Patients’ priorities in assessing organisational aspects of a general dental practicei dj12001

ORIG INAL ART ICLE

Patients’ priorities in assessing organisational aspects ofa general dental practice

Rutger E. Sonneveld1, Wolter G. Brands1, Ewald M. Bronkhorst1, Jos V. M. Welie2 andGert-Jan Truin1

1Department 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 practice

In recent years, most western countries have seen amove towards greater transparency in health care andthe Netherlands is no exception. More specifically, avariety of initiatives have been undertaken to make thedelivery of health-care services more transparent toend users (the patients)1. The assumption underlyingthese initiatives is that patients, when provided withrelevant information about the nature of health-careservices and the quality of health-care service provid-ers, will be able to make more informed decisions andultimately receive greater benefit from the particularservices they decide to use2,3. A number of Europeancountries have pushed the development of these initia-tives through legislation, essentially forcing increasedtransparency onto the health-care system4. For exam-ple, new health law initiatives currently being devel-oped in the Netherlands will require health-careprofessionals to provide patients with informationabout the quality of their own health-care services,and to respect the patients’ right to make an informedchoice about those services5. While inspired by and

modelled on much older initiatives to foster informedconsent by patients, these initiatives are more exten-sive in scope. The normal informed consent processtakes place in a situation in which a patient isinformed by a specific health-care provider about aspecific medical condition, its prognosis with and with-out specific treatment options, and the side-effects ofeach treatment option. In contrast, new attempts atfostering transparency aim at two broader goals6:● Providing patients with information about the

quality of health-care service such that patientscan chose which health-care provider they wish toconsult

● Levelling the power differential between patientsand health-care providers by providing patientswith information about health conditions andtreatment options that used to be available only tohealth-care professionals.

These two objectives directly benefit the patient.However, the strategies developed to make health-careservices more transparent to patients can also enable

30 © 2013 FDI World Dental Federation

International Dental Journal 2013; 63: 30–38

doi: 10.1111/idj.12001

health professionals to compare their own perfor-mance with those of colleagues or allow their perfor-mance to be compared by third parties, such asinsurance companies or consumer advocacy organisa-tions, that want to grade health professionals on theirability to deliver quality care7.As is true of other health-care services, patients in

need of oral health-care services need informationabout general dental practitioners (GDPs) in order tomake an informed choice about which practitioners tovisit for which types of procedures. As no literatureappears to be available, Dutch patients currently donot have sufficient information on the quality of caredelivered or information on dental services to makesuch choices.

DUTCH EFFORTS AT INCREASING TRANSPARENCY

The Dutch government is an ardent supporter ofincreased transparency in health care and to that availhas launched the ‘Zichtbare Zorg’ programme, liter-ally translated as ‘Visible Care’ programme8. Stake-holders in health care such as patient organisationsand the medical professions take part in this pro-gramme. The Visible Care programme seeks to:

• Provide patients with medical information concern-ing the safety, efficiency, efficacy and patient-centr-edness of health care, using quality indicators thatmeasure the process, structure and outcomes of thehealth care delivered

• Provide patients with information concerning orga-nisational aspects of health care, such as informa-tion on opening hours and accessibility; and

• Survey patients’ experiences with the health caredelivered, measured using the Consumer Qualityindex (CQ-index), which is based on the AmericanCAHPS (Consumer Assessment of Health careProviders and Systems) questionnaire and DutchQUOTE (QUality Of care Through the patient’sEyes) instrument9.

The study described in this article is part of theencompassing Visible Care programme. It focuses ongeneral dental care and especially on informationdirected at patients concerning organisational aspectsof general dental practices. Consistent with the overallpurpose of the Visible Care programme, stakeholdersfocusing on oral health care seek to increase the trans-parency of dental services by providing patients withinformation about these services. However, this canonly be done effectively if it is known what informa-tion patients themselves consider relevant when decid-ing between different GDPs. Furthermore, as GDPsthemselves play a key role in this informative process,it is vitally important to them to know what informa-tion patients really need and want or their efforts toboost transparency could become highly inefficient

and hence very costly. No data are available aboutthe informational needs and wishes of Dutch dentalpatients in general, or of specific patient populationsin particular, leaving GDPs at a loss as to what infor-mation concerning organisational aspects of generaldental practices to provide to which patient popula-tions. It is therefore not surprising that most dentalpractices do not even have a website providing infor-mation about their practice, quality of care, dentalservices or patient experiences, although the use ofsuch websites will have to increase if the objectives ofthe Visible Care programme are to be realised10,11.As part of the Visible Care programme, the Dutch

