A qualitative study to develop a tool to examine patients’ perceptions of NHS orthodontic treatment

The Sheldon Friel Memorial Lecture 2020 It's not just about the teeth: Patient-centred Orthodontics

The provision of high-quality health care involves many different aspects, including safety, effectiveness, efficiency, and patient centredness. In order for care to be truly patient centred requires patients' views being sought and considered, and this may be achieved through patient-centred research. Patient-centred research is fundamentally important in contemporary health care and has many benefits; for example, it ensures that research is relevant, identifies those aspects of care that are important to patients, provides information that is important to current and future patients, and allows the integration of patients' views regarding how services may be enhanced in the future. This paper provides an overview of how we currently involve patients in orthodontic research, what this means to the specialty and how we can enhance patient involvement in the future.

Managing orthodontic appliances in everyday life: A qualitative study of young people's experiences with removable functional appliances, fixed appliances and retainers

OBJECTIVE

To compare young people's experiences of wearing a range of orthodontic appliances.

DESIGN

A cross-sectional, qualitative study with purposive sampling.

SETTING

UK dental teaching hospital.

PARTICIPANTS

Twenty-six orthodontic patients aged 11-17 years.

METHODS

Patients participated in in-depth semi-structured interviews. All interviews were transcribed verbatim and analysed thematically.

RESULTS

Young people reported physical, practical and emotional impacts from their appliances. Despite these reported impacts, participants described 'getting used' to and, therefore, not being bothered by their appliance. Framework analysis of the data identified a multi-dimensional social process of managing everyday life with an appliance. This involves addressing the 'dys-appearance' of the body through physically adapting to an appliance. This process also includes psychological approaches, drawing on social networks, developing strategies and situating experiences in a longer-term context. Engaging in this process allowed young people to address the physical, practical and emotional impacts of their appliances.

CONCLUSION

This qualitative research has identified how young people manage everyday life with an appliance. Understanding this process will help orthodontists to support their patients.

Evidence in Orthodontics related to qualitative research

Introduction:

Research in Orthodontics has historically followed the positivist model based on the direct relationship of cause and effect between diseases and their specific etiological factors. Despite the objectivity and the great potential of statistical procedures, quantitative methods have progressively been sharing space with other models that can encompass the multiplicity of factors that affect the health-disease process, which until such time was reduced to its biological dimension.

Objectives:

This study aims, through an integrative review, to identify orthodontics articles published over a 10-year period that have used, exclusively or not, some method of qualitative research, and analyze the main aspects of their content.

Methods:

A survey was performed on Pubmed, Medline, Scopus, and Lilacs databases from 2007 to 2016 with a focus on the applicability of the qualitative methodology in orthodontic research.

Results:

The 27 articles selected showed a trend to increase in publications, with the most recent four years concentrating almost 60% of them. Most studies were from Europe, particularly the UK, and the more frequent study objectives were related to the perception of people about the reasons for orthodontic treatment, about the aesthetic and psychosocial impact of malocclusion or orthodontic treatment, and the implications of these factors for their quality of life.

Conclusions:

Because of its potential to explore behaviours and socio-cultural attitudes sustained in subjectivity, qualitative research offers new possibilities for orthodontic studies and can be used in an exclusive or complementary way in relation to quantitative methods.

Adolescent perceptions of orthodontic treatment risks and risk information: A qualitative study

INTRODUCTION

For effective risk communication, clinicians must understand patients' values and beliefs in relation to the risks of treatment. This qualitative study aimed to explore adolescent perceptions of orthodontic treatment risks and risk information.

METHODS

Five focus groups were carried out with 32 school/college pupils aged 12-18 in Wales, UK. Participants were purposively selected and had all experienced orthodontic treatment. A thematic approach was used for analysis and data collection was completed at the point of data saturation.

RESULTS

Four themes emerged from the data; (a) day-to-day risks of orthodontic treatment, (b) important orthodontic risk information, (c) engaging with orthodontic risk information and (d) managing the risks of orthodontic treatment. Day-to-day risks of orthodontic treatment that were affecting participants "here and now" were of most concern. Information about preventing the risks of treatment was deemed to be important. Participants did not actively seek risk information but engaged passively with information from convenient sources. Perceptions of risk susceptibility influenced participants' management of the risks of orthodontic treatment.

