COMPARISON OF PATIENT AND DOCTOR PERCEPTIONS OF BARRIERS TO HEPATITIS C TREATMENT: A SURVEY

AND LITERATURE REVIEW.

Pavan Mankal, MD, MA1; Jean Abed, MD1; Ellen S. Engelson,EdD1,2; Donald Kotler, MD1,2

1Department of Medicine and 2Division of Gastroenterology, Mount Sinai St Luke’s and Mount Sinai

Roosevelt Hospitals, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY,

USA.

Keywords: psychosocial, substance abuse, patient-doctor relationship, patient education, obstacles

Corresponding Author:

Pavan Kumar Mankal, MD, MA

Mount Sinai St Luke’s and Mount Sinai Roosevelt Hospitals,

1111 Amsterdam Avenue, Clark Building, 7th floor, New York, NY 10025

Telephone: (212) 523-3670, Fax: (212) 531-7650

Email: pmankal@chpnet.org

Word count: 4535Main body of manuscript word count: 2754

2 figures and 2 tables

There are no financial support and no conflict of interest that may have a direct bearing on our work.

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Abstract

Background/Aims: Although Hepatitis C (HCV) infection is widespread, only a minority of patients

receives the currently standard of care. The rationale for this disparity may be multifactorial.

However, overcoming known psychosocial barriers, particularly in the doctor-patient relationship,

remains essential in providing HCV care. In this cross-sectional study, we aim to not only identify

these perceived barriers in treating our HCV-prevalent population from both patients and

physicians’ responses, but also cross-analyze for association between the two cohorts’ perceptions.

Methods: We surveyed 100 patients and their physicians, anonymously and separately, during their

visit to our outpatient hepatology clinic about their views on twelve psychosocial barriers. Results:

Differences in perceptions of patients and their doctors regarding medical adherence (p<0.001),

substance abuse (p=0.01), knowledge of risks (p=0.046), and social support (p<0.001) were found in

patients undergoing evaluation and not yet treated, but were not evident when comparing to

patients with Hepatitis C that have already initiated treatment. Conclusion: Using the above

information, we hope to plan smarter road maps for successful HCV treatment delivery to reduce

and bridge these barriers.

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Background

The prevalence of chronic Hepatitis C infection (HCV) is higher than that of human

immunodeficiency virus (HIV) infection in the United States.(1-3) In the US, the prevalence now

equates to 4.1 million people (estimated to be 1.6% of the general population with specific

communities having higher rates).(4) Without treatment, HCV is an important cause of mortality as

well as liver transplantation.(5) Fortunately, we have a robust pipeline of novel medications

promising higher “cure rates” with fewer side effects. Comparably, the current regimen provides

nearly 60% of the patients with a sustained viral response (SVR) in genotype 1; higher rates evident

with genotypes 2 and 3.(6, 7) However, only a small minority of patients with HCV actually receives

current standard of care.(8, 9) HCV treatment rates ranges between 1.1% in Vancouver

metropolitan inner-city population to around 30% in a university-affiliated VA hospital.(10, 11)

More often than not, the treatment rate is likely to be much closer to the smaller proportion, only

to leave a significant number of people at risk of continual progression towards developing liver

fibrosis, cirrhosis and its decompensatory mechanisms, as well as hepatocellular cancer.

The dichotomy between the treatment success rates and the low catchment rates illustrates the

distinction between the notions of efficacy and effectiveness; where the latter suggests real world

experiences, not clinical ones. In other words, efficacy often reflects the world of SVR rates in

patients treated in clinical trials, while the effectiveness conveys the number cured in a complete

cohort of HCV-infected patients. Partly, the reasons for these low rates of effectiveness are the

obstacles, both psychosocial and medical barriers, to treatment. Ultimately, these barriers may

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diminish effectiveness of Hepatitis C treatment irrespective of efficacy. Social determinants of

health like incarceration, intravenous drug use, human immunodeficiency virus, and homelessness

among others often go hand-in-hand with Hepatitis C infection.(12-14) These at-risk factors may

dictate a person’s health, directly and indirectly, by affecting the socioeconomic status, access to

health care and state sponsored programs, stigmatization by family and society, and medication

adherence. When these obstacles affect deferment of treatment, the lack of treatment of HCV can

eventually lead to long term effects of irreversible scarring and liver failure decreasing the quality

of life further with higher morbidity and mortality rates.

