A national survey of the public's views on quality in dental care

Do health systems cover the mouth? Comparing dental care coverage for older adults in eight jurisdictions

Oral health is an important component of general health, yet there is limited financial protection for the costs of oral health care in many countries. This study compares public dental care coverage in a selection of jurisdictions: Australia (New South Wales), Canada (Alberta), England, France, Germany, Italy, Sweden, and the United States. Drawing on the WHO Universal Coverage Cube, we compare breadth (who is covered), depth (share of total costs covered), and scope (services covered), with a focus on adults aged 65 and older. We worked with local experts to populate templates to provide detailed and comparable descriptions of dental care coverage in their jurisdictions. Overall most jurisdictions offer public dental coverage for basic services (exams, x-rays, simple fillings) within four general types of coverage models: 1) deep public coverage for a subset of the older adult population based on strict eligibility criteria: Canada (Alberta), Australia (New South Wales) and Italy; 2) universal but shallow coverage of the older adult population: England, France, Sweden; 3) universal, and predominantly deep coverage for older adults: Germany; and 4) shallow coverage available only to some subgroups of older adults in the United States. Due to the limited availability of comparable data within and across jurisdictions, further research would benefit from standardized data collection initiatives for oral health measures.

Impact of changing provider remuneration on NHS general dental practitioner services in Northern Ireland: a mixed-methods study

Background

Policy-makers wanted to reform the NHS dental contract in Northern Ireland to contain costs, secure access and incentivise prevention and quality. A pilot project was undertaken to remunerate general dental practitioners using a capitation-based payment system rather than the existing fee-for-service system.

Objective

To investigate the impact of this change in remuneration.

Design

Mixed-methods design using a difference-in-difference evaluation of clinical activity levels, a questionnaire of patient-rated outcomes and qualitative assessment of general dental practitioners’ and patients’ views.

Setting

NHS dental practices in Northern Ireland.

Participants

General dental practitioners and patients in 11 intervention practices and 18 control practices.

Interventions

Change from fee for service to a capitation-based system for 1 year and then reversion back to fee for service.

Main outcome measures

Access to care, activity levels, service mix and financial impact, and patient-rated outcomes of care.

Results

The difference-in-difference analyses showed significant and rapid changes in the patterns of care provided by general dental practitioners to patients (compared with the control practices) when they moved from a fee-for-service system to a capitation-based remuneration system. The number of registered patients in the intervention practices compared with the control practices showed a small but statistically significant increase during the capitation period (p < 0.01), but this difference was small. There were statistically significant reductions in the volume of activity across all treatments in the intervention practices during the capitation period, compared with the control practices. This produced a concomitant reduction in patient charge revenue of £2403 per practice per month (p < 0.05). All outcome measures rapidly returned to baseline levels following reversion from the capitation-based system back to a fee-for-service system. The analysis of the questionnaires suggests that patients did not appear to notice very much change. Qualitative interviews showed variation in general dental practitioners’ behaviour in response to the intervention and how they managed the tension between professional ethics and maximising the profits of their business. Behaviours were also heavily influenced by local context. Practice principals preferred the capitation model as it freed up time and provided opportunities for private work, whereas capitation payments were seen by some principals as a ‘retainer fee’ for continuing to provide NHS care. Non-equity-owning associates perceived the capitation model as a financial risk.

Limitations

The active NHS pilot period was only 1 year, which may have limited the scope for meaningful change. The number of sites was restricted by the financial budget for the NHS pilot.

Conclusions

General dental practitioners respond rapidly and consistently to changes in remuneration, but differences were found in the extent of this change by practice and provider type. A move from a fee-for-service system to a capitation-based system had little impact on access but produced large reductions in clinical activity and patient charge income. Patients noticed little difference in the service that they received.

Future work

With changing population need and increasing financial pressure on the NHS, research is required on how to most efficiently meet the expectations of patients within an affordable cost envelope. Work is also needed to identify and evaluate interventions that can complement changes in remuneration to meet policy goals.

