AbstractPatient-physician relationship (PPR) plays a key role in modern healthcare, especially within gastrointestinal medical practice. In 2017 Kurlander et al. developed a Patient-Physician-Relationship-Scale (PPRS), a questionnaire used to assess the patients’ medical care-satisfaction. The PPRS was later simplified by Drossman et al. in 2021 by creating a PPRS-SF (short form). This study aimed to validate the PPRS-SF in Italian and to administer it to patients with “functional” and “organic” esophageal diseases, to highlight the differences in the PPR between the two categories. The process of validation was carried out following a standardized forward-backward procedure and each step was overseen by a Rome foundation independent clinical monitor. The Italian version of the PPRS-SF was then administered to 50 Eosinophilic Esophagitis (EoE), 53 Achalasia, 48 Gastroesophageal Reflux Disease (GERD) and 44 esophageal disorders of gut brain interaction (eDGBI) patients. In eDGBI and GERD, the degree of patients’ satisfaction was significantly lower. Between a score of -36 and + 36, the mean score for patients with EoE was 30.20 (± 9.78), for Achalasia 23.78 (± 19.9); for GERD 20.46 (± 16.03) and for esophageal DGBI 17.91 (± 18.41). Moreover, there was a negative significant correlation between the PPR and age (R=- 0.208). This study validated the Italian version of the PPRS-SF questionnaire and showed that the patients’ diagnosis together with other factors such as their age, can affect the PPR. In particular, patients with DGBI and older patients reported lower scores than the ones with organic diseases and the younger ones, respectively.
IntroductionThe importance of patient-physician relationship (PPR) in modern health care is rapidly increasing, as it is now considered one of the key factors for adherence to treatment and for the achievement of the best clinical outcome1,2.Recent changes in the health care system have brought physicians to spend less time with patients, reducing the ability to gather relevant information, to comprehend and to address patient needs, as medical doctors often have to establish an order of clinical priorities, focusing on making the right diagnosis or choosing the appropriate treatment. This deeply and negatively affects the patient-physician relationship2.Within gastrointestinal (GI) medical practice, the dissatisfaction of patients is particularly evident in those affected by non-structural disorders, such as “functional”disorders (now better described as disorders of gut-brain interaction (DGBI)3. Patients with DGBI often feel like they are given lower priority than those with acute or structural illness by their gastroenterologists, who can have a different perception of the severity of the symptoms compared to what patients have been experiencing, due to the lack of objective endoscopic, structural, or histological findings4. This situation can affect the clinic outcome since a positive physician-patient interaction has been shown to be an important factor in improving medical care and treatment satisfaction on both the side of the patients as well as the physicians, in DGBI such as Irritable Bowel Syndrome (IBS)5,6. As Drossmann et al. stated “it is now well recognized that patients’ satisfaction with medical care is a critical determinant to physician satisfaction, adherence to treatment, and improved clinical outcome”7.On the other hand, a good patient-physician relationship is also fundamental in patients with chronic “organic” diseases8, especially in relatively “rare” conditions where the treatment options are limited, such as eosinophilic esophagitis (EoE) or Achalasia. These patients tend to report an impaired quality of life (QoL), which can result in a more troubled relationship with their physicians9,10,11.In 2017, Kurlander et al.12 developed and validated the Patient-Physicial Relationship Scale (PPRS), a questionnaire used to assess the level of expectations that patients with IBS have towards their physicians, although the items are not condition-specific and could apply to patients with various medical problems.In 2021, Drossman et al.7created a short-form version of the PPRS (PPRS-SF), consisting of a brief 12-item questionnaire, unlike the original one, which consisted of 32 questions. Its purpose was to take into consideration the most relevant aspects of the original PPRS questionnaire to evaluate GI medical care satisfaction. The PPRS-Patient SF was administered to 173 patients suffering from a broad range of both organic/structural (61.3%) and functional/motility (30.6%) GI diseases7 .To our best knowledge, the PPRS-SF questionnaire has yet to be validated in a language other than English. Moreover, it has not been directly applicable in a cultural context other than the American one.The aims of this study were to translate and validate the PPRS-SF questionnaire in Italian in order to provide a useful instrument for assessing adult patients suffering from esophageal diseases and to administer it in patients with esophageal DGBI and patients with “organic” gastrointestinal diseases such as Achalasia, EoE and GERD, to identify any discrepancy in the satisfaction of these patients with their physicians.MethodsItalian validation of the PPRS-SF