Besides the above barriers, the relationship between the patient and the doctor itself may pose a

barrier to treatment. Any breakdown in communication, trust and misjudgment leads to deferment

of therapy, additional testing, poor compliance of medication, poor follow up and discordant care.

(15-17) From an initial office visit, the doctor-patient interaction should include a psychosocial

assessment - an integral part prior to providing treatment, which should address topics including

substance abuse, depression, social support, knowledge of benefits and risks of Hepatitis C

treatment, ability to take medications and adherence. While these barriers and its perceptions are

known, there seems to be a lack of evidence in assessing the interaction between doctors and

patients’ perceptions of Hepatitis C care as majority of patients continue to be untreated even if

they overcome enough barriers to seek care from a specialist.

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To our knowledge, no study has attempted to address this aspect in HCV care and we aim to cross

analyze responses by patients and their physicians and see if there are any differences between

patients who have initiated therapy and patients who have not.

Methods

We conducted a cross-sectional survey study in an outpatient setting at St Luke's Roosevelt

Hospital Center in the City of New York by reviewing responses (by both patients and physicians) to

our voluntary, anonymous questionnaire - in English (Figure 1) and in Spanish (not shown) -

focusing on barriers patients and physicians face while receiving and providing HCV care. During a

7-month period (February 1st, 2013 to August 30th, 2013), patients with Hepatitis C were given an

information sheet regarding the questionnaire detailing the purpose of the study as well as the

risks and benefits of their participation. Patients were recruited during their visit to our outpatient

hepatology clinic. Data obtained from the questionnaires were entered into a Microsoft Excel file

with the following headings: demographic information (age, race, sex), ordinal data from each of

the questionnaire questions answered by patients and physicians, treatment status for Hepatitis C

(previous, current, future).

Eligibility criteria for patients included (1) Age 18-85 years, (2) documented Hepatitis C infection

(treated or untreated), and (3) ability to read in English and/or Spanish. Patients were excluded if

any of the above criteria were not met. The patients and the physician who provided care during

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the same visit were given the questionnaires (see Figure 1) and separated from each other when

completing the survey without providing assistance to fill the survey.

Statistical Analysis

Using Microsoft Excel, we analyzed ordinal data from the questionnaire responses using descriptive

statistical analyses and linked the interaction between the responses from the providers and the

patients using two-tailed paired t-test to investigate any differences between the responses.

Additionally, we separated the patient population into non-treated and treated groups to

investigate any differences in patient-doctor perception responses to questions between the two

cohorts.

Results

One hundred patients and their physicians (Gastroenterologists and GI fellows at the liver clinic)

were surveyed with no identifying information. The patient population included in the study has an

average age of 57 years with standard deviation of 11 years where 55% are male, 35% are female

and 10% did not report their sex. Additionally, 47% are African-American, 30% are Hispanic, 12%

are Caucasian, 1% are of multiple races and 10% did not report their race. 63% of the participants

were not treated, 29% were treated (9% completed treatment, 18% were undergoing treatment),

and 5% failed to respond their Hepatitis C treatment status. 1 patient and 3 physicians refused to

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complete the survey and only 2.2% of the patient survey questions and 4.2% of the physician

survey questions were left blank.

Two-tailed paired t-tests were performed for each question between doctors’ and patients’

responses with further stratification into non-treated and treated cohorts. Overall, while most

questions are in agreement regarding the perceptions of doctors and their patients on their

Hepatitis C care, certain questions are notable for incongruence. For example, questions #2, #4, #7,

#8 and #10 were statistically significant for difference seen in responses between doctors and

patients. Firstly, patients perceive themselves to be more motivated (Question #2) than what

doctors responded (Mean 4.45 vs. 3.78, p=0.004). Secondly, doctors believe that patients’

substance use involving alcohol or drugs (Question #4) is higher than the patients’ views (Mean

0.49 vs. 1.01, p=0.004). Third, patients’ perception of their understanding of risks (Question #7)

involved with Hepatitis C treatment is significantly lower than their doctors (2.29 vs. 3.44, p=0.004).

Fourth, doctors have a significantly lower opinion of patients’ adherence (Question #8) to

medications (5.47 vs. 4.31, p<0.001). Lastly, patients perceive their social support in life to be more

supportive (Question #10) than did their doctors (4.35 vs. 3.26, p<0.001). All other questions

(involving patients’ knowledge, mood, access to medications, benefits from treatment, daily

stressors, communication with their providers, and quality of sleep) convey no significant

difference between the doctors and their patients (not shown).

