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Concordance between patient satisfaction and the dentist's view: Findings from The National Dental Practice-Based Research Network Joseph L. Riley III, Valeria V. Gordan, Susan E. Hudak-Boss, Jeffery L. Fellows, D. Brad Rindal and Gregg H. Gilbert JADA 2014;145(4):355-362 10.14219/jada.2013.32 The following resources related to this article are available online at jada.ada.org (this information is current as of June 29, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/4/355
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ARTICLE 4
Concordance between patient satisfaction and the dentist’s view Findings from The National Dental Practice-Based Research Network Joseph L. Riley III, PhD; Valeria V. Gordan, DDS, MS, MS-CI; Susan E. Hudak-Boss, DMD; Jeffery L. Fellows, PhD; D. Brad Rindal, DDS; Gregg H. Gilbert, DDS, MBA; for The National Dental Practice-Based Research Network Collaborative Group
T
he results of a number of studies have shown that the quality of the affiliation between dentist and patient is important to patients.1 In addition, patient satisfaction increasingly is seen as an essential element in assessments of the quality of oral care.1 Nonetheless, patient satisfaction is multifaceted and constitutes a complex set of objective and subjective elements.1-3 A large aspect of this relationship involves communication, and investigators in studies consistently have reported that the quality of dentist-patient communication is related closely to patient satisfaction.4-9 Studies of the extent to which patients prefer to be involved in decision making are common in medicine,10 but investigators in few studies have examined this for the practice of dentistry. Furthermore, research findings have shown that health care providers generally are poor judges of patients’ actual preferences,11,12 in part because patients often are unable or unwilling to express their expectations and needs.13,14 Several investigators have suggested that satisfaction Dr. Riley is a professor, Department of Community Dentistry and Behavioral Sciences, College of Dentistry, University of Florida, Gainesville. Dr. Gordan is a professor, Department of Restorative Dental Sciences, Operative Dentistry Division, College of Dentistry, University of Florida, Gainesville, e-mail [email protected]. Address correspondence to Dr. Gordan. Dr. Hudak-Boss is in private practice in Seminole, Fla. Dr. Fellows is an investigator, Center for Health Research, Kaiser Permanente Northwest, Portland, Ore. Dr. Rindal is a practitioner in the HealthPartners Dental Group, Minneapolis, and an investigator at the HealthPartners Institute for Education and Research, Minneapolis. Dr. Gilbert is a professor and the chair, Department of Clinical and Community Sciences, School of Dentistry, University of Alabama at Birmingham.
abstract Objectives. In this study, the authors examined the dentist’s view of the patient’s experience and concordance with the patient’s rating of satisfaction. Methods. Practitioners from 197 practices in The National Dental Practice-Based Research Network recruited consecutively seen patients who had defective restorations that were replaced or repaired. At the end of the dental visit, the treating dentist and 5,315 patients completed and returned a survey that asked about the patient’s satisfaction. Results. Most dentists viewed their patients as having been satisfied with the treatment experience (n = 4,719 [89 percent]) and as having perceived them as friendly (n = 5,136 [97 percent]). Dentists had less strong feelings about whether patients had a preference for the restorative material (n = 2,271 [43 percent]) or an interest in obtaining information about the procedure (n = 1,757 [33 percent]). Overall, patients were satisfied, and most of the time dentists correctly predicted this outcome. Among patients who were less than satisfied, there was a substantial subset of cases in which dentists were not aware of this dissatisfaction. Conclusion. For improved patient-centered care, dentists should assess patients’ desires, expectations and perceptions of the dental care experience and then manage or correct the expectations and perceptions as needed. Practical Implications. By taking a patientcentered approach, dentists should seek to understand how patients evaluate and rate the services provided, thereby enabling them to focus on what each patient values most. Key Words. Access to care; behavioral sciences; community dentistry; consumer satisfaction; dental care utilization; public opinion; dentist-patient relations; patient affect; patient relations; professional-family relations. JADA 2014;145(4):355-362. doi:10.14219/jada.2013.32 JADA 145(4) http://jada.ada.org April 2014 355
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ORIGINAL CONTRIBUTIONS
with one’s dentist can facilitate stress reduction, which may, in turn, promote further satisfaction.8,15,16 Consistent with this finding, researchers in several studies have highlighted the importance that patients give to dentists’ willingness to discuss patients’ fears and perceived pain.8,15,16 By inference, when complications occur or when the patient is in pain and experiencing significant anxiety, the dentist should realize that without proper management of the patient’s care, the patient’s overall experience and satisfaction could be affected negatively. Thus, assessing patients’ perceptions of the dental experience is important to ensure that patients’ expectations are consistent with the services to be performed. Because few researchers have examined patients’ satisfaction with regard to specific dental procedures, it is possible that dentists err in their assumptions. We report findings from participants in The National Dental Practice-Based Research Network (the “network”), a consortium of dental practices and dental organizations focused on improving the scientific basis for clinical decision making.17 The network was funded in 2012 and builds on the former regional dental networks, including the Dental Practice-Based Research Network18 (DPBRN), that existed from 2003 to 2012. The DPBRN was established in 2003 with a seven-year grant from the National Institute of Dental and Craniofacial Research, National Institutes of Health. The data for this study were collected under the auspices of the DPBRN. That organization subsequently evolved into The National Dental PBRN, under the aegis of which we prepared the manuscript of this article. At the time of this study, the network was composed primarily of clinicians from five regions: Alabama/ Mississippi; Florida/Georgia; dentists in Minnesota, either employed by HealthPartners in Bloomington, Minn., or in private practice; Permanente Dental Associates, in cooperation with Kaiser Permanente’s Center for Health Research in Portland, Ore.; and dentists from Denmark, Norway and Sweden. The network has a wide representation of practice types, treatment philosophies and patient populations, including diversity regarding race, ethnicity, geographical location and rural/urban area of residence of practitioners and their patients. Analyses of these characteristics confirm that network dentists have much in common with dentists at large,19 while offering substantial diversity with respect to these characteristics.20 We were unable to find any studies in which researchers examined the extent to which dentists understood their patients’ views or experiences during a restorative procedure. Making use of the diversity of patient and practitioner characteristics in the network, we sought to build on our earlier study2 in which we found that patient satisfaction comprised three components: interpersonal relationship-comfort factors, material choice-value factors and sensory-evaluative factors.
