International Dental Journal 2013; 63: 30–38     ORIGINAL ARTICLE                                                         ...
Patients’ priorities in a dental practicehealth professionals to compare their own perfor-           and hence very costly...
Sonneveld et al.I Infrastructure                                           inhabitants). In addition, in each selected com...
Patients’ priorities in a dental practicethe OR was used to quantify the relationship between                             ...
34                                                                                                                        ...
Patients’ priorities in a dental practicepatients had a lower preference for this aspect com-        services were not inc...
Sonneveld et al.domain and then divided them by the number of                availability of information on dental service...
Patients’ priorities in a dental practicespeculated why this might be so. However, we could          as being important. O...
Sonneveld et al.Acknowledgements                                                         15. Stichting Harmonisatie Kwalit...
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Patients’ priorities in assessing organisational aspects of a general dental practicei dj12001

  1. 1. International Dental Journal 2013; 63: 30–38 ORIGINAL ARTICLE doi: 10.1111/idj.12001Patients’ priorities in assessing organisational aspects ofa general dental practiceRutger E. Sonneveld1, Wolter G. Brands1, Ewald M. Bronkhorst1, Jos V. M. Welie2 andGert-Jan Truin11 Department of Preventive and Restorative Dentistry, School of Dentistry, Radboud University Nijmegen Medical Centre, Nijmegen,the Netherlands; 2Center for Health Policy and Ethics, Creighton University, Omaha, NE, USA.Objectives: To explore which organisational aspects are considered most important by patients when assessing a generaldental practice, and which patients’ characteristics influence their views on these aspects by a paper questionnaire. Parti-cipants: The questionnaire was handed out to a sample of 5,000 patients in the Netherlands. Results: The response ratewas 63%. Six organisational aspects out of a list of 41 aspects were valued as most important by at least 50%. Indecreasing order of importance, these were: accessibility by telephone; continuing education for general dental practitio-ners; Dutch-speaking general dental practitioners; in-office waiting times; information about treatments offered; andwaiting lists. For four out of these six aspects, respondents’ age and education significantly influenced their preferences.Conclusions: Aspects concerning the infrastructure of a general dental practice were chosen more often than aspects suchas working to professional standards, working according to protocols and guidelines, quality assessment and guaranteedtreatment outcomes. The findings will enable organisations to increase the transparency of health-care delivery systemsto focus on those organisational aspects of dental practices that patients themselves consider most important. These find-ings can also assist general dental practitioners in adapting their organisational services to the preferences of patients orspecific patient groups.Key words: Quality of care, organisation, patient preferences, patient centredness, dental practiceIn recent years, most western countries have seen a modelled on much older initiatives to foster informedmove towards greater transparency in health care and consent by patients, these initiatives are more exten-the Netherlands is no exception. More specifically, a sive in scope. The normal informed consent processvariety of initiatives have been undertaken to make the takes place in a situation in which a patient isdelivery of health-care services more transparent to informed by a specific health-care provider about aend users (the patients)1. The assumption underlying specific medical condition, its prognosis with and with-these initiatives is that patients, when provided with out specific treatment options, and the side-effects ofrelevant information about the nature of health-care each treatment option. In contrast, new attempts atservices and the quality of health-care service provid- fostering transparency aim at two broader goals6:ers, will be able to make more informed decisions and ● Providing patients with information about theultimately receive greater benefit from the particular quality of health-care service such that patientsservices they decide to use2,3. A number of European can chose which health-care provider they wish tocountries have pushed the development of these initia- consulttives through legislation, essentially forcing increased ● Levelling the power differential between patientstransparency onto the health-care system4. For exam- and health-care providers by providing patientsple, new health law initiatives currently being devel- with information about health conditions andoped in the Netherlands will require health-care treatment options that used to be available only toprofessionals to provide patients with information health-care professionals.about the quality of their own health-care services, These two objectives directly benefit the patient.and to respect the patients’ right to make an informed However, the strategies developed to make health-carechoice about those services5. While inspired by and services more transparent to patients can also enable30 © 2013 FDI World Dental Federation