Interestingly, separating the treated (both ‘completely’ and ‘partially treated’) and non-treated

(both ‘never treated’ and ‘future treatment’) reveals some remarkable findings when comparing

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the two cohorts. Analyzing the data from the latter cohort (average age 52.8 years +/- 12, 61%

male) reveals significant differences in responses for Questions #4, #7, #8, #10; largely consistent

with the overall picture above (Table 1). First, as seen in the overall group, patients believe that

their substance use (Question #4) is lower than their doctors’ views (Mean 0.62 vs. 1.23, p=0.01).

Second, doctors believed patients had a significantly higher understanding of the risks of Hepatitis

C treatment (Question #7) than the patients themselves (2.31 vs. 2.91, p=0.046). Third, doctors

have a lower opinion of patients’ ability (Question #8) to take medications (5.48 vs. 4.15,

p<0.0001). Lastly, doctors had a more pessimistic picture of patients’ social support system

(Question #10) than the patients themselves (4.56 vs. 3.32, p<0.0001).

However, as seen on Table 2, these perceptions drastically different when analyzing data from the

treated cohort (average age 57.9 years +/- 7.9, 68% male). Only responses to one question now

reveal a difference in perceptions of patients and their physicians (e.g. Question #12). After

initiating treatment or completing treatment, patients believe that they now do not get adequate

sleep every night compared to their doctors’ view (2.71 vs. 3.71, p=0.04). All other questions

revealed no difference in responses between doctors and their patients. Though limited due to

smaller number of patients who have completed treatment, further analysis reveals that patients

who have undergone full treatment believe they have less adequate sleep compared to their

doctors perception (2.13 vs. 4.25, p=0.006); a result not seen in partially treated cohort.

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Discussion

In the setting of very high degree of participation and low incomplete questions frequency in our

study, the differences in perceptions - particularly issues of substance abuse (p=0.01), knowledge of

risks (p=0.046), medical adherence (p<0.0001) and social support (p<0.0001) – were not seen when

comparing patients with Hepatitis C that have initiated or completed treatment to patients who

have not yet been treated, a finding not presented before. Additionally, greater differences in the

responses between the two groups were evident in the latter two issues. While many prior

investigations of known barriers have sought answers from different perspectives (see below)

separately, these results are indicative of the interaction between patients and doctors during a

clinic visit. Our study provides a potential dynamic marker for investigating barriers that prevent

patients from getting treated.

Barriers exist in multiple levels from access to care and diagnosis to psychological and psychosocial

barriers hindering the effectiveness of the existing medical therapy. Simply put, one can

differentiate these barriers in providing care for HCV patients at the patient, provider and systems

levels.(18) This leaves a great need to decrease the obstacles for health providers to focus not only

on efficacy, but also effectiveness. Overcoming these barriers can also be cost effective allowing

for antiviral treatment for Hepatitis C infection to increase likelihood of sustained viral response to

therapy, quality of life improvement, prolongation of life expectancy, as well as avoid costs related

to complications of end stage liver disease.(19) Improving anti-viral delivery will certainly help

reduce health-care costs since liver-related deaths are projected to increase the next 10-20 years

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due to the chronicity of the problem, even though the incidence has dropped from its peak. Of

note, while we have anti-viral medications in the pipeline showing promising results of higher

efficacy and higher sustained viral response to therapy, these obstacles (comprehensively medical,

psychological and social barriers) still need to be overcome for adequate health care delivery.(20,

21) Without overcoming known barriers to Hepatitis C treatment, the higher efficacy can only

benefit a small portion of the 170-200 million people affected with HCV worldwide.(21)

At the patient level, deferment of treatment has been mainly attributed to active psychological

issues (34.3%) and ongoing substance abuse (33.6%) have subsequently led to falling rates of follow

up.(18, 22) Depression, sometimes subtle, can affect patients in a profound way, their willingness

to seek medical help, motivation, general outlook, leading to lower levels of treatment. However,

the single most common obstacle for treatment is lack of knowledge and awareness estimated at

75% and 49.6%, respectively. (23, 24) However, the reasons for lack of effectiveness are not limited

to the above factors, but also extend to genetic polymorphism, fear of side effects, the lack of

social support, ability to adhere to medication regimen, mistrust of the health care system, social

stigmatization as well as the reduced quality of life. At the recent Liver Meeting 2013, a survey

highlighted higher levels of perceived stigma were associated with less social support, more

depression, worse quality of life and less likely to seek medical help for their HCV infection. As a

solution, the support of non-medical providers, such as community-based organizations, may

compensate for a lack of social support. Nevertheless, acknowledging and addressing these issues

may lead to improve patient retention and Hepatitis C care provided by the provider.

