Quality of Care in Doctor's Office Adjacent to Pharmacies
Calidad de atención en Consultorios Adyacentes a Farmacias
Mexican Journal of Medical Research ICSA, vol. 9, no. 17, 56-59, 2021
Universidad Autónoma del Estado de Hidalgo
Articles
Received: 18 March 2020
Accepted: 29 April 2020
Published: 05 January 2021
Corresponding author: iveth_2901@hotmail.com
Abstract: Introduction: In recent years, the use of private outpatient services, specifically Doctor’s Office Adjacent to Pharmacies (CAF), has had remarkable growth. The aim is to review the researches that have studied whether these establishments provide a quality service based on the categorization established by Avedis Donabedian (structure, process and result). Methods: A systematic review of the Internet network was carried out in different search engines such as PubMed, Medline, LILACS, Scielo and IBECS using keywords such as: doctor´s office with pharmacies and quality of care. Studies that provide information on the quality of care in CAF and comparing public and private services, were included. Results: Of the 15 articles selected, the 53.3% correspond to structure evaluation pointing out that Medical personnel of CAF faces a difficult employment situation, 60% of articles evaluate the process referring to the preference of users is due to dissatisfactions produced in public services and 26.6% are evaluating the result mentioning that there is a conflict of interest that impact assessments. Conclusion: The limited information on CAF highlights the need for more research to know the quality of care in its operation. It is therefore important to consider the CAF as part of the health system and create specific and standardized indicators that can measure and evaluate objectively their care process.
Keywords: Doctor’s Office Adjacent to Pharmacies, quality, health system.
Resumen: Introducción: En los últimos años, el uso de servicios ambulatorios privados, específicamente Consultorios Adyacentes a Farmacias (CAF), ha tenido un crecimiento notable. El objetivo es revisar las investigaciones que han estudiado si estos establecimientos otorgan un servicio de calidad con base en la categorización establecida por Avedis Donabedian (estructura, proceso y resultado). Métodos: Se realizó una revisión sistemática en la red de internet en diferentes buscadores como PubMed, Medline, LILACS, Scielo e IBECS mediante palabras clave como: consultorios con farmacias y calidad de atención. Fueron incluidos los estudios que brindan información de la calidad de atención en los CAF y los que comparan los servicios públicos y privados. Resultados: De los 15 artículos seleccionados el 53.3% corresponden a evaluación de estructura señalando que el personal médico de CAF enfrenta una difícil situación laboral, 60% de artículos evalúan el proceso refiriendo que la preferencia de los usuarios se debe a las insatisfacciones producidas en los servicios públicos y el 26.6% corresponde a evaluación del resultado mencionando que existe un conflicto de intereses que repercute en las evaluaciones. Conclusión: La escasa información en relación a CAF pone de manifiesto la necesidad de realizar más investigación para poder conocer la calidad de atención en su funcionamiento. Para ello es importante considerar a los CAF como parte del sistema de salud y así crear indicadores específicos y estandarizados que puedan medir y evaluar de manera objetiva su proceso de atención.
Palabras clave: Consultorios Adyacentes a farmacias, calidad, sistema de salud.