Therefore, the aim of this study was to examine the dentist’s view of the patient’s experience and concordance with the patient’s rating of satisfaction by using specific areas of a restorative dental visit that are important to patients. In particular, we focused on the extent to which dentists were aware of patients’ viewpoints when patients did not report being satisfied. We also tested the hypothesis that certain practice, patient and procedural variables were associated with dentists’ lack of awareness. METHODS
Network dentists. We recruited network practitioners through continuing education courses, mass mailings to licensed dentists within the participating regions or both. As part of the eligibility criteria, all dentists completed an enrollment questionnaire describing their demographic and practice characteristics and certain personal characteristics; completed an assessment of caries diagnosis and caries treatment questionnaire; completed training in human participants’ protection; and attended a network orientation session with the regional coordinator in their practices. The institutional review boards of the participating regions approved the study. Recruitment and data collection. The overall project involved collecting data regarding the restoration procedures, assessing patient satisfaction with the restorative visit and conducting a longitudinal follow-up of the restorations. Each participating dentist (n = 197) recruited consecutively seen patients who had defective restorations that were replaced or repaired in the treatment of permanent teeth. Practitioners obtained written informed consent from patients before the study procedures took place. Each participant received the satisfaction survey form, along with a stamped envelope, and was instructed to complete the survey the following day. Patients mailed the completed satisfaction survey directly to the network regional coordinators to ensure that dentists remained masked to patient satisfaction ratings. Once the patient questionnaire was received, a network staff member mailed to the participant as compensation either $10 or a gift bag of the same value. At the end of the dental restorative procedure, the dentist completed a form about the visit and forwarded it to the regional center. Data from this form are the focus of this report. Two dentists did not provide complete data and were not included in the study. Measures. The survey development was an iterative process in which we began by interviewing 15 patients who had had a recent restorative visit and 16 practicing dentists about specific characteristics of tooth restoration visits that are important to patients. We designed the preliminary set of questions and field-tested it among nine ABBREVIATION KEY. DPBRN: Dental Practice-Based Research Network. LGP: Large group practice. PHP: Public health practice. SGP: Small group practice.
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dentists and 39 patients who had had a restoration-related dental visit within the previous year. The final patient instrument, which consisted of 20 items, is described in detail elsewhere.2 We also developed a dentist version that asked about selected aspects of the treatment and visit. In this study, we focused on items from the dentistcompleted questionnaire, which was designed to assess the dentist’s view of the patient’s experience. In addition, we compared the answers on this questionnaire with patients’ responses to the following subset of statements or questions about their level of satisfaction with their dental treatment and visit: dOverall, how satisfied were you with all aspects of your dental treatment and visit?; dthe friendliness of my dentist; dhow my dentist gave me a choice between different materials to fix my tooth; dhow the dental procedure was explained before it was started; dhow my dentist limited pain during the procedure; dhow my dentist tried to limit my fear and anxiety. Response choices for the first item were “not at all satisfied,” “slightly satisfied,” “moderately satisfied,” “very satisfied” and “extremely satisfied.” Response choices for the remaining items were “strongly disagree,” “disagree,” “neither agree nor disagree,” “agree” and “strongly agree.” Data analysis. We dropped from further analysis those patients’ questionnaires with missing items. For the concordance analysis, we recoded responses to the satisfaction statements from patients so that responses of “agree” and “strongly agree” were classified as “satisfied” and “strongly disagree,” “disagree” and “neither agree nor disagree” were classified as “not satisfied.” Similarly, we recoded dentists’ responses on the dentist survey as “agree” (includes “somewhat agree” and “strongly agree”) and “did not agree” (includes “strongly disagree,” “somewhat disagree” and “neither agree nor disagree”). We used a binary logistic model, with generalized estimating equations, to adjust for clustering within dental practices and restorations within patients to examine practice, patient and procedure variables as predictors of dentists’ awareness of their patients’ views. We tested prediction models when the patient was “not satisfied.” This model is based on the premise that a satisfied patient is the intended outcome, and practice changes are not indicated. A dentist’s awareness of the patient who is not satisfied is the scenario that has implications for improving clinical practice and, therefore, is the focus of this report. Details of patients’ satisfaction ratings are reported elsewhere.2 We used a backward elimination approach to remove the least significant index variable from the model in subsequent steps until all remaining variables were significant at P < .10 for retention.21 We categorized dentists associated with Permanente Dental Associates or HealthPartners in the large group practice (LGP) model.
TABLE 1
Characteristics of dentists and patients. CHARACTERISTIC
NO. (%* ) †
Dentists’ Characteristics (n = 195) Sex (male)
137 (70)
Mean (SD ‡ ) years since dental school graduation
22.4 (10.5)
Mean (SD) percentage of time spent on nonimplant restorative care (missing data = 12)
60 (20)
Practice model Small group practice (includes solo)
110 (56)
Large group practice
72 (37)
Public health practice
13 (7)
Practices according to region Alabama/Mississippi
39 (20)
Florida/Georgia
44 (23)
Permanente Dental Associates
40 (21)
HealthPartners and private practitioners in Minnesota
36 (18)
Scandinavia (Denmark, Norway, Sweden)
36 (18)
Patients’ Characteristics (n = 5,315) Sex (male)
2,206 (42)
Mean (SD) age, in years
52.4 (15.5)
Race/ethnicity (missing data = 94 [2 percent]) Hispanic
605 (11)
White
4,179 (79)
African American
261 (5)
Other
176 (3)
Patients treated, according to practice model Small group practice (includes solo)
3,248 (61)
Large group practice
1,807 (34)
Public health practice
260 (5)
No. of restorations per patient (total no. of restorations = 8,213) One
4,064 (77)
Two
941 (18)
Three
224 (4)
Four
86 (2)
Patients with dental insurance
1,175 (22)
* Percentages may not total 100 because of rounding. † Unless otherwise specified. ‡ SD: Standard deviation.