government wants all GDPs to provide a list with com-parative information on those organisational aspects oftheir dental practices that will best assist patients inmaking an informed choice about which GDP to visit.This list should cover: first, aspects that dental profes-sionals are already obligated to inform patients about,such as costs and quality of care; second, aspects thatthe majority of patients consider important; and, third,aspects reflecting the needs of particularly vulnerablepatient populations. Although the number itself issomewhat arbitrary, a decision was made to initiallylimit the list to 10 informational items in total.Our study was designed to get a better sense of the

second set of informational items listed above. As it ispresently unknown which types of information aboutdental practices and practitioners patients actuallyconsider important, we explored which organisationalaspects are considered most important by patientswhen assessing a general dental practice and whichpatients’ characteristics influence their views on theseaspects.

MATERIALS AND METHODS

Development of the questionnaire

A questionnaire was developed for assessing theviews of patients on the organisational aspects ofgeneral dental practices. A framework of 169 organi-sational aspects was compiled, based on a literaturesearch and aspects described in the InternationalOrganisation for Standardisation (ISO) 9001 certifica-tion method (113 aspects), adapted to the Dutchhealth-care model (Corporation Harmonization Qual-ity Assessment in Healthcare: HKZ) and the Euro-pean Practice Assessment (EPA) instrument (56aspects)12–14. The HKZ model renders quality inhealth-care institutions assessable and sets norms thatoriginate from the ISO 9001 certification model15.The EPA instrument is a framework for general prac-tice management comprising quality indicators sharedby six European countries12. Our framework con-sisted of five domains:

© 2013 FDI World Dental Federation 31

Patients’ priorities in a dental practice

I InfrastructureII StaffIII InformationIV Finance; andV Quality and safety.The combined list of 169 organisational aspects

was rated on overlapping aspects, double-namedaspects and usefulness for assessing a general dentalpractice. This resulted in a list of 113 aspects. Inorder to reduce the number of questions even furtherand thereby increase the response rate, several relatedaspects were clustered at a higher aggregation leveland reduced to a list of 61 aspects. For example,aspects such as accessibility by telephone after-hours,during working hours or in the case of an emergencywere combined into a single aspect – accessibility bytelephone. In addition to the variables gender andage, patients were asked to indicate their level of edu-cation by choosing from the following options:

• Low-education (defined as: no education or elemen-tary school)

• Middle-to-low-education (defined as: junior highschool)

• Middle-education (defined as: high school)

• Middle-to-high-education (defined as: college/uni-versity–bachelor degree); and

• High-education group (defined as: university/mas-ters degree or above).Finally, we asked patients whether they had dental

insurance and whether they lived in a one-personhousehold.Three focus groups (two consisting of patients, ran-

domly selected by a patient platform, and one consist-ing of GDPs) rated the instrument for relevance,usefulness and clarity. Based on consensus discussionsa final list of 41 organisational aspects of a generaldental practice was derived (Table 2). The aspectswere divided into five domains, based on the EPAinstrument described above. Finally, the questionnairewas pilot-tested among 50 patients in a general dentalpractice; this resulted in several small refinements.

Sampling procedure

The study population, equally divided over the wholecountry, consisted of Dutch patients visiting a dentalpractice. We aimed at a response rate of 50% and aminimum of 2,500 questionnaires returned. Samplingwas as done across the 12 provinces of the Netherlands.From each province a stratified sample of three smallcommunities (< 30,000 inhabitants), three medium-to-large communities (between 30,000 and 80,000 inhab-itants) and three large communities (over 80,000inhabitants) was drawn. This procedure resulted in atotal of 103 communities (not every province in theNetherlands has communities with more than 80,000

inhabitants). In addition, in each selected community, aGDP (working in a dental practice) was randomly cho-sen from all GDPs registered in that community withthe Dutch Dental Association in 2008. The GDPs werecontacted by telephone to explain the purpose of thestudy and asked to participate. If a GDP did not wishto participate, the GDP listed next in the Dutch DentistGuide 2008 for that community was approached. Inthis manner, 147 GDPs were contacted by phone. Astandardised confirmation letter was sent to the partici-pating GDPs (n = 103) as well as a letter of instructionand 50 patient questionnaires and related materials.The GDPs were asked to approach the first 50

patients they treated in the third week of January2009 to participate in the survey. Patients could com-plete the questionnaire anonymously at home andreturn it to the research team at the University ofNijmegen in a stamped pre-addressed envelope. Forany patient who accepted the survey, the GDPs ordental assistant wrote the name and address of thatpatient on the standardised reminder envelope. Twoweeks after the last questionnaire was handed out,reminders were sent by the GDPs. As the survey wascompletely anonymous, and no questions were askedabout the patients’ own health status or the healthcare delivered, approval by an Institutional ReviewBoard/Research Ethics Committee was not necessaryunder Dutch law. At the end of the study, all partici-pating GDPs received a report with the outcomes oftheir own practice compared with the other practices.

