1. Azza Awad Almujali (specialist Family medicine HMC, Doha, Qatar)
Phone: 009745508354
Mobile: 009745508354
Email: azzaco5@hotmail.com

2. Ameena Hassan Alshehy (specialist Family medicine HMC, Doha, Qatar)
Phone: 009745833567
Mobile: 009745833567
Email: aalshahi@hotmail.com

3. Abdulmajeed Ahmed (Professor in Family Medicine dept., Faculty of Medicine, Suez Canal University, Egypt)
Phone: 0020192423399
Mobile: 0020192423399
Email: adham3332003@yahoo.com

4. Dr. Mansoura Fawaz S. Ismail (Fawaz M, M.Sc., PhD family medicine)
Lecturer Family Medicine, Suez Canal University Egypt and Fulltime Trainer Family Medicine Department, HMC
Phone: 4931158
Mobile: 5344029

INTRODUCTION

Assessment of patient satisfaction is one way to determine the quality of primary care, although it is dependent on the service that patients utilize and the subjectivity of their opinions. Patient satisfaction questionnaires can be used as a useful tool to evaluate the performance of health care providers during consultations¹.Consultation is considered to imply a meeting face to face, between patient and doctor. The standard medical model of the consultation, which follows history taking, examination, diagnosis, and treatment is lacking what is happening in the process of communication between physician and patient². Palmer (1997)³ said that measures of consultation outcome are imperfect. It is extremely difficult to measure the average health, medical knowledge or prognosis of a doctor's list and to relate it to variations in consultative approach. Three important outcomes that can be counted are patient satisfaction, patient improvement and patient compliance. When the consultation is judged according to these criteria it is clear that the outcome could be maximized. Various techniques can be employed to improve such outcomes as diagnostic accuracy, patient satisfaction, communication and compliance. A good relationship, and expectation, keeping the message simple and clear, repeating the message and stressing its importance will lead to enhancement of patient compliance and satisfaction. Different studies were conducted worldwide on the effect and quality of care in the general practice consultation. Howie et al, 2000⁴ conducted a study to determine the relationship between quality of consultation and some variables. The author found that the mean duration of a consultation increased when the consultation had a psychological component. Patients aged over 65 had high enablement and long consultations. Consultations for women lasted longer than those for men. Patients with social problems alone had the lowest enablement score; the more problems a patient wanted to discuss, the longer the consultation and the greater the enablement. Good doctor-patient relationships will result in considerably increased enablement effect5. So such a study is greatly required in our practice to assess the quality of care. This study was conducted to measure quality of consultation among patients attending PHC centers in Doha, and to determine the factors affecting the quality and outcome of these consultations.

Sample size determination was conducted by Epi-info stat-calculator, and was calculated to be 189 subjects, after considering a 10% dropout. The subjects of the study were all patients equal or more than 18 years old attending 2 randomly selected primary health centers in Qatar, one urban and one semi-urban (95 patients from each center) by systematic randomisation (every third patient was included in the sample). Each eligible patient was exposed to a pre-coded questionnaire in a structured interview before consulting their physician to collect data about socio-demographic variables, the type of patient problem (acute or chronic), the cause of visit, their ability to choose their consulting physician and previous physician - patient relationship. Doctors completed another questionnaire including the duration of the consultation and whether the consultation was new or it was for follow up. After the consultation, the patient was exposed to another questionnaire to measure the enablement effect of this consultation. It contained 6 questions about ability of the patient to understand his/her illness, dealing with the illness and how they can maintain their health. These questions scored as 2 for much better, 1 better, 0 same or less. A good score was considered as >60% of the total score (8 out of 12). Each physician included in this study was exposed to a physician questionnaire to collect data regarding duration and type of consultation and reason for visit. The patient's pre-consultation information was hidden from the doctor. Collection of data was over a period of three months from January to March 2008. Patients enrolled in the study had to sign a special consent form which was approved by the Research committee of HMC. Data were analyzed using the SPSS for Windows version 16 software program. Frequency tables and descriptive statistics were done. Significance test used included confidence intervals, odds ratio and chi square test. Frequency rates were compared to available data on national averages and trends. The value of p was considered significant if less than 0.05.

