Incongruent Views of Quality of Life between Patients and Physicians: A Mixed-Methods Enquiry

Abstract

Functional gastrointestinal disorders (FGIDs) continue to be the most common disorders treated in gastroenterological practice. They are associated with higher levels of psychological distress, impaired quality of life and increased healthcare use. The main objective of the current thesis was to evaluate the level of discrepancy (i.e., incongruence) between patients and physicians quality of life, as well as the effect this has on psychological distress, physician satisfaction and quality of life. More specifically, we explored the effect of incongruence in a primary care setting and compared this between two patient groups: patients with an FGID diagnosis and patients with an organic diagnosis. In order to pursue our main objective, two studies were carried out. The first study involved a systematic review examining the potential benefits of short-term educational interventions. The second study was a cross sectional mixed-methods study that aimed to explore the differences that exist between incongruent and diagnostic groups in relation to psychological distress, physician satisfaction and quality of life. This also involved assessing the aforementioned variables whilst taking into account other variables that could potentially be moderating the relationship. The final part of the study involved implementing a qualitative approach which consisted of focus groups with patients and semi-structured interviews with physicians. The results from the first study indicated that short educational programmes could benefit both patients and physicians, yet there still appears to be limited research regarding effective programmes that specifically target symptom severity and quality of life of patients. Furthermore, training and intervention opportunities for physicians are still relatively sparse leading to difficulties when assisting patients in practice.

The findings from the analyses conducted with incongruence as a dichotomised variable showed that both incongruence and diagnosis contribute to psychological distress. Patients in the incongruent group had higher scores on psychological distress than congruent patients. On the other hand, no significant differences were found between incongruent and congruent patients in relation to physician satisfaction levels. Patients with an FGID diagnosis had higher scores on psychological distress and lower physician satisfaction levels than patients with an organic diagnosis. The results from the analyses carried out with incongruence as a continuous variable supported this further. Statistically significant positive correlations were found for incongruence with psychological distress and age. Female patients and patients with an FGID diagnosis had higher levels of psychological distress and worse quality of life, as well as lower physician satisfaction in the case of patients with an FGID diagnosis. A statistically significant positive correlation was found only for physician satisfaction and age. When carrying out multiple regression models, we found that gender and incongruence had the greatest influence on psychological distress. Finally, from the moderation models we found that only age was a significant moderator between incongruence and psychological distress. From the qualitative part of the research, five major themes were found when conducting a thematic analysis: (1) Illness, Emotional and Personal Problems (2) Disease- Healthcare System Interaction (3) Health system (4) Intervention and (5) Patients. From the patient focus groups key factors were outlined as needing to be addressed such as the overload of the healthcare system and long waiting lists. From the physician interviews we identified that a lack of resources and a clear referral pathway to mental health services may be contributing to the difficulties when treating these patients.

To our knowledge, this is the first study to investigate the influence of incongruence in primary healthcare settings using this procedure. Additionally, as far as we are aware this is also the first study to explore the underlying reasons for incongruence using a qualitative approach.

Los trastornos gastrointestinales funcionales (TGF) siguen siendo los trastornos más habituales tratados en la práctica gastroenterológica. Están asociados con los niveles más altos de distrés psicológico, deterioro de la calidad de vida y un mayor uso de la atención médica. El objetivo principal de la tesis fue evaluar el nivel de discrepancia (es decir, la incongruencia) entre la percepción de pacientes y médicos sobre la calidad de vida del paciente y el efecto que esto tiene sobre el distrés psicológico, la satisfacción con el médico y la calidad de vida. Más específicamente, exploramos el efecto de la incongruencia en un entorno de atención primaria y lo comparamos entre dos grupos de pacientes; pacientes con diagnóstico de TGF y pacientes con diagnóstico orgánico. Los resultados del primer estudio indicaron que los programas educativos breves podrían beneficiar tanto a los pacientes como a los médicos, sin embargo, todavía parece haber bibliografía limitada con respecto a programas efectivos que se enfoquen específicamente en la gravedad de los síntomas y la calidad de vida de los pacientes. Los hallazgos de los análisis realizados con la incongruencia mostraron que tanto la incongruencia como el diagnóstico contribuyen el distrés psicológico. Los resultados de los análisis cuantitativos adicionales respaldaron esto aún más, además en estos se encontraron correlaciones positivas estadísticamente significativas para la incongruencia con el distrés psicológico y la edad. Las pacientes del sexo femenino y los pacientes con diagnóstico de TGF presentaron mayores niveles del distrés psicológico y peor calidad de vida, además de menor satisfacción con el médico que en el caso de los pacientes con diagnóstico TGF. De la parte cualitativa de la investigación, se encontraron cinco grandes tópicos al realizar un análisis temático; (1) Enfermedad, problemas emocionales y personales (2)

Interacción enfermedad-sistema sanitario (3) Sistema sanitario (4) Intervención y (5) Pacientes. Hasta donde sabemos, este es el primer estudio que investiga la influencia de la incongruencia en los entornos de atención primaria de la salud utilizando este procedimiento. Además, este es también el primer estudio que explora las razones subyacentes de la incongruencia utilizando un enfoque cualitativo.