almost double that seen in public clinics (50.0% versus 27% of total RFE respectively) whereas public clinics saw more chronic cases than private clinics (20.0% versus 3.1% of total RFE respectively). There were 33.7 chronic diseases for every 100 encounters in public clinics whilst in private clinics only 5.6 chronic diseases were seen for every 100 encounters.

For the ten most frequent diagnoses using ICPC-2, hypertension, diabetes mellitus, lipid disorder and asthma constituted 49.7 diagnoses per 100 encounters in public clinics whilst hypertension and bronchial asthma constituted 12.3 diagnoses per 100 encounters in private clinics (Table 6). Pregnancy contributed 8.8 diagnoses per 100 encounters in public clinics whereas it did not appear in the ten most frequent diagnoses in private clinics.

Table 6: Ten most frequent diagnoses by ICPC-2 in public and private clinics

Public				Private
ICPC-2 code	Description	N=5865 n (%)	Rate per 100 encounters (Total=3474)	ICPC-2 code	Description	N=1415 n (%)	Rate per 100 encounters (Total=788)
K86	Hypertension, Uncomplicated	849 (16.4)	24.4	R74	Upper respiratory infection, Acute	271 (21.2)	34.4
R74	Upper respiratory infection, Acute	574 (11.1)	16.5	A03	Fever	62 (4.9)	7.9
T90	Diabetes, Non-insulin dependent	536 (10.4)	15.4	K86	Hypertension, Uncomplicated	62 (4.9)	7.9
T93	Lipid disorder	223 (4.3)	6.4	D73	Gastroenteritis, presumed infection	37 (2.9)	4.7
W78	Pregnancy	176 (3.4)	5.1	R96	Asthma	35 (2.7)	4.4
W84	Pregnancy high risk	129 (2.5)	3.7	R05	Cough	33 (2.6)	4.2
R96	Asthma	122 (2.4)	3.5	D87	Stomach function disorder	30 (2.3)	3.8
A03	Fever	121 (2.3)	3.5	N01	Headache	24 (1.9)	3.0
R05	Cough	76 (1.5)	2.2	N17	Vertigo/Dizziness	22 (1.7)	2.8
D87	Stomach function disorder	75 (1.5)	2.2	S88	Dermatitis, Contact/Allergic	22 (1.7)	2.8

There were 60 complaints of backache (0.8% RFE) and 288 (4.0% RFE) of headache/vertigo/dizziness. However, there was no record of psychological problems such as anxiety or depression in public clinics.

DISCUSSION AND CONCLUSION

This is the first study in Malaysia to concurrently compare the morbidity patterns of public and private primary care clinics nationwide. The response rate in public clinics was 82% and thus the findings would be representative of public clinics. However, the response rate from private clinics was low despite researchers personally approaching general practitioners for consent to participate in the study hence limiting the generalisability of the findings for private clinics. Nevertheless, the findings can provide an insight of the problem.

We found doctors in public clinics saw more chronic and complex diseases as well as pregnancy related complaints while in private clinics more acute and minor illnesses were seen.⁷ This is similar to findings in Sri Lanka.⁸ In addition, in Malaysia, it has been shown that the incidence of acute respiratory infection in the community was 18.2% and about half of these were seen in private sectors.⁹ It is possible that doctors in private clinics were seeing more acute illnesses because their opening hours are longer and are more accessible to the patients. In public clinics, more patients are treated for chronic diseases and one of the reasons could be the heavy subsidy by the Malaysian government for the cost of treatment. The situation is different in Singapore where the private sector treated an almost equal percentage of chronic conditions as the public sector.¹⁰ An approach for Malaysian public clinics to cope with the chronic disease workload is to delegate the management of minor ailments to paramedics either at the ‘Klinik Kesihatan’ or via the newly introduced ‘1 Malaysia Clinics’. This could potentially free as much as one-fifth of the physician’s time⁷ to concentrate on improving the quality of care of patients with chronic diseases.

Problems related to the respiratory system were the most frequent RFE and this trend has remained unchanged from 1982.⁷ However, conditions seen at a hospital-based general medical clinic in 1982 that involved the digestive system, nervous system, infections, genitourinary system, skin and musculoskeletal system were not as common in this study. Reason for this is beyond the scope of this study although improved community hygiene could be a possibility.⁷

Our data had shown a low rate of patient encounters for medical check-up in both public and private clinics. As the burden of chronic diseases in Malaysia are increasing, it is imperative to strengthen the preventive component of health care by patient empowerment and structured programs.^11,12 We have shown that patients seen were mainly in the 20 to 49 years age group and hence this is a good opportunity to implement screening and prevention strategies. Studies have shown that only half of the GP practices in Malaysia did cervical smear and breast screening although these cancers ranked sixth in the overall burden of disease.^11,13 It is therefore crucial to encourage screening in primary care.

The rate of visits for pregnancy related complaints to private clinics were low (5.2 per 100 encounters in private clinic versus 12.3 per 100 encounters in public clinics). This could possibly be attributed to financial reasons as the visits may not be funded by employers and insurance companies. Nevertheless, the reasons can be ascertained in future studies. Pregnancy and pregnancy related complications were the top two principal causes for government hospital admission in 2009 in Malaysia.¹⁴ It is therefore important to update the knowledge of primary care doctors in this area to improve the maternal mortality and perinatal mortality rates.

It is intriguing that we found no record of psychological problems of anxiety or depression. Even the complaints of backache, headache, vertigo, dizziness that could raise the possibility of psychosomatic symptoms were less than 5%. This finding is similar to an earlier study.⁹ The Third National Health and Morbidity Survey (NHMS III) in Malaysia has reported the prevalence of psychiatric morbidity among children and adolescents was 20.3% while it was 11.2%⁹ for adults. The low prevalence of psychological or psychiatric problems in this study may be due to under-diagnosis and under-recording. Hence, there is a need to train primary care doctors to increase their awareness and knowledge on mental health.

Limitations of this study could be due to under-estimation of the morbidity data due to unidentified patient problems during consultations, recording, diagnosis and coding.^15-17 Although almost all diagnoses in private clinics were recorded, a quarter of RFEs were not documented; perhaps reflecting local GPs’ unfamiliarity with recording RFE. This is not unique to Malaysia as this has been noted in developed countries that adopt ICPC for routine data collection in primary care.^18,19 It is known that there is general agreement for RFE and diagnoses although there is better agreement for RFE.²⁰ Unlike other disease classifications, the ICPC allows the diagnoses of symptom and complaint which is more relevant in primary care settings and has high inter-observer reliability and secondary coding reliability.^21-23 Capturing RFE in ICPC can give rise to error^8,24 due to difficulty in interpretation of symptoms and may lead to coding error by research assistants for example when deciding whether the symptom of cough should be coded as upper respiratory tract infection. To reduce this error, researchers checked and verified codes entered by research assistants.

CONCLUSION AND RECOMMENDATION

Chronic diseases are burgeoning in Malaysia and will be a major health crisis in the future if effective preventive measures are not initiated. Looking at current trends, the burden of managing chronic diseases lies mainly with the public clinics unless private clinics are provided with support and incentives to share the workload. Hence, the Malaysian government’s plan to integrate public and private health services is timely and should be studied and implemented.

ACKNOWLEDGEMENT

We would like to thank the Ministry of Health Malaysia for funding this project, the Director General of Health for his permission to present this study and all primary care doctors and staff for their invaluable assistance in the data collection. This study was presented as a poster presentation at the 14th Malaysian Family Medicine Specialist Conference in 2010.

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