Statistical analyses

In the questionnaire, patients were asked to choose the10 most important organisational aspects out of the 41aspects listed. As a considerable number of respondentsdid not abide by this instruction, only respondents whochose between 8 and 12 aspects (n = 2,676) wereincluded in the analysis. Logistic regression was appliedto analyse the relationship between patients’ character-istics and their choices. In the logistic regression model,gender, age, education, dental insurance and livingstatus were used as independent variables. For the vari-able age, the 65+year age-group (n = 379) was the ref-erence group. The other age groups were created inaccordance with the categories used by StatisticsNetherlands16: under 20 years (n = 35), 20–39 years(n = 627), 40–54 years (n = 1,048) and 55–64 years(n = 587). For the education variable, the low-educa-tion group was the reference group (n = 300). Thegroups compared were the middle-to-low-educationgroup (n = 1,110), the middle-education group(n = 292), the middle-to-high-education group(n = 756) and the high-education group (n = 218).For analyses of the patients’ characteristics, odds

ratios (ORs) were calculated. Using logistic regression,


Sonneveld et al.

the OR was used to quantify the relationship betweenbackground variables (age, gender, education, dentalinsurance and one-person household) and the likeli-hood of a given aspect to be chosen among a respon-dent’s top 10. The OR can be interpreted as relativerisk. If, for example, the OR = 2 for females com-pared with males then, all other background variablesbeing 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 aspectschosen by a minimum of 50% of the respondents asmost important. All statistical analyses were per-formed using SPSS, version 16 (IBM, Armonk, NY,USA).

RESULTS

Response

The overall response rate was 63% (n = 3,127). Ofthe respondents, 59% were female and 41% weremale. The respondents differed from national popula-tion data with regard to gender and age: males wereunder-represented and the 40- to 64-year age-groupwas over-represented (Table 1). The response rates ofrespondents living in large, medium and small com-munities were 58%, 60% and 68%, respectively.Table 2 shows the ranking and percentages of the

organisational aspects chosen by the respondents asthe 10 most important aspects. At least 50% of therespondents included in their top 10 the following sixaspects:

• Accessibility by phone

• Continuing education courses for GDPs

• Dutch-speaking GDP

• In-office waiting times

• Availability of information on dental servicesoffered; and

• Availability of appointments (waiting lists).The top six varied only slightly between the vari-

ables gender, age and education. Looking at all theserankings separately (which yields 78 rankings), onlythree times were aspects chosen in the top six thatwere not in the six aspects listed above.

Patients’ characteristics

Patients aged 20–39 years and 40–54 years selectedthe aspect accessibility by telephone significantly lessoften, with ORs of 0.59 and 0.39, respectively, com-pared with the reference group of patients aged65 years and over (Table 3). More highly educated

Table 1 Distribution of patient sample and nationalfigures on gender and age: percentages of total

Patients (n = 3,127) Visiting patients(national data)

GenderMale 41.1 47.4Female 58.9 52.6

Age (years)16–19 1.3 5.920–39 23.7 31.240–64 60.0 44.1>65 15.0 18.8

Table 2 Ranking and percentages of the 10 most cho-sen organisational aspects for assessing a dental prac-tice by patients

Ranking Aspects % Domain

1 Accessibility by telephone 76.5 I2 Continuing education of GDP 61.9 II3 Dutch-speaking GDP 57.0 V4 In-office waiting times 54.8 I5 Availability of information on

dental services54.3 III

6 Availability of appointments(waiting lists)

51.7 I

7 Guarantee on treatments 43.0 IV8 Quality assessment 41.4 V9 System for check-up of perishable

goods37.7 V

10 Treatment by same dental therapist 34.6 II11 Specialties in dental practice 33.5 II12 Information on tasks of staff 29.6 II13 Working according to

professional standard28.3 V

14 Information on dental bill 27.4 III15 Reminder of routine oral

examination26.9 III

16 Opening hours evening and/orweekend

26.0 I

17 Physical accessibility 25.0 I18 Accessibility for disabled patients 21.1 I19 Parking spaces 20.5 I20 Working according to protocols