  2. 2. Patients’ priorities in a dental practicehealth professionals to compare their own perfor- and hence very costly. No data are available aboutmance with those of colleagues or allow their perfor- the informational needs and wishes of Dutch dentalmance to be compared by third parties, such as patients in general, or of specific patient populationsinsurance companies or consumer advocacy organisa- in particular, leaving GDPs at a loss as to what infor-tions, that want to grade health professionals on their mation concerning organisational aspects of generalability to deliver quality care7. dental practices to provide to which patient popula- As is true of other health-care services, patients in tions. It is therefore not surprising that most dentalneed of oral health-care services need information practices do not even have a website providing infor-about general dental practitioners (GDPs) in order to mation about their practice, quality of care, dentalmake an informed choice about which practitioners to services or patient experiences, although the use ofvisit for which types of procedures. As no literature such websites will have to increase if the objectives ofappears to be available, Dutch patients currently do the Visible Care programme are to be realised10,11.not have sufficient information on the quality of care As part of the Visible Care programme, the Dutchdelivered or information on dental services to make government wants all GDPs to provide a list with com-such choices. parative information on those organisational aspects of their dental practices that will best assist patients in making an informed choice about which GDP to visit.DUTCH EFFORTS AT INCREASING TRANSPARENCY This list should cover: first, aspects that dental profes-The Dutch government is an ardent supporter of sionals are already obligated to inform patients about,increased transparency in health care and to that avail such as costs and quality of care; second, aspects thathas launched the ‘Zichtbare Zorg’ programme, liter- the majority of patients consider important; and, third,ally translated as ‘Visible Care’ programme8. Stake- aspects reflecting the needs of particularly vulnerableholders in health care such as patient organisations patient populations. Although the number itself isand the medical professions take part in this pro- somewhat arbitrary, a decision was made to initiallygramme. The Visible Care programme seeks to: limit the list to 10 informational items in total.• Provide patients with medical information concern- Our study was designed to get a better sense of the ing the safety, efficiency, efficacy and patient-centr- second set of informational items listed above. As it is edness of health care, using quality indicators that presently unknown which types of information about measure the process, structure and outcomes of the dental practices and practitioners patients actually health care delivered consider important, we explored which organisational• Provide patients with information concerning orga- aspects are considered most important by patients nisational aspects of health care, such as informa- when assessing a general dental practice and which tion on opening hours and accessibility; and patients’ characteristics influence their views on these• Survey patients’ experiences with the health care aspects. delivered, measured using the Consumer Quality index (CQ-index), which is based on the American MATERIALS AND METHODS CAHPS (Consumer Assessment of Health care Providers and Systems) questionnaire and Dutch Development of the questionnaire QUOTE (QUality Of care Through the patient’s Eyes) instrument9. A questionnaire was developed for assessing the The study described in this article is part of the views of patients on the organisational aspects ofencompassing Visible Care programme. It focuses on general dental practices. A framework of 169 organi-general dental care and especially on information sational aspects was compiled, based on a literaturedirected at patients concerning organisational aspects search and aspects described in the Internationalof general dental practices. Consistent with the overall Organisation for Standardisation (ISO) 9001 certifica-purpose of the Visible Care programme, stakeholders tion method (113 aspects), adapted to the Dutchfocusing on oral health care seek to increase the trans- health-care model (Corporation Harmonization Qual-parency of dental services by providing patients with ity Assessment in Healthcare: HKZ) and the Euro-information about these services. However, this can pean Practice Assessment (EPA) instrument (56only be done effectively if it is known what informa- aspects)12–14. The HKZ model renders quality intion patients themselves consider relevant when decid- health-care institutions assessable and sets norms thating between different GDPs. Furthermore, as GDPs originate from the ISO 9001 certification model15.themselves play a key role in this informative process, The EPA instrument is a framework for general prac-it is vitally important to them to know what informa- tice management comprising quality indicators sharedtion patients really need and want or their efforts to by six European countries12. Our framework con-boost transparency could become highly inefficient sisted of five domains:© 2013 FDI World Dental Federation 31
