Milieu in Dental Schools and Practice
Patient Satisfaction with the Comprehensive
Care Model of Dental Care Delivery
Ana Karina Mascarenhas, B.D.S., Dr.P.H.
Abstract: In the summer of 1997, the College of Dentistry, The Ohio State University, changed its predoctoral clinics from the traditional model to the comprehensive care (CC) model. Although the CC model is considered the better model for delivery of care, from the patient perspective it has not been previously evaluated. The purpose of this study was to compare the two dental care delivery systems—the traditional model and the CC model—using patient satisfaction. The Dental Satisfaction Question-naire (DSQ) developed by the Rand Corporation was used to assess patient satisfaction. The questionQuestion-naire consists of nineteen items, measuring overall satisfaction and subscales of access, pain management, and quality. The questionnaire was self-administered to active and recall patients in the summers of 1997 and 1998 to evaluate satisfaction with care in the traditional and CC models respectively. The completed DSQ was returned by 119 respondents in 1997 and 116 respondents in 1998. There were no significant differences in age, gender, and self-rated general and oral health of patients using the two delivery systems. No statistically significant differences were seen in the overall Dental Satisfaction Index and the sub-scales of access, pain manage-ment, and quality of care. Statistically significant differences were observed on only two of the nineteen individual items. We conclude that there was no difference in satisfaction levels of our patients between the two dental care delivery models. Dr. Mascarenhas is Associate Professor, Health Policy and Health Services Research, Boston University Goldman School of Dental Medicine. Direct correspondence and requests for reprints to her at Boston University Goldman School of Dental Medicine, Health Policy and Health Services Research, B-306 Robinson Bldg., 715 Albany St., Boston, MA 02118; 617-638-4456 phone; 617-638-6381 fax; karinam@bu.edu.
Key words: patient satisfaction, dental delivery system, dental school, traditional model, comprehensive care model
Submitted for publication 3/26/01; accepted 8/28/01
P
atient satisfaction with care is a useful mea-sure that evaluates care, including the quality of care and provider-patient relationships. It has been used in medicine for several years, and, as reflected in the recent literature, is increasingly be-ing used in dentistry.1-5 With the shift in medicineand dentistry to patients being “consumers” of care and the concept of “consumerism,” inclusion of pa-tients’ opinions in assessment of services has gained greater prominence.6 Patient satisfaction measures
the “process” of care, broadly defined as the profes-sional activities associated with providing care.7,8
Measuring patient satisfaction allows for evaluation of health systems, particularly comparisons between different models of care delivery.
Patient satisfaction is a multidimensional con-cept.9,10 Some dimensions of dental care satisfaction
that have been identified are technical or aspects of care related to the process of diagnosis and treatment; interpersonal; accessibility/availability; financial ac-cess; efficacy/outcomes; continuity of care; facilities; and general or attitudes about overall care.9,10
Recognizing the need to teach and deliver pa-tient-centered care, The Ohio State University Col-lege of Dentistry in 1997 moved its entire predoctoral program from the traditional model of patient care to a comprehensive care (CC) model delivery sys-tem. The traditional model of patient care as prac-ticed at The Ohio State University was specialty- or discipline-oriented clinics, with students rotating through these clinics. Patients were referred to these clinics depending on the care they needed.
The comprehensive care model of dental de-livery is centered around the patient, and is more rep-resentative of the model of dentistry practiced in pri-vate practice. Patients are assigned to predoctoral students at the initial screening appointment. This student then becomes the patient’s primary dental care provider and provides most of the care needed much like the general dentist. If specialty care is needed by the patient, such as periodontal surgery for which the predoctoral student does not have the required expertise, then the patient is referred to the appro-priate clinical area with the predoctoral student
as-sisting in the patient’s care. Advantages of the CC model are that it identifies one primary dental care provider for the patient, there is continuity of care, and the chief complaint of the patient is addressed earlier. Therefore, the CC model is considered the better model for delivery of care both for the clinical training of dentists11-13 and from the patient care
per-spective11 than the traditional model. Although
rec-ommended by Gerbert and colleagues14 in 1996,
pa-tient satisfaction with care has not yet been evaluated in the CC model. Patient satisfaction with care is only one of the numerous outcomes that can be measured to assess the effectiveness of the CC model, gener-ally measuring the process of care from the patient perspective. In the broader context, numerous other facets of the comprehensive care model pertinent to the clinical education of dentists as well as the effec-tiveness and efficiency of care delivery can be mea-sured. Other outcomes that can be measured or have been previously been used as outcomes are number of procedures performed,11-13 number of patients who
receive care,11,13 overall efficiency of the clinics such
as time taken to complete treatment plans, clinic uti-lization, or total patient charges,12 and student,
fac-ulty, and staff satisfaction with the clinical system. To measure the effectiveness of the CC model in care delivery from the patient perspective, patient satisfaction data was collected in the summer of 1998, a year after the CC model was put in place, and com-pared to data previously collected in 1997 when the clinic was organized in the traditional model of den-tal care. The purpose of this paper is to report on patient satisfaction with the two dental delivery sys-tems, traditional model and CC model, and the ef-fect of patient demographics on satisfaction. The null hypothesis was that there is no difference in patient satisfaction between these two dental delivery sys-tems.