and guidelines20.1 V

21 Clarity of responsibilities 19.1 II22 Meetings of GDP with colleagues 17.8 II23 Waiting room facilities 17.7 I24 Continuing education of dental

hygienist17.5 II

25 Information on internet 17.3 III27 Patient consultation in dental team 14.9 II26 Having liability insurance 14.8 V28 Continuing education dental

assistant13.9 II

29 Meetings of GDP with dentaltechnicians

11.7 II

30 GDP taking part in peer supervision 10.5 V31 Patient satisfaction survey 9.2 II32 Receiving dental bill 8.9 IV33 Disease diagnoses 8.7 V34 Payment possibilities 8.4 IV35 Meetings of GDP with health insurers 8.1 II36 Attending complaint committee 7.5 V37 Risk assessment 5.9 V38 Insight of health insurer in

medical records5.5 V

39 Parking fees 4.4 I40 Information about complaints

procedure4.1 III

41 Employee satisfaction survey 3.4 II

GDP, general dental practitioner. Domain: I = infrastructure;II = staff; III = information; IV = finance; V = quality and safety.



Table

3Significance,oddsratio(O

R)andconfidence

intervalfortheeffect

ofgender,age,

education,dentalinsurance

andlivingstatusonaspects

cho-

senbyatleast

50%

ofthepatients.Allstatisticscalculatedbymultivariate

logisticregression

Accessibilitybyphone

ContinuingeducationofGDP

Dutch-speakingGDP

POR

95%

CIofOR

POR

95%

CIofOR

POR

95%

CIofOR

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

20years

<0.001

0.59

0.25–1

.39

<0.001

0.57

0.28–1

.15

0.386

0.85

0.41–1

.74

20–3

90.39

0.28–0

.54

0.73

0.56–0

.96

0.89

0.68–1

.16

40–5

4years

0.57

0.42–0

.79

1.06

0.83–1

.36

0.78

0.61–1

.01

55–6

4years

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–h

igh

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

Dentalinsurance

(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-personhousehold

(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

waitingtimes

Availabilityofinform

ationaboutdental

services

Availabilityofappointm

ents

(waitinglists)

POR

95%

CIofOR

POR

95%

CIofOR

POR

95%

CIofOR

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

20years

0.047

1.54

0.74–3

.18

<0.001

0.37

0.18–0

.77

0.050

1.57

0.77–3

.21

20–3

9years

1.25

0.96–1

.63

0.60

0.46–0

.78

1.28

0.99–1

.67

40–5

4years

1.35

1.06–1

.72

0.69

0.54–0

.88

1.32

1.03–1

.68

55–6

4years

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–h

igh

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

Dentalinsurance

(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-personhousehold

(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,generaldentalpractitioner.SignificantP-values

(P<0.05)are

marked

inbold.


Sonneveld et al.

patients had a lower preference for this aspect com-pared with a lower education level (middle education,OR = 0.60, middle-to-high education, OR = 0.62,and high education, OR = 0.43).Age, gender and level of education significantly

influenced the respondents’ choices for the aspectcontinuing education for a GDP. A significantly higherpercentage of women chose the aspect refresher coursefor a GDP as most important compared with men(OR = 1.30); younger patients scored lower odds onthis aspect (under 20 years, OR = 0.57; 20–39 years,OR = 0.73) in comparison with the reference groupaged 65+ years. This organisational aspect was morefrequently selected with increasing level of education.Education groups differed significantly for the

aspect Dutch-speaking GDP (P < 0.001). This aspectwas chosen less by more highly educated patientscompared with the reference group. Compared withthe reference group, all other age groups chose theaspect in-office waiting times more often (P = 0.047).Significant differences for gender, age and dental

insurance were found for the aspect availability ofinformation on dental services. Women chose thisaspect more often than did men (OR = 1.57;P < 0.001). Older age groups selected this aspectmore often in comparison with younger age groups,as did patients who had a dental insurance comparedwith uninsured patients (P = 0.029).The OR for the aspect availability of appointments

(waiting lists) increased with education. More highlyeducated patients chose the aspect more often thandid the less well-educated patients (P < 0.001).

