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FACTORS ASSOCIATED WITH THE QUALITY OF THE DOCTOR-PATIENT RELATIONSHIP IN BRAZIL.

Lucas Wollmann, Grupo Hospitalar Conceição, lucasw.bm@gmail.com, https://orcid.org/0000-0002-3543-0794
Lisiane Hauser, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, lisiane.hauser@ymail.com, https://orcid.org/0000-0003-3324-5533
Christina van der Feltz-Cornelis, Institute of Health Informatics, University College London, prof.vanderfeltz.york@gmail.com, https://orcid.org/0000-0001-6925-8956
Sotero Serrate Mengue, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, sotero@ufrgs.br, https://orcid.org/0000-0002-3349-8541
Rudi Roman, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, rudiroman@gmail.com, https://orcid.org/0000-0002-2663-4314
Milena Rodrigues Agostinho Rech, Departamento de Medicina, Universidade de Caxias do Sul, milena.rodrigues.agostinho@gmail.com, https://orcid.org/0000-0003-1852-1632
Erno Harzheim. Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, eharzheim@hcpa.edu.br, https://orcid.org/0000-0002-8919-7916
 
ABSTRACT
The quality of the doctor-patient relationship plays a crucial role in treatment adherence, disease control and care satisfaction, with various factors potentially influencing its healthy development. This study investigated the influence of patient- and doctor-related factors on the relationship’s quality in Primary Care settings of Brazil\'s Unified Health System, as measured by the Patient-Doctor Relationship Questionnaire (PDRQ-9). Data were collected from 5,971 adult patients and 494 doctors at Family Health Clinics across all regions of Brazil. Multivariate analysis indicated that patient characteristics alone were significantly associated with the quality of the doctor-patient relationship. These included living in urban areas, being male, having 10 or more years’ education, obtaining a same-day appointment, having had more than three appointments with the same doctor in the prior year and being seen at a family health clinic offering high-quality primary care. The findings highlight inequalities in the doctor-patient relationship and show that patients who shared characteristics in common with their doctors (urban background and higher education) or attended higher-quality primary care clinics reported more satisfactory relationships. This underscores the importance of developing doctors\' cultural competence and the impact of service organisation on relationship quality.
KEYWORDS: doctor-patient relations; quality of health care; process assessment, health care; patient-reported experience measures.

INTRODUCTION
The doctor-patient relationship is a central element to be considered to improve the quality of population health. A good doctor-patient relationship is associated with a number of beneficial effects including better adherence to medical treatment and recommendations1, control of diseases and symptoms, functional and psychological status2,3 and satisfaction with care received4. Established paradigms of quality, such as the Quadruple Aim5, a person-centred clinical method6, see the doctor-patient relationship as a fundamental component of quality and an essential attribute of primary health care (PHC)7.
The doctor-patient relationship is expressed in the trust established between health care practitioner and patient, in the doctor’s empathetic behaviour and in good communication and interaction skills. These can build into a therapeutic alliance, in which goals and responsibilities are established jointly and strengthened by a bond forged over time8–11.
A number of factors can influence the development of a good relationship between doctor and patient. These include patient-related factors, such as age, sex, race, schooling, socioeconomic position and the existence of comorbidities12–15. On the other hand, doctors’ working conditions and job satisfaction can affect the quality of the relationship, as well as characteristics relating to their professional training and experience16–18.
Usually, psychometric scales have been used to study the doctor-patient relationship9. The Patient-Doctor Relationship Questionnaire (PDRQ-9), a practical instrument with good psychometric parameters19, evaluates the doctor-patient relationship from the patient’s perspective, focusing on their perception of the doctor’s empathy and willingness to help20. The PDRQ-9 validated for use in Brazil has been deployed in assessing PHC nationally21,22.
The PDRQ-9, as a key component of care, should also form part of the set of indicators of pay for performance in the new model of federal funding for PHC23. In order to surmount the quality challenges facing Brazil, it is important to learn what factors affect the doctor-patient relationship and obtain information that can serve as input to improving health outcomes and experiences of care24.
This study assesses the association, in SUS primary health care, between patient- and doctor-related factors and the quality of doctor-patient relationships as measured using the PDRQ-9.