  3. 3. Sonneveld et al.I Infrastructure inhabitants). In addition, in each selected community, aII Staff GDP (working in a dental practice) was randomly cho-III Information sen from all GDPs registered in that community withIV Finance; and the Dutch Dental Association in 2008. The GDPs wereV Quality and safety. contacted by telephone to explain the purpose of the The combined list of 169 organisational aspects study and asked to participate. If a GDP did not wishwas rated on overlapping aspects, double-named to participate, the GDP listed next in the Dutch Dentistaspects and usefulness for assessing a general dental Guide 2008 for that community was approached. Inpractice. This resulted in a list of 113 aspects. In this manner, 147 GDPs were contacted by phone. Aorder to reduce the number of questions even further standardised confirmation letter was sent to the partici-and thereby increase the response rate, several related pating GDPs (n = 103) as well as a letter of instructionaspects were clustered at a higher aggregation level and 50 patient questionnaires and related materials.and reduced to a list of 61 aspects. For example, The GDPs were asked to approach the first 50aspects such as accessibility by telephone after-hours, patients they treated in the third week of Januaryduring working hours or in the case of an emergency 2009 to participate in the survey. Patients could com-were combined into a single aspect – accessibility by plete the questionnaire anonymously at home andtelephone. In addition to the variables gender and return it to the research team at the University ofage, patients were asked to indicate their level of edu- Nijmegen in a stamped pre-addressed envelope. Forcation by choosing from the following options: any patient who accepted the survey, the GDPs or• Low-education (defined as: no education or elemen- dental assistant wrote the name and address of that tary school) patient on the standardised reminder envelope. Two• Middle-to-low-education (defined as: junior high weeks after the last questionnaire was handed out, school) reminders were sent by the GDPs. As the survey was• Middle-education (defined as: high school) completely anonymous, and no questions were asked• Middle-to-high-education (defined as: college/uni- about the patients’ own health status or the health versity–bachelor degree); and care delivered, approval by an Institutional Review• High-education group (defined as: university/mas- Board/Research Ethics Committee was not necessary ters degree or above). under Dutch law. At the end of the study, all partici- Finally, we asked patients whether they had dental pating GDPs received a report with the outcomes ofinsurance and whether they lived in a one-person their own practice compared with the other practices.household. Three focus groups (two consisting of patients, ran- Statistical analysesdomly selected by a patient platform, and one consist-ing of GDPs) rated the instrument for relevance, In the questionnaire, patients were asked to choose theusefulness and clarity. Based on consensus discussions 10 most important organisational aspects out of the 41a final list of 41 organisational aspects of a general aspects listed. As a considerable number of respondentsdental practice was derived (Table 2). The aspects did not abide by this instruction, only respondents whowere divided into five domains, based on the EPA chose between 8 and 12 aspects (n = 2,676) wereinstrument described above. Finally, the questionnaire included in the analysis. Logistic regression was appliedwas pilot-tested among 50 patients in a general dental to analyse the relationship between patients’ character-practice; this resulted in several small refinements. istics and their choices. In the logistic regression model, gender, age, education, dental insurance and living status were used as independent variables. For the vari-Sampling procedure able age, the 65+year age-group (n = 379) was the ref-The study population, equally divided over the whole erence group. The other age groups were created incountry, consisted of Dutch patients visiting a dental accordance with the categories used by Statisticspractice. We aimed at a response rate of 50% and a Netherlands16: under 20 years (n = 35), 20–39 yearsminimum of 2,500 questionnaires returned. Sampling (n = 627), 40–54 years (n = 1,048) and 55–64 yearswas as done across the 12 provinces of the Netherlands. (n = 587). For the education variable, the low-educa-From each province a stratified sample of three small tion group was the reference group (n = 300). Thecommunities (< 30,000 inhabitants), three medium-to- groups compared were the middle-to-low-educationlarge communities (between 30,000 and 80,000 inhab- group (n = 1,110), the middle-education groupitants) and three large communities (over 80,000 (n = 292), the middle-to-high-education groupinhabitants) was drawn. This procedure resulted in a (n = 756) and the high-education group (n = 218).total of 103 communities (not every province in the For analyses of the patients’ characteristics, oddsNetherlands has communities with more than 80,000 ratios (ORs) were calculated. Using logistic regression,32 © 2013 FDI World Dental Federation