DISCUSSION

In this study, patients were asked to choose the 10organisational aspects they found most importantwhen assessing a general dental practice. The rankingof aspects gives an indication of the relative impor-tance patients assigned to each of the organisationalaspects. This paper focuses on aspects chosen by atleast 50% of the patients and therefore it appears thatonly a few aspects are very important for patients.However, we emphasise that some of the lower-ranked aspects may be extremely important to certain(categories of) patients. The differences in the percent-ages are relatively small and demonstrate a fluentdecrease. The only large percentage differences arebetween aspects 1 and 2 between aspects 6 and 7.A response rate of 63% is fairly good. However,

bias could have occurred in the selection procedure ofthe patients. The results of the questionnaire, com-pleted by 3,127 patients, provide a satisfactory pictureof what patients see as most important organisationalaspects of a dental practice. Owing to the samplingprocedure, patients who rarely or never seek dental

services were not included in the study. As such ‘non-attenders’ can have different views, it would havebeen preferable if the study had been able to capturetheir views, although the impact of this limitation ofthe study is probably modest. The majority of theDutch adult population (85%) visits a dentist once ayear and therefore the non-attenders are a minority.Further, most persistent non-attenders are unlikely tosuddenly start frequenting a dental office when moreinformation is available on the dentists’ websites. Forexample, one of the major reasons not to visit a den-tist is dental anxiety (prevalence rates from 13.1% to19.8% among the population)17.The respondents were recruited from different com-

munities and dental clinics. In the Netherlands, oralhealth care is provided in different oral health-caresettings (e.g. solo practices and large team practices orspecialised practices). Differences in the infrastructureof the dental clinics may have an impact on the ser-vices that are provided in these settings, influencingthe responses of the patients participating in thestudy. However, 60% of the oral health care in theNetherlands is provided in a solo dental practice set-ting18, thus limiting the impact of the infrastructureof dental practices on the study outcomes. In addition,in the questionnaire, the respondents were asked togive their (organisational) preferences for an idealdental practice and not to assess the actual dentalpractice.The percentages of respondents did not differ statis-

tically by the size of the communities. However, asmentioned previously, compared with national data ofDutch dental patients, the 20- to 39-year age groupwas under-represented (24% vs. 31%) and the 40- to64-year age group was overrepresented (60% vs.44%). Hence, the results presented in Table 3 may bebiased towards the preferences of elderly patients.Combining the modest differences between age groupsand the extent of over- or under-representation of spe-cific age groups, the bias can be estimated to be 2%or less. Therefore, the top of the list of aspects is notlikely to have been affected.The use of patients’ views to improve health-care

delivery requires valid and reliable measurementsmethods. Because no single method existed that couldreliably yield the information we sought to obtain, wehad to design a new instrument. Our list of 41 itemsor aspects was developed using a literature search,focus group meetings and consensus discussions.In general, it appears that patients put the greatest

emphasis on the domain ‘infrastructure.’ However,not each domain had the same number of aspectsincluded in it. Hence, the odds of any single domainbeing given priority increased by the number ofaspects included. In order to correct for this potentialbias, we added the percentages of the aspects per



domain and then divided them by the number ofaspects per domain, resulting in the average percent-age per domain. After this recalculation, ‘infrastruc-ture’ aspects are still deemed most important bypatients with 33.1% of patients selecting such aspectsin their top 10; ‘information’ domain aspects werenext (26.0%), followed by aspects concerning ‘qualityand safety’ (21.6%), aspects in the domain ‘staff’(21.2%) and finally aspects in the domain ‘finance’(20.1%) (data not given in table).Three of the top six top scoring aspects [accessibility

by telephone, in-office waiting times, and availability ofappointments (waiting lists)] fall in the infrastructuredomain. An international survey of the World HealthOrganisation in 41 countries measuring patient experi-ence with the non-clinical quality of care revealed thatprompt attention (e.g. short in-office waiting time, littletravel time and short waiting lists) was valued as mostimportant19. Other studies showed the same find-ings20,21. In contrast, only one aspect from the ‘qualityand safety’ domain made the top six: continuing educa-tion courses for GDPs. Patients ranked the aspectcontinuing education courses for GDP as far moreimportant than similar courses for dental hygienists (22places lower in ranking). This is an interesting finding.In the Netherlands, dental hygienists treat patients with-out the supervision of a GDP. Therefore, one wouldhave expected that patients would rank this aspect fordental hygienists equally highly. In this study, respon-dents were drawn from dental practices. We do notknow whether dental hygenists were working in thosepractices; neither do we know whether the respondentsvisit independent dental hygenists regularly.It is remarkable that the domain ‘infrastructure’

was more important to patients than the domain‘quality and safety’ (which, in addition to CE courses,included aspects such as professional standards, work-ing according to protocols and guidelines, qualityassessment, guarantee on treatments). An explanationof this finding could be that patients trust the Dutchhealth system to assure high quality and safety stan-dards among health professionals. They may simplytake it for granted that their dentist is competent.The aspect Dutch-speaking GDP is also included in

