The effect of an educational intervention in family phisicians on self-rated quality of life in patients with medically unexplained symptoms

The FPs were asked to complete Questionnaire A (demographic information about the physician and practice), whereas the patients answered Questionnaire B, consisting of the PHQ-15 (Patient Health Questionnaire) for assessing the severity of non-specific somatic symptoms that have been shown to be highly associated with MUS diagnosis in the past four weeks (15), and three additional questions regarding the patients’ problems and the physicians’ clinical opinion (i.e., the symptom has been present for at least three months, the symptom has been causing clinically significant problems for the patient, and the symptom cannot be explained by any known physical disease) (1). A PHQ-15 score of 15 or higher and positive answers to all three additional questions formed the criteria for the inclusion of patients with MUS. The patients were also asked to complete Questionnaire D, which included theEQ-5D-3L (EuroQoL 5D-3L) instrument rating quality of life (16), as well as the 4DSQ (Four-Dimensional Symptom Questionnaire) for assessing depression, anxiety, stress and somatisation (17), the WI (Whiteley Hypochondriasis Index) (18), the MISS-21 (Medical Interview Satisfaction Scale) for measuring patient satisfaction (19), and the PEI (Patient Enablement Instrument) for assessing the physician-patient relationship (20).

Questionnaires A and B were completed only in the first phase of the study (0 months), and Questionnaire D was completed at inclusion into the study (0 months) and 12 months later. The latest data are crucial for this study aim, providing 269 MUS patients’ reflection on depression, anxiety, stress and somatisation, satisfaction, and also assessing the physician-patient relationship.

Those parts of the questionnaire which were adapted from international questionnaires were assessed for their construct validity (using factor analysis) and measuring reliability. The reliability of all measures was exemplary (Cronbach’s alpha α > 0.80). To analyse the differences in MUS patients before and after the EI, we used the paired sample t-test for numeric variables and the chi-square test for categorical variables. Statistical significance for the entire analysis was set at a 5% risk level (p≤0.05).

The data were statistically processed using SPSS 21.0 statistical software (IBM Corp., Grouponk, NY, USA).

After the EI, patients with MUS gave a lower (total) mean rating of their health issues and a higher self-rating of their quality of life (Table 1). A more recent Dutch study (26), which also employed the EQ-5D questionnaire, observed that MUS have a greater effect on the quality of life in a younger population (aged less than 65 years). A Slovenian study from 2014 (16) found that – considering the results of the EQ-5D questionnaire – the presence of psychological symptoms is associated with lower quality of life. Klemenc Ketiš et al. (16) observed a correlation between factors identified using the EQ-5D questionnaire (the presence of chronic disease, pain, and anxiety and depression), which are independently associated with psychological symptoms. In addition, findings of other authors (27) confirm the correlation between psychological and unexplained symptoms, and lower quality of life, as measured by the EQ-5D questionnaire. We reached the same conclusion with regard to the patients’ quality of life, and we also confirmed the El’s effect on patients with MUS in terms of their quality of life.

In our study, patients with MUS had a lower mean level of depression, anxiety, stress and somatisation after the EI, and this reduction in stress and somatisation was confirmed as statistically significant (Table 2). Similar to our study, the majority of other studies (12, 28) found that improved communication with the MUS patient is beneficial, as is the use of empathy in the physician-patient relationship, or better acceptance of MUS patients as they are.

The analysis of differences in hypochondriasis in patients with MUS before and after the EI (Table 2) confirmed that the intervention – i.e., capacity building in physicians – significantly reduced (but did not eliminate altogether) hypochondriasis in MUS patients. A recent German study from 2013 (29) analysed the effect of the EI (a multidisciplinary approach and the inclusion of a psychosomatic therapist in the education of family physicians) on the treatment of MUS patients, and found a decrease in the level of hypochondriasis, which is comparable to the findings of our study.

Statistical analysis did not reveal significant differences in the (total) rating of treatment satisfaction before and after the EI (Table 1). Similarly, a study by Jackson, J. et al. (30) found that there were no significant differences in the treatment satisfaction of patients with MUS compared to patients without MUS. A study from Sri Lanka (31) investigated the effect of an intervention on several factors, including patients’ treatment satisfaction, and showed that patient satisfaction increased after the EI (mainly the education of physicians in cognitive-behavioural techniques). Differences in the findings of various authors and those of this study are probably a result of the use of different types of intervention and different questionnaires for analysing patient satisfaction; this is why the findings are difficult to compare.

We found (Table 1) that intervention in patients with MUS significantly improved their opinion of the physician-patient relationship. The results of our study match those of another study carried out in Scotland (32), which showed that intervention in MUS patients significantly improved their opinion of the physician-patient relationship, but failed to confirm significant differences in the (total) rating of treatment satisfaction before and after the EI. We could not find any data on the intervention’s effect on the physician-MUS patient relationship in comparable foreign studies (33, 34), which provides an opportunity for new research in this field, and for improving the quality of treatment of patients with MUS.

The criteria for including patients in the group of patients with MUS are non-standardised, due to the non-existence of an accurate definition of MUS. For the purposes of this study, the inclusion criteria were based on a large review of the literature, and represented a combination of several factors to reduce this limitation. The acquisition of data excluded all physicians and patients who refused to participate in the study.

The study included patients who had visited their physician for three ‘typical’ working days, coming to the practice for different reasons, many due to an acute disease or the worsening of a chronic disease. Because of this, frequent visitors to family medicine practices had a greater chance of being included in the study. This study limitation could have been eliminated if we had included random sampling of patients using a register of family medicine practice patients, but the participation of patients would have most probably been even lower.

The decrease in the number of participating FPs and patients was relatively large by the end of the study, which is also reported by other researchers of MUS (12, 35). We also failed to track possible patterns within the MUS patients group after one-year-period, and did not analyse characteristics of the fall-out patients.

The EI was relatively short (two days) and was a ‘one-off.’ The EI attendees were probably more motivated to participate (a personal interest in this topic) than other physicians.

The success of the EI was at first limited to the observation of quality of life, treatment satisfaction and opinion of the physician-patient relationship. However, this limitation has been mitigated by the fact that quality of life was additionally evaluated based on the assessment of somatisation, depression, anxiety and hypochondriasis. The success of the EI was followed up only over one-year-period. Unfortunately, we do not have any follow-up data for the participating physicians and patients after one year. We also do not have any follow-up data about the incidence of MUS symptoms after EI, neither about the frequency of patients’ attendance at family clinics.

In this study, we decided not to record the occurrence of acute diseases or the worsening frequency of chronic disease, which might have affected the self-rated quality of life in our patients.