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At the provider level, reports of communication gaps in the doctor-patient relationship have been

widely reported in caring for patients with HCV.(25-27) Moreover, communication issues affect

delivery of long Hepatitis C treatment; one cross-sectional study reported 41% of the respondents

acknowledged communication difficulties with their health care provider.(25) Additionally, the lack

of screening in patients with known risk factors of multiple tattoos, incarceration and blood

transfusion prior to 1992 among others is due to inadequate knowledge and/or experience.(24, 28)

Besides the knowledge gap, a recently presented poster at American Association for the Study of

Liver Diseases 2013 Meeting showed that negative attitudes might exist among treating physicians.

Screening presents another problem as only half of the primary care physicians refer the patients

to a specialist, the rate further drops to 30% if the liver function tests are within normal limits.(29,

30) Where applicable, the unfamiliarity of Hepatitis C treatment in primary care and inaccessibility

to a specialist only worsens the situation. One solution was telemedicine where primary care

physicians discussed cases with specialists using technology that ultimately achieved similar rates

of sustained virologic response (SVR) for patients in primary care as those treated by specialists,

and fostered more confidence in treating Hepatitis C.(31)

Lastly, at the systems level, economic and social pressures add to the problem, where high

percentage of Hepatitis C patients are uninsured and financial problems with work obligations

often prevents them from accessing care, even if they are adequately insured.(32-34) Not

surprisingly, race is an important issue to address. African-Americans and Hispanics are at twice the

risk of acquiring HCV infection compared to the general population according to the National

Health and Nutrition Examination Survey (NHANES) with differing rates of progression to cirrhosis;

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African-Americans being relatively lower and Hispanics being relatively higher.(35, 36) Lastly,

barriers within the health system including lack of access to care and medications may play a role in

opting for no treatment in patients.

In all, our results investigated the interaction between the patients and their doctors surrounding

questions of known barriers in providing adequate Hepatitis C care yielding significant results

surrounding questions of substance abuse (p=0.01), knowledge of risks (p=0.046), medical

adherence (p<0.0001) and social support (p<0.0001) in untreated patients.

Limitations

These differences can be attributed to overcoming the perception of known barriers to begin

initiation of medical therapy. However, as a cross-sectional study, it is also important to note that

patients in the two cohorts may in fact be two distinct groups due to (a) different characteristics

due to selection bias for treatment, (b) hidden underlying temporal relationship that isn’t explored

(i.e. a person who has initiated therapy is likely to be a follow up rather than their initial visit) or (c)

better patient-doctor relationship may allow a patient to more likely be treated, rather than

withhold treatment. Additionally, the study was anonymized to preserve honesty and increase

response rates while dealing with a sensitive topic, so a longitudinal study was not possible.

Nevertheless, our study shows a snap-shot of our patient population in our outpatient hepatology

clinic and the barriers they face while highlighting the ones that are not appreciated accurately by

their health care providers.

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Future Directions

Future research can expand on the initial knowledge from a patient-centered perspective to

include longitudinal studies as more patients are treated with the advent of new medications. For

example, one could explore include a temporal relationship of obstacles as patients go from being

non-treated to treated, all the while quantifying qualitative data on barriers. With the possibility of

interferon-free regimens (i.e. decreased toxicities) and increased efficacy in newer regimens,

there’s room to also investigate effectiveness between old and new regimens. Other avenues

include investigating the evaluation period of patients to see where the breakdown of doctor-

patient relationship gives way to withholding therapy for the patient or assessing the impact on

patients who do not overcome barriers after initial evaluation period.

