Medication use and patient satisfaction: a population-based survey
a Department of Economics, University of Thessaly, 38221 Volos
b Department of Health Economics, National School of Public Health, 11521 Athens
c Department of Public Health, Medical School, University of Patras, 26500 Rio Patras, Greece
Correspondence to Evangelos C Alexopoulos, Department of Public Health, Medical School, University of Patras, 26500 Rio Patras, Greece; Email: ecalexop{at}upatras.gr
Received 31 March 2008; Accepted 29 August 2008.
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Abstract |
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Background. In recent years, there is a growing interest to assess patients' satisfaction which further triggers the existing debate on the severe methodological issues regarding the interpretation of comparative surveys results.
Objective. This cross-sectional national survey aimed to examine satisfaction of Greek households with specific aspects of medication use and their correlates.
Methods. Between November 2004 and February 2005, telephone interviews were used for collecting information about socio-demographic and health-related characteristics in a systematic sample of 1000 Greek households. Respondents were classified into three categories: chronic or short-term prescribed medication use, occasional medication use and no medication use during the 3 months preceding the survey. Satisfaction was assessed through various aspects of medication use like physician's consultation, physician's response to adverse events, consultation and advice by pharmacists, symptoms' resolution, route of drug administration, drug tolerability and drug cost.
Results. The prescribed drugs' use in the 3 months preceding the survey interview was 36.9%; 28.6% for subjects under chronic treatment and 8.3% under short-term treatment. During the same time period, 52.8% of the respondents reported the occasional self-use of over the counter drugs for minor symptoms. A high prevalence of hypertension, cardiovascular, musculoskeletal and endocrine disorders has been observed. In general, respondents expressed a high degree of satisfaction with all aspects of medication use examined, the only exception being costs. Age, area of residence, social insurance scheme and self-reported health status were associated with specific aspects of patient satisfaction.
Conclusions. Patient satisfaction with the aspects of medication use examined seems to be influenced by demographic and social factors; this points out to the necessity of taking into account socio-cultural variations and the structure of the health-care system in policymaking.
Keywords. Greece, health insurance, medication use, patient satisfaction, primary health care.
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Introduction |
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Patient satisfaction is an important outcome measure for evaluating the extent to which the health-care sector meets patients’ needs and expectations. More detailed information about the factors affecting satisfaction could possibly assist health-care providers and planners to improve the quality in the provision of health services. Monitoring patient satisfaction is important for service quality assurance purposes, in treatment evaluations, and because satisfaction can affect health outcome.1–3 However, over reliance on negative statements to elicit information about users’ perceptions and views may also provide a misleading picture and poor foundation for informing policy directed at improving the quality of care.3–5
The difficulty in measuring patient satisfaction lies in the fact that satisfaction is a multidimensional concept with inputs or determinants that are not yet clearly defined.1,6–10 Empirical studies reveal that reported satisfaction is profoundly influenced by patient-related factors, health provider characteristics, health system structure and cost.3,5,11,12 Patients’ satisfaction with medication use depends not only on the clinical outcomes achieved such as the symptoms’ resolution, the control of the disease progression and prevention but also on the route of drug administration, drug tolerability, trademark name etc.13–17
In recent years, there is continuous debate on the severe methodological issues in the interpretation of the comparative surveys results. Despite this debate, there is a growing interest to assess patients’ satisfaction as well as a large, diverse and expanding literature.1,4,8–10,18–21 Cross-national variations suggest the importance of taking into account the structure of the heath care system as well as the cultural factors in estimating patient satisfaction.22–24 In Greece, primary health care is provided by (i) the National Health System (NHS) through health centres in rural areas, semi-urban clinics and public hospital outpatient units; (ii) the Social Insurance Organizations (IKA is the largest Social Security Organization in Greece covering more than 55% of the insured population working in the private sector. People insured by IKA receive primary health care in its owned local polyclinics. OGA is the Social Security Organization covering mainly the agricultural population. People insured by OGA receive primary health care in the NHS outpatient facilities. All other funds do not provide primary health care in their own facilities and use contracted private physicians as well as NHS and private health sector facilities which cover different professional groups and provide primary health care through polyclinics owned by the funds or through contracted physicians; (iii) local authority services; and (iv) the private sector. On the contrary, hospital care is mostly provided by the NHS hospitals. Pharmaceutical care is provided by all social funds with a 25% patient participation rate for drug costs. There are exceptions related to the severity of the disease and the socio-economic status of the insured falling into the subcategories of 0% and 10% participation rates. Existing literature suggests that the fragmentation in the provision of primary health care and the variations in the services provided by social insurance funds are the primary reasons for both inequities in access to health care and the low satisfaction with the health system performance reported by the Greek population.7,25
In Greece, only a few publications refer to the satisfaction measurement, some of which are focused on the assessment of the health system performance7,23,26,27 and the rest on the assessment of the delivery of inpatient and outpatient care.28–33 In this regard, the objective of this survey was to examine satisfaction of Greek households with aspects of medication use and to determine their correlates.