questionnaireThe process of validation to the Italian language of the PPRS-SF (12 items) questionnaire was carried out following a standardized forward-backward procedure. It started by contacting the Rome Foundation, which permitted us to translate it into Italian following all the validation parameters. Then, we selected three professional translators, with previous experience in the medical area and who were previously approved by the Rome Foundation’s Director of Translations, with two of these three translators being the forward translators and the third one being the backward translator.The forward translators were independent native Italian speakers who first translated the original version of the PPRS-SF questionnaire to Italian separately; when a consensus on a pre-version of the questionnaire was reached, the questionnaire was reverse translated to English by the backward translator, a native English speaker. The translated and back-translated versions were examined carefully for accuracy; then discrepancies were discussed until a final agreement was reached.At the end of the process of translation, it underwent a cognitive debriefing by pre-testing it in a pilot study on 30 patients: it was submitted twice, about 2 months apart, to verify the translation in terms of clarity, comprehensibility and repeatability of the questions. The agreement was almost perfect (2 patients changed one single answer of one score point and 1 patient changed 2 answers of one score point), therefore no further changes have been made.Each of these steps was overseen by a Clinical Monitor, a native Italian speaker, familiar with scientific translations, completely independent to the translation process, assigned by the Rome Foundation itself. Supplementary Table 1 shows the Italian version of PPRS-SF and Supplementary Table 2 shows the original English version.PatientsThe Italian version of the PPRS-SF (PPRS-SF IV) questionnaire was administered to patients recruited from an outpatient clinic of the University of Salerno devoted to esophageal diseases. Patients were required to be fluent and literate native Italian speakers as well as to have been under follow-up in our clinic for a minimum of 2 years.Patients with gastroesophageal reflux diseases (GERD) were diagnosed according to Lyon’s criteria, using a positive multichannel intraluminal impedance-pH (MII-pH) monitoring or through endoscopic findings of grade C or D esophagitis according to the Los Angeles classification17. Esophageal DGBI (eDGBI) patients received a prior diagnosis of functional heartburn or functional dysphagia, according to the Rome IV diagnostic criteria (Supplementary Table 3)18. Achalasia was diagnosed in all the patients by performing a high-resolution esophageal manometry (HRM), according to the fourth version of the Chicago Classification, and a timed barium esophagogram, when needed. Before the diagnosis, an esophagogastroduodenoscopy (EGDS) was performed in every patient, to exclude other diseases14,15. The patients affected by EoE received a proper diagnosis according to the most recent guidelines, as they had symptoms of esophageal dysfunction and at least 15 eosinophils per high-power field on tissue biopsies of the proximal, medium and distal esophagus.The diagnosis was formulated only after patients went through a comprehensive assessment of non-EoE disorders that could contribute to esophageal eosinophilia and could cause the symptoms16. None of the patients had a previous diagnosis of GERD.All the enrolled patients underwent the PPRS-SF IV, together with a standardized questionnaire for the evaluation of GI symptoms13.The study protocol was approved by the “ASL Napoli 3 Sud Ethical Committee” and informed consent was obtained from participants. All methods were carried out in accordance with relevant guidelines and regulations.Upper and lower GI symptoms questionnaireGI symptoms were assessed by a previously published standardized questionnaire which is routinely used in our outpatient clinic13,19,20. It deals with the presence, the frequency from 0 to 3 (0 = absent, 1 = 2 d/wk; 2 = 3–5 d/wk; and 3 = 6 or 7 d/wk) and the intensity from 0 to 3 (0 = absent; 1 = not very bothersome, not interfering with daily activities; 2 = bothersome, but not interfering with daily activities; and 3 = interfering with daily activities) of a number of upper and lower GI symptoms. In this study we considered for statistical analysis those symptoms that are a common complaint for patients suffering from Achalasia, EoE, GERD and eDGBI such as dysphagia for solids, dysphagia for liquids, regurgitation, heartburn, non-cardiac chest pain. For each symptom, a frequency-intensity score was obtained, from 0 up to a maximum of 6.Statistical analysisFrequencies, median and Interquartile range (IQR) or means and standard deviations for discrete or continuous variables were computed, respectively. When appropriate, a χ2 test to compare categorical data and Analysis of Variance (ANOVA) to compare continuous variables were calculated. A non-parametric Spearman correlation (rs) was calculated between each esophageal symptom (dysphagia for solids, dysphagia for liquids, regurgitation, heartburn, non-cardiac chest pain) and the cumulative PPRS-SF score, obtained by the 12 items questionnaire. Multiple ANOVA was used as appropriate. The significance was expressed as p < 0.05. Computation was carried out by the SPSS software package for Windows (release 2019; SPSS Inc., Chicago, IL, USA).ResultsFrom January 2023 to June 2023 two hundred and seventeen patients with esophageal diseases were enrolled in this study. All the study subjects were fluent and literate native Italian speakers. 195 (90%) patients completed the questionnaire. 22 patents were excluded because their questionnaire was incomplete; their age and sex did not significantly differ from the 195 included patients. 105/195 (55.7%) were males. Among the enrolled patients, 53 had a diagnosis of esophageal Achalasia (28%), 50 of EoE (26%), 48 patients of GERD (24%) and 44 patients of esophageal DGBI (22%). The demographic characteristics were reported in Table 1.Mean age of EoE patients was significantly lower than Achalasia patients (p Scheffé <0.001) and GERD patients (p Scheffé <0.001). Mean BMI of EoE patients was significantly lower than GERD patients (p Scheffé =0.002).Mean PPRS-SF score, calculated as cumulative score, was significantly higher in EoE patients compared to esophageal DGBI patients and GERD (p = 0.008 and p = 0.04, respectively). Mean PPRS-SF scores in each group were reported in Fig. 1. Between a minimum of −36 and a maximal of + 36, the mean score for patients with Achalasia was 23.3 ± 20.1; for patients with Eoe 30.1 ± 9.8; for patients with GERD 20.5 ± 16.0; for esophageal DGBI patients 18.0 ± 18.6.Table 1 Demographics of all participants; EoE: eosinophilic esophagitis; gerd = gastroesophageal reflux disease; eDGBI = esophageal disorders of gut-bran interaction.Full size tableFig. 1Mean Italian version PPRS-SF score. EoE = Eosinophilic Esophagitis; GERD = Gastroesophageal Reflux Disease; DGBI = Disorders of Gut-Brain Interaction.Full size imageThere was a negative significant correlation between the PPRS score and age (rs=- 0.208; p = 0.004).The PPRS score was significantly higher in patients with “organic diagnosis” such as Achalasia, EoE and GERD compared to patients with “functional diagnosis” i.e. eDGBI after adjusting for covariates: age, sex, and BMI. Age was significantly related to the PPRS score [Table 2].Table 2 PPRS score by “organic” and “functional” esophageal diseases, taking into account age, sex and BMI. D.f = degrees of freedom; F = F-value.Full size tableTable 3 showed the frequency-intensity scores of those symptoms that are a common complaint for patients suffering from Achalasia, EoE, GERD and eDGBI.Table 3 Frequency-intensity score (from a minimum of 0 up to a maximum of 6) of the main upper GI symptoms.Full size tableThe frequency-intensity score of dysphagia for solids was significantly higher in Achalasia patients than all other groups (p Scheffé <0.001), while the score of dysphagia for liquids was higher in Achalasia patients compared to DGBI (p Scheffé = 0.02) and GERD (p Scheffé = 0.008), but not in EoE patients. The frequency-intensity score of regurgitation in EoE patients was significantly lower than all other groups (p Scheffé <0.001 vs. Achalasia and Gerd, and p = 0.003 vs. DGBI). There were no significant differences between groups regarding heartburn and chest pain.Furthermore, there was no significant relationship between the PPRS-SF score and esophageal symptoms (dysphagia for solids rs=0.046; dysphagia for liquids rs=−0.014; heartburn rs=−0.047; regurgitation rs=−0.103; non cardiac chest pain rs=−0.072).DiscussionIn G.I. medical practice, patient satisfaction towards their medical care is generally considered lower in those affected by non-structural disorders. This might be due to gastroenterologists often giving these patients lower clinical priority, due to the lack of objective endoscopic and/or histological findings, and it is a phenomenon well described in scientific literature4.This difficult interaction is supported by the current literature, showing that about one-third of physicians reported frustration in treating patients with IBS21,22 .On the other hand, even chronic organic diseases such as Achalasia and EoE can significantly impact the quality of life of affected patients and an impaired quality of life could also lead to a troubled physician-patient relationship8,9,10.The Rome Foundation in 2021 convened a multidisciplinary working team to review of the evidence on communication skills and PPR, producing recommendations on how to better interact with chronic patients, especially those affected by functional disorders10. The lack of a tool capable of measuring the PPR quantitatively is what brought Kurlander et al. to develop a specific questionnaire12in 2017 and Drossman to simplify it in 2021 by ideating a short form of the original questionnaire (PPR-SF)7.We have embarked upon this project to translate and validate the PPR-SF questionnaire, which was originally developed in English for American patients, in order to provide a tool for evaluating patient-physician relationship in a completely different sociocultural background such as the Italian one.Once the Italian version of the PPRS-SF was validated, we decided to administer it only to patients affected by esophageal diseases to have a more specific look at what the differences in medical care satisfaction would be, especially when comparing organic to non-structural esophageal diseases.Every enrolled patient had been regularly followed at our outpatient clinic for at least 2 years by the same two referring gastroenterologists (AS & PI).The questionnaires were filled out by the patients after the scheduled medical examination, without the presence of the said physicians in order to avoid an interviewer bias23. During the compilation, a designed person was always available to patients in case of difficulties in understanding the questionnaire.Our main result is that patients affected by DGBI reported the lowest score regarding the patient-physician relationship. On the other hand, patients suffering from organic diseases such as Eosinophilic Esophagitis and Achalasia reported the highest scores.Although to our best knowledge in current literature, there’s no other study that has taken into consideration mainly esophageal diseases patients, our results are coherent to the evidence in the literature of difficult PPR in functional diseases.Using a standardized questionnaire commonly used in our outpatient clinic, we were able to identify and to quantify patients’ main GI symptoms. Although symptoms varied between the patients, by standardizing the data for different symptoms, there was not a single GI symptom that was correlated with a significantly higher or lower satisfaction with their medical care.Sex could be another influencing factor, as the mean male satisfaction was higher (25.5 ± 14.4), compared to the reported female score (20.4 ± 19.5), but the results were not statistically significative at univariate statistical analysis.Interestingly, the most important factor influencing the PPR, besides their diagnosis, was the patients’ age. The older patients are, the more they seem to be unsatisfied with their medical care. This result has not been explored in depth in literature, although in previous studies emerged a similar trend, even in the original PPRS-SF. One possible explanation is that patients suffering from chronic disorders such as esophageal DGBI for a long time, while having access only to limited medical treatments, could experience frustration towards their physicians and thus, report a lower PPR-SF score. Further studies could be helpful to confirm this finding.It’s important to note that some sociodemographic characteristics such as education, income and marital status not taken into consideration in this project, could influence the PPR. Furthermore, interaction of patients with two different physicians may be considered as a confounding factor for the PPR; even if it is important to consider that patients did not refer to one single physician in the original questionnaire either. Although this study involved only patients with esophageal diseases, the items of the questionnaire are not specific to any disorder, so the PPRS-SF Italian Version could potentially be used in any medical condition involving a patient-physician relationship.ConclusionsThis study has produced an Italian version of the PPRS-SF questionnaire which, after a transcultural validation, has proven to be a valid tool for assessing patient-physician relationship within esophageal diseases.Our study shows that the patients’ diagnosis together with other factors such as their age, can affect the quality of the patient-physician relationship.In particular, patients with DGBI and older patients reported lower scores than the ones with organic diseases and the younger ones, respectively.The PPRS-SF Italian Version questionnaire is configuring as a promising tool for the evaluation of these factors, although further studies are necessary.
Data availability
The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.
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Download referencesAuthor informationAuthors and AffiliationsGastrointestinal Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Salerno, ItalyCarlo Soldaini, Antonella Santonicola, Luigi Ruggiero, Angela Caloro, Luca De Leo & Paola IovinoDepartment of Internal Medicine and Medical Specialties, “Sapienza” University, Rome, ItalyNadia PallottaAuthorsCarlo SoldainiView author publicationsYou can also search for this author inPubMed Google ScholarAntonella SantonicolaView author publicationsYou can also search for this author inPubMed Google ScholarLuigi RuggieroView author publicationsYou can also search for this author inPubMed Google ScholarAngela CaloroView author publicationsYou can also search for this author inPubMed Google ScholarLuca De LeoView author publicationsYou can also search for this author inPubMed Google ScholarNadia PallottaView author publicationsYou can also search for this author inPubMed Google ScholarPaola IovinoView author publicationsYou can also search for this author inPubMed Google ScholarContributionsConceptualization PI, methodology, PI.and NP; writing of the manuscript (original draft and review and editing) CS. AS. and PI; data curation and editing CS, AS, LR., LDL, AC. and PI.Corresponding authorCorrespondence to
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KeywordsPatient-Physician relationship scaleEosinophilic esophagitisAchalasiaGastroesophageal reflux diseaseEsophageal disorders of gut-brain interaction