METHOD
Design and sample
This study was nested in a nationwide cross-sectional study conducted to assess the quality of primary health care (PHC) provided, in Brazil, by doctors with different profiles25. In each region of the country, sampling chose municipalities by their probability proportional to the number of family health clinics (FHCs) that adopted Brazil’s family health strategy (FHS). In each municipality, FHCs were selected by systematic sampling, stratified by the number of FHS teams. Sample selection data were obtained from a list of all doctors working with the FHS in Brazil supplied by the Ministry of Health.
In each FHC selected, adult users were interviewed on site, after consecutive selection following their appointment with a doctor. These users responded to the PDRQ-9 questionnaire, the short version of the Primary Care Assessment Tool (PCATool-Brasil), and to structured questions on sociodemographic, morbidity and quality of care received variables. All doctors selected were also interviewed on the basis of a shortened, structured questionnaire on sociodemographic factors, their professional training and experience and the Warr-Cook-Wall Job Satisfaction Scale, a job satisfaction evaluation instrument intended for health care practitioners26. Data were collected between July and November 2016.
Calculation of the original study sample contemplated 6,193 users distributed in 516 clusters (doctors), with a view to identifying PCATool-Brasil score differences of 0.3 points between groups. The study considered a standard deviation of 1.7, design effect (DEFF) of 3.4, 20% losses, 80% statistical power and 5% significance. The total number of users was also distributed among the three groups of doctors, and it was decided to interview 12 patients per doctor.
The cutoff point used to distinguish a high-quality patient-doctor relationship, as evaluated by the PDRQ-9, was a score of 3.5 on a scale of 1 to 5 (higher scores indicating a better relation). The cutoff point was selected using the Youden index.
Inclusion criteria
Doctors: having worked for at least 12 months in the selected FHC.
Patients: over 18 years of age; having had a same-day appointment with the doctor selected at least once prior to the interview; and being in a condition to respond to the questionnaire.
Statistical analysis
The qualitative variables were described using absolute and relative frequencies in the total sample, and were also stratified by high and low PDRQ-9 scores. The variables associated with higher PDRQ-9 scores were identified by generalised estimating equation and Poisson distribution, with robust estimate of variance, to show prevalence ratios (PRs) and respective confidence intervals (CIs). The generalised estimating method considers the structure of correlation among observations and is used primarily in analyses with binary outcomes27. Especially in this study, patients were grouped by doctor (health care service), which suggested the need for the adjusted model to contemplate correlations among patients of the same doctor28,29. To improve modelling, the analysis used information from clusters (doctors) with more than six patient interviewed.
To begin with, explanatory variables retained in the multivariate model were those that individually showed an association with high PDRQ-9 scores and returned a p-value of less than 0.20 by the Wald test. Then, variables with higher p-values were excluded successively so as to arrive at a model with only variables with p-values of less than 0.05. In order to fit the model, these were evaluated by the Wald-Wolfowitz test and Quasi-likelihood under Independence Model Criterion, and Pearson residuals were inspected for graphically. All analyses were performed using the Statistical Package for the Social Sciences (SPSS), version 23.
Legal and ethical considerations
This project was approved by the research ethics committee of the Hospital de Clínicas de Porto Alegre (CAAE 48653615.6.0000.5327).
All interviewees signed a declaration of free and informed consent. The questionnaires were applied by trained interviewers at the health care clinics, by means of an electronic tool (a tablet). The information was transferred anonymously for analysis.
The research was funded by the Pan American Health Organisation (PAHO).

RESULTS
The participants’ characteristics are shown in Table 1. Most of the 5,971 patients included in the sample were women, self-declared their skin colour as non-white and were over 45 years old. Two thirds had at least one of the chronic comorbidities examined: arterial hypertension, diabetes mellitus, respiratory disease (asthma or chronic obstructive pulmonary disease), depression, obesity and tobacco use. Most were treated at FHCs with high PHC scores, as rated by the PCATool-Brasil, and had had more than three appointments in the prior 12 months.
Of the 494 doctors participating in the study, most were women and up to 40 years old. Most of the doctors were specialists in family and community medicine (FCM), had more than five years’ experience working in PHC and had been at the same FHC for more than two years.
Table 2 shows the prevalence ratios (PRs) associated, in univariate and multivariate analyses, with high quality doctor-patient relationships identified by PDRQ-9 scores.
As regards the patients’ characteristics, the univariate analysis associated better doctor-patient relationships with residing in an urban municipality, being male, having 10 or more years of schooling, working or being retired, belonging to socioeconomic classes A, B or C, having a same-day appointment, having had more than three appointments with their doctor in the prior year and being treated at an FHC with a high PHC quality score. As for the doctors’ characteristics, the univariate analysis showed associations with having specialised in FCM and seeing up to 12 patients per work shift.
In the multivariate analysis, only patient characteristics continued significantly associated with quality of the doctor-patient relationship: residing in an urban municipality, being male, having 10 or more years of schooling, having a same-day appointment, having seen their doctor more than three times in the prior year and having been treated at an FHC with a high PHC quality score.