Conclusion

While many barriers exist for treating patients with Hepatitis C, however, we show that differences

in perceptions between doctors and their patients are not evident in treated group when

compared with the non-treated group. As a preliminary study in patient centered clinical research,

we hope to bring forward information regarding the doctor-patient relationship that will help plan

smarter road maps prior to initiating HCV treatment to reduce and bridge known barriers that

hamper genuine efforts towards successful therapy

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References

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19. John BW. Hepatitis C: cost of illness and considerations for the economic evaluation of antiviral therapies. Pharmacoeconomics 2006;24:661-672.20. Lawitz E, Mangia A, Wyles D, Rodriguez-Torres M, Hassanein T, Gordon SC, Schultz M, et al. Sofosbuvir for Previously Untreated Chronic Hepatitis C Infection. New England Journal of Medicine 2013;368:1878-1887.21. Shrivastava S, Mukherjee A, Ray RB. Hepatitis C virus infection, microRNA and liver disease progression. World J Hepatol 2013;5:479-486.22. Evon DM, Verma A, Dougherty KA, Batey B, Russo M, Zacks S, Shrestha R, et al. High deferral rates and poorer treatment outcomes for HCV patients with psychiatric and substance use comorbidities. Dig Dis Sci 2007;52:3251-3258.23. Denniston MM, Klevens RM, McQuillan GM, Jiles RB. Awareness of infection, knowledge of hepatitis C, and medical follow-up among individuals testing positive for hepatitis C: National Health and Nutrition Examination Survey 2001-2008. Hepatology 2012;55:1652-1661.24. Mitchell AE, Colvin HM, Palmer Beasley R. Institute of Medicine recommendations for the prevention and control of hepatitis B and C. Hepatology 2010;51:729-733.25. Zickmund S, Hillis SL, Barnett MJ, Ippolito L, LaBrecque DR. Hepatitis C virus-infected patients report communication problems with physicians. Hepatology 2004;39:999-1007.26. Balfour L, Cooper C, Tasca GA, Kane M, Kowal J, Garber G. Evaluation of health care needs and patient satisfaction among hepatitis C patients treated at a hospital-based, viral hepatitis clinic. Can J Public Health 2004;95:272-277.27. Giordano C, Cooper C. The influence of race and language on chronic hepatitis C virus infection management. Eur J Gastroenterol Hepatol 2009;21:131-136.28. Shehab TM, Sonnad SS, Lok AS. Management of hepatitis C patients by primary care physicians in the USA: results of a national survey. J Viral Hepat 2001;8:377-383.29. Boaz K, Fiore AE, Schrag SJ, Gonik B, Schulkin J. Screening and counseling practices reported by obstetrician-gynecologists for patients with hepatitis C virus infection. Infect Dis Obstet Gynecol 2003;11:39-44.30. Shehab TM, Orrego M, Chunduri R, Lok AS. Identification and management of hepatitis C patients in primary care clinics. Am J Gastroenterol 2003;98:639-644.31. Arora S, Thornton K, Murata G, Deming P, Kalishman S, Dion D, Parish B, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med 2011;364:2199-2207.32. Ong JP, Collantes R, Pitts A, Martin L, Sheridan M, Younossi ZM. High rates of uninsured among HCV-positive individuals. J Clin Gastroenterol 2005;39:826-830.33. Evon DM, Simpson KM, Esserman D, Verma A, Smith S, Fried MW. Barriers to accessing care in patients with chronic hepatitis C: the impact of depression. Aliment Pharmacol Ther 2010;32:1163-1173.34. Fraenkel L, McGraw S, Wongcharatrawee S, Garcia-Tsao G. What do patients consider when making decisions about treatment for hepatitis C? Am J Med 2005;118:1387-1391.35. Kallwitz ER, Layden-Almer J, Dhamija M, Berkes J, Guzman G, Lepe R, Cotler SJ, et al. Ethnicity and body mass index are associated with hepatitis C presentation and progression. Clin Gastroenterol Hepatol 2010;8:72-78.36. Wiley TE, Brown J, Chan J. Hepatitis C infection in African Americans: its natural history and histological progression. Am J Gastroenterol 2002;97:700-706.

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From a level of 1 to 10, circle the number that best represents :1) Your patient’s knowledge of Hepatitis C infection and its treatments 0 1 2 3 4 5 6

Poor Excellent2) Your patient’s motivation towards getting Hepatitis C treatment 0 1 2 3 4 5 6

Low High

3) Your patient’s emotional issues (i.e. mood, depression) 0 1 2 3 4 5 6 Stable Unstable

4) Your patient’s current substance use (e.g. alcohol, drugs) 0 1 2 3 4 5 6 None Daily

5) Your patient’s ability to get medical help or medications 0 1 2 3 4 5 6 Easy Difficult

6) Your patient’s understanding of benefits with current treatments 0 1 2 3 4 5 6 Minimum Maximum