  4. 4. Patients’ priorities in a dental practicethe OR was used to quantify the relationship between Patients’ characteristicsbackground variables (age, gender, education, dentalinsurance and one-person household) and the likeli- Patients aged 20–39 years and 40–54 years selectedhood of a given aspect to be chosen among a respon- the aspect accessibility by telephone significantly lessdent’s top 10. The OR can be interpreted as relative often, with ORs of 0.59 and 0.39, respectively, com-risk. If, for example, the OR = 2 for females com- pared with the reference group of patients agedpared with males then, all other background variables 65 years and over (Table 3). More highly educatedbeing equal, the chance that females will choose thataspect is twice as great as it is for men. The logisticregression analyses were only applied to those aspects Table 2 Ranking and percentages of the 10 most cho-chosen by a minimum of 50% of the respondents as sen organisational aspects for assessing a dental prac-most important. All statistical analyses were per- tice by patientsformed using SPSS, version 16 (IBM, Armonk, NY, Ranking Aspects % DomainUSA). 1 Accessibility by telephone 76.5 I 2 Continuing education of GDP 61.9 IIRESULTS 3 Dutch-speaking GDP 57.0 V 4 In-office waiting times 54.8 I 5 Availability of information on 54.3 IIIResponse dental services 6 Availability of appointments 51.7 IThe overall response rate was 63% (n = 3,127). Of (waiting lists)the respondents, 59% were female and 41% were 7 Guarantee on treatments 43.0 IV 8 Quality assessment 41.4 Vmale. The respondents differed from national popula- 9 System for check-up of perishable 37.7 Vtion data with regard to gender and age: males were goodsunder-represented and the 40- to 64-year age-group 10 Treatment by same dental therapist 34.6 II 11 Specialties in dental practice 33.5 IIwas over-represented (Table 1). The response rates of 12 Information on tasks of staff 29.6 IIrespondents living in large, medium and small com- 13 Working according to 28.3 Vmunities were 58%, 60% and 68%, respectively. professional standard 14 Information on dental bill 27.4 III Table 2 shows the ranking and percentages of the 15 Reminder of routine oral 26.9 IIIorganisational aspects chosen by the respondents as examinationthe 10 most important aspects. At least 50% of the 16 Opening hours evening and/or 26.0 I weekendrespondents included in their top 10 the following six 17 Physical accessibility 25.0 Iaspects: 18 Accessibility for disabled patients 21.1 I• Accessibility by phone 19 Parking spaces 20.5 I• Continuing education courses for GDPs 20 Working according to protocols and guidelines 20.1 V• Dutch-speaking GDP 21 Clarity of responsibilities 19.1 II• In-office waiting times 22 Meetings of GDP with colleagues 17.8 II• Availability of information on dental services 23 24 Waiting room facilities Continuing education of dental 17.7 17.5 I II offered; and hygienist• Availability of appointments (waiting lists). 25 27 Information on internet Patient consultation in dental team 17.3 14.9 III II The top six varied only slightly between the vari- 26 Having liability insurance 14.8 Vables gender, age and education. Looking at all these 28 Continuing education dental 13.9 IIrankings separately (which yields 78 rankings), only assistant 29 Meetings of GDP with dental 11.7 IIthree times were aspects chosen in the top six that technicianswere not in the six aspects listed above. 30 GDP taking part in peer supervision 10.5 V 31 Patient satisfaction survey 9.2 IITable 1 Distribution of patient sample and national 32 Receiving dental bill 8.9 IVfigures on gender and age: percentages of total 33 Disease diagnoses 8.7 V 34 Payment possibilities 8.4 IV Patients (n = 3,127) Visiting patients 35 Meetings of GDP with health insurers 8.1 II (national data) 36 Attending complaint committee 7.5 V 37 Risk assessment 5.9 VGender 38 Insight of health insurer in 5.5 V Male 41.1 47.4 medical records Female 58.9 52.6 39 Parking fees 4.4 IAge (years) 40 Information about complaints 4.1 III 16–19 1.3 5.9 procedure 20–39 23.7 31.2 41 Employee satisfaction survey 3.4 II 40–64 60.0 44.1 >65 15.0 18.8 GDP, general dental practitioner. Domain: I = infrastructure; II = staff; III = information; IV = finance; V = quality and safety.© 2013 FDI World Dental Federation 33
