Physicians' knowledge of health-related quality of life and perception of its importance in daily clinical practice

  • Maurizio Bossola1Email author,

    Affiliated with

    • Rita Murri2,

      Affiliated with

      • Graziano Onder3,

        Affiliated with

        • Adriana Turriziani4,

          Affiliated with

          • Massimo Fantoni2 and

            Affiliated with

            • Luca Padua5, 6

              Affiliated with

              Health and Quality of Life Outcomes20108:43

              DOI: 10.1186/1477-7525-8-43

              Received: 29 June 2009

              Accepted: 23 April 2010

              Published: 23 April 2010

              Abstract

              Background

              Health-related quality of life (QoL) has become a crucial outcome in medical care. However, few studies have assessed physician knowledge of QoL and rate of physicians adopting QoL measures in clinical practice. The present study aimed at assessing the level of knowledge of QoL and the perceived importance of incorporating QoL assessment in clinical practice among physicians of a tertiary level academic hospital in Rome, Italy.

              Materials and methods

              A survey study performed through the distribution of a questionnaire assessing knowledge of QoL studies that used the SF-36 scale, participation in studies evaluating QoL as well as knowledge of journals publishing articles on QoL Physicians and residents at the hospital Policlinico Gemelli, Catholic University of Rome.

              Results

              Three-hundred nine physicians completed the questionnaire. Thirty-eight percent % reported knowing studies on QoL and using their results in clinical practice or for research purposes; 29% reported knowing the SF-36 questionnaire; 30% stated that at least one study assessing QoL had been conducted in their department. Fourty-six percent % stated that QoL must influence much or very much diagnostic choices and an even higher percentage reported that QoL must influence much or very much therapeutic and palliative strategies (70.8% and 91.3%, respectively). Reported barriers to the use of QoL measures in clinical practice were related to time constraints (8.7%) but also to doubts on methodological issues of QoL (30.7%). The large majority of physicians (94.3%) would have used more expensive drugs if these could improve QoL.

              Conclusions

              The present study shows that in a tertiary level academic italian hospital one third of the physicians, reported to know QoL measures and that more than 80% of them would like to use QoL in their daily clinical practice. Future studies are needed to identify the best strategies to implement the use of QoL measures in clinical practice.

              Introduction

              Health-related quality of life (QoL) has become a crucial outcome in medical care [1, 2]. A communication style in which physicians ask their patients about both physical health problems and psycho-social issues has been found to be related to a higher patient satisfaction and even better health outcomes [3, 4]. However, little is known about physicians' attitudes towards QoL and rate of physicians adopting QoL measures in clinical practice [5, 6]. For example, a study exploring the knowledge of hospital physicians about QoL assessment revealed that less than two-thirds had some knowledge of QoL assessment in oncology [5]. Recently, a survey among oncologists has shown that there is lack of understanding of the justification and rationale for QoL assessment, lack of guidance on implementing assessment and limited knowledge of literature about QoL [6]. The present study aimed at assessing the level of knowledge of QoL and the perceived importance of incorporating QoL assessment in clinical practice among physicians of a tertiary level academic hospital in Rome, Italy.

              Methods

              The survey was conducted on physicians and residents at the hospital Policlinico Gemelli, Catholic University of Rome. The Policlinico Gemelli is a 1700-bed academic hospital, located in the North of the town, built in 1964 (with more than 57.000 admissions per year). It is a public hospital and it is classified as hospital of a National relevance with high specialization. The mission of the hospital is to provide the best health care services, to implement a partnership with patients, to implement the best education in medicine and in management of health care services, and to combine technical health care services with a managerial approach. Since 1997 a process of re-engineering is ongoing with the purpose of developing a new vision of patient care, focused on patient centredness, on efficacy, effectiveness, and safety. The Policlinico Gemelli staff includes 999 physicians and 320 residents. Two hundred nine physicians (21.9%) were not included in the survey since they do not have contact with patients (for example microbiologists, laboratory personnel) The questionnaire items assessed knowledge of studies that used the SF-36 scale, participation in studies evaluating QoL and knowledge of journals publishing articles on QoL (Table 1). The SF-36 questionnaire was chosen since it is one of the most used instrument for the assessment of QoL in many different clinical fields.
              Table 1

              Questionnaire to assess the knowledge of QoL issue

              What is your knowledge of QOL studies and trials?