Regional coordinators assigned other practices to one of two categories: solo private practice or small group practice (SGP) (fewer than four dentists) or public health practice (PHP). Other variables in the models were as follows: ddentist’s ratings of the negative consequences associated with treatment (complications, pain or anxiety); dwhether the treatment was a replacement or repair; JADA 145(4) http://jada.ada.org April 2014 357
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(http://nationaldental pbrn.org/peer-reviewedpublications.php). SURVEY ITEM NO. (%) OF PATIENTS Table 2 shows the (n = 5,315) * distribution of response Strongly Somewhat Neither Somewhat Strongly choices for each of the Agree Agree) Agree Nor Disagree Disagree No. (%) No. (%) Disagree No. (%) No. (%) dentists’ questions. DenNo. (%) tists tended to view their Overall Satisfaction With All 1,721 (32) 2,998 (56) 559 (11) 36 (< 1) 1 (< 1) patients as satisfied with Aspects of Dental Treatment their treatment experience and Visit† (n = 4,719 [89 percent]) The Patient Perceived Me 2,900 (55) 2,236 (42) 161 (3) 9 (< 1) 9 (< 1) As Friendly and as having perceived The Patient Had a Strong 916 (17) 1,355 (26) 2,225 (42) 465 (9) 354 (7) them as friendly (n = 5,136 Preference for the Restorative [97 percent]). They had Material I Used Today less strong feelings about The Patient Was Interested 367 (7) 1,390 (26) 2,486 (47) 768 (14) 304 (6) whether patients had a in Information About the Restorative Procedure preference for the restorThe Filling Procedure Was 46 (< 1) 558 (11) 540 (10) 1,506 (28) 2,665 (50) ative material to be used Painful for the Patient Today (n = 2,271 [43 percent]) The Patient Was Anxious 215 (4) 745 (14) 822 (16) 1,328 (25) 2,205 (42) or an interest in informaDuring the Restorative tion about the procedure Procedure Today (n = 1,757 [33 percent]). The Restoration Procedure 3,559 (67) 1,388 (26) 167 (3) 160 (3) 41 (< 1) Went Without Complications Dentists agreed that the * Percentages may not total 100 because of rounding. procedure was painful for † Response choices for this item were as follows: extremely satisfied, very satisfied, moderately satisfied, 604 patients (11 percent) slightly satisfied and not at all satisfied. and that 960 patients (18 percent) were anxious dwhether the treating dentist placed the original during the procedures. They considered the procedures restoration; to have been without complications for 4,947 patients ddentist’s sex; (93 percent). dyears since dental school graduation; Dentists’ awareness when patients were not satdoriginal and new restorative materials; isfied. This series of analyses examined agreement dtooth involved (coded as molar versus premolar between the patient’s response and the dentist’s percepand anterior); tion of the patient’s experience. We combined the data to dnumber of surfaces involved; create three categories: satisfied, meaning that the patient dwhether the patient had dental insurance; is satisfied; not satisfied–aware, meaning that the dentist dpatient’s age; correctly identified the patient’s lack of satisfaction; and dpatient’s sex. not satisfied–unaware, meaning that the dentist was unaware of the patient’s dissatisfaction. Table 3 shows RESULTS the concordance between the dentist’s responses and the Network dentists returned completed restorative treatpatient’s responses. ment data forms for 7,286 patients enrolled in this study. Overall satisfaction. For the overall satisfaction quesThe network regional coordinators received a total of tion, 4,589 patients (86 percent) rated themselves as sat5,879 surveys from these patients (for a compliance rate isfied or very satisfied (Table 3). Among the 726 patients of 81 percent). Of these patients, 90 percent (n = 5,315) who were not satisfied, dentists were aware in only 42 had completed all of the survey items and provided the cases (1 percent) and unaware in 684 cases (13 percent). data used in this report (dentist and patient characterisNone of the patient or dentist variables was associated tics are presented in Table 1). Included are a total of 8,213 with the dentist’s awareness in cases in which the patient restorations. Patients who failed to complete all items was not satisfied. were older (mean [standard deviation {SD}] age, 58.6 Dentist’s friendliness. Regarding the question about [15.6] years) than those who completed all survey items the dentist’s friendliness, 4,861 patients (91 percent) rated (mean [SD] age, 52.4 [15.5] years) and more likely to have themselves as satisfied. For the 454 patients who were been seen in a PHP (13 percent) compared with an SGP not satisfied with the friendliness of the dentist, only (8 percent) or LGP (7 percent). Additional informa37 dentists (1 percent) correctly identified the patients’ tion related to patient compliance (as well as the dissatisfaction (that is, aware), whereas for 417 patients study’s data collection forms) is available online (8 percent), dentists responded incorrectly that they had TABLE 2
Dentist’s viewpoint of the patient’s experience.
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been perceived as friendly TABLE 3 (that is, unaware). None Concordance between the dentist’s and patient’s of the patient or dentist responses. variables were associated VARIABLE PATIENT SATISFIED PATIENT NOT SATISFIED with the dentist’s awareNO. (%) NO. (%) ness in cases in which the Agreement— Disagreement— patient was not satisfied Dentist Aware* Dentist Not Aware † with the dentist’s Overall Satisfaction 4,589 (86) 42 (1) 684 (13) friendliness. Dentist’s Friendliness 4,861 (91) 37 (1) 417 (8) Information about Information About Procedure 3,701 (70) 947 (18) 667 (13) procedure. For the quesMaterial Choice 3,396 (64) 736 (14) 1,183 (22) tion regarding informa* The dentist’s response is congruent with the patient’s response (for example, the patient was not satisfied tion about the procedure, with the dentist’s friendliness, and the dentist responded that the patient did not perceive him or her as 3,701 (70 percent) of friendly). † The dentist’s response is not congruent with the patient’s response (for example, the patient was not satisthe 5,315 patients rated fied with the dentist’s friendliness, and the dentist responded that the patient did perceive him or her as themselves as satisfied. friendly). For the 1,614 patients who were not satisfied, dentists correctly perceived 947 patients (18 percent) as However, little information has been collected about having an interest in information about the restorative dentists’ views of their patients’ experiences or patients’ procedure and incorrectly perceived 667 patients (13 overall satisfaction with dental treatment. We found that most dentists believed their patients viewed them as percent) as not having an interest. Among patients who friendly and were satisfied. However, in cases in which were not satisfied, dentists were more likely to be aware patients were not satisfied, dentists seldom were aware. that the patient was interested in information about We also found large discrepancies between patients’ lack the restorative procedure if the dentist was in a private of satisfaction with regard to several domains of commupractice model (that is, SGP or LGP) (odds ratio [OR] = 0.8; 95 percent confidence interval [CI], 0.6-0.9); the nication and dentists’ awareness of their patients’ desires, dentist had not placed the original restoration (OR = 1.3; suggesting that some dentists need to better assess their patients’ expectations with regard to a treatment visit. 95 percent CI, 1.1-1.5); the dentist was female (OR = 1.7; Regardless of patients’ viewpoints, if they were satis95 percent CI, 1.2-2.4); multiple surfaces were involved (OR = 1.2; 95 percent CI, 1.1-1.3); the restoration was in fied, we presume that their desires and expectations were a molar tooth (OR = 1.2; 95 percent CI, 1.1-1.4); or there met. Even if the dentist was not aware of the patient’s were complications during the procedure (OR = 1.4; 95 needs, yet met or exceeded them, we arbitrarily defined percent CI, 1.1-1.6). this as a desired outcome. Therefore, we focused on Restorative material choice. For the question perthe dentist’s view of the patient’s experience during the taining to material choice, 3,396 (64 percent) of the 5,315 restorative visit when the patient was not satisfied. The patients rated themselves as satisfied. For the 1,919 padentist could be aware or unaware of the patient’s distients who were not satisfied, dentists correctly perceived satisfaction. A dentist who is aware of a patient’s lack of 736 patients (14 percent) as having a strong preference satisfaction but does not address it may lack the skills, for the restorative material and incorrectly perceived time or interest to rectify the situation. Nothing can be 1,183 patients (22 percent) as not having a strong preferdone when a dentist is not aware, regardless of the denence. Among patients who were not satisfied, dentists tist’s intention. Thus, the dentist needs to do a better job were more likely to be aware that the material choice was of perceiving the patient’s expectations and desires with important if the dentist was female (OR = 1.3; 95 percent respect to treatment.22 Little attention has been paid to this distinction. CI, 1.2-1.5); the patient was female (OR = 1.4; 95 percent Overall satisfaction. Overall, patients were satisfied CI, 1.1-1.7); the procedure involved a replacement reswith dental treatment and the visit, and dentists correctly toration (OR = 1.3; 95 percent CI, 1.1-1.7); or there were predicted this outcome most of the time. Among the 726 complications (OR = 1.4; 95 percent CI, 1.1-1.6). Dentists patients who were not satisfied, there was a substantial were less likely to be aware of patients’ dissatisfaction if subset of cases (684 [94 percent]) in which dentists were the replacement material was composite (OR = 0.2; not aware. This survey measure asked about overall 95 percent CI, 0.1-0.3). satisfaction with all aspects of the treatment and visit; DISCUSSION consequently, we do not know the specific nature of the Researchers in a number of studies have documented dissatisfaction. Dental patients seek not only technical patient ratings of satisfaction with their dentists, with competence in a dentist but also interpersonal skills to dental care in general or with their last dental visit.1 reduce their anxiety and, ultimately, to be satisfied with JADA 145(4) http://jada.ada.org April 2014 359 Copyright © 2014 American Dental Association. All Rights Reserved.