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Methods |
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Study design and data collection
A sample was selected so as to be representative of the national population according to the 2001 Census of the National Statistical Service of Greece, by age, sex and geographical location at place of residence. Data were collected from a sample of 1000 individuals through a computer-assisted telephone interview (CATI).34,35 The survey was conducted between November 2004 and February 2005. From a sampling frame of all telephone numbers listed in an electronic directory (Hellenic Telecommunications Organization), a systematic national sample of 1000 participants stratified by geographical region was drawn. Once selected, a telephone number was considered eligible if it was a residential connection. Ineligible telephone numbers such as business telephones were replaced by the subsequent residential entry. In Greece, 95% of households have at least one fixed telephone line.36 Mobile phone numbers were not included. Sampling continued until we had 1000 completed interviews. The interviewers were instructed to follow standard procedures for selecting interviewees and to replace persons who were originally selected for the interview but were unavailable (e.g. incorrect phone number, not answering the phone, not at home and unwilling to participate in the survey). The person who initially answered the telephone was eligible to be interviewed if s/he was older than 17 years of age. To avoid oversampling of specific age or gender subgroups, whenever possible an attempt was made to sample a subject different by age and gender in each subsequent interview.
The questionnaire consisted of two parts: first, a set of items drawn from the World Health Organization (WHO) health survey ‘Health and Health System Responsiveness Postal Survey’26,27 and second, a set of items designed to explore the satisfaction of patients with specific aspects of medication use. WHO queries included information about participants’ characteristics (age, gender, family status, number of family members, education, area of residence, working status, insurance coverage, family or household financial income), self-rated (or perceived) health [on a five-point scale ranging from (1) very poor to (5) excellent], medical conditions (disorders) and health-care use. Medical disorders were classified as chronic when requiring continuous therapy or short term when requiring therapy for a definite amount of time. Subjects were initially classified as those who were under chronic or short-term prescribed medication use, those who had occasionally used over the counter (OTC) drugs for minor symptoms and those who had used no drugs at all during the 3 months preceding the survey interview. In addition, subjects who had received chronic or short-term prescribed medication were classified in 12 discrete disease categories.
Due to the lack of a valid instrument in Greek for measuring satisfaction with medication use, the second part of the questionnaire was based on ongoing studies1,5,12,14,28–33 and experts’ opinion, coordinated by the National School of Public Health. The questionnaire was piloted with 20 individuals to ensure the wording of the questions. Rating of satisfaction was measured on a five-point scale (fully satisfied, satisfied, moderately, poorly and not at all satisfied). Patient satisfaction was assessed based on eight different aspects of medication use (physician's consultation, physician's response to adverse events, consultation and advice by pharmacists, symptoms’ resolution, route of drug administration, drug tolerability, drug cost and perceived contribution of the treatment to the improvement of health). Questions designed to explore patient satisfaction were only administered to 369 subjects who were under chronic or short-term prescribed medication use during the 3 months preceding the survey. Data have also been collected on the frequency of prescription use, compliance with the physician's instructions in terms of daily dosages intake and consistency in treatment duration (completeness of treatment schedule), amount of non-consumed drugs (excess of medicines), costs and insurance coverage. The National Ethics Committee approved the study protocol.