the top six. Language barriers between provider andpatient can have a significant detrimental impact onthe quality of the care rendered. Indeed, this was alsoone of the preferences among patients when selectinga primary care physician, as shown in a study by Aro-ra et al.22. Highly educated Dutch dental patients findthis aspect less important. An explanation may be thathighly educated Dutch patients generally speak differ-ent languages and therefore could communicate withtheir GDP in another language, such as English.The only aspect in the domain ‘information’ that

was chosen by 50% of the patients in their top 10 is

availability of information on dental services. This isan expected outcome as patients need information onthe dental services offered in order to determinewhether the services offered are wanted by them.Conversely, if we look at the organisational aspects

that were considered very important by only a smallnumber of respondents (< 5% of respondents), we findat place 39 (out of 41), the aspect parking fees. This isquite understandable as although parking can be a nui-sance in the Netherlands, patients probably know thatGDPs cannot influence the parking policy of the localauthorities. More surprising is the finding that infor-mation about complaints procedures was consideredimportant by only a few patients. We know from juris-prudence and disciplinary proceedings that Dutchpatients rarely file complaints about dentists. Our find-ing would lead to the conclusion that their hesitanceto do so apparently is not a matter of lack of informa-tion about available complaints procedures. PerhapsDutch patients are already aware of the variousoptions for launching a complaint. or are simplyhighly satisfied with their dentists and almost neverfeel the urge to formally complain. Most curious is thefact that patients are least interested in receiving infor-mation about employee satisfaction. We can only spec-ulate on the reasons for this. Perhaps patients simplyassume that all persons working in dental offices arehighly satisfied or that employee satisfaction has littleimpact the care they themselves receive.The second goal of our study was to explore

whether patients’ characteristics influence their prefer-ences. ‘Age’ was significantly associated with four outof six aspects chosen by at least 50% of the respon-dents. It appears that the importance of the aspectsrelated to the domain ‘infrastructure’ decreases withage; the elderly found these aspects less important,although they chose accessibility by telephone moreoften. In some other studies, age and gender werefound to be significant variables associated with prior-itising in a general medical practice, assessing primarycare and patient experiences of accessibility of pri-mary care23–25. , As one might expect, the aspectcontinuing education for GDPs was chosen moreoften by respondents who were themselves highly edu-cated. Less self-evident is that the aspect availabilityof appointments (waiting lists) was also chosen moreoften by respondents with a higher level of education.Again, we can only speculate on the reasons for this.It is unlikely that highly educated people have greaterdifficulty adjusting their calendars (usually, people inlower paid jobs are those with less flexibility). Rather,this finding may reflect that highly educated peopleare less in awe of their GDP and hence less tolerantof waiting lists. We have mentioned that this group ofrespondents is less likely to consider it important thattheir GDP is Dutch-speaking, and we have already


Sonneveld et al.

speculated why this might be so. However, we couldnot find a reasonable explanation for the fact that thissame group also considered the aspect accessibility bytelephone less important.The study provides insight into the organisational

aspects of dental practices that patients themselves tendto consider important. This does not mean that otheraspects, such as clinical indicators and patient evalua-tions can be disregarded. Being part of the Visible Careprogramme, much effort will also be put in the devel-opment of those indicators. However, the outcomes ofthis study can be used in the Visible Care programmefor the development of a list of comparative informa-tion on dental practices that patients can next use tomake an informed choice for a particular GDP.We pointed out earlier that the stakeholders in the

Visible Care programme have decided initially to limitthe comparative list of informational items to 10items only. Our research has shown that only 6 of 41aspects were considered by at least 50% of patients tobe very important. This leaves four open slots. Stake-holders may want to add aspects that the majority ofrespondents in our study considered less importantbut which could be crucially important for vulnerableminority populations, such as the aspect accessibilityfor disabled patients (# 18 in Table 2). As there arerelatively few disabled patients in most dental prac-tices, their views may be under represented in our sur-vey. One of the tasks of a government is to ensurethat vulnerable patient groups are heard and are beingprotected.In their comparative list, the Visible Care pro-

gramme may include some organisational items thatare not chosen by the majority of the respondents inthis study. Aspects, such as information about the dif-ferent tasks and the responsibilities of providers oforal health care are required by Dutch health law26.Therefore, they will be added to the comparative listof 10 items.Finally, the objectives of the Visible Care pro-