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the visit.23,24 Experiencing anxiety during dental treatment is a common problem,25 and fear of pain is one of the most commonly cited factors associated with dental anxiety.26 On the basis of dentists’ reports, approximately 18 percent of patients in this study experienced anxiety, and for 12 percent, the procedure was painful. Surprisingly, pain and anxiety, as reported by the dentists, were not associated with patients’ reports of overall satisfaction. We speculate that because patients understood the potential for negative experiences (such as pain) during dental treatment and because of other overriding positive factors, such as a high level of rapport and trust, patients were satisfied with the treatment and dental visit. Relationship factors. The results of studies of patient-physician encounters generally show that patient-caregiver pairs more frequently were similar in affiliation than they were on other dimensions, with both groups expressing friendliness and cooperation, including greater nonverbal ‘‘interaction synchrony.’’10 In our study, patients overwhelmingly reported that their dentists were friendly.2 Ross and Duff27 also found that dentists generally were friendly, but that when patients were not satisfied with the dentist’s friendliness, the dentists often misinterpreted the patient’s preferences for treatment. Dentists in our study also perceived themselves as friendly, agreeing with the friendliness statement for 97 percent of the restorative visits. As with the overall satisfaction rating, when patients were not satisfied, dentists seldom were aware. None of the practice, patient or procedure variables were associated with accurately predicting the dentist’s awareness of a patient’s lack of satisfaction with their friendliness. Communication. One finding from this study involved direct communication between dentist and patient (that is, the information provided by the dentist about the procedure before it started and the patient’s having input into the choice of restorative material). Ratings of satisfaction among dental patients were considerably lower for these measures than they were for other measures. In addition, although the percentages for dentists’ lack of awareness were lower than those for the satisfaction or friendliness variables, misunderstanding their patients’ level of interest occurred at a higher frequency for the dentist-patient communication behaviors. Our finding is consistent with those of studies in which investigators compared patients’ views of ideal and actual behaviors of dentists.28-30 In these studies, the largest discrepancies occurred for the communicative and informative factor. We speculate that because dentists are so familiar with the restorative procedures, they forget the importance of explaining them to patients. Network dentists rated patients’ interest in information as relatively low, with only 33 percent agreeing with the statement that the patient was interested in information about the procedure. A dentist’s misinterpretation of the patient’s interest could explain why patients’ satisfac-
tion was relatively low (70 percent). It is surprising that when patients were not satisfied, dentists more often than not were aware of this dissatisfaction. This finding supports an assumption that dentists either did a poor job of communicating or made a conscious decision not to provide more details of the procedure or provide a review of the details already covered. Our study findings show that when the restorative procedure involved complications, dentists were more likely to be aware of the patient’s interest in information. Similarly, awareness among dentists was more likely if the procedure involved multiple surfaces or was performed on a molar tooth, both situations making for more complicated cases. Consequently, in situations involving higher risk, dentists appeared to take greater care to review with the patient what might occur than they did for simpler procedures. A lack of awareness of the need for information also was associated with the dentist’s having placed the original restoration. One possible explanation is that with long-time patients, dentists presumed that patients simply trusted them and no explanation was needed.31 Patients were least satisfied with respect to having a choice regarding the restorative material. Moreover, dentists often were not aware of their patients’ lack of satisfaction. Dentists’ awareness was associated with the procedure having been a replacement and involving complications. As discussed earlier, dentists may have been more likely to cover restorative materials with patients in more complex cases. Our study findings show that more dentists were aware of patients’ interest in the material choice when the original restorative material was an amalgam, but awareness was not associated with the choice of replacement material. We should note that amalgam was not the main restorative material used for either repairs or replacements, and dentists were much more likely to replace the restoration when the original restoration was amalgam.32 There was an interesting finding related to the sex of the dentist. Male dentists were less likely than female dentists to be aware of the importance to patients of both procedural information and a discussion of the restorative material choices. There are two possible explanations, which are not mutually exclusive. The first is related to sex differences in health care provider communication patterns. Research findings indicate that female providers generally conduct longer consultations with patients, provide more information and are more explicitly reassuring and encouraging than are male clinicians.33-35 Second, study findings show that both male and female patients often vary their responses depending on the clinician’s sex.36,37 In addition, the sex makeup of the patient-provider dyad may influence overall patient satisfaction.38 A patient sex difference effect also occurred, but only for the restorative material choice variable, as dentists were less likely to be aware of dis-
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satisfaction when the patient was male. Evidence shows that health care providers may provide more information and support to female patients, not because of presumptions about the health care needs of women, but because female patients express their feelings, concerns and questions more openly.39 Patients’ involvement. Findings from research among physicians indicate little agreement between patients’ and physicians’ perceptions of the physicianpatient relationship.33,40,41 Dentists have reported that they are aware of patients’ preferences regarding treatment42,43; however, our results suggest that often they are not aware. The results of several reviews indicate that patients vary in the extent to which they want to be involved in their health care, with some patients wishing to become active in treatment decision making and others preferring to adopt a more passive role.44-46 Neufeld and colleagues47 found that increasing patients’ knowledge of available options increased their willingness to participate in treatment decisions, but when a mismatch occurred, it involved patients who had less active roles than they preferred.10 It is possible that the patients in our study, as has been documented in other studies, failed to match their desire for information and participation in decision making with their overt behavior (that is, communicating clearly with the dentist).13,48 CONCLUSIONs
The primary finding of this study was that when dental patients were not satisfied with some aspect of restorative treatment or the visit, dentists often were unaware of it. This was most common with regard to patients’ desire for greater communication and, surprisingly, occurred most often during less complicated restorative procedures. The main implication is that for improved patient-centered care, dentists need to determine patients’ desires, expectations and perceptions of the dental care experience and then manage the care of patients or correct behavior as needed for all cases. Reaching a mutual understanding of the nature of the problem and its solutions requires dynamic communication during dental visits. It appears that for some dentist-patient dyads, this does not occur. n Disclosure. None of the authors reported any disclosures. This work was supported by grants U01-DE-16746, U01-DE-16747 and U19-DE-22516 from the National Institutes of Health, Bethesda, Md. Opinions and assertions contained herein are those of the authors and are not to be construed as necessarily representing the views of the respective organizations or the National Institutes of Health. All participants in this investigation provided informed consent after receiving a full explanation of the nature of the procedures. The National Dental Practice-Based Research Network Collaborative Group includes practitioners, faculty and staff investigators who contributed to this network activity. A list of these people is available at http:// nationaldentalpbrn.org/collaborative-group.php under the title “Patient satisfaction with dental restorations.”