  5. 5. 34 Sonneveld et al. Table 3 Significance, odds ratio (OR) and confidence interval for the effect of gender, age, education, dental insurance and living status on aspects cho- sen by at least 50% of the patients. All statistics calculated by multivariate logistic regression Accessibility by phone Continuing education of GDP Dutch-speaking GDP P OR 95% CI of OR P OR 95% CI of OR P OR 95% CI of OR Gender (f = 1, m = 0) 0.193 1.13 0.94–1.37 0.002 1.30 1.10–1.53 0.436 0.94 0.80–1.10 Age (ref = 65+ years) Under 20 years <0.001 0.59 0.25–1.39 <0.001 0.57 0.28–1.15 0.386 0.85 0.41–1.74 20–39 0.39 0.28–0.54 0.73 0.56–0.96 0.89 0.68–1.16 40–54 years 0.57 0.42–0.79 1.06 0.83–1.36 0.78 0.61–1.01 55–64 years 0.77 0.54–1.09 1.24 0.95–1.63 0.84 0.64–1.10 Education (ref = low education) Middle–low <0.001 0.79 0.56–1.11 <0.001 1.31 1.01–1.71 <0.001 0.64 0.48–0.85 Middle 0.60 0.40–0.90 1.75 1.25–2.45 0.54 0.38–0.76 Middle–high 0.62 0.44–0.89 2.06 1.56–2.72 0.41 0.30–0.54 High 0.43 0.28–0.66 2.37 1.63–3.45 0.24 0.16–0.34 Dental insurance (y = 1, n = 0) 0.661 0.95 0.75–1.20 0.987 1.00 0.81–1.23 0.423 1.09 0.88–1.34 One-person household (y = 1, n = 0) 0.086 1.27 0.97–1.65 0.338 1.12 0.89–1.43 0.149 1.19 0.94–1.50 In-office waiting times Availability of information about dental Availability of appointments services (waiting lists) P OR 95% CI of OR P OR 95% CI of OR P OR 95% CI of OR Gender (f = 1, m = 0) 0.641 0.96 0.82–1.13 <0.001 1.57 1.34–1.85 0.396 1.07 0.91–1.26 Age (ref = 65+ years) Under 20 years 0.047 1.54 0.74–3.18 <0.001 0.37 0.18–0.77 0.050 1.57 0.77–3.21 20–39 years 1.25 0.96–1.63 0.60 0.46–0.78 1.28 0.99–1.67 40–54 years 1.35 1.06–1.72 0.69 0.54–0.88 1.32 1.03–1.68 55–64 years 1.05 0.81–1.36 0.85 0.65–1.11 1.03 0.79–1.34 Education (ref = low education) Middle–low 0.374 1.16 0.90–1.51 0.071 1.37 1.05–1.78 <0.001 1.54 1.18–2.01 Middle 1.30 0.94–1.82 1.25 0.90–1.74 1.79 1.28–2.49 Middle–high 1.04 0.79–1.36 1.49 1.13–1.95 2.02 1.53–2.66 High 1.21 0.85–1.72 1.28 0.90–1.82 2.72 1.89–3.91 Dental insurance (y = 1, n = 0) 0.621 1.05 0.86–1.29 0.029 1.26 1.02–1.55 0.156 0.86 0.70–1.06 One-person household (y = 1, n = 0) 0.075 1.23 0.98–1.56 0.716 1.04 0.83–1.32 0.659 1.05 0.83–1.33 GDP, general dental practitioner. Significant P-values (P < 0.05) are marked in bold.© 2013 FDI World Dental Federation
  6. 6. Patients’ priorities in a dental practicepatients had a lower preference for this aspect com- services were not included in the study. As such ‘non-pared with a lower education level (middle education, attenders’ can have different views, it would haveOR = 0.60, middle-to-high education, OR = 0.62, been preferable if the study had been able to captureand high education, OR = 0.43). their views, although the impact of this limitation of Age, gender and level of education significantly the study is probably modest. The majority of theinfluenced the respondents’ choices for the aspect Dutch adult population (85%) visits a dentist once acontinuing education for a GDP. A significantly higher year and therefore the non-attenders are a minority.percentage of women chose the aspect refresher course Further, most persistent non-attenders are unlikely tofor a GDP as most important compared with men suddenly start frequenting a dental office when more(OR = 1.30); younger patients scored lower odds on information is available on the dentists’ websites. Forthis aspect (under 20 years, OR = 0.57; 20–39 years, example, one of the major reasons not to visit a den-OR = 0.73) in comparison with the reference group tist is dental anxiety (prevalence rates from 13.1% toaged 65+ years. This organisational aspect was more 19.8% among the population)17.frequently selected with increasing level of education. The respondents were recruited from different com- Education groups differed significantly for the munities and dental clinics. In the Netherlands, oralaspect Dutch-speaking GDP (P < 0.001). This aspect health care is provided in different oral health-carewas chosen less by more highly educated patients settings (e.g. solo practices and large team practices orcompared with the reference group. Compared with specialised practices). Differences in the infrastructurethe reference group, all other age groups chose the of the dental clinics may have an impact on the ser-aspect in-office waiting times more often (P = 0.047). vices that are provided in these settings, influencing Significant differences for gender, age and dental the responses of the patients participating in theinsurance were found for the aspect availability of study. However, 60% of the oral health care in theinformation on dental services. Women chose this Netherlands is provided in a solo dental practice set-aspect more often than did men (OR = 1.57; ting18, thus limiting the impact of the infrastructureP < 0.001). Older age groups selected this aspect of dental practices on the study outcomes. In addition,more often in comparison with younger age groups, in the questionnaire, the respondents were asked toas did patients who had a dental insurance compared give their (organisational) preferences for an idealwith uninsured patients (P = 0.029). dental practice and not to assess the actual dental The OR for the aspect availability of appointments practice.