                 - None

                 - Unspecific knowledge

                 - Specific knowledge without research activity

                 - Use of QOL assessment in clinical practice

                 - Use of QOL assessment for research purpose

              The SF-36 is:

                 - Self administered and measures disability

                 - Self-administered, unspecific tool to measure QOL

                 - Filled by the physician

                 - Unknown

              Have you ever partecipated a study on QoL?

                 - Never

                 - Once

                 - Several times

              Do you know a medical journal that publishes studies on QoL?

                 - Yes

                 - No

              Studies on QoL are usually performed in your department?

                 - Yes

                 - No

              Similarly, the following attitudes of physicians towards QoL were also investigated: influence of QoL in diagnostic, therapeutic choices and palliative strategies; relevance of QoL outcomes in clinical studies and importance to plan QoL studies in the next future; role of physicians, nurses, psychologists in assessing QoL; barriers to the use of QoL in daily clinical practice (Table 2). Diagnostic strategies may have a different impact on QoL. For example, an accelerated diagnostic protocol for patients presenting to the emergency department with acute chest pain resulted in better QoL compared to the usual-care arm [7].
              Table 2

              Questionnaire to assess the perception of the importance of QoL in clinical practice

              QoL must influence diagnostic strategies?

                 - No

                 - A little

                 - Quite

                 - Much

                 - Very much

                 - I do not know

              QoL must influence therapeutic strategies?

                 - No

                 - A little'

                 - Quite

                 - Much

                 - Very much

                 - I do not know

              QoL must influence palliative care?

                 - No

                 - A little'

                 - Quite

                 - Much

                 - Very much

                 - I do not know

              Do you have in mind QoL in your diagnostic and therapeutic strategies, although you don't meausre it?

                 - No

                 - A little'

                 - Quite

                 - Much

                 - Very much

              When you read and score a scientific article is QoL important?

                 - No

                 - A little'

                 - Quite

                 - Much

                 - Very much

              Is the measurement of QoL in clinical trials useful?

                 - No

                 - A little

                 - Quite

                 - Much

                 - Very much

              Who should measure QoL?

                 - Physician

                 - Other (nurse, psychologist)

              Is useful to increase the number of clinical trials in QoL?

                 - No

                 - A little

                 - Quite

                 - Much

                 - Very much

              Should you use more expensive drugs if they shoul improbe QoL?

                 - No

                 - A little

                 - Quite

                 - Much

                 - Very much

              Physicians were also asked whether, among drugs with the same efficacy, they would have used those more expensive if these could improve QoL (Table 2). Five response categories were available from "no" to "very much".

              The questionnaire was administered by mail, and a face-to-face distribution in every department was also done. For each department a reference person was identified to distribute and collect the filled questionnaire. Since the present study did not involve any patient and since all the data used for the analysis were provided directly by each participant, ethical approval was not requested.

              Statistical analysis

              A descriptive analysis was performed. Moreover, to compare rate of answers among groups contingency tables were done and chi-square test applied. P < 0.05 was considered as statistically significant.

              Results

              Out of 780 physicians and 320 residents, 308 (28%) completed the questionnaire. Their characteristics are shown in Table 3. One hundred sixty three (52.9%) were male. Forty-nine percent were < 35 years, 44.1% between 35-54 years, and only 7% were 55 years or older. Most (64.5%) worked in medical departments, 18.4% in surgical departments and 14.5% in radiology or in other services. The majority of responders answered to work in team. Considering the whole population of 999 physicians of the Gemelli Hospital, 68.4% are males, 27% less than 40 years-old, 44.6% more than 50 years-old; 395 (39.5%) work in medical areas.
              Table 3

              Characteristics of the physicians who answered the questionnaire

               

              N (%)

              Gender:

               

              - Male

              163(52.8)

              - Female

              146 (47.2)