1. Newsome PR, Wright GH. A review of patient satisfaction, 2: dental patient satisfaction—an appraisal of recent literature. Br Dent J 1999;186(4 special number):166-170. 2. Riley JL 3rd, Gordan VV, Rindal DB, et al; Dental Practice-Based Research Network Collaborative Group. Components of patient satisfaction with a dental restorative visit: results from the Dental Practice-Based Research Network. JADA 2012;143(9):1002-1010. 3. Anderson R, Thomas DW, Phillips CJ. The effectiveness of out-ofhours dental services, II: patient satisfaction. Br Dent J 2005;198(3):151-156; discussion 146. 4. Gerbert B, Bleecker T, Saub E. Dentists and the patients who love them: professional and patient views of dentistry. JADA 1994;125(3): 264-272. 5. Gürdal P, Cankaya H, Onem E, Dinçer S, Yílmaz T. Factors of patient satisfaction/dissatisfaction in a dental faculty outpatient clinic in Turkey. Community Dent Oral Epidemiol 2000;28(6):461-469. 6. Holt VP, McHugh K. Factors influencing patient loyalty to dentist and dental practice. Br Dent J 1997;183(10):365-370. 7. Corah NL, O’Shea RM, Pace LF, Seyrek SK. Development of a patient measure of satisfaction with the dentist: the Dental Visit Satisfaction Scale. J Behav Med 1984;7(4):367-373. 8. Chakraborty G, Gaeth GJ, Cunningham M. Understanding consumers’ preferences for dental service. J Health Care Mark 1993;13(3):48-58. 9. Mellor AC, Milgrom P. Dentists’ attitudes toward frustrating patient visits: relationship to satisfaction and malpractice complaints. Community Dent Oral Epidemiol 1995;23(1):15-19. 10. Kiesler DJ, Auerbach SM. Optimal matches of patient preferences for information, decision-making and interpersonal behavior: evidence, models and interventions. Patient Educ Couns 2006;61(3):319-341. 11. Bruera E, Sweeney C, Calder K, Palmer L, Benisch-Tolley S. Patient preferences versus physician perceptions of treatment decisions in cancer care. J Clin Oncol 2001;19(11):2883-2885. 12. Coulter A, Peto V, Doll H. Patients’ preferences and general practitioners’ decisions in the treatment of menstrual disorders. Fam Pract 1994;11(1):67-74. 13. Schouten BC, Hoogstraten J, Eijkman MA. Patient participation during dental consultations: the influence of patients’ characteristics and dentists’ behavior. Community Dent Oral Epidemiol 2003;31(5):368-377. 14. Keating NL, Guadagnoli E, Landrum MB, Borbas C, Weeks JC. Treatment decision making in early-stage breast cancer: should surgeons match patients’ desired level of involvement? J Clin Oncol 2002;20(6):1473-1479. 15. Corah NL, O’Shea RM, Bissell GD. The dentist-patient relationship: perceptions by patients of dentist behavior in relation to satisfaction and anxiety. JADA 1985;111(3):443-446. 16. Corah NL. Dental anxiety: assessment, reduction and increasing patient satisfaction. Dent Clin North Am 1988;32(4):779-790. 17. Gilbert GH, Williams OD, Korelitz JJ, et al; National Dental PBRN Collaborative Group. Purpose, structure, and function of the United States National Dental Practice-Based Research Network. J Dent 2013;41(11):1051-1059. 18. Gilbert GH, Williams OD, Rindal DB, Pihlstrom DJ, Benjamin PL, Wallace MC; DPBRN Collaborative Group. The creation and development of the Dental Practice-Based Research Network. JADA 2008;139(1):74-81. 19. Makhija SK, Gilbert GH, Rindal DB, Benjamin PL, Richman JS, Pihlstrom DJ; DPBRN Collaborative Group. Dentists in practicebased research networks have much in common with dentists at large: evidence from the Dental Practice-Based Research Network. Gen Dent 2009;57(3):270-275. 20. Makhija SK, Gilbert GH, Rindal DB, et al; DPBRN Collaborative Group. Practices participating in a dental PBRN have substantial and advantageous diversity even though as a group they have much in common with dentists at large. BMC Oral Health 2009;9:26. 21. Menard S. Applied Logistic Regression Analysis (Quantitative Applications in the Social Sciences). Thousand Oaks, Calif.: SAGE Publications; 1995. 22. Newsome PR, Wright GH. Qualitative techniques to investigate how patients evaluate dentists: a pilot study. Community Dent Oral Epidemiol 2000;28(4):257-266. 23. Rouse RA, Hamilton MA. Dentists’ technical competence, communication, and personality as predictors of dental patient anxiety. J Behav Med 1990;13(3):307-319.
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24. Street RL Jr. Patients’ satisfaction with dentists’ communicative style. Health Commun 1989;1(3):137-154. 25. Smith TA, Heaton LJ. Fear of dental care: are we making any progress? JADA 2003;134(8):1101-1108. 26. McNeil DW, Berryman ML. Components of dental fear in adults? Behav Res Ther 1989;27(3):233-236. 27. Ross CE, Duff RS. Returning to the doctor: the effect of client characteristics, type of practice, and experiences with care. J Health Soc Behav 1982;23(2):119-131. 28. Lahti S, Tuutti H, Hausen H, Kääriäinen R. Dentist and patient opinions about the ideal dentist and patient: developing a compact questionnaire. Community Dent Oral Epidemiol 1992;20(4):229-234. 29. Lahti S, Tuutti H, Hausen H, Kääriänen R. Patients’ expectations of an ideal dentist and their views concerning the dentist they visited: do the views conform to the expectations and what determines how well they conform? Community Dent Oral Epidemiol 1996;24(4):240-244. 30. Lahti S, Verkasalo M, Hausen H, Tuutti H. Ideal role behaviours as seen by dentists and patients themselves and by their role partners: do they differ? Community Dent Oral Epidemiol 1996;24(4):245-248. 31. Goedhart H, Eijkman MA, ter Horst G. Quality of dental care: the view of regular attenders. Community Dent Oral Epidemiol 1996;24(1): 28-31. 32. Gordan VV, Riley JL 3rd, Geraldeli S, et al; Dental Practice-Based Research Network Collaborative Group. Repair or replacement of defective restorations by dentists in The Dental Practice-Based Research Network. JADA 2012;143(6):593-601. 33. Hall JA, Stein TS, Roter DL, Rieser N. Inaccuracies in physicians’ perceptions of their patients. Med Care 1999;37(11):1164-1168. 34. Elderkin-Thompson V, Waitzkin H. Differences in clinical communication by gender. J Gen Intern Med 1999;14(2):112-121. 35. Krupat E, Rosenkranz SL, Yeager CM, Barnard K, Putnam SM, Inui TS. The practice orientations of physicians and patients: the effect of doctor-patient congruence on satisfaction. Patient Educ Couns 2000;39(1):49-59.