(waiting lists) increased with education. More highly The percentages of respondents did not differ statis-educated patients chose the aspect more often than tically by the size of the communities. However, asdid the less well-educated patients (P < 0.001). mentioned previously, compared with national data of Dutch dental patients, the 20- to 39-year age group was under-represented (24% vs. 31%) and the 40- toDISCUSSION 64-year age group was overrepresented (60% vs.In this study, patients were asked to choose the 10 44%). Hence, the results presented in Table 3 may beorganisational aspects they found most important biased towards the preferences of elderly patients.when assessing a general dental practice. The ranking Combining the modest differences between age groupsof aspects gives an indication of the relative impor- and the extent of over- or under-representation of spe-tance patients assigned to each of the organisational cific age groups, the bias can be estimated to be 2%aspects. This paper focuses on aspects chosen by at or less. Therefore, the top of the list of aspects is notleast 50% of the patients and therefore it appears that likely to have been affected.only a few aspects are very important for patients. The use of patients’ views to improve health-careHowever, we emphasise that some of the lower- delivery requires valid and reliable measurementsranked aspects may be extremely important to certain methods. Because no single method existed that could(categories of) patients. The differences in the percent- reliably yield the information we sought to obtain, weages are relatively small and demonstrate a fluent had to design a new instrument. Our list of 41 itemsdecrease. The only large percentage differences are or aspects was developed using a literature search,between aspects 1 and 2 between aspects 6 and 7. focus group meetings and consensus discussions. A response rate of 63% is fairly good. However, In general, it appears that patients put the greatestbias could have occurred in the selection procedure of emphasis on the domain ‘infrastructure.’ However,the patients. The results of the questionnaire, com- not each domain had the same number of aspectspleted by 3,127 patients, provide a satisfactory picture included in it. Hence, the odds of any single domainof what patients see as most important organisational being given priority increased by the number ofaspects of a dental practice. Owing to the sampling aspects included. In order to correct for this potentialprocedure, patients who rarely or never seek dental bias, we added the percentages of the aspects per© 2013 FDI World Dental Federation 35
  7. 7. Sonneveld et al.domain and then divided them by the number of availability of information on dental services. This isaspects per domain, resulting in the average percent- an expected outcome as patients need information onage per domain. After this recalculation, ‘infrastruc- the dental services offered in order to determineture’ aspects are still deemed most important by whether the services offered are wanted by them.patients with 33.1% of patients selecting such aspects Conversely, if we look at the organisational aspectsin their top 10; ‘information’ domain aspects were that were considered very important by only a smallnext (26.0%), followed by aspects concerning ‘quality number of respondents (< 5% of respondents), we findand safety’ (21.6%), aspects in the domain ‘staff’ at place 39 (out of 41), the aspect parking fees. This is(21.2%) and finally aspects in the domain ‘finance’ quite understandable as although parking can be a nui-(20.1%) (data not given in table). sance in the Netherlands, patients probably know that Three of the top six top scoring aspects [accessibility GDPs cannot influence the parking policy of the localby telephone, in-office waiting times, and availability of authorities. More surprising is the finding that infor-appointments (waiting lists)] fall in the infrastructure mation about complaints procedures was considereddomain. An international survey of the World Health important by only a few patients. We know from juris-Organisation in 41 countries measuring patient experi- prudence and disciplinary proceedings that Dutchence with the non-clinical quality of care revealed that patients rarely file complaints about dentists. Our find-prompt attention (e.g. short in-office waiting time, little ing would lead to the conclusion that their hesitancetravel time and short waiting lists) was valued as most to do so apparently is not a matter of lack of informa-important19. Other studies showed the same find- tion about available complaints procedures. Perhapsings20,21. In contrast, only one aspect from the ‘quality Dutch patients are already aware of the variousand safety’ domain made the top six: continuing educa- options for launching a complaint. or are simplytion courses for GDPs. Patients ranked the aspect highly satisfied with their dentists and almost nevercontinuing education courses for GDP as far more feel the