gramme can only be realised if dentists increase theinformation on the internet about their practices, eventhough this source of information was given quite alow ranking by patients. The internet is an effectiveand efficient medium for dentists to provide informa-tion to potential patients. It therefore makes sense forthe Visible Care programme to plan on having GDPsmake the comparative list of 10 organisational itemsavailable on the internet.The Visible Care programme, in addition to provid-

ing information about treatment outcomes and organi-sational aspects of their dental practices, will alsorequire GDPs to execute and publish the results ofpatient experience or satisfaction surveys. Table 2shows that the aspect patient satisfaction survey waschosen by fewer than 10% of the responding patients

as being important. One possible explanation for thisoutcome is that patients are not interested in the opin-ions of other patients and will not use this informationwhen assessing a dental practice. However, this is atleast from a first impression unlikely, because we knowthat many dental patients rely heavily on ‘word ofmouth’ quality indicators provided by family or friendswhen deciding about a dentist27. Alternatively, mostpatients do not deem this aspect important becausethey are generally satisfied with their GDP28,29.Although developed and executed to meet the

objectives of the Visible Care programme, anotherbeneficial outcome of our study is that GDPs can useour findings to adjust the organisation of their prac-tice to the preferences of patients in general or to thepreferences of specific patient groups, such as theelderly. For example, now that GDPs know that mostpatients consider accessibility by telephone extremelyimportant for patients, they may wish to ensure thattheir practice is accessible at all times by means of anassistant and an/or answering service. At the veryleast, they may want to install an answering machinewith pertinent information about items such as open-ing hours and waiting lists. Another aspect that wefound to be important to most patients is in-officewaiting times. In view of this, GDPs may wish todesign strategies for reducing waiting times andpromptly inform patients in their waiting rooms ifunexpected delays in treatment do occur.

CONCLUSION

When Dutch dental patients were presented with a listof 41 different organisational aspects about generaldental practices and asked to choose the top 10 mostimportant aspects when selecting a practice, only sixof these aspects were chosen by the majority of therespondents. Aspects concerning the infrastructure ofthe dental practice were chosen more often than otheraspects, such as working to professional standards,working according to protocols and guidelines, qualityassessment and guaranteed treatment outcomes. Thefindings of this study will enable organisations thatseek to increase the transparency of health-care deliv-ery systems, such as the Visible Care programme inthe Netherlands, to focus on those organisationalaspects of dental practices that patients themselvesconsider most important. Even in the absence of suchnation-wide efforts, these findings can assist GDPs inadapting their organisational services to the prefer-ences of patients or specific patient groups. Our studywas targeted at Dutch dental patients and we makeno predictions about the relevance of our specific find-ings for other countries. However, we believe that themethod used for uncovering patient preferences isprobably applicable in many other national contexts.



Acknowledgements

The authors declare that they have no conflict ofinterest. The study was supported by grants fromRadboud University Nijmegen Medical Centre and aDutch health insurance company (CZ).

Conflicts of interest

Nothing to declare.

REFERENCES

1. McMullan M. Patients using the Internet to obtain health infor-mation: how this affects the patient-health professional relation-ship. Patient Educ Couns 2006 63: 24–28.

2. Damman OC, Hendriks M, Rademakers J et al. How dohealthcare consumers process and evaluate comparative health-care information? A qualitative study using cognitive interviews.BMC Public Health 2009 9: 423.

3. Salzburg statement on shared decision making. BMJ 2011 342:d1745.

4. Nys H, Stulti€ens L. De rechten van de pati€ent. Verslag van eenonderzoek naar de rechten van de pati€ent in: Belgi€e, Denemar-ken, Duitsland, Frankrijk, Luxemburg, Spanje en het VerenigdKoninkrijk, in opdracht van de Inspectie voor de Gezondheids-zorg. [Patients’ Rights: report on patients’ rights in Belgium,Denmark, Germany, Luxembourg, Spain, and the UK]. Leuven:Katholieke Universiteit Leuven; 2006.

5. Wet cli€entenrechten zorg [Patients’ Rights Act], 32402, Ministe-rie van VWS 2010.

6. Nilsen ES, Myrhaug HT, Johansen M et al. Methods of con-sumer involvement in developing healthcare policy andresearch, clinical practice guidelines and patient informationmaterial. Cochrane Database Syst Rev 2006 3: CD004563.