Statistical analysis
Descriptive statistics and logistic regression were used for data analysis. In the logistic regression model, similar answers rated on a Likert scale (e.g. either ‘fully satisfied’ or ‘satisfied’) were combined into a unique category for the purpose of analysis. Due to the small number of patients receiving more than one medication, additional adjustment for this variable was not performed. Relation of characteristics of study participants with satisfaction levels was examined firstly by univariate analysis. The baseline variables with a P < 0.15 in univariate analysis were included in a multiple logistic regression model. A backward conditional elimination procedure with a removal criterion of P = 0.10 was applied. Variables were retained into the model if the Wald test P values were <0.05. Results are expressed as odds ratios (ORs) with their 95% confidence intervals (CIs). Statistical analyses were performed with SPSS 11.0 software (SPSS Inc., Chicago, IL).
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Results |
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The total study population consisted of 486 males and 514 females. The representativeness of the sample was checked against demographic indicators (e.g. age, gender and area of residence) collected by the National Statistical Service of Greece during the 2001 Population Census. In our sample, males comprised 48.6% compared to 48.9% of the general population. In all, 41.5% aged between 18 and 39 years old and 32.5% between 40 and 59 years old compared to 41.1% and 31% of the general population, respectively. The geographical (according to residence) distribution of the sample was similar to that of the Greek population.
The response rate of the survey was 55% since some of the individuals considered eligible for the interview were unwilling to participate. In addition, approximately 4.5% of the telephone numbers were replaced as being business or non-residential telephones. To avoid oversampling, a replacement of around 95 individuals (75% due to age and the rest due to gender oversampling) was identified as necessary. In general, missing data are estimated at 7%, the only exception being questions regarding income-related variables.
In the 3 months preceding the survey, 286 (28.6%) subjects were under chronic and 83 (8.3%) were under short-term prescribed drugs treatment. In all, 528 subjects reported the occasional self-use of OTC drugs for minor symptoms while 103 did not take any medication.
Table 1 shows the general characteristics of the 369 respondents under chronic or short-term treatment. Approximately 50% of the study subjects reported a monthly household income of less than 
1500 (euros); however, 34.4% of the study subjects did not answer this question. Less than 2% of the respondents had no health insurance coverage. The majority of participants were entitled with compulsory health insurance coverage according to their employment status. In all, 16% of subjects had an additional private insurance. A bad/moderate perceived health was reported by 61.9% of respondents under chronic treatment and by 22.9% of individuals who were under short-term treatment.
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Table 2 depicts the treatment status and the clinical entities reported by the study participants. Among subjects who were under chronic drug treatment, 25.2% suffered from hypertension, 18.9% from endocrine disorders (mainly diabetes mellitus and thyroid disease), 16.8% from cardiovascular and 11.2% from musculoskeletal disorders. Among the 528 individuals who reported occasional use, 101 (19.1%) used two different drugs, whereas 58 (11%) used three or more. The most commonly self-used drugs included anti-inflammatory and painkillers (67%), gastroenterological drugs (antacids 11.4%), drugs for skin disorders (9.6%) and eye, ear, nose and throat drugs (9.5%) (data available if requested).
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The majority of patients who were currently taking drugs for chronic disorders had a good compliance to the prescribed treatment schedule in terms of daily dosages intake (Table 3). In contrast, 21.5% of the subjects who were taking drugs on a short-term basis did not complete their treatment schedule (treatment duration). Among the respondents under chronic treatment, social security funds covered the entire cost of 8.7% of respondents, whereas 22% paid more than
60 per month for their medications. It is worth noting that 12.9% of patients under chronic and 25.3% under short-term treatment paid their medicines by themselves. The reasons for the respondents’ out of pocket payments were time consuming for prescribing, accreditation, accessibility, low price as well as the lack of patient free choice and the limited drugs’ selection included in the social funds’ formulary (positive list).