Trial registration

Current Controlled Trials ISRCTN29840057.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 6. See the NIHR Journals Library website for further project information.

A systematic review of quality measures used in primary care dentistry

INTRODUCTION

'Quality' in primary care dentistry is poorly defined. There are significant international efforts focussed on developing quality measures within dentistry. The aim of this research was to identify measures used to assess quality in primary care dentistry and categorise them according to which dimensions of quality they attempt to measure.

METHODS

Quality measures were identified from the peer-reviewed and grey literature. Peer-reviewed papers describing the development and validation of measures were identified using a structured literature search. Measures from the grey literature were identified using structured searches and direct contact with dental providers and institutions. Quality measures were categorised according to domains of structure, process and outcome and by disaggregated dimensions of quality.

RESULTS

From 22 studies, 11 validated measure sets (comprising nine patient satisfaction surveys and two practice assessment instruments) were identified from the peer-reviewed literature. From the grey literature, 24 measure sets, comprising 357 individual measures, were identified. Of these, 96 addressed structure, 174 addressed process and 87 addressed outcome. Only three of these 24 measure sets demonstrated evidence of validity testing. The identified measures failed to address dimensions of quality, such as efficiency and equity.

CONCLUSIONS

There has been a proliferation in the development of dental quality measures in recent years. However, this development has not been guided by a clear understanding of the meaning of quality. Few existing measures have undergone rigorous validity or reliability testing. A consensus is needed to establish a definition of quality in dentistry. Identification of the important dimension of quality in dentistry will allow for the production of a core quality measurement set.

Exploring implementation of an electronic referral management system and enhanced primary care service for oral surgery: perspectives of patients, providers and practitioners

BACKGROUND

A specialist primary care oral surgery service combined with an electronic referral management and triage system was developed in response to concerns raised around overburdened secondary care services in the UK. Whilst the system has the potential to manage conflicting demand for oral surgery services against an objective need, the new pathway represents a number of challenges to existing working practices and could compromise the sustainability of existing hospital services. The aim of this research was to carry out a qualitative exploration of implementation of a new intervention to gain insight into how these challenges have manifested and been addressed.

METHODS

Views were sought from stakeholders (dentists, hospital staff, commissioners and patients) at various time points over 3 years during and after implementation using semi-structured interviews. Normalization Process Theory informed a qualitative thematic analysis which was carried out using data from interview transcripts to identify important emerging issues.

RESULTS

Themes emerging from the data were; amenability to change and assimilation into practice (primary care dentists), compliance and governance, changing perceptions of impact (secondary care staff and commissioners) understanding change in service provision and priorities for treatment (patients). The new pathway impacted stakeholders at different stages of implementation.

CONCLUSION

Electronic referral management with a primary care advanced service for oral surgery was successfully implemented in a specific area of the UK. The service model evaluated has the potential to be expanded across a wider geographical footprint and to support demand management in other specialist services.

An evaluation of a referral management and triage system for oral surgery referrals from primary care dentists: a mixed-methods study

Background

Oral surgery referrals from dentists are rising and putting increased pressure on finite hospital resources. It has been suggested that primary care specialist services can provide care for selected patients at reduced costs and similar levels of quality and patient satisfaction.

Research questions

Can an electronic referral system with consultant- or peer-led triage effectively divert patients requiring oral surgery into primary care specialist settings safely, and at a reduced cost, without destabilising existing services?

Design

A mixed-methods, interrupted time study (ITS) with adjunct diagnostic test accuracy assessment and health economic evaluation.

Setting

The ITS was conducted in a geographically defined health economy with appropriate hospital services and no pre-existing referral management or primary care oral surgery service. Hospital services included a district general, a foundation trust and a dental hospital.

Participants

Patients, carers, general and specialist dentists, consultants (both surgical and Dental Public Health), hospital managers, commissioners and dental educators contributed to the qualitative component of the work. Referrals from primary care dental practices for oral surgery procedures over a 3-year period were utilised for the quantitative and health economic evaluation.