urge to formally complain. Most curious is theimportant than similar courses for dental hygienists (22 fact that patients are least interested in receiving infor-places lower in ranking). This is an interesting finding. mation about employee satisfaction. We can only spec-In the Netherlands, dental hygienists treat patients with- ulate on the reasons for this. Perhaps patients simplyout the supervision of a GDP. Therefore, one would assume that all persons working in dental offices arehave expected that patients would rank this aspect for highly satisfied or that employee satisfaction has littledental hygienists equally highly. In this study, respon- impact the care they themselves receive.dents were drawn from dental practices. We do not The second goal of our study was to exploreknow whether dental hygenists were working in those whether patients’ characteristics influence their prefer-practices; neither do we know whether the respondents ences. ‘Age’ was significantly associated with four outvisit independent dental hygenists regularly. of six aspects chosen by at least 50% of the respon- It is remarkable that the domain ‘infrastructure’ dents. It appears that the importance of the aspectswas more important to patients than the domain related to the domain ‘infrastructure’ decreases with‘quality and safety’ (which, in addition to CE courses, age; the elderly found these aspects less important,included aspects such as professional standards, work- although they chose accessibility by telephone moreing according to protocols and guidelines, quality often. In some other studies, age and gender wereassessment, guarantee on treatments). An explanation found to be significant variables associated with prior-of this finding could be that patients trust the Dutch itising in a general medical practice, assessing primaryhealth system to assure high quality and safety stan- care and patient experiences of accessibility of pri-dards among health professionals. They may simply mary care23–25. , As one might expect, the aspecttake it for granted that their dentist is competent. continuing education for GDPs was chosen more The aspect Dutch-speaking GDP is also included in often by respondents who were themselves highly edu-the top six. Language barriers between provider and cated. Less self-evident is that the aspect availabilitypatient can have a significant detrimental impact on of appointments (waiting lists) was also chosen morethe quality of the care rendered. Indeed, this was also often by respondents with a higher level of education.one of the preferences among patients when selecting Again, we can only speculate on the reasons for this.a primary care physician, as shown in a study by Aro- It is unlikely that highly educated people have greaterra et al.22. Highly educated Dutch dental patients find difficulty adjusting their calendars (usually, people inthis aspect less important. An explanation may be that lower paid jobs are those with less flexibility). Rather,highly educated Dutch patients generally speak differ- this finding may reflect that highly educated peopleent languages and therefore could communicate with are less in awe of their GDP and hence less toleranttheir GDP in another language, such as English. of waiting lists. We have mentioned that this group of The only aspect in the domain ‘information’ that respondents is less likely to consider it important thatwas chosen by 50% of the patients in their top 10 is their GDP is Dutch-speaking, and we have already36 © 2013 FDI World Dental Federation
  8. 8. Patients’ priorities in a dental practicespeculated why this might be so. However, we could as being important. One possible explanation for thisnot find a reasonable explanation for the fact that this outcome is that patients are not interested in the opin-same group also considered the aspect accessibility by ions of other patients and will not use this informationtelephone less important. when assessing a dental practice. However, this is at The study provides insight into the organisational least from a first impression unlikely, because we knowaspects of dental practices that patients themselves tend that many dental patients rely heavily on ‘word ofto consider important. This does not mean that other mouth’ quality indicators provided by family or friendsaspects, such as clinical indicators and patient evalua- when deciding about a dentist27. Alternatively, mosttions can be disregarded. Being part of the Visible Care patients do not deem this aspect important becauseprogramme, much effort will also be put in the devel- they are generally satisfied with their GDP28,29.opment of those indicators. However, the outcomes of Although developed and executed to meet thethis study can be used in the Visible Care programme objectives of the Visible Care programme, anotherfor the development of a list of comparative informa- beneficial outcome of our study is that GDPs can usetion on dental practices that patients can next use to our findings to adjust the organisation of their prac-make an informed choice for a particular GDP. tice to