INTRODUCTION
Quality
One of the challenges of health policy is to raise the quality of care for all institutions in the sector, guaranteeing levels of homogeneous quality as well. The chances of successful treatment, whether simple or complex, should be similar throughout the sector and not depend on the unit or institution in which the person serves.1
The quality of care is the application of science and medical technology in a way that maximizes its benefits to health without increasing their risk proportionately. The degree of quality is therefore the extent that it is expected that the care provided achieves the most favourable balance of risks and benefits.2
By weighing the health organizations as systems properly structured, the following must be observed for evaluation: the structure, process, and results, as established by Avedis Donabedian. The evaluation of the structure focuses on the context in which it is supported by the health institution, that is, what kind of resources are those used to perform their functions and meet the demand for their services. The evaluation process includes all methods to recognize, diagnose and establish certain direct or indirect actions to help achieve the goals of the institution and will be evaluated with the degree of satisfaction expressed by users. Among the criteria used to measure outcomes, there are the coverage, effectiveness, and efficiency. Coverage is defined as the proportion of needs that are satisfied by the services provided. The assessment of effectiveness is the analysis of the achievement of the objectives, expressing them, if possible, as the reduction of the services’ problems. The effectiveness of the services provided by the institution reflects the general influence of the service or the institution in the health and socioeconomic development associated with health.3
Therefore, quality must be understood as the extent to which services improve health levels, consistent with professional standards and values of patients. The concept includes two dimensions: the technical and interpersonal. The first seeks to achieve the best results that modern science makes possible. The second is what has been called the "warmth" of care, meaning the respect for the patient as an integral human being and the pursuit of their satisfaction.4
Doctor’s Office Adjacent to Pharmacies (CAF)
In Mexico, the private outpatient units can be classified into independent doctor’s offices (CMI, by its acronym in Spanish) and doctor´s offices adjacent to private pharmacies (CAF, by its acronym in Spanish). The latter began operating almost two decades ago, mainly linked to drug chains oriented selling generic drugs.5
CAFs are defined as medical offices that are adjacent to a pharmacy with which they have a direct or indirect link (belong to the same business group, to be on the same site, sharing trade name, the pharmacy can set business hours of the office and the price of the consultation, etc.). Further research is needed to accurately characterize the different types of connection between pharmacy and doctor’s office, which are often located in the same building or property and are separated only by a wall.6
In recent years, the use of private outpatient services, specifically CAF has had a remarkable growth, which has been attributed to the lack of response capacity of the public sector, despite efforts by policies implemented aimed at increasing public spending and expand health coverage.7
For the above, the aim of this paper is to review the researches that have studied whether the CAF provides a quality service based on the categorization established by Avedis Donabedian (structure, process, and result).
METHODS
A systematic review was carried out on the Internet based on articles published in scientific journals. The literature search was conducted in different search engines like PubMed, Medline, LILACS, Scielo and IBECS, where articles were selected published in the journal Salud Pública de México, Gaceta Sanitaria, BMC Health Services Research, Panamericana de Salud Pública, Digital Universitaria UNAM, Salud Pública de Cuba, BMJ Open and Elsevier. The key words that were used are: Doctor’s Office Adjacent to Pharmacies, quality, health system.
They were included in the analysis studies that refer to the characteristics of the CAF and those who provide information on the quality of care at these establishments or comparing public and private services. Studies related exclusively to quality public health systems were excluded. The search was not restricted to the language or time periods.
RESULTS
They were selected 15 articles, from which, based on their impact factor and according to the qualitative classification of journals scientific periodicals issued by the Ministry of Health of the United Mexican States, 13.3% are in group 1, 20% group 2 and the remaining 66.6% are located in group 3. The latter with an impact factor between 0.90 and 2.99 according to the JCR Journal Citation Reports Science Edition 2016 and Social Science Edition 2016, published by the Institute for Scientific Information.
From the 15 articles reviewed, one-third (33.3%) correspond to articles published in the last 5 years, another third (33.3%) published in the last 10 years and the rest also of 5 (33.3%) higher than 10 years.
Hundred percent of the papers agree that one way to improve the health service is through evaluation, specifically quality,. however 20% of articles mention that in order to do this, it is needed to have indicators in addition to provide quantitative information to identify areas with high probability of attention problems .. It is stated that among the complications to carry out such assessment, it is found the concerning to the lack of indicators that suit all types of people and are useful in any health services, besides, the quality monitoring lacks the necessary rigor to be useful and credible.10
The first with 53.3% of articles belonging to structure evaluation. They conclude that medical personnel working in Doctor´s offices Adjacent to Pharmacies, face a difficult situation,11 working in precarious conditions which are concealed by the corporate ideology of helping the poor,12 not fully satisfied with the expectations surrounding the profession for low pay, informality in recruitment and lack of labour guarantees established by law11 besides, this entails lower regulatory compliance in its action in relation to the development of medical history and prescription13.