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As it can be seen in Table 4, the majority of the respondents were satisfied with specific aspects of medication use. Notably, more than 80% of subjects expressed high levels of satisfaction with his/her physician, pharmacist and treatment outcomes (e.g. symptoms’ resolution, route of drug administration and tolerability). Among patients under chronic medication, only 60.6% were satisfied with costs. In addition, four of six patients perceived the contribution of treatment to the improvement of their health status as either low or moderate. There was a high degree of variation observed in satisfaction levels according to the patient characteristics, some of which reached the statistical significance threshold. Gender was not associated significantly with satisfaction levels in univariate analysis. However, males were more satisfied with treatment outcomes (e.g. symptoms’ resolution, route of drug administration and tolerability), whereas females were more satisfied with their physician consultations. Elderly patients and those with lower educational level had a higher degree of satisfaction with physician (P < 0.05). Residents in rural areas showed a trend towards higher satisfaction levels in all the study outcomes, albeit these differences failed to reach the statistical significance in the majority of cases. A moderate/bad perceived health was associated with a lower degree of satisfaction with treatment outcomes, but with a higher perceived contribution of treatment to the improvement of health, as well as with a higher acceptance of medication costs. Patients under chronic drug treatment were significantly more satisfied with their health-care providers, but had low perceived contribution of treatment to the improvement of their health status.
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Results of logistic regression analysis entering age, gender and other variables as covariates are shown in Table 5. Elderly patients (aged >60 years) were more likely to express higher satisfaction levels with the physician's consultations (OR: 3.86) and the physician's response to adverse events (OR: 3.25). With regard to drug tolerability (data available if requested) and satisfaction with the physician's response to adverse events, residents in urban or semi-urban areas and people insured to either OGA or IKA showed lower satisfaction levels. The social insurance organization and the perceived health status were the most significant predictors of treatment outcomes. It seems to be a significant influence of the health insurance fund on several outcome measures. Specifically, subjects insured to IKA and OGA reported a significantly lower satisfaction level compared to the rest social insurance bodies (Table 5). Subjects with a good health status reported higher satisfaction levels with treatment outcomes (e.g. symptoms’ resolution, route of drug administration and tolerability, OR: 1.98–5.32).
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An inverse association was observed between the self-rated health status and the perceived contribution of treatment to the overall health improvement. A similar inverse relation between the health status and satisfaction with costs was also ascertained. Specifically, respondents with a better health status perceived the contribution of treatment to the improvement of their health status to a lesser extent (OR: 0.36; 95% CI: 0.23–0.55) and expressed a lower satisfaction with costs (OR: 0.61; 95% CI: 0.39–0.94).
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Discussion |
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This is a cross-sectional national survey of 1000 representative Greek households designed to examine satisfaction with aspects of medication use and their correlates. In the 3 months preceding the survey, 36.9% of respondents were either under chronic or short-term prescribed drug treatment while 52.8% were under occasional use of OTC drugs. In general, the respondents reported high degree of satisfaction with specific aspects of medication use, despite the fact that the contribution of treatment to the improvement of their overall health status was generally perceived as moderate.
Satisfaction with medication costs was reported poor. Treatment cost is an important concern for health-care providers and insurers (third-party payers) and can also impose a financial burden on patients, either in the form of direct payments or co-insurance.15–17 Low patient satisfaction may result in poor compliance with the potential for waste of resources and suboptimal clinical outcomes.3,5,11,13 Our findings that social insurance schemes covered the entire cost of medication for only 8.7% of the respondents under chronic treatment and 12.9% of them paid their medicines by themselves justify another of our results that the majority of patients (60.6%) under chronic drug treatment were dissatisfied. Those findings appear to be very important, since patients under chronic treatment are supposed not to contribute to the drug cost.
Another feature of our study is in accordance with the results of a recent study37 which also showed a high prevalence of occasional use of common drugs (OTC). This suggests that self-care for minor symptoms is widely common among the Greek population. A finding that merits consideration is patients’ poor compliance in terms of early discontinuation of treatment.