Interventions

A consultant- then practitioner-led triage system for oral surgery referrals embedded within an electronic referral system for oral surgery with an adjunct primary care service.

Main outcome measures

Diagnostic test accuracy metrics for sensitivity and specificity were calculated. Total referrals, numbers of referrals sent to primary care and the cost per referral are reported for the main intervention. Qualitative findings in relation to patient experience and whole-system impact are described.

Results

In the diagnostic test accuracy study, remote triage was found to be highly specific (mean 88.4, confidence intervals 82.6 and 92.8) but with lower values for sensitivity. The implementation of the referral system and primary care service was uneventful. During consultant triage in the active phases of the study, 45% of referrals were diverted to primary care, and when general practitioner triage was used this dropped to 43%. Only 4% of referrals were sent from specialist primary care to hospital, suggesting highly efficient triage of referrals. A significant per-referral saving of £108.23 [standard error (SE) £11.59] was seen with consultant triage, and £84.13 (SE £11.56) with practitioner triage. Cost savings varied according the differing methods of applying the national tariff. Patients reported similar levels of satisfaction for both settings, and speed of treatment was their over-riding concern.

Conclusions

Implementation of electronic referral management in primary care can lead, when combined with triage, to diversions of appropriate cases to primary care. Cost savings can be realised but are dependent on tariff application by hospitals, with a risk of overestimating where hospitals are using day case tariffs extensively.

Study limitations

The geographical footprint of the study was relatively small and, hence, the impact on services was minimal and could not be fully assessed across all three hospitals.

Future work

The findings suggest that the intervention should be tested in other localities and disciplines, especially those, such as dermatology, that present the opportunity to use imaging to triage.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Patient Feedback on Orthodontic Therapist Student Outreach Training

The introduction of orthodontic therapists as a new group of dental care professionals (DCPs) requires that their training in specialist orthodontic practices has provision for monitoring the level of supervision and clinical care provided by the students. The University of Warwick Diploma in Orthodontic Therapy programme has developed a patient questionnaire with the aim of assessing the patient's perception of the student. The observational questionnaire was designed to cover the four General Dental Council (GDC) domains and learning outcomes for orthodontic therapists, such that patient response could potentially provide valuable feedback to support the training programme. Each of the 10 students had 30 questionnaires to complete. The questionnaire was anonymous and it was designed to be suitable for both young patients and their carers to complete in less than five minutes. The response rate was very high, with 291 of the 300 questionnaires being completed. The level of co-operation may have been partly due to the ease of completion of the questionnaire, but might suggest the willingness to provide supportive feedback for the students. This study provided formative feedback to students' educational and clinical development without impacting on a student's clinical activity and will be used to develop further assessment tools.

Quality management in dental care: patients' perspectives on communication. a qualitative study

Background and aim

Dental care usually faces the traditional doctor-patient relationship, according to which the doctor does not seek feedback and patients feel uncomfortable when being involved in the healthcare process.

The current study aims at analyzing patients’ attitudes and knowledge about dental care and asses the level of communication between them and their dentists.

Methods

A series of telephone interviews (N=40) were applied to patients in the city of Cluj-Napoca in order to identify attitudes and knowledge about dental care. The interview guide was applied separately to each respondent and each interview was audio recorded with the verbal consent of the respondent. The data collected was assessed and we performed thematic analysis on the provided answers.

Results

When asked about the dentist’s attitude during the consultation, the respondents reported only positive attitudes. The majority of the respondents stated that the communication with their dentist was an efficient and professional one, focused on their dental problems. When asked if they understood the verbal and written information received from the dentist, the majority of respondents said they understood the information without any problems.

Conclusion

Identifying the patients’ health literacy about dental services leads to better communication between dentist and patient, which is essential for establishing a quality management system in dentistry. Effective communication leads to a high level of patient involvement.