Methods
A review of the literature identified the Dental Satisfaction Questionnaire (DSQ)9,10 developed by
the Rand Corporation as a suitable instrument to be used in the predoctoral clinics. The only change made to the questionnaire was to customize it for our clics by using the phrases “OSU dental students” in-stead of “dentists” and “OSU dental clinics” inin-stead of “dentist’s office.” Separate questions on individual patient characteristics such as age and gender, gen-eral and oral health, and parking at OSU were added.
These questions will not be included in the Dental Satisfaction Index (DSI).
The DSQ is a nineteen-item questionnaire, us-ing a 5-point Likert scale rangus-ing from “strongly agree” to “agree,” “not sure,” “disagree” to “strongly disagree.” The DSQ measures overall satisfaction with care (DSI) and three dimensions of access, qual-ity, and pain-management.
The questionnaire was self-administered to active and recall patients over a three-week period in August 1997 and the same time period in 1998. All active and recall patients during the three-week pe-riod were approached to take part in the study in each year of data collection. Two second-year dental stu-dents approached patients in the clinic waiting room as they came in for their appointment. The DSQ takes five minutes to complete. Patients were assured that refusal to participate would not impact their treat-ment. A drop box was used for the patient to return the completed questionnaire. As an incentive to com-pleting the questionnaire respondents were given a toothbrush when they returned it. Approval for this study was received from the Office of Risks and Pro-tection at the Ohio State University prior to its com-mencement.
Statistical analyses were carried out using Epi-Info version 6.0 and the SAS system. The question-naires were coded and data entered using a custom-designed program in Epi-Info Version 6. Epi-Info was used to compute variables such as the overall DSI score, the subscales of access, pain management, and quality of care, scaled means, and prorated means. The scaled mean is the mean score of the scale di-vided by the number of items in that scale.11 The
scaled mean puts the overall score, and the subscale scores on a 1 (strongly agree) to 5 (strongly disagree) scoring dimension. Scaled mean scores near 1.0 re-flect extreme dissatisfaction, scores near 3.0 rere-flect neutrality, and score near 5.0 reflect extreme satis-faction. The prorated mean is the raw mean expressed as a percent of the highest possible scale or subscale score.9 Categorical variables such as self-reported oral
health and general health were dichotomized. Epi-Info was also used to obtain descriptive statistics and frequency distributions of all the vari-ables in the dataset. A new dataset was made using Epi-Info so that it could be exported into SAS for further analysis.
ANOVA was used to evaluate the difference in mean scores between the traditional and CC models. Chi-square and Fisher’s exact tests were used to de-termine if the observed differences between
indi-vidual satisfaction questions and the dental delivery systemswere statistically significant. The Mantel-Haenszel Chi-square technique was used to adjust for, or to evaluate for, confounding factors such as gender, age, and missing teeth. Finally, the hypoth-esis that there is no difference in satisfaction between the two delivery systems was tested using linear and ordinal logistic regression simultaneously controlling for gender, age, missing teeth, self-reported general and oral health, and use of an oral prosthesis.
Results
A total of 235 active or recall patients com-pleted the DSQ questionnaire, with 119 respondents in 1997 and 116 respondents in 1998. In each year, only about six patients declined to answer it. As a consequence, more than 95 percent of all active and recall patients completed the DSQ questionnaire in 1997 and 1998. Table 1 reports the demographic dis-tribution and self-rated general and oral health of the patients treated in the traditional model and the CC model. As seen from the p-values, no significant dif-ferences were seen in the patient characteristics at-tending the two clinic systems.
Tables 2 gives the mean, standard deviation (sd), scaled mean, and prorated mean for each subscale and overall DSI for the two dental delivery systems. The values for the mean, scaled mean, and prorated mean for the two delivery systems were very similar, resulting in no statistically significant dif-ferences in means for overall DSI (p=0.31) or the subscales of access (p=0.13), pain management (p=0.94), and quality (p=0.67).
