title: Ambulatory health service users' experience of waiting time and expenditure and factors associated with the perception of low quality of care in Mexico.
abstract: BACKGROUND
  A principal reason for low use of public health care services is the perception of inferior quality of care. Studying health service user (HSU) experiences with their care and their perception of health service quality is critical to understanding health service utilization. The aim of this study was to define reference points for some aspects of health care quality and to analyze which HSU experiences resulted in perceptions of overall low quality of care.
  
  
  METHODS
  Data from the National Health Survey 2006 were used to compare the experiences of HSUs with their ambulatory care at Ministry of Health and affiliated institutions (MOH), social security institutions (SSI) and private institutions (PrivI). Reference points of quality of care related to waiting time and expenditure were defined for each of the three types of institutions by analyzing HSU experiences rated as 'acceptable'. A multivariable logistic regression model was used to identify the principal factors associated with the general perception of low quality of care.
  
  
  RESULTS
  A total of 11,959 HSUs were included in the analysis, of whom 37.6% (n = 4,500) HSUs received care at MOH facilities; 31.2% (n = 3,730) used SSI and 31.2% (n = 3,729) PrivI. An estimated travel and waiting time of 10 minutes respectively was rated as acceptable by HSUs from all institutions. The differences between the waiting time rated as acceptable and the actual waiting time were the largest for SSI (30 min) in comparison to MoH (20 min) and PrivI (5 min) users. The principal factors associated with an overall perception of low quality of care are type of institution (OR 4.36; 95% CI 2.95-6.44), waiting time (OR 3.20; 95% CI 2.35-4.35), improvement of health after consultation (OR 2.93; CI 2.29-3.76) and consultation length of less than 20 minutes (2.03; 95% CI 1.60-2.57).
  
  
  CONCLUSIONS
  The reference points derived by the HSUs' own ratings are useful in identifying where quality improvements are required. Prioritizing the reduction of waiting times and improving health status improvement after consultation would increase overall quality of care ratings.
authors.affiliation: Center for Health Systems Research, National Institute of Public Health, Mexico.
authors.forename: Alma Lucila
authors.initials: AL
authors.lastname: Sauceda-Valenzuela
authors.forename: Veronika J
authors.initials: VJ
authors.lastname: Wirtz
authors.forename: Yared
authors.initials: Y
authors.lastname: Santa-Ana-Téllez
authors.forename: Maria
authors.initials: M
authors.lastname: de la Luz Kageyama-Escobar
mesh_terms: D000293:Adolescent; D000328:Adult; D000554:Ambulatory Care Facilities; D002648:Child; D002675:Child, Preschool; D005260:Female; D019538:Health Care Surveys; D005102:Health Expenditures / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008800:Mexico; D008875:Middle Aged; D017060:Patient Satisfaction; D011787:Quality of Health Care; D014850:Waiting Lists; D055815:Young Adult