36. Christen RN, Alder J, Bitzer J. Gender differences in physicians’ communicative skills and their influence on patient satisfaction in gynaecological outpatient consultations. Soc Sci Med 2008;66(7):1474-1483. 37. Hall JA, Roter DL. Medical communication and gender: a summary of research. J Gend Specif Med 1998;1(2):39-42. 38. Schmid Mast M, Hall JA, Roter DL. Disentangling physician sex and physician communication style: their effects on patient satisfaction in a virtual medical visit. Patient Educ Couns 2007;68(1):16-22. 39. Hall JA, Irish JT, Roter DL, Ehrlich CM, Miller LH. Gender in medical encounters: an analysis of physician and patient communication in a primary care setting. Health Psychol 1994;13(5):384-392. 40. Anderson LA, Zimmerman MA. Patient and physician perceptions of their relationship and patient satisfaction: a study of chronic disease management. Patient Educ Couns 1993;20(1):27-36. 41. Street RL Jr. Analyzing communication in medical consultations: do behavioral measures correspond to patients’ perceptions? Med Care 1992;30(11):976-988. 42. Kay EJ, Blinkhorn AS. A qualitative investigation of factors governing dentists’ treatment philosophies. Br Dent J 1996;180(5):171-176. 43. Rao CP, Rosenberg LJ. Consumer behavior analysis for improved dental services marketing. Health Mark Q 1986;3(4):83-96. 44. Frosch DL, Kaplan RM. Shared decision making in clinical medicine: past research and future directions. Am J Prev Med 1999;17(4): 285-294. 45. Benbassat J, Pilpel D, Tidhar M. Patients’ preferences for participation in clinical decision making: a review of published surveys. Behav Med 1998;24(2):81-88. 46. Coulter A. Partnerships with patients: the pros and cons of shared clinical decision-making. J Health Serv Res Policy 1997;2(2):112-121. 47. Neufeld KR, Degner LF, Dick JA. A nursing intervention strategy to foster patient involvement in treatment decisions. Oncol Nurs Forum 1993;20(4):631-635. 48. Beisecker AE, Beisecker TD. Patient information-seeking behaviors when communicating with doctors. Med Care 1990;28(1):19-28.
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Concordance between patient satisfaction and the dentist's view: Findings from The National Dental Practice-Based Research Network Joseph L. Riley III, Valeria V. Gordan, Susan E. Hudak-Boss, Jeffery L. Fellows, D. Brad Rindal and Gregg H. Gilbert JADA 2014;145(4):355-362 10.14219/jada.2013.32 The following resources related to this article are available online at jada.ada.org (this information is current as of June 29, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/4/355
This article cites 47 articles, 10 of which can be accessed free: http://jada.ada.org/content/145/4/355/#BIBL Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx
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ARTICLE 4
Concordance between patient satisfaction and the dentist’s view Findings from The National Dental Practice-Based Research Network Joseph L. Riley III, PhD; Valeria V. Gordan, DDS, MS, MS-CI; Susan E. Hudak-Boss, DMD; Jeffery L. Fellows, PhD; D. Brad Rindal, DDS; Gregg H. Gilbert, DDS, MBA; for The National Dental Practice-Based Research Network Collaborative Group
T
he results of a number of studies have shown that the quality of the affiliation between dentist and patient is important to patients.1 In addition, patient satisfaction increasingly is seen as an essential element in assessments of the quality of oral care.1 Nonetheless, patient satisfaction is multifaceted and constitutes a complex set of objective and subjective elements.1-3 A large aspect of this relationship involves communication, and investigators in studies consistently have reported that the quality of dentist-patient communication is related closely to patient satisfaction.4-9 Studies of the extent to which patients prefer to be involved in decision making are common in medicine,10 but investigators in few studies have examined this for the practice of dentistry. Furthermore, research findings have shown that health care providers generally are poor judges of patients’ actual preferences,11,12 in part because patients often are unable or unwilling to express their expectations and needs.13,14 Several investigators have suggested that satisfaction Dr. Riley is a professor, Department of Community Dentistry and Behavioral Sciences, College of Dentistry, University of Florida, Gainesville. Dr. Gordan is a professor, Department of Restorative Dental Sciences, Operative Dentistry Division, College of Dentistry, University of Florida, Gainesville, e-mail [email protected]. Address correspondence to Dr. Gordan. Dr. Hudak-Boss is in private practice in Seminole, Fla. Dr. Fellows is an investigator, Center for Health Research, Kaiser Permanente Northwest, Portland, Ore. Dr. Rindal is a practitioner in the HealthPartners Dental Group, Minneapolis, and an investigator at the HealthPartners Institute for Education and Research, Minneapolis. Dr. Gilbert is a professor and the chair, Department of Clinical and Community Sciences, School of Dentistry, University of Alabama at Birmingham.