7. Russell TR. Nothing to hide: transparency in healthcare. Med-GenMed 2006 8: 83.

8. Zichtbare Zorg [Visible Care]. Available from: http://www.zichtbarezorg.nl. Accessed 24 November 2010.

9. Triemstra M, Winters S, Kool RB et al. Measuring client expe-riences in long-term care in the Netherlands: a pilot study withthe Consumer Quality Index Long-term Care. BMC Health ServRes 2010 10: 95.

10. Addy LD, Uberoi J, Dubal RK et al. Does your practice websiteneed updating? Br Dent J 2005 198: 259–260.

11. Chestnutt IG, Reynolds K. Perceptions of how the Internet hasimpacted on dentistry. Br Dent J 2006 200: 161–165.

12. Engels Y, Campbell S, Dautzenberg M et al. Developing aframework of, and quality indicators for, general practice man-agement in Europe. Fam Pract 2005 22: 215–222.

13. Lemmens KMM, Harteloh PPM, Walburg JA. De validiteit vankwaliteitssystemen in zorginstellingen. Rotterdam: Instituut Be-leid & Management Gezondheidszorg; 2003.

14. Shortell SM, O’Brien JL, Carman JM et al. Assessing theimpact of continuous quality improvement/total quality man-agement: concept versus implementation. Health Serv Res 199530: 377–401.

15. Stichting Harmonisatie Kwaliteitsbeoordeling in de Zorgsector[Association for quality assessment in health care]. Availablefrom: http://www.hkz.nl. Accessed 10 Mai 2012.

16. Centraal Bureau voor de Statistiek [Statics Netherlands]. Avail-able from: http://www.cbs.nl. Accessed 15 Mai 2012.

17. Oosterink FM, De Jongh A, Hoogstraten J. Prevalence of dentalfear and phobia relative to other fear and phobia subtypes. EurJ Oral Sci 2009 117: 135–143.

18. Nederlandse Maatschappij tot bevordering der Tandheelkunde[Dutch Dental Association]. Staat van de mondzorg. Nieuweg-ein: NMT; 2011.

19. Valentine N, Darby C, Bonsel GJ. Which aspects of non-clinicalquality of care are most important? Results from WHO’s gen-eral population surveys of “health systems responsiveness” in41 countries. Soc Sci Med 2008 66: 1939–1950.

20. Jung HP, Wensing M, Grol R. What makes a good generalpractitioner: do patients and doctors have different views? Br JGen Pract 1997 47: 805–809.

21. Razzouk N, Seitz V, Webb JM. What’s important in choosing aprimary care physician: an analysis of consumer response. Int JHealth Care Qual Assur Inc Leadersh Health Serv 2004 17:205–211.

22. Arora R, Singer J, Arora A. Influence of key variables on thepatients’ choice of a physician. Qual Manag Health Care 200413: 166–173.

23. Grol R, Wensing M, Mainz J et al. Patients’ priorities withrespect to general practice care: an international comparison.European Task Force on Patient Evaluations of General Prac-tice (EUROPEP). Fam Pract 1999 16: 4–11.

24. Salisbury C, Wallace M, Montgomery AA. Patients’ experienceand satisfaction in primary care: secondary analysis using multi-level modelling. BMJ 2010 341: c5004.

25. Kontopantelis E, Roland M, Reeves D. Patient experience ofaccess to primary care: identification of predictors in a nationalpatient survey. BMC Fam Pract 2010 11: 61.

26. Wet Marktordening Gezondheidszorg [Health Market Regula-tion Act]. Available from: http://wetten.overheid.nl/BWBR0020078/geldigheidsdatum_27-04-2010#Hoofd-stuk5986746. Accessed 20 June 2011.

27. Heuvel L, Mooren I. Keuze voor de kiezen. Nijmegen: UMC StRadboud; 2008.

28. Karydis A, Komboli-Kodovazeniti M, Hatzigeorgiou D et al.Expectations and perceptions of Greek patients regarding thequality of dental health care. Int J Qual Health Care 2001 13:409–416.

29. Klingenberg A, Walther W, Dorfer CE et al. [Patient evaluationof dental care. Results of a written patient survey in dentalpractices]. Gesundheitswesen 2008 70: 525–531.

Correspondence to:Rutger Sonneveld,

Department of Preventive and Restorative Dentistry,School of Dentistry,

Radboud University Nijmegen Medical Centre,Postbus 9101, 6500 HB Nijmegen,

the Netherlands.Email: [email protected]


Sonneveld et al.

Patients’ priorities in assessing organisational aspects of a general dental practicei dj12001

Documents

Transcript of Patients’ priorities in assessing organisational aspects of a general dental practicei dj12001