the preferences of patients in general or to the We pointed out earlier that the stakeholders in the preferences of specific patient groups, such as theVisible Care programme have decided initially to limit elderly. For example, now that GDPs know that mostthe comparative list of informational items to 10 patients consider accessibility by telephone extremelyitems only. Our research has shown that only 6 of 41 important for patients, they may wish to ensure thataspects were considered by at least 50% of patients to their practice is accessible at all times by means of anbe very important. This leaves four open slots. Stake- assistant and an/or answering service. At the veryholders may want to add aspects that the majority of least, they may want to install an answering machinerespondents in our study considered less important with pertinent information about items such as open-but which could be crucially important for vulnerable ing hours and waiting lists. Another aspect that weminority populations, such as the aspect accessibility found to be important to most patients is in-officefor disabled patients (# 18 in Table 2). As there are waiting times. In view of this, GDPs may wish torelatively few disabled patients in most dental prac- design strategies for reducing waiting times andtices, their views may be under represented in our sur- promptly inform patients in their waiting rooms ifvey. One of the tasks of a government is to ensure unexpected delays in treatment do occur.that vulnerable patient groups are heard and are beingprotected. CONCLUSION In their comparative list, the Visible Care pro-gramme may include some organisational items that When Dutch dental patients were presented with a listare not chosen by the majority of the respondents in of 41 different organisational aspects about generalthis study. Aspects, such as information about the dif- dental practices and asked to choose the top 10 mostferent tasks and the responsibilities of providers of important aspects when selecting a practice, only sixoral health care are required by Dutch health law26. of these aspects were chosen by the majority of theTherefore, they will be added to the comparative list respondents. Aspects concerning the infrastructure ofof 10 items. the dental practice were chosen more often than other Finally, the objectives of the Visible Care pro- aspects, such as working to professional standards,gramme can only be realised if dentists increase the working according to protocols and guidelines, qualityinformation on the internet about their practices, even assessment and guaranteed treatment outcomes. Thethough this source of information was given quite a findings of this study will enable organisations thatlow ranking by patients. The internet is an effective seek to increase the transparency of health-care deliv-and efficient medium for dentists to provide informa- ery systems, such as the Visible Care programme intion to potential patients. It therefore makes sense for the Netherlands, to focus on those organisationalthe Visible Care programme to plan on having GDPs aspects of dental practices that patients themselvesmake the comparative list of 10 organisational items consider most important. Even in the absence of suchavailable on the internet. nation-wide efforts, these findings can assist GDPs in The Visible Care programme, in addition to provid- adapting their organisational services to the prefer-ing information about treatment outcomes and organi- ences of patients or specific patient groups. Our studysational aspects of their dental practices, will also was targeted at Dutch dental patients and we makerequire GDPs to execute and publish the results of no predictions about the relevance of our specific find-patient experience or satisfaction surveys. Table 2 ings for other countries. However, we believe that theshows that the aspect patient satisfaction survey was method used for uncovering patient preferences ischosen by fewer than 10% of the responding patients probably applicable in many other national contexts.© 2013 FDI World Dental Federation 37
  9. 9. Sonneveld et al.Acknowledgements 15. Stichting Harmonisatie Kwaliteitsbeoordeling in de Zorgsector [Association for quality assessment in health care]. AvailableThe authors declare that they have no conflict of from: http://www.hkz.nl. Accessed 10 Mai 2012.interest. The study was supported by grants from 16. Centraal Bureau voor de Statistiek [Statics Netherlands]. Avail-Radboud University Nijmegen Medical Centre and a able from: http://www.cbs.nl. Accessed 15 Mai 2012.Dutch health insurance company (CZ). 17. Oosterink FM, De Jongh A, Hoogstraten J. Prevalence of dental fear and phobia relative to other fear and phobia subtypes. Eur J Oral Sci 2009 117: 135–143.Conflicts of interest 18. Nederlandse Maatschappij tot bevordering der Tandheelkunde [Dutch Dental Association]. Staat van de mondzorg. Nieuweg-Nothing to declare. ein: NMT; 2011. 19. Valentine N, Darby C, Bonsel GJ. Which aspects of non-clinical quality of care are most important? 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