When patients’ responses to individual items that comprise the DSQ were compared between the two delivery systems, only two of the nineteen items were statistically significant (Table 3). The first item was “people are usually kept waiting a long time when they are at the OSU dental clinic” (p=0.02). Higher proportions of patients were more likely to agree to this statement or be unsure in the compre-hensive care model (40 percent) compared to the tra-ditional model (21.9 percent). The other item was “OSU dental students are able to relieve or cure most dental problems that people have” (p=0.02). Lower proportions of patients were more likely to agree with this statement in the comprehensive care model (64.3 percent) compared to the traditional model (82.5 percent). These differences were still significant af-ter controlling for age, gender, self-rated general and
Table 1. Demographic distribution of the patients in the two clinic systems
Traditional Comprehensive Model Care Model (1997) (1998) N=119 N=116 p-value Age 54.9±15.2 53.9±18.7 p=0.66* Gender Males 41.4% 47.1% p=0.39† Females 58.6% 52.9%
Self-Rated General Health
Excellent 11.1% 15.7% p=0.83‡
Very good 35.0% 36.5%
Good 38.5% 35.7%
Fair 13.7% 12.2%
Poor 1.7% 0%
Self-Rated Oral Health
Excellent 10.3% 5.2% p=0.45‡ Very good 17.1% 24.1% Good 43.6% 39.7% Fair 22.2% 24.1% Poor 6.8% 6.9% Missing Teeth 85.5% 77.0% p=0.09† (other than 3rd molars) Use of Prosthesis Complete Dentures 15.7% 11.6% p=0.06‡ Partial Dentures 30.4% 15.1% Implants 3.9% 2.3%
Fixed bridge work 15.7% 19.8%
None 34.3% 51.2%
* p-value from ANOVA
†p-value from Chi-square test
‡p-value from Fisher’s Exact test
Table 2: Mean±sd, scaled mean, and prorated mean for the subscales and overall dental satisfaction index with the traditional and comprehensive care models
Traditional Model Comprehensive Care Model
Number Scaled Prorated Scaled Prorated
Scale of items Mean±sd Mean Mean (%) Mean±sd Mean Mean (%)
Access 7 24.1±3.8 3.4 68.9 23.3±3.8 3.3 66.6
Pain management 3 10.8±2.5 3.6 72.0 10.7±2.6 3.6 71.3
Quality 7 28.4±2.9 4.1 81.4 28.2±3.4 4.0 80.6
oral health, and missing teeth using ordinal logistic regression.
No significant differences in overall patient satisfaction and the subscales were seen in the two delivery systems in demographic factors, such as age and gender, and other factors such as missing teeth and type of dental prosthesis used.
Multivariate linear regression was used to test the hypothesis that patient satisfaction was different between the two delivery systems, controlling for other factors such as patients’ age and gender, gen-eral and oral health, and missing teeth (Table 4). No statistically significant differences were seen in pa-tient satisfaction between the two dental delivery models (p=0.17).
Discussion
To be able to easily evaluate differences in pa-tient satisfaction between the two dental care
deliv-ery systems, two underlying issues are important: the characteristics of the patient populations using the two systems and the instrument used to measure pa-tient satisfaction. The characteristics of the papa-tient populations using the two systems should be as simi-lar as possible, so that any differences in the out-comes are attributed to the differences in the deliv-ery systems, rather than to underlying patient characteristics. We chose to evaluate patient satis-faction in August, as that is the start of the new clini-cal year. In August 1997 the CC clinics were just getting started, and in August 1998 they had com-pleted a whole year. Using the same time frame elimi-nated some of the seasonal variations in patients. Use of only active and recall patients guaranteed that they had been in the system for some time. These steps ensured that the patient populations were similar. Further, as reported in Table 1, there were no statisti-cally significant differences in patient demograph-ics and no differences in general and oral health be-tween the patients accessing the two dental delivery systems. This allows us to conclude that the two pa-tient samples were very similar. Therefore, if any differences in patient satisfaction are seen in this study, they are most likely due to differences in the care delivery systems.