              Academic role:

               

                 - Chairman/Associate Professor

              38 (12.3)

                 - Asssistant Professor

              82 (26.6)

                 - Assistano

              63 (20.5)

                 - Residents

              94 (30.5)

                 - Other

              31 (10.1)

              Tipe of activity

               

                 - Within a team

              256 (82.6))

                 - alone

              37 (11.9)

                 - unknown

              17 (5.5)

              Age (years):

               

                 - <34

              149 (48.1)

                 - 35-44

              71 (22.9)

                 - 45-54

              66 (21.3)

                 - 55-64

              22 (7.1)

                 - >65

              1 (0.3)

              Department

               

                 - Medicine

              200 (64.5)

                 - Surgery

              57 (18.4)

                 - Specialised Surgery

              28 (49.1)

                 - General Surgery

              29 (50.9)

                 - Radiology- Nuclear Medicine - Other Services

              45 (14.5)

                 - Unknown

              8 (2.6)

              As shown in Table 4, among the physicians who completed the questionnaire, 38% reported knowing studies on QoL and using their results in clinical practice or for research purposes; 29% reported knowing the SF-36 questionnaire; 30% stated that at least one study assessing QoL had been conducted in their department. Twenty three percent of physicians reported to have participated in studies assessing QoL whereas only 16.5% of them indicated the name of a journal publishing studies on QoL.
              Table 4

              Answers to the questionnaire assessing the knowledge of QoL issue

              What is your knowledge of QOL studies and trials?

               

                 None

              48 (15.5)

                 - Unspecific knowledge

              173 (55.8)

                 - Specific knowledge without research activity

              31 (10)

                 - Use of QOL assessment in clinical practice

              22 (7.1)

                 - Use of QOL assessment for research purpose

              34 (11)

              The SF-36 is:

               

                 - Self administered and measures disability

              15 (4.8)

                 - Self-administered, unspecific tool to measure QOL

              90 (29)

                 - Filled by the physician

              6 (1.9)

                 - Unknown

              197 (63.5)

              Have you ever partecipated a study on QoL?

               

                 - Never

              235 (75.8)

                 - Once

              42 (13.5)

                 - Several times

              32 (10.3)

              Do you know a medical journal that publishes studies on QoL?

               

                 - Yes

              51 (16.5)

                 - No

              259 (83.5)

              Studies on QoL are usually performed in your department?

               

                 - Yes

              94 (30.3)

                 - No

              216 (69.7)

              However, as shown in Table 5, 46.1% of the physicians who completed the questionnaire stated that QoL must influence much or very much diagnostic choices and an even higher percentage of them reported that QoL must influence much or very much therapeutic and palliative strategies (70.8% and 91.3%, respectively). Seventy eight percent of physicians considered mandatory to measure QoL in clinical trials and to increase the number of QoL studies (67.4%). Most physicians (73.5%) reported that themselves or residents should measure QoL. The majority of physicians (94.3%) would have used more expensive drugs if these could improve QoL.
              Table 5

              Answers to the questionnaire assessing the perception of the importance of QoL in clinical practice

              Must QoL influence diagnostic strategies?

               

                 - No

              15 (4.8)

                 - A little

              46 (14.8)

                 - Quite

              101 (32.6)

                 - Much

              119 (38.4)

                 - Very much

              24 (7.7)

                 - I do not know

              4 (1.3)

              Must QoL influence therapeutic strategies?

               

                 - No

              8 (2.6)

                 - A little

              12 (3.9)

                 - Quite

              66 (21.3)

                 - Much

              166 (53.5)

                 - Very much

              52 (16.8)

                 - I do not know

              4 (1.3)

              Must QoL influence palliative care?

               

                 - No

              3 (1)

                 - A little

              2 (0.6)

                 - Quite

              18 (5.8)

                 - Much

              97 (31.3)

                 - Very much

              186 (60)

                 - I do not know

              3 (1)

              Do you have in mind QoL in your diagnostic and therapeutic strategies, although you don't meausre it?