abstract Objectives. In this study, the authors examined the dentist’s view of the patient’s experience and concordance with the patient’s rating of satisfaction. Methods. Practitioners from 197 practices in The National Dental Practice-Based Research Network recruited consecutively seen patients who had defective restorations that were replaced or repaired. At the end of the dental visit, the treating dentist and 5,315 patients completed and returned a survey that asked about the patient’s satisfaction. Results. Most dentists viewed their patients as having been satisfied with the treatment experience (n = 4,719 [89 percent]) and as having perceived them as friendly (n = 5,136 [97 percent]). Dentists had less strong feelings about whether patients had a preference for the restorative material (n = 2,271 [43 percent]) or an interest in obtaining information about the procedure (n = 1,757 [33 percent]). Overall, patients were satisfied, and most of the time dentists correctly predicted this outcome. Among patients who were less than satisfied, there was a substantial subset of cases in which dentists were not aware of this dissatisfaction. Conclusion. For improved patient-centered care, dentists should assess patients’ desires, expectations and perceptions of the dental care experience and then manage or correct the expectations and perceptions as needed. Practical Implications. By taking a patientcentered approach, dentists should seek to understand how patients evaluate and rate the services provided, thereby enabling them to focus on what each patient values most. Key Words. Access to care; behavioral sciences; community dentistry; consumer satisfaction; dental care utilization; public opinion; dentist-patient relations; patient affect; patient relations; professional-family relations. JADA 2014;145(4):355-362. doi:10.14219/jada.2013.32 JADA 145(4) http://jada.ada.org April 2014 355
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with one’s dentist can facilitate stress reduction, which may, in turn, promote further satisfaction.8,15,16 Consistent with this finding, researchers in several studies have highlighted the importance that patients give to dentists’ willingness to discuss patients’ fears and perceived pain.8,15,16 By inference, when complications occur or when the patient is in pain and experiencing significant anxiety, the dentist should realize that without proper management of the patient’s care, the patient’s overall experience and satisfaction could be affected negatively. Thus, assessing patients’ perceptions of the dental experience is important to ensure that patients’ expectations are consistent with the services to be performed. Because few researchers have examined patients’ satisfaction with regard to specific dental procedures, it is possible that dentists err in their assumptions. We report findings from participants in The National Dental Practice-Based Research Network (the “network”), a consortium of dental practices and dental organizations focused on improving the scientific basis for clinical decision making.17 The network was funded in 2012 and builds on the former regional dental networks, including the Dental Practice-Based Research Network18 (DPBRN), that existed from 2003 to 2012. The DPBRN was established in 2003 with a seven-year grant from the National Institute of Dental and Craniofacial Research, National Institutes of Health. The data for this study were collected under the auspices of the DPBRN. That organization subsequently evolved into The National Dental PBRN, under the aegis of which we prepared the manuscript of this article. At the time of this study, the network was composed primarily of clinicians from five regions: Alabama/ Mississippi; Florida/Georgia; dentists in Minnesota, either employed by HealthPartners in Bloomington, Minn., or in private practice; Permanente Dental Associates, in cooperation with Kaiser Permanente’s Center for Health Research in Portland, Ore.; and dentists from Denmark, Norway and Sweden. The network has a wide representation of practice types, treatment philosophies and patient populations, including diversity regarding race, ethnicity, geographical location and rural/urban area of residence of practitioners and their patients. Analyses of these characteristics confirm that network dentists have much in common with dentists at large,19 while offering substantial diversity with respect to these characteristics.20 We were unable to find any studies in which researchers examined the extent to which dentists understood their patients’ views or experiences during a restorative procedure. Making use of the diversity of patient and practitioner characteristics in the network, we sought to build on our earlier study2 in which we found that patient satisfaction comprised three components: interpersonal relationship-comfort factors, material choice-value factors and sensory-evaluative factors.
Therefore, the aim of this study was to examine the dentist’s view of the patient’s experience and concordance with the patient’s rating of satisfaction by using specific areas of a restorative dental visit that are important to patients. In particular, we focused on the extent to which dentists were aware of patients’ viewpoints when patients did not report being satisfied. We also tested the hypothesis that certain practice, patient and procedural variables were associated with dentists’ lack of awareness. METHODS
Network dentists. We recruited network practitioners through continuing education courses, mass mailings to licensed dentists within the participating regions or both. As part of the eligibility criteria, all dentists completed an enrollment questionnaire describing their demographic and practice characteristics and certain personal characteristics; completed an assessment of caries diagnosis and caries treatment questionnaire; completed training in human participants’ protection; and attended a network orientation session with the regional coordinator in their practices. The institutional review boards of the participating regions approved the study. Recruitment and data collection. The overall project involved collecting data regarding the restoration procedures, assessing patient satisfaction with the restorative visit and conducting a longitudinal follow-up of the restorations. Each participating dentist (n = 197) recruited consecutively seen patients who had defective restorations that were replaced or repaired in the treatment of permanent teeth. Practitioners obtained written informed consent from patients before the study procedures took place. Each participant received the satisfaction survey form, along with a stamped envelope, and was instructed to complete the survey the following day. Patients mailed the completed satisfaction survey directly to the network regional coordinators to ensure that dentists remained masked to patient satisfaction ratings. Once the patient questionnaire was received, a network staff member mailed to the participant as compensation either $10 or a gift bag of the same value. At the end of the dental restorative procedure, the dentist completed a form about the visit and forwarded it to the regional center. Data from this form are the focus of this report. Two dentists did not provide complete data and were not included in the study. Measures. The survey development was an iterative process in which we began by interviewing 15 patients who had had a recent restorative visit and 16 practicing dentists about specific characteristics of tooth restoration visits that are important to patients. We designed the preliminary set of questions and field-tested it among nine ABBREVIATION KEY. DPBRN: Dental Practice-Based Research Network. LGP: Large group practice. PHP: Public health practice. SGP: Small group practice.
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dentists and 39 patients who had had a restoration-related dental visit within the previous year. The final patient instrument, which consisted of 20 items, is described in detail elsewhere.2 We also developed a dentist version that asked about selected aspects of the treatment and visit. In this study, we focused on items from the dentistcompleted questionnaire, which was designed to assess the dentist’s view of the patient’s experience. In addition, we compared the answers on this questionnaire with patients’ responses to the following subset of statements or questions about their level of satisfaction with their dental treatment and visit: dOverall, how satisfied were you with all aspects of your dental treatment and visit?; dthe friendliness of my dentist; dhow my dentist gave me a choice between different materials to fix my tooth; dhow the dental procedure was explained before it was started; dhow my dentist limited pain during the procedure; dhow my dentist tried to limit my fear and anxiety. Response choices for the first item were “not at all satisfied,” “slightly satisfied,” “moderately satisfied,” “very satisfied” and “extremely satisfied.” Response choices for the remaining items were “strongly disagree,” “disagree,” “neither agree nor disagree,” “agree” and “strongly agree.” Data analysis. We dropped from further analysis those patients’ questionnaires with missing items. For the concordance analysis, we recoded responses to the satisfaction statements from patients so that responses of “agree” and “strongly agree” were classified as “satisfied” and “strongly disagree,” “disagree” and “neither agree nor disagree” were classified as “not satisfied.” Similarly, we recoded dentists’ responses on the dentist survey as “agree” (includes “somewhat agree” and “strongly agree”) and “did not agree” (includes “strongly disagree,” “somewhat disagree” and “neither agree nor disagree”). We used a binary logistic model, with generalized estimating equations, to adjust for clustering within dental practices and restorations within patients to examine practice, patient and procedure variables as predictors of dentists’ awareness of their patients’ views. We tested prediction models when the patient was “not satisfied.” This model is based on the premise that a satisfied patient is the intended outcome, and practice changes are not indicated. A dentist’s awareness of the patient who is not satisfied is the scenario that has implications for improving clinical practice and, therefore, is the focus of this report. Details of patients’ satisfaction ratings are reported elsewhere.2 We used a backward elimination approach to remove the least significant index variable from the model in subsequent steps until all remaining variables were significant at P < .10 for retention.21 We categorized dentists associated with Permanente Dental Associates or HealthPartners in the large group practice (LGP) model.
