Introduction

Pharmacy practice has considerably expanded to provide patient-centered care [1]. Consequently, efforts in evaluating patient satisfaction and the development of instruments measuring the outcomes have been documented from various countries in the literature [2–6]. Patient satisfaction is an important humanistic outcome as a patient’s subjective assessment of health care services [7, 8]. Growing interest in patient satisfaction initially arose as a result of consumerism. However, patient satisfaction has recently emerged as a prerequisite to providing adequate health care, as it may be able to improve patients’ health behaviors, resulting in better health care outcomes [9]. Previous studies demonstrated that patient satisfaction related to medication was potentially important to patient-reported outcome linked to better adherence, which has been a major concern in health care [10–13]. These studies suggested that greater treatment satisfaction of the patients was associated with better medication adherence and improved persistence, and with lower regimen complexity or treatment burden.

South Korea has a unique National Health Insurance (NHI) system with universal coverage covering almost the entire population with a centrally financed national health service [14]. The Ministry for Health, Welfare and Family Affairs (MIHWFA) has overall responsibility and a supervisory role for the health of the population. The National Health Insurance Corporation (NHIC) is the single insurer, responsible for providing health care benefits to the population, as well as collecting contributions and reimbursing providers. In 2000, the separation reform of drug prescribing and dispensing responsibilities between physicians and pharmacists was enforced to provide the general public with better quality of medical services and to prevent the misuse and overuse of medicines [14]. Since the passage of the Korean Health Care System Reform Act of 2000, the overall demand for care services in the pharmacy setting has been reported to rise because of a rapid increase in prescription volume and expenditure [15]. While patient satisfaction with pharmacy services is one of the most important topics for pharmacists in South Korea, very few studies are reported [16] and even fewer studies used national level data. Statistics Korea (KOSTAT), a central government organization for statistics, reported rates of patient satisfaction with pharmacy services on non-prescription medications, it does not explain the overall satisfaction of patients with comprehensive areas of pharmacy services including prescription medications [17]. Therefore, the objective of this study was to evaluate overall patient satisfaction with comprehensive areas of pharmacy services and its predictors in South Korea using the latest national level survey including pharmacy satisfaction.

Materials and Methods

Results

A total of 9,744 people, representing 48.2 million South Koreans, participated in the 2008 KNHANES IV survey, of whom 2,188 (23.6%) reported their pharmacy visits among those who aged 19 years and older. Sociodemographic characteristics and the health status of patients with one or more pharmacy visits are summarized in Table 1. Of the patients who visited pharmacies, 74.6%reported to be either ‘very satisfied’ (17.2%) or ‘satisfied’(57.4%), and 25.4% responded as being ‘neutral’ (23.3%), ‘dissatisfied’ (1.8%), or ‘very dissatisfied’ (0.3%). Patients aged between 30 and 39 years had the highest number of pharmacy visits (22.2%), whereas those in the age group of 50–59 years had the least number of visits (17.3%). The number of pharmacy visits made by female patients was similar to those by males (50.6% and 49.4%, respectively). The pharmacy visits were higher in urban areas (80.3%) than rural areas (19.7%).

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Table 1. Descriptive Characteristics and Health Status of Pharmacy Users from 2008 KNHANES.

https://doi.org/10.1371/journal.pone.0142269.t001

In bivariate analysis, family income, health insurance status, and perceived health status were significantly associated with patient satisfaction with pharmacy services (p<0.05, data not shown in table).

A multivariate ordinal logistic regression was performed, with sociodemographic characteristics, perceived health status, and clinical conditions as covariates predicting patient satisfaction with pharmacy services (Table 2). Our findings showed that patients with middle to low family incomes were more likely to be satisfied with pharmacy services, compared to those with high family incomes (adjusted OR 1.34; 95% CI 1.02–1.76; p<0.05) (Table 2). In particular, a statistically significant association between perceived health status and satisfaction was observed—patients with ‘Fair ‘ perceived health reported higher satisfaction, compared to patients with ‘Very good/Good’ perceived health (adjusted OR 1.32; 95% CI 1.01–1.74; p<0.05). In addition, individuals insured through their workplace were less likely to be satisfied with pharmacy services compared to those who were covered through their community (adjusted OR 0.80; 95% CI 0.65–0.97; p<0.05). No statistically significant associations were observed between patient satisfaction and education level, age, or gender.

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Table 2. Unadjusted and Adjusted Odds Ratios and 95% Confidence Interval from Ordinal Logistic Regression on Patient Satisfaction.

https://doi.org/10.1371/journal.pone.0142269.t002

Discussion

Our study revealed that family income, perceived health status, and health insurance status were significant predictors for patient satisfaction with pharmacy services in Korea. With the use of the rich data, findings from our study can provide an important insight on patient satisfaction and its predictors.