               

                 - No

              3 (1)

                 - A little

              23 (7.4)

                 - Quite

              121 (39)

                 - Much

              130 (41.9)

                 - Very much

              29 (9.4)

              When you read and score a scientific article is QoL important?

              ?

               

                 - No

              38 (12.3)

                 - A little

              70 (22.6)

                 - Quite

              136 (43.9)

                 - Much

              54 (17.4)

                 - Very much

              6 (1.9)

              Is the measurement of QoL in clinical trials useful?

               

                 - No

              1 (0.3)

                 - A little

              16 (52)

                 - Quite

              83 (26.8)

                 - Much

              174 (56.1)

                 - Very much

              35 (11.3)

              Who should measure QoL?

               

                 - Physician

              228 (73.5)

                 - Other (nurse, psychologist)

              73 (23.5)

              Is useful to increase the number of clinical trials in QoL?

               

                 - No

              1 (0.3)

                 - A little

              11 (3.5)

                 - Quite

              54 (17.4)

                 - Much

              190 (61.3)

                 - Very much

              51 (16.5)

              Should you use more expensive drugs if they shoul improbe QoL?

               

                 - No

              2 (0.6)

                 - A little

              15 (4.8)

                 - Quite

              68 (21.9)

                 - Much

              167 (53.9)

                 - Very much

              55 (17.7)

              Reported barriers to the use of QoL measures in clinical practice were related to time constraints (8.7%) but also to doubts on methodological issues (30.7%).

              We did not find any significant difference in the characteristics of the physicians who answered to know or not to know the SF-36 questionnaire. Results are shown in Table 6.
              Table 6

              Comparison between physicians who answered to know or not to know the SF-36 questionnaire

               

              Physicians who know SF-36

              (N. = 89)

              Physician who do not know SF-36

              (N. = 215)

              p

              Female

              46 (51.7)

              98 (45.6)

               

              male

              43 (48.3)

              117 (54.4)

              0.33

              Academic role:

                 

                 - Professor/Associate professor

              6 (6.7)

              31 (14.4)

               

                 - Assistant Professor

              47 (52.8)

              96 (44.7)

               

                 - Resident

              26 (29.2)

              67 (31.2)

              0.39

                 - Other

              10 (11.2)

              21 (9.8)

               

              Age

                 

                 - < = 44 years

              68 (76.4)

              147 (68.7)

              0.18

                 - >44 years

              21 (23.6)

              67 (31.3)

               

              Medical area:

                 

                 - Medicine

              66 (75)

              132 (62.9)

               

                 - Surgery

              10 (11.4)

              46 (21.9)

              0.07

                 - Diagnostic/Service

              12 (13.6)

              32 (15.2)

               

              Did you partecipate studies on QoL?

                 

                 - yes

              43 (48.9)

              30 (13.9)

              <0.0001

                 - no

              45 (51.1)

              186 (86.1)

               

              Discussion

              The present study shows that the majority of physicians who answered to the questionnaire on QoL are aware of its usefulness in clinical management. More than 80% of participants would like to use QoL in their daily clinical practice but only one third of the physicians who participated to the survey know QoL measures. To our knowledge, this is the first survey that on physicians of different specialities of a tertiary level academic hospital to evaluate their knowledge and perception of QoL.