Ethical considerations
Approval of the research as well as the national ethical committee was gained. Informed consent was signed by participants after explanation of purpose of the study, the direct and indirect benefits and risks, as well as confidentiality of collected data with their right to withdraw at any stage of the study.

More than three quarters of the studied population were aged £45 years (77.06%), 73.3% of them were female. It was found that 82.4% of the studied population attending family practice centers had acute illnesses and 17.6% had chronic illnesses. An important finding was that the consultation time was =5 minutes for 68% of the studied population and 21.8 % of them had consultation time > 10 minutes with mean duration of 6.69 minutes. Almost two thirds of the studied population (63%) showed a good enablement score (>60% or more than 8 out of 12) as shown in (Figure1). The current study showed that all items of the enablement questionnaire demonstrated statistical significant difference individually and collectively. The mean enablement score was (7.54) as shown (Table 1). Only the ability to choose the physician and the consultation time, were statistical significant variables in relation to good and poor enablement scores as shown in (Table 2). The regression analysis was made between some variables and the enablement score. The result illustrates that there was a positive and significant correlation between age, social score, established Doctor-Patient Relationship (DPR) and choosing of their physician on one hand and enablement on the other hand (P <0.05) as shown in (Table 3).

APPENDIX: Figure (1)

Patient satisfaction is a strong measure in the evaluation of quality of care because it reflects the experiences of those who receive the care. Although positive feelings towards doctors can be affected by factors such as the personality of the doctor, the ability of the doctor to reassure, the nature of the patient's disease and characteristics of the patient¹. In the present study, the majority of the attending patients presented with acute illnesses (82.4%) compared to (17.6%) of patients with chronic illnesses. These results were different to a study conducted in Britain and showed that 45.2% of patients reported acute illnesses, 42.1% reported chronic illnesses and 8.4% of patients sought general health advice5. The mean duration of consultation in the current study was (6.69) minutes. These results were partially in agreement with many reported results of a group of studies in western countries which concluded that the mean duration of consultation time ranged between 2 and 21 minutes^6-11. The variation among the results of the present and the above mentioned studies could be explained by the differences among different family practice settings regarding the flow rate and the existence of appointment systems that ensure adequate time for consultation. Also, the family physician may behave in different ways according to the nature of sessions, as counseling sessions, for example, may need more time. This view was supported by Freeman (2001)¹¹. In the present study it was shown that the mean enablement score was 7.54. This result differed with Howie et al (1999)5 who reported that the mean enablement score was 4.5. It was found that, enablement score showed no significant difference in relation to some socio-demographic variables such as age (increasing enablement score with increasing age), sex (p > 0.05). These results disagreed with Kotic (2001)¹² who demonstrated that patient satisfaction had a positive correlation with age, sex and educational level. Baker (1995)¹³ in a study conducted in the UK found that the duration of consultation and patient enablement were affected by sex, age and number of problems discussed. The result of the present study confirmed that there was a positive correlation between duration of consultation and enablement score (p<0.05). These results were supported by other studies^5,15,16. Campbell (2001)¹⁷ found a significant positive correlation between duration of consultation and the enablement score. Goedhuys (2001)¹⁵ in his study conducted in Belgium found that there was a positive correlation also between duration of consultation and patient satisfaction and Freeman et al11 found that 12% of patients complained of having insufficient time with their general practitioner, but this figure became 30% when the patient was consulted for five minutes or less. Howie et al (1999)⁵ concluded that for individual consultations, the enablement score was most closely correlated with duration of consultation. In the present study it was shown that 65.1% of patients who attended family practice centers had established doctor-patient relationships. We have found a positive correlation between the enablement score and both of the established doctor-patient relationships and the patient ability to choose his physician ( P< 0.05). These results were in agreeance with many other studies such as Howie et al (1999)5, Baker (2003)¹⁸, Hjortahl, (1999)¹⁹ and Little et al. (2001)²⁰. A study conducted in the Netherlands found that the doctor patient relationship has a positive correlation with satisfaction and compliance²¹.

This study indicates that building an established doctor patient relationship and giving more time for consultation are prerequisites for improvement in the outcome of consultation in terms of enablement effect.

ACKNOWLEDGEMENTS

We wish to thank the research committee in Hamad Medical Corporation, which had a big role in study design, data collection, data analysis, data interpretation, and writing of the report.

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