After reviewing the literature, we chose to use the DSQ developed by the Rand Corporation for the Health Insurance Experiment as a satisfaction mea-sure in our environment. 10 Although not used or
re-ported in the literature very frequently, this was the
Table 3. Results of Fisher’s exact chi-square test comparing responses to individual items of the DSQ in the tradi-tional model and CC model
DSQ Question p-value
1. There are things about the dental care I receive at the OSU Dental Clinic that could be better. 0.34 2. OSU dental students are very careful to check everything when examining their patients. 0.61
3. The fees at the OSU Dental Clinic are too high. 0.61
4. Sometimes I avoid going to the dentist because it is so painful. 0.57 5. People are usually kept waiting a long time when they are at the OSU Dental Clinic. 0.02* 6. OSU dental students always treat their patients with respect. 0.63 7. One of the reasons I come to the OSU Dental Clinic is because there are not enough dentists in my area. 0.59
8. OSU dental students should do more to reduce pain. 0.97
9. OSU Dental Clinic is very conveniently located. 0.10
10. OSU dental students always avoid unnecessary patient expenses. 0.12 11. OSU dental students aren’t as thorough as they should be. 0.96 12. I see the same dental student just about every time I go for dental care. 0.10 13. It’s hard to get an appointment at the OSU Dental Clinic for dental care right away. 0.78 14. OSU dental students are able to relieve or cure most dental problems that people have. 0.02* 15. Office hours at the OSU Dental Clinic are good for most people. 0.16 16. Dental students usually explain what they are going to do and how much it will cost before they begin treatment. 0.78 17. Dental students should do more to keep people from having problems with their teeth. 0.27
18. The OSU Dental Clinic is very modern and up to date. 0.07
19. I am not concerned about feeling pain when I go for dental care at OSU Dental Clinic. 0.92 * Statistically significant at the p<0.05 level
Table 4. Multiple regression model for overall dental satisfaction index with the two delivery systems
Standard Independent Variable Estimate Error p-value
Age -0.001 0.04 0.97
Gender (males) -0.66 0.79 0.40 Self-rated oral health -0.91 0.61 0.14 Self-rated general health -1.21 0.72 0.10 Missing teeth (except 3rd molars) -0.65 1.64 0.69
only dental satisfaction questionnaire that was de-veloped to measure major dental satisfaction con-structs, and the validity and reliability of the DSQ has been tested and reported. 9-11
The DSQ measures overall patient satisfaction and three subscales of access, pain management, and quality of care. No significant differences were seen in the overall patient satisfaction or any of the subscales between the two dental delivery systems. These results indicate that those patients attending the College of Dentistry were equally satisfied with the two delivery systems. Although the CC model has been described or depicted as the better model of dental care delivery, from our results it seems that as far as the patient is concerned there is no advan-tage to the patient in the dimensions of care mea-sured by the DSQ such as access to care, pain man-agement, or quality of care. One reason for this result could be that generally patient satisfaction scores are on the favorable side of the response midpoint as was the case in this study, therefore leaving little room for improvement. Other possible explanations for the results are that a one-year time period is not suffi-cient to elicit or register change in patient satisfac-tion or that the process of care measured by the DSQ did not meaningfully differ between the traditional and CC models.
The only items of the DSQ that were signifi-cantly different were “people are usually kept wait-ing a long time when they are at the OSU dental clinic” (p=0.02) and “OSU dental students are able to relieve or cure most dental problems that people have” (p=0.02). In both cases, patients were less sat-isfied with the CC model. Again, the CC model is supposed to improve both these dimensions of care. A possible reason for the longer patient waiting times in the CC model is that there was a learning curve that first year for all involved—clinic staff, students, and patients. This learning curve resulted in patients being kept waiting longer than before.
The perception that students were not able to relieve or cure dental problems of their patients to the same level they had previously been able to may be a function of the CC model. In our CC model the patient is assigned to a single student who acts as the patient’s “primary dental care provider.” The assigned student may be a new clinical student who does not yet have the expertise to treat the patient’s problems. Whereas in the traditional model of dental care, patients are assigned to students depending on the complexity of the condition the patient has and the student’s expertise or ability to treat.
Demographic factors such as age and gender and factors such as self-rated general and oral health, missing teeth, and use of prosthesis did not influ-ence patient satisfaction. When our patient satisfac-tion results are compared to two other studies by Davies and Ware and Golletz that used the DSQ, our overall satisfaction and subscale scores are higher and better than reported in these studies.9,10,15
Sev-eral reasons can be given for this finding. One is that the mean ages of patients in the present study were much higher than in the Davies and Wareand Golletz studies.9,10,15 Previous research on satisfaction with
health care has shown that older individuals are more likely to report higher satisfaction than younger in-dividuals.3,6 Another reason is that in the present study
the patients were actively accessing care at the Col-lege of Dentistry compared to the population based samples in the Davies and Ware and Golletz studies. Other possible reasons for the differences in results include the dynamics of the dental school clinic en-vironment where patients receive low-cost dental services and thus may have lower expectations or are more easily pleased; alternatively patients may per-ceive that quality of care is better at an educational institution where students work under very close su-pervision of highly trained faculty.
In conclusion, no differences in overall patient satisfaction and in the subscales of access, pain man-agement, and quality were seen between the two den-tal care delivery models. We will continue to moni-tor patient satisfaction in the CC model and use results to make improvements.
Acknowledgments
We would like to thank Matthew Parker and Rudyard Whipps for their invaluable assistance with data collection.
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