              Indeed, little is known about physicians' attitudes towards QoL and rate of physicians adopting QoL measures in clinical practice. An Italian study exploring the knowledge of hospital physicians on QoL assessment revealed that 62% had some knowledge of QoL assessment in oncology but that most tended to rely on a physician-base assessment rather than patient-based instruments [8]. In 1998, a survey of family physicians reported that for 78% of them it was possible to measure QoL, that 89% believed that QoL issue should be discussed with patients and that 89% would use a validated QoL measure if one were devised [9]. Meanwhile, Bezjak et al [10] collected information from a group of oncologists of a large Canadian cancer care centre on their perspectives on QoL and QoL information, through a self-administered questionnaire containing 75 items with a 4-point Likert categorical response scale. Of 67 eligible respondents, 54 replied. A total of 87% felt that published QoL data are useful for individual patient care, but 69% indicated that, at present, they would be more likely to base their recommendations on personal experience rather than on published literature and 57% felt that decisions were made more difficult when QoL issues were considered. Padua et al [11] conducted a fact-finding study among Italian neurologists to evaluate the degree of knowledge in the QoL field. Most responders indicated that it would be important either to increase knowledge of the real impact of a disease on a patient's QoL or to better evaluate the effects of therapy. More recently, Skevington et al. [12] approached 800 general practitioners in UK through the national postal system to find out if they used quality of life information in primary care, to explore their reasoning and to assess any barriers to use. Two hundred eighty physicians (38%) provided qualitative and quantitative information. The majority said that QoL was interesting and important. Users had seen more information and scales, and were more aware of their use; only 8% had ever used formal standardised questionnaires. The main barriers to implementation were a shortage of time and information, and experience with QoL assessment. A sizable minority wanted to know more. Seventy-one percent would use QoL to monitor treatment effectiveness.

              Results from the present survey suggested that the importance of assessment of QoL is highly perceived. Many institutions are implementing programs including the assessment of patient-reported outcomes and, particularly, of QoL. The National Health Service (NHS) in Great Britain, for example, asks all patients who are having hip or knee replacements, varicose vein surgery or groin hernia surgery to fill in a questionnaire on patient-reported outcomes to help improving the quality of care. http://​www.​nhs.​uk/​NHSEngland/​thenhs/​records/​proms/​Pages/​aboutproms.​aspx. The gap between the knowledge of QoL and the perception of its importance documented in the present study merits further attention especially in order to find strategies to reduce this gap. Several causes may explain the gap: first, QoL methodology is scarcely taught during education courses [5]; second, papers including or primarily focusing on QoL are still rarely published in medical journals other than oncology journals [6]. Moreover, physicians caring for acute patients may pay a greater attention to survival rather than to QoL. We warrant that further studies may demonstrate whether education courses or spread of guidelines on QoL methodology for students, residents and physicians would result in decreasing the gap between perception of importance and feasibility of the QoL methodology in daily routine clinical practice and clinical trials.

              Another interesting finding of this study is that, comparing the characteristics of physicians who answered to know or not to know the SF-36, we did not find significant differences. It seems that the knowledge of QoL measures is independent of age, gender, academic role, and medical speciality.

              Also interesting is the finding that to the question Who should measure the quality of life? most answered that physicians should do so. We think that this is a topical issue. Some authors believe that physicians' perceptions of QoL may be at odds with those held by the patients and QoL assessment should be performed by the patients themselves using adequate and valid measures or, in alternative, by someone who acts as a proxy or surrogate, such as a family member or a health professional [13]. However, it is well known that many patients are unable to assess their own QoL and complete a QoL measure because of cognitive impairment, difficulties in communication, symptom-related distress, or complexity of QoL measure. Moreover, the high percentage of physicians answering they should personally measure QoL highlights the perception of the great importance of the QoL issue.

              This study has several limitations. First, less than one fourth of the physicians answered the questionnaire and we do not know why about 70% of the physicians did not answer. It could be that they were not interested in the target of the study and in this case the conclusion of the study could be different. However, it is useful to underline that the rate of answer in surveys involving a large number of physicians may be low or very low [14]. Second, this is the result of one single Academic Center and findings can not be generalized to other settings. Third, since the questionnaire was built specifically for the purpose of the study, it was not previously validated. Finally, the meaning for some questionnaire items (for example for knowledge) can be differently interpretated by participants. However, the simplicity of the questions may have reduced the bias of variability in interpretation.

              In summary, the present study shows that, in a tertiary level academic Italian hospital, one third of the physicians who answered to a questionnaire on QoL, reported to know QoL measures and over 80% of them would like to use QoL in their daily clinical practice. Further studies, also in different medical settings, could assess whether increasing the knowledge on health-related QoL could lead to a growing use of QoL measures in daily clinical practice, possibly increasing also the quality of clinical care.