Numerous factors were identified as being associated with several outcome measures, including age, area of residence, social insurance scheme and self-rated health status. Elderly people showed higher satisfaction levels in the light of their more positive attitudes towards physicians. This is mainly because they face greater uncertainty over medical issues and rely more heavily on the physician's consultations. Self-rated health status was found to be associated positively with satisfaction with treatment aspects (e.g. symptoms’ resolution, route of drug administration and drug tolerability). In addition, associations on satisfaction measures are also found regarding the area of residence (geographical regions) and the social insurance organizations. More specifically, differentiations observed among the social insurance funds appear to influence the satisfaction of their insured members on the basis of patient choice to select his/her physician. The lower satisfaction reported by the insured of IKA and OGA compared to the other funds ascertain our findings, given that other funds allow a greater degree of patient choices through the contracted primary health-care physicians. In addition, long waiting lists and time delays in the urban and semi-urban areas regarding the access to IKA and NHS facilities justify the lower satisfaction in these areas.
Although most surveys’ data differ from our study in the research hypothesis and methodology, some of our findings are in accordance with previous studies. A high degree of patients’ satisfaction with the provision of hospital and outpatient care has been reported in various studies.32,33 The influence of age and health status on satisfaction levels has also been previously identified in a several studies.38,39 Since patients with a better health status tend to recover faster from their disease without complications, they perceive the contribution of treatment to the improvement of health status to a lesser extent and express a lower satisfaction level with costs. In addition, the influence of the area of residence on satisfaction ratings has been previously described in Greece.33 Finally, the patient choice to select physician is also found to be associated with patient satisfaction in several previous studies.40,41
There are some limitations that merit consideration. The sampling selection, the procedures used for collecting data (telephone interviews), time and resources available for the survey limited the number of subjects contacted to the minimum number of participants required for the sample to be nationally representative. The use of a CATI has minimized transcribing errors and provided substantial quality control benefits and time efficiency.34,35 Satisfaction with medication could not be captured by the WHO questionnaire since satisfaction with the way health care runs does not seem comparable with the WHO goal attainment.12,19 Given the lack of a valid instrument in Greek focused on medication use, validated satisfaction scales could not be used. Nevertheless, the pilot study of the questionnaire helped in overcoming methodological problems and limitations related to the context and wording of the questions. Finally, differences related to disease status and treatment characteristics could not be tested due to the small patient number in each subgroup.
Despite the limitations discussed above, there are several reasons to try to draw some preliminary conclusions. Even though public opinion on health-care issues at European level has not been extensively measured7 and relevant studies most times use different methodologies,1,4,8–10,12 comparative findings seem to be useful because they highlight some fundamental limitations to comparing satisfaction over time and across populations. For example, the development of survey instruments that address some of these limitations appear to be very important. The conduction of similar surveys on a—both local and international—regular basis should minimize the effects of specific circumstances that may influence participants’ responses and could be used to evaluate changes over a period of time.
In Greece, the use of scientific evidence on public attitudes towards health issues should be encouraged and be taken into account in health policy formation. Greece is among the European Union member states that preach that one of their health system aims is to increase patients’ choice and participation. However, low satisfaction with medication use was observed in the greatest social insurance funds because of the lack of patient choice in the provision of primary health care. Low satisfaction, if persistent, may indicate that specific measures have to be changed and further research should be focused mainly on social insurance schemes cross-comparisons. In this regard, cross-comparison studies results could verify and improve our knowledge on how different political, economic and cultural environments affect satisfaction. However, we believe that the results of our survey should establish a starting point in the Greek literature where any changes in citizens’ views in the future could be used as an indirect indicator of public acceptability of any regulatory intervention.
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Declaration |
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Funding: National School of Public Health.
Ethical approval: None.
Conflicts of interest: None.
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Acknowledgments |
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The research methodology was based on a nationwide survey conducted by the National School of Public Health of Greece in collaboration with the WHO as a part of WHO preparation for the World Health Report. The authors acknowledge the contribution of Greek experts to the formation of the set of questions on satisfaction. They would also like to thank the two anonymous referees as well as Prof. Brendan Delaney for their helpful comments.
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Notes |
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Geitona M, Kyriopoulos J, Zavras D, Theodoratou T and Alexopoulos EC. Medication use and patient satisfaction: a population-based survey. Family Practice 2008; 25: 362–369.
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