One of the major findings in this study indicated that individuals with middle to low family incomes were more likely to be satisfied with pharmacy services. Our results were consistent with the findings from a previous study by Oparah and Kikanme that evaluated consumer satisfaction with pharmacies in a city in Nigeria [19]. They reported that individuals who had lower incomes experienced higher satisfaction toward health services provided [19]. However, Bleichet al. demonstrated that patients with higher income per capita reported higher satisfaction with the health care system in association with more spending on health care expenses and an increased access to advanced technologies [20]. We believe that patient satisfaction in association with financial status can be a more complicated matter and may not be sufficiently explained by family income or spending on health care expenses without considering the insurance structure or health care system of each society.

Interestingly, our study revealed that patients with ‘Fair’ perceived health were more likely to report their satisfaction toward pharmacy services. A number of published studies reported a direct relationship between perceived physical health status and patient satisfaction [21–23]. For example, Rahmqvist reported that patient satisfaction significantly decreased when their subjective health status moved toward ill conditions and pain increased [22]. A study by Xiao and Barber, using the 1999 Medical Expenditure Panel Survey from the United States, reported that patients who rated their health status as excellent or good were more likely to have higher scores on patient satisfaction among all three dimensions of access to care, provider quality, and quality of care [23]. As the measurements of patient satisfaction from KNHANES IV were not specific by service dimensions, patient satisfaction should be cautiously interpreted and further studies are needed to evaluate more accurately the association between perceived health and patient satisfaction with pharmacy services.

In addition, our study showed that insurance type was a significant predictor indicating that individuals insured through their workplace were less likely to be satisfied with pharmacy services. According to the National Health Insurance Corporation in Korea, insured employees contribute 5.08% of their average salary toward the health insurance, while individuals covered through the community based program pay their insurance premium set by primarily their income and assets [24]. The effects of age, perceived health, health status, or economic determinants on pharmacy satisfaction were described in the literature [19–23]. Although higher proportions of the individuals in their 20’s and 30’s are represented in workplace insurance group, the role of health insurance type on pharmacy satisfaction is not reported in the literature and our study is limited on speculating potential reasons for the association. Thus, further studies are in need to describe the impact of health insurance type on their pharmacy satisfaction in Korea.

This study has shown some strength. One of the major changes in the health care system in South Korea was the implementation of the new prescription law in July 2000. Therefore, it has become increasingly important to evaluate patient satisfaction with pharmacy services and to identify subgroups of patients whose needs were not met under the current health care system. However, a literature review showed that published studies on patient satisfaction were mostly from developed countries [16, 25–30] and limited reports are available from Asian countries like South Korea. In this sense, our study used the latest national-level data containing rich information on demographic characteristics, clinical data, and patient-reported health-related outcomes providing a comprehensive picture on the level of patient satisfactions with pharmacy services. From the perspectives of consumers, pharmacists, and policy decision maker, an additional strength of our study is its capacity in offering a balanced view regarding the level of patient satisfaction in South Korea. Moreover, the associated predictors of patient satisfaction was described in our study after adjusting for demographic confounders as well as clinical comorbidity, and thus have a clinical implication in identifying target patient populations for pharmacists to improve the overall level of satisfaction. Evaluations of patient satisfaction with pharmacy services are important efforts in tracking changes in order to prepare structured action plans, to develop innovative pharmacy services, and to conduct program assessments to better serve patients and maximize the professional capacity in pharmacies at local and national levels. From that perspective, we believe continuous collection of patient satisfaction data at a national level would enable researchers and other stakeholders to produce more comprehensive evaluations of pharmacy services, especially in the era of the expanded services by pharmacists in Korea although the pharmacy satisfaction survey component has not been collected after 2008, as part of KNHANES, by KCDC [31].

This study has several limitations. First of all, the data of this survey has more than seven years. However, KNHANES IV data from 2008used in our study was the latest available data source that allowed the evaluation of pharmacy satisfaction at present and pharmacy satisfaction is no longer collected with administrative reasons. Additionally, as this study used the secondary analysis of KNHANES IV, several limitations originating from the nature of the primary dataset should be recognized. Using the KNHANES data, responses to questions of patient satisfaction with pharmacy services relied solely on subjective memory, which may lead to recall bias. However, the bias appeared to be minimal, as the survey asked for patients’ recollection of pharmacy visits made within the last 2 weeks prior to the survey collection. Also the cross-sectional design of the study hinders the identification of the causal relationships between the variables and patient satisfaction. Lastly, this study assessed the global patient satisfaction with pharmacy services. Therefore, the satisfaction level for specific domains of pharmacy services, such as the quality of the counseling, waiting time, physical environment, or drug expenditures, was not considered [4, 21, 32–33]. However, despite its limitations, our study is one of the few studies using national-level data that represent South Korean adult pharmacy users.

Conclusions

Patients with a fair perception of their health and those with middle to low family incomes were significantly more satisfied with pharmacy services, and employment based health insurers reported significantly lower satisfaction with pharmacy services in South Korea. This implies these patients’ health perception, health insurance type, and the level of family income factors should be taken into consideration concurrently with other predictive determinants when interpreting the results of patient satisfaction to assess the quality of pharmacy services. In an era with the need to improve the quality of health care delivery, continuous evaluation of national level data as a tracking tool can provide important insights in decisions making process from the perspectives of consumers, pharmacists, and policy makers.