CONCLUSIONS

This study demonstrates that adolescent patients can understand information about the nature and severity of orthodontic treatment risks. However, adolescent patients can have false perceptions if the risks are unfamiliar, perceived only to have a future impact or if seen as easy to control. Adolescent patients must be provided with timely and easily accessible risk information and with practical solutions to prevent the risks of treatment.

CLINICAL SIGNIFICANCE

The views and experiences gathered in this study can assist clinicians to better understand their young patients' beliefs about treatment risks, facilitate effective risk communication and contribute to improved patient-centred care.

Evaluation of the orthodontic component of the hypodontia care pathway

INTRODUCTION

This study evaluated patients' experiences of the Hypodontia Care Pathway at a large teaching hospital at key stages: specifically patient expectations/experience following the diagnosis of hypodontia and then patient satisfaction with the orthodontic care received and the outcome at the end of active orthodontic treatment.

METHODOLOGY

In-depth, semi-structured interviews were conducted with 20 hypodontia patients following completion of orthodontic treatment but prior to any planned prosthodontic treatment commencing. Interviews were analysed qualitatively, using a framework approach.

RESULTS

The framework analysis identified four main themes: perceptions of treatment, impact of the original malocclusion and the treatment process, the care team and communication. The themes were then further divided into subthemes.

DISCUSSION

There was a large amount of positive feedback and the importance of the patient-clinician relationship was evident throughout. Where issues of concern were identified, these related mainly to communication and areas were identified where change could take place in the future.

CONCLUSIONS

Positive feedback was received and the importance of patient-clinician rapport was highlighted in all interviews. The main areas that could be enhanced related to the importance of ensuring optimum communication, particularly with a cohort of patients who are often undergoing complex multidisciplinary treatment. Recommendations for the service have been made.

A Patient- and Family-Centered Care Approach to Orthodontics: Assessment of Feedbacks from Orthodontic Patients and Their Families

Objective

This study aimed to evaluate orthodontic patients and their families' clinical satisfaction and their perception of dentists in the framework of the Patient and Family Centered Care (PFCC) concept.

Methods

The study population comprised patients treated at the Orthodontics clinic and their families. A mixed method research with quantitative and qualitative components was employed by conducting questionnaires with 62 patients and 65 parents. Collected data were recorded on the computer, and analyses were performed.

Results

A majority of the patients who received treatment at our clinic were high school graduates, while their parents were university graduates. The patient's and their parents' overall satisfaction were similar. We also found that the patients and their parents expected doctors to have ethical perception and professional behavior in the treatment process.

Conclusion

According to the results obtained from the survey questionnaires, the patients and their parents expect a dentist to have the following qualities: courtesy, friendliness, respect, punctuality, communication skills, and knowledgeableness. Dentists can optimize clinical and patient satisfaction by providing care and attention based on the principles of patient centered care (PCC) and PFCC and shaped in accordance with the expectations of the patients and their parents.

Patient-centred care in general dental practice--a systematic review of the literature

Background

Delivering improvements in quality is a key objective within most healthcare systems, and a view which has been widely embraced within the NHS in the United Kingdom. Within the NHS, quality is evaluated across three key dimensions: clinical effectiveness, safety and patient experience, with the latter modelled on the Picker Principles of Patient-Centred Care (PCC). Quality improvement is an important feature of the current dental contract reforms in England, with “patient experience” likely to have a central role in the evaluation of quality. An understanding and appreciation of the evidence underpinning PCC within dentistry is highly relevant if we are to use this as a measure of quality in general dental practice.

Methods

A systematic review of the literature was undertaken to identify the features of PCC relevant to dentistry and ascertain the current research evidence base underpinning its use as a measure of quality within general dental practice.

Results

Three papers were identified which met the inclusion criteria and demonstrated the use of primary research to provide an understanding of the key features of PCC within dentistry. None of the papers identified were based in general dental practice and none of the three studies sought the views of patients. Some distinct differences were noted between the key features of PCC reported within the dental literature and those developed within the NHS Patient Experience Framework.

Conclusions

This systematic review reveals a lack of understanding of PCC within dentistry, and in particular general dental practice. There is currently a poor evidence base to support the use of the current patient reported outcome measures as indicators of patient-centredness. Further research is necessary to understand the important features of PCC in dentistry and patients’ views should be central to this research.