The second group with 60% of articles refers to the evaluation of the process which is studied mainly by the user satisfaction14 and this review indicates the limited information regarding CAF, only 13.3% of articles focus exclusively on this sector, the other 46.6% perform a comparison between public and private systems and determine that based on the experience of patients, qualifies the medical care as acceptable.15 They refer that there has been progress in the quality of care;16 only one article states that it is increasingly common to find discontent and distrust of patients to their physicians;17 however within dissatisfied users it is stated that among the main elements that determine poor quality of care, are long waiting times, omissions in physical examination and diagnosis, difficulty of getting an appointment and abuse by personnel providing services.17 Based on this information the two articles focused on the quality of the CAF process specifically refer to the increase in the number of services provided in these establishments and user preference is mainly due to the dissatisfactions produced in public services.18,19.
And the last group with 26.6% of the articles corresponds to the evaluation of the result which is the t less studied subject, referring to it as an inherently complex task since to the measurement of abstract concepts it is added the variety of interests that may influence the subsequent evaluations, 9 in addition to current health systems do not provide high-quality care consistently to everyone, this results in the presence of adverse events, most of them preventable, causing physical, psychological, disability and even death.20 An article mentions that the costs of quality failures represent 20 to 40% of the cost of health systems.21 It is worth mentioning that 33.3% of the articles evaluate more than one aspect.
DISCUSSION
Doctor´s office adjacent to pharmacies have positioned themselves as an option for health care in a major way7, improving access and opportunity to the attention of the population among other benefits, however, the exponential growth has not allowed to closely monitor its operation.
Today, the quality assessment has become an international priority or challenge for everyone involved in the system4, however, the lack of official standards and/or laws necessary for the exercise impair the free exercise of physicians, jeopardizing the achievement of national health objectives and the health of the population.
Therefore, the present review indicates the need to develop organizational capacity to implement systems of quality management to identify, evaluate, overcome and prevent the challenges of the health care system from the three components established by Donabedian: thestructure, process, and results, as it is the correct administrative way to evaluate a system and identify specific areas of opportunity to improve the quality of care of the health system.3
Moreover, it is also necessary to strengthen the implementation of existing regulation to adjacent offices to pharmacies and generate policies from monitoring its operation, taking into account that even if it is a private institution the quality of its operation also affects the population’s health, so constant supervision is needed and is similar to any institution, whether public or private, to ensure that there are positive results regardless of where the people are attended.4
It is also important to note that the articles analysed were conducted in reduced populations so it is considered to conduct studies with larger samples so they can be representative of a general population. Also, all the components of a CAF system should be evaluated, since the majority only focus on analysing the characteristics of structure, leaving aside the process and outcome indicators.
CONCLUSION
The limited information on doctor´s offices adjacent to pharmacies highlights the need for more research with larger populations to know the quality of care in their structure, process and result. It is therefore important to consider the CAF as part of the private health system and create specific and standardized indicators that can measure and evaluate objectively the quality of the whole process of care, as well as maintain close monitoring of the standards and laws already established for their operation taking into account that the current and constant regulation of these institutions has a positive impact on the population’s health.
REFERENCES
1. Niño-Effio BS, Perales-Carrasco JCT, Chavesta-Manrique XP, Leguía- Cerna JA, Díaz-Vélez C. Calidad de servicio en la consulta externa de un hospital de la región Lambayeque octubre 2010. Rev. Cuerpo méd. HNAAA. 2012;5(1):5-9.
2. Secretaría de Salud. Programa Nacional de Salud 2001 -2006. Available from:http://www.salud.gob.mx/unidades/cdi/nom/compi/pns20012006.pdf [Accessed 27 february 2020].
3. Secretaría de Salud. La calidad de la atención a la salud en México a través de sus instituciones. Available from: http://www.calidad.salud.gob.mx/site/editorial/dgr-editorial_01.html [Accessed 25 february 2020].
4. Instituto Nacional de Salud Pública. Encuesta Nacional de Salud y Nutrición. Resultados nacionales 2012. Available from: https://ensanut.insp.mx [Accessed 28 february 2020].
5. Chu M, Garcia-Cuellar R. Farmacias Similares: private and public health care for the base of the pyramid in Mexico. Harvard Business School. 2007; 2:307-92.
6. Funsalud. Estudio sobre la práctica de la atención médica en consultorios médicos adyacentes a farmacias privadas. Available from: https://www.researchgate.net/publication/305319200_Estudio_sobre_l a_practica_de_la_atencion_medica_en_consultorios_medicos_adyacen tes_a_farmacias_privadas [Accessed 27 february de 2020].