TABLE 1
Characteristics of dentists and patients. CHARACTERISTIC
NO. (%* ) †
Dentists’ Characteristics (n = 195) Sex (male)
137 (70)
Mean (SD ‡ ) years since dental school graduation
22.4 (10.5)
Mean (SD) percentage of time spent on nonimplant restorative care (missing data = 12)
60 (20)
Practice model Small group practice (includes solo)
110 (56)
Large group practice
72 (37)
Public health practice
13 (7)
Practices according to region Alabama/Mississippi
39 (20)
Florida/Georgia
44 (23)
Permanente Dental Associates
40 (21)
HealthPartners and private practitioners in Minnesota
36 (18)
Scandinavia (Denmark, Norway, Sweden)
36 (18)
Patients’ Characteristics (n = 5,315) Sex (male)
2,206 (42)
Mean (SD) age, in years
52.4 (15.5)
Race/ethnicity (missing data = 94 [2 percent]) Hispanic
605 (11)
White
4,179 (79)
African American
261 (5)
Other
176 (3)
Patients treated, according to practice model Small group practice (includes solo)
3,248 (61)
Large group practice
1,807 (34)
Public health practice
260 (5)
No. of restorations per patient (total no. of restorations = 8,213) One
4,064 (77)
Two
941 (18)
Three
224 (4)
Four
86 (2)
Patients with dental insurance
1,175 (22)
* Percentages may not total 100 because of rounding. † Unless otherwise specified. ‡ SD: Standard deviation.
Regional coordinators assigned other practices to one of two categories: solo private practice or small group practice (SGP) (fewer than four dentists) or public health practice (PHP). Other variables in the models were as follows: ddentist’s ratings of the negative consequences associated with treatment (complications, pain or anxiety); dwhether the treatment was a replacement or repair; JADA 145(4) http://jada.ada.org April 2014 357
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(http://nationaldental pbrn.org/peer-reviewedpublications.php). SURVEY ITEM NO. (%) OF PATIENTS Table 2 shows the (n = 5,315) * distribution of response Strongly Somewhat Neither Somewhat Strongly choices for each of the Agree Agree) Agree Nor Disagree Disagree No. (%) No. (%) Disagree No. (%) No. (%) dentists’ questions. DenNo. (%) tists tended to view their Overall Satisfaction With All 1,721 (32) 2,998 (56) 559 (11) 36 (< 1) 1 (< 1) patients as satisfied with Aspects of Dental Treatment their treatment experience and Visit† (n = 4,719 [89 percent]) The Patient Perceived Me 2,900 (55) 2,236 (42) 161 (3) 9 (< 1) 9 (< 1) As Friendly and as having perceived The Patient Had a Strong 916 (17) 1,355 (26) 2,225 (42) 465 (9) 354 (7) them as friendly (n = 5,136 Preference for the Restorative [97 percent]). They had Material I Used Today less strong feelings about The Patient Was Interested 367 (7) 1,390 (26) 2,486 (47) 768 (14) 304 (6) whether patients had a in Information About the Restorative Procedure preference for the restorThe Filling Procedure Was 46 (< 1) 558 (11) 540 (10) 1,506 (28) 2,665 (50) ative material to be used Painful for the Patient Today (n = 2,271 [43 percent]) The Patient Was Anxious 215 (4) 745 (14) 822 (16) 1,328 (25) 2,205 (42) or an interest in informaDuring the Restorative tion about the procedure Procedure Today (n = 1,757 [33 percent]). The Restoration Procedure 3,559 (67) 1,388 (26) 167 (3) 160 (3) 41 (< 1) Went Without Complications Dentists agreed that the * Percentages may not total 100 because of rounding. procedure was painful for † Response choices for this item were as follows: extremely satisfied, very satisfied, moderately satisfied, 604 patients (11 percent) slightly satisfied and not at all satisfied. and that 960 patients (18 percent) were anxious dwhether the treating dentist placed the original during the procedures. They considered the procedures restoration; to have been without complications for 4,947 patients ddentist’s sex; (93 percent). dyears since dental school graduation; Dentists’ awareness when patients were not satdoriginal and new restorative materials; isfied. This series of analyses examined agreement dtooth involved (coded as molar versus premolar between the patient’s response and the dentist’s percepand anterior); tion of the patient’s experience. We combined the data to dnumber of surfaces involved; create three categories: satisfied, meaning that the patient dwhether the patient had dental insurance; is satisfied; not satisfied–aware, meaning that the dentist dpatient’s age; correctly identified the patient’s lack of satisfaction; and dpatient’s sex. not satisfied–unaware, meaning that the dentist was unaware of the patient’s dissatisfaction. Table 3 shows RESULTS the concordance between the dentist’s responses and the Network dentists returned completed restorative treatpatient’s responses. ment data forms for 7,286 patients enrolled in this study. Overall satisfaction. For the overall satisfaction quesThe network regional coordinators received a total of tion, 4,589 patients (86 percent) rated themselves as sat5,879 surveys from these patients (for a compliance rate isfied or very satisfied (Table 3). Among the 726 patients of 81 percent). Of these patients, 90 percent (n = 5,315) who were not satisfied, dentists were aware in only 42 had completed all of the survey items and provided the cases (1 percent) and unaware in 684 cases (13 percent). data used in this report (dentist and patient characterisNone of the patient or dentist variables was associated tics are presented in Table 1). Included are a total of 8,213 with the dentist’s awareness in cases in which the patient restorations. Patients who failed to complete all items was not satisfied. were older (mean [standard deviation {SD}] age, 58.6 Dentist’s friendliness. Regarding the question about [15.6] years) than those who completed all survey items the dentist’s friendliness, 4,861 patients (91 percent) rated (mean [SD] age, 52.4 [15.5] years) and more likely to have themselves as satisfied. For the 454 patients who were been seen in a PHP (13 percent) compared with an SGP not satisfied with the friendliness of the dentist, only (8 percent) or LGP (7 percent). Additional informa37 dentists (1 percent) correctly identified the patients’ tion related to patient compliance (as well as the dissatisfaction (that is, aware), whereas for 417 patients study’s data collection forms) is available online (8 percent), dentists responded incorrectly that they had TABLE 2
Dentist’s viewpoint of the patient’s experience.
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been perceived as friendly TABLE 3 (that is, unaware). None Concordance between the dentist’s and patient’s of the patient or dentist responses. variables were associated VARIABLE PATIENT SATISFIED PATIENT NOT SATISFIED with the dentist’s awareNO. (%) NO. (%) ness in cases in which the Agreement— Disagreement— patient was not satisfied Dentist Aware* Dentist Not Aware † with the dentist’s Overall Satisfaction 4,589 (86) 42 (1) 684 (13) friendliness. Dentist’s Friendliness 4,861 (91) 