Satisfaction with orthodontic treatment outcome

OBJECTIVES

To examine factors associated with treatment outcome satisfaction in a group of adolescent patients.

MATERIALS AND METHODS

One hundred and twenty patients (60 girls and 60 boys; mean age, 14.3 years; standard deviation [SD], 1.73 years) were consecutively recruited. The inclusion criteria for all patients were as follows: adolescents with a permanent dentition in need of orthodontic treatment and a treatment plan involving extractions (two or four premolars) followed by fixed appliances in both jaws. Questionnaire 1, concerning treatment motivation and expectations, was assessed prior to treatment start. Questionnaire 2 was assessed after active treatment and included questions about satisfaction with treatment outcome, quality of care and attention, and perceived pain and discomfort during active treatment.

RESULTS

One hundred and ten patients completed the trial (54 boys and 56 girls; mean age, 16.9 years; SD, 1.78 years). Median values for satisfaction with treatment outcome were generally high. There was a clear correlation (P ≤ .001) between satisfaction with treatment outcome and patients' perception of how well they had been informed and cared for during treatment. Pain and discomfort during treatment also strongly affected treatment satisfaction. Sex, treatment time, and Peer Assessment Rating index pre- and posttreatment as well as expectations for future treatment showed no correlation with treatment satisfaction.

CONCLUSIONS

Care and attention was the variable showing the highest correlation with satisfaction with treatment outcome. Patients' perceptions of pain and discomfort during treatment had an overall negative correlation with treatment satisfaction. Satisfaction with treatment outcome is a complex issue and requires further exploration in future research.

Piloting a patient-based questionnaire to assess patient satisfaction with the process of orthodontic treatment

OBJECTIVE

To test the scientific properties of a patient-based questionnaire developed to measure adolescent patient's satisfaction with the process of orthodontic treatment.

MATERIALS AND METHODS

Forty-nine consecutive patients aged 9 to 17 years undergoing orthodontic treatment were asked to complete the questionnaire on two separate occasions. Test-retest reliability, readability, ease of administration, criterion validity, and construct validity were tested. All patients answered the questionnaire at time 1 and took part in the construct validity study. Ten patients took part in an ease of administration study and 17 patients took part in the criterion validity study.

RESULTS

Thirty-one patients completed the questionnaire at time 2, giving a response rate of 63.3%. The test-retest reliability was excellent in one section, moderate in six sections, and poor in one. The questionnaire had a Flesch Reading Score of 79.8, equivalent to a reading age of 10 years and was easily administered in 5 to 15 minutes. Although the construct validity of the questionnaire was excellent in five of the six measures and moderate in the other, the criterion validity was poor for 7 of the 14 items selected to test.

CONCLUSION

This pilot study demonstrates the need to test a questionnaire before use in audit or research.

Where have all the copy letters gone? A review of current practice in professional-patient correspondence

OBJECTIVE

This article reviews the literature in relation to patients receiving copies of health professional correspondence. It examines progress in adopting the practice 3 years on from its introduction as policy in the UK, and considers potential benefits and obstacles to implementation.

METHODS

A review of the literature on copy correspondence, accessed via Medline, PubMed, CINAHL and also online resources, using the search terms "patient letter", "copy letter", "copy correspondence" and "doctor letter".

RESULTS

Studies describe a range of benefits from copying letters, but implementation remains inconsistent, ranging from 8 to 87% of patients reporting receiving copy correspondence. A number of concerns are identified which may be delaying whole scale adoption of the policy by health professionals.

CONCLUSION

This review suggests that researchers should move from examining the benefits and concerns around copying letters to patients, and instead focus on exploring the quality of correspondence and the optimum process of implementing the practice. As patients can "opt out" of receiving copy correspondence, audit of service delivery may be better assessed by whether patients have been offered a letter, rather than the current measure of whether one has been received.

PRACTICE IMPLICATIONS

Copying letters to patients may have a number of important benefits and should be routine practice where patients wish to receive correspondence. Further discussion regarding the style and content of letters would be beneficial, together with attention paid to the mechanisms for recording patient preference. There is also a need for studies in non-medical professions.