7. Bautista-Arredondo S, Serván-Mori E, Colchero MA, Ramírez- Rodríguez B, Sosa-Rubí SG. Análisis del uso de servicios ambulatorios curativos en el contexto de la reforma para la protección universal en salud en México. Salud Pública Méx. 2014;56(1):18 -31.
8. Molina Astúa M, Quesada Mena LD, Ulate Gómez D, Vargas Abarca S. La calidad en la atención médica. Med. Leg. Costa Rica. 2004;21(1):109-17.
9. Jiménez Paneque RE. Indicadores de calidad y eficiencia de los servicios hospitalarios. Una mirada actual. Rev. Cub. Salud Púb. 2004;30(1):17- 36.
10. Saturno-Hernández PJ, Martínez-Nicolás I, Poblano-Verástegui O, Vértiz-Ramírez JJ, Suárez-Ortíz C, Magaña-Izquierdo M, et al. Implementación de indicadores de calidad de la atención en hospitales públicos de tercer nivel en México. Salud Pública Méx. 2017;59(3):227- 35.
11. Díaz-Portillo SP, Reyes-Morales H, Cuadra-Hernández SM, Idrovo AJ, Nigenda G, Dreser A. Condiciones de trabajo en consultorios adyacentes a farmacias privadas en Ciudad de México: perspectiva del personal médico. Gac. Sanit. 2017;31(6):459-65.
12. Leyva Piña MA, Pichardo Palacios S. Los médicos de las Farmacias Similares: ¿degradación de la profesión médica? Polis. 2012;8(1):143- 75.
13. Díaz-Portillo SP, Idrovo AJ, Dreser A, Bonilla FR, Matías-Juan B, Wirtz VJ. Consultorios adyacentes a farmacias privadas en México: infraestructura y características del personal médico y su remuneración. Salud Pública Méx. 2015;57(4):320-8.
14. Sauceda-Valenzuela AL, Wirtz VJ, Santa-Ana-Téllez Y, Kageyama- Escobar ML. Ambulatory health service users´ experience of waiting time and expenditure and factors associated with the perception of low Quality of care in Mexico. BMC Health Services Research. 2010; 10:178.
15. Reyes-Morales H, Flores-Hernández S, Sauceda -Valenzuela AL, Vértiz-Ramírez JJ, Juárez-Ramírez C, Wirtz VJ, et al. Percepción de los usuarios sobre la calidad de la atención ambulatoria en servicios de salud en México. Salud Pública Méx. 2013;55(suppl)2: S100-S105.
16. Cabello Morales E. Calidad de la Atención Medica: ¿Paciente o cliente? Rev. Med. Hered. 2001;12(3):96-9.
17. Ortiz Espinosa RM, Muñoz Juárez S, Lechuga Martín del Campo D, Torres Carreño E. Consulta externa en instituciones de salud de Hidalgo,México, según la opinión de los usuarios. Rev. Panam. Salud Pública. 2003;13(4):229-38.
18. López-Manning M, García-Díaz R. Doctors Adjacent to Private Pharmacies: The New Ambulatory Care Provider for Mexican Health Care Seekers. Value in Health Regional Issues. 2017; 14:81 -8.
19. Pérez-Cuevas R, Doubova SV, Wirtz VJ, Servan-Mori E, Dreser A, Hernández-Ávila M. Effects of the expansion of doctors’ offices adjacent to private pharmacies in Mexico: secondary data analysis of a national survey. BMJ Open. 2014;4(5): e004669.
20. González Medécigo LE, Gallardo Díaz EG. Calidad de la atención médica: la diferencia entre la vida o la muerte. Rev. Dig. Univ. UNAM. 2012;13(8):3-15.
21. Saturno-Hernández PJ, Hernández-Avila M, Magaña-Valladares L, Garcia-Saisó S, Vertiz-Ramírez JJ. Estrategia integral de formación para la mejora continua de la calidad de los servicios de salud. Salud Pública Méx. 2015;57(3):275-83.
Author notes
iveth_2901@hotmail.com