7) Your patient’s understanding of risks with current treatments 0 1 2 3 4 5 6 Minimum Maximum

8) Your patient’s ability to take medications regularly 0 1 2 3 4 5 6 Unable Able

9) Your patient’s stress level (e.g. money, job, family, housing) 0 1 2 3 4 5 6 Low High

10) Your patient’s social support in life 0 1 2 3 4 5 6 None Supportive

11) Communication with your patient 0 1 2 3 4 5 6 Easy Difficult

12) Your patient’s sleep every night 0 1 2 3 4 5 6 Inadequate Adequate

Figure 1. Anonymous Survey Questions given to the physicians at the liver clinic.

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From a level of 1 to 10, circle the number that best represents : 1) Your knowledge of Hepatitis C infection and its treatments?

0 1 2 3 4 5 6 Poor Excellent

2) Your motivation towards getting Hepatitis C treatment

0 1 2 3 4 5 6 Low High

3) Your emotional issues (i.e. mood, depression) 0 1 2 3 4 5 6

Stable Unstable

4) Current substance use (e.g. alcohol, drugs) 0 1 2 3 4 5 6 None Daily

5) Your ability to get medical help or medications 0 1 2 3 4 5 6

Easy Difficult

6) Benefits with current treatments 0 1 2 3 4 5 6 Minimum Maximum

7) Risks with current treatments

0 1 2 3 4 5 6 Minimum Maximum

8) Your ability to take your medications regularly

0 1 2 3 4 5 6 Unable Able

9) Your stress level (e.g. money, job, family, housing) 0 1 2 3 4 5 6

Low High

10) Family/Friends/Social support in your life 0 1 2 3 4 5 6 None Supportive

11) Communication with your doctor 0 1 2 3 4 5 6 Easy Difficult

12) Your sleep every night 0 1 2 3 4 5 6 Inadequate Adequate

Figure 2. Anonymous Survey Questions given to the Patients. Additional information (not shown) asked age,

race, and treatment status.

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Patient Mean MD Mean P(T<=t) two-tailt Critical two-tail df t Stat

Non-TreatedQ1 2.77 2.62 0.47 2.00 60.00 0.73Non-TreatedQ2 4.27 3.73 0.052 2.00 61.00 1.98Non-TreatedQ3 2.21 2.48 0.43 2.00 60.00 -0.80Non-TreatedQ4 0.62 1.23 0.01 2.00 59.00 -2.59Non-TreatedQ5 2.00 2.07 0.82 2.00 60.00 -0.22Non-TreatedQ6 3.05 2.95 0.74 2.00 59.00 0.33Non-TreatedQ7 2.31 2.91 0.046 2.00 57.00 -2.04Non-TreatedQ8 5.48 4.15 <0.0001 2.00 61.00 5.79Non-TreatedQ9 3.23 3.16 0.81 2.00 60.00 0.24Non-TreatedQ10 4.56 3.32 <0.0001 2.00 61.00 4.82Non-TreatedQ11 1.87 2.37 0.09 2.00 61.00 -1.74Non-TreatedQ12 3.59 3.59 1.00 2.00 60.00 0.00

Table 1. Comparison of Means between Patients’ (NOT TREATED) and Doctors’ Responses to Survey Questions

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Patient Mean MD MeanP(T<=t) two-tail t Critical two-tail df t Stat

TreatedQ1 3.08 3.38 0.51 2.06 25.00 -0.67TreatedQ2 4.69 4.08 0.08 2.06 25.00 1.82TreatedQ3 2.16 1.96 0.66 2.06 24.00 0.44TreatedQ4 0.15 0.50 0.06 2.06 25.00 -1.98TreatedQ5 2.00 2.15 0.76 2.06 25.00 -0.31TreatedQ6 3.52 3.32 0.70 2.06 24.00 0.39TreatedQ7 2.54 3.46 0.07 2.06 25.00 -1.89TreatedQ8 5.31 4.77 0.15 2.06 25.00 1.49TreatedQ9 2.76 2.40 0.42 2.06 24.00 0.81TreatedQ10 3.62 3.19 0.38 2.06 25.00 0.90TreatedQ11 2.04 1.60 0.41 2.06 24.00 0.85TreatedQ12 2.71 3.71 0.04 2.09 20.00 -2.24

Table 2. Comparison of Means between Patients’ (TREATED) and Doctors’ Responses to Survey Questions

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