DISCUSSION
From PHC patient- and doctor-related factors examined in this study, an association was found in the SUS between the quality of the doctor-patient relationship and the patient’s residing in an urban municipality, being male, having 10 or more years’ schooling, obtaining a same-day appointment, having been seen by their doctor more than three times in the prior year and attending an FHC with a high PHC quality score.
By and large, these findings align with those of other studies that have sought to identify factors associated with the doctor-patient relationship12,30,31. Interestingly, no associations were found with patient age or skin colour, which have been found in other studies31,33 and are normally factors representing a lack of equity. At the same time, other factors possibly related to inequity were identified: positive associations were found between quality of the doctor-patient relationship and variables such as male sex, living in predominantly urban municipalities and higher levels of schooling. These findings are in agreement with the literature 30-32. The lesser quality found in doctor-patient relationships with women can be explained by gender bias, either because women received lesser quality care or because women tend to assess care received more critically than men, possibly because they are more demanding of having their needs met.
Associations between the quality of the doctor-patient relationship and factors such as urbanisation and schooling – characteristics often shared by the doctors themselves – suggests difficulty in establishing good relations with patients whose sociocultural profile is different. In that regard, cultural competence, an attribute derived from PHC, becomes an essential factor to be considered in reducing such disparities in Brazil. Cultural competence is the ability to recognise and meet the particular needs of sub-populations that may not be visible because of their specific ethnic, racial or cultural nature7. It is thus a fundamental component to be incorporated into clinical care, especially in contexts marked by inequities.
No association was found between multi-comorbidity and the doctor-patient relationship, although this has been found in other studies12,15. In this case, however, severity of comorbidity mediates the association. Comorbidity severity was not examined in this study and may explain the absence of an association.
Doctor-related characteristics, such as workload and specialisation in FCM, were associated with better doctor-patient relations in the univariate analysis, which is supported by the literature17,18. However, no doctor-related characteristic was retained in the multivariate analysis. That absence can be explained, at least partly, by the smaller sample size and the greater homogeneity of the doctors’ characteristics as compared with the patient sample.
High PHC quality score and obtaining a same-day appointment for an acute problem were both retained in the multivariate analysis. Health service characteristics influenced the development of the doctor-patient relationship. Longitudinal care is an important component of the doctor-patient relationship and an essential quality attribute of PHC services7. It is not present consistently in all countries and depends on the health system: some services focus solely on providing access, but not necessarily to the same doctor over time. Health services organised to offer quality access and effective treatment contribute to the development of better relations between doctor and patient, as is also supported by the literature30,34.
To summarise, the quality of doctor-patient relationships continued to be associated with health service characteristics and with characteristics of patients who displayed sociocultural similarities with their doctors. This points to the importance of developing cultural competence among doctors, as well as better-quality organisation of PHC, so as to produce significant impact on the doctor-patient relationship and thus on the quality of care offered.
This was the first study to use doctor-patient relationship quality categories based on PDRQ-9 scores. This enabled the results to be understood more simply and intuitively, because doctor and patient characteristics were associated with a quality category (rather than a quality score), which also made it easier to communicate the conclusions. The fact that the sample is national confers greater external validity on the results. As this was a cross-sectional study, no causal inferences can be drawn with regard to the factors found; these will have to explored in greater depth in further research with appropriate methodologies. Neither were the covariables included intended to exhaust all important possibilities. Other factors not studied here may be involved, offering other research possibilities. The study was conducted with data collected in 2016. Although the doctor-patient relationship tends to be relatively stable over time, sociodemographic or cultural changes since then may affect interpretation of the results in the present context.
The doctor-patient relationship is a key component of care quality, so the point where it forms part of health system quality indicators and evaluation and performance pay mechanisms. Researchers, practitioners and managers will be able to use the results of this study to extend discussion of the influence of doctor, patient and health care service characteristics on the quality of doctor-patient relationships. That will make it possible to develop professional and health service improvement initiatives to reduce inequities and offer person-centred care that respects individual needs, characteristics and values.

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