              Declarations

              Authors’ Affiliations

              (1)
              Department of Surgery, Catholic University of the Sacred Heart, Largo A Gemelli
              (2)
              Institute of Infectious Diseases, Catholic University of the Sacred Heart, Largo A Gemelli
              (3)
              Department of Geriatrics, Catholic University of the Sacred Heart, Largo A Gemelli
              (4)
              Department of Radiotherapy, Catholic University of the Sacred Heart, Largo A Gemelli
              (5)
              Institute of Neurology; Catholic University of the Sacred Heart, Largo A Gemelli
              (6)
              Fondazione Don Gnocchi

              References

              1. Stewart MA: Effective physician-patient communication and health outcomes: a review. Can Med Assoc J 1995, 152: 1423–1433.
              2. Bredart A, Bouleuc C, Dolbeault S: Doctor-patient communication and satisfaction with care in oncology. Curr Opin Oncol 2005, 17: 351–354. 10.1097/01.cco.0000167734.26454.30PubMedView Article
              3. Stewart MA: Effective physician-patient communication and health outcomes: a review. CMAJ 1995, 152: 1423–1433.PubMed CentralPubMed
              4. Velikova G, Booth L, Smith AB, Brown PM, Lynch P, Brown JM, Selby PJ: Measuring quality of life in routine oncology practice improves communication and patient well-being: a randomized controlled trial. J Clin Oncol 2004, 22: 714–724. 10.1200/JCO.2004.06.078PubMedView Article
              5. Young T, Maher J: Collecting quality of life data in EORTC clinical trials - what happens in practice. Psycho-Oncology 1999, 8: 260–263. 10.1002/(SICI)1099-1611(199905/06)8:3<260::AID-PON383>3.0.CO;2-ZPubMedView Article
              6. Bezjak A, Ng P, Skeel R, DePetrillo AD, Comis R, Taylor KM: Oncologist' use of quality of life information. Results of a survey of eastern Cooperative Oncology Group Physicians. Quality of Life Res 2001, 10: 1–13. 10.1023/A:1016692804023View Article
              7. Nucifora G, Badano LP, Sarraf-Zadegan N, Karavidas A, Trocino G, Scaffidi G, Pettinati G, Astarita C, Vysniauskas V, Gregori D, Ilerigelen B, Fioretti PM: Effect on quality of life of different accelerated diagnostic protocols for management of patients presenting to the emergency department with acute chest pain . Am J Cardiol 2009, 103: 592–7. 10.1016/j.amjcard.2008.10.030PubMedView Article
              8. Belli G, Tamburini M, Paci E: What do italian hospital physicians know about quality of life assessment in oncology. Tumori 1994, 80: 24–27.PubMed
              9. Walsh D, Emrich L: Measuring cancer patients' quality of life - a look at physician attitudes. New York State Journal of Medicine 1998, 88: 354–357.
              10. Bezjak A, Taylor KM, Ng P, Macdonald K, DePetrillo AD: Quality-of-life information and clinical practice: the oncologist's perspective. Cancer Prev Control 1998, 2: 230–235.PubMed
              11. Padua L, Aprile I, Caliandro P, Pazzaglia C, Mazza S, Padua R, Beghi E, Tonali p for the Italian QoL Study Group of the Italian Neurological Society: Fact-finding study about knowledge and interest in quality of life assessment among neurologists. Neurol Sci 2004, 25: 114–115. 10.1007/s10072-004-0242-3PubMedView Article
              12. Skevington SM, Day R, Chisholm A, Trueman P: How much do doctors use quality of life information in primary care? Testing the trans-theoretical model of behaviour change. Qual Life Res 2005, 14: 911–22. 10.1007/s11136-004-3710-6PubMedView Article
              13. Addingngton-Hall J, Kalra L: Who should measure quality of life? Br Med J 2001, 322: 1417–1420. 10.1136/bmj.322.7299.1417View Article
              14. Sanders C, Egger M, Donovan J, Tallon D, Frankel S: Reporting on quality of life in randomised controlled trials: bibliographic study. BMJ 1998, 317: 1191.PubMed CentralPubMedView Article

              Copyright

              © Bossola et al; licensee BioMed Central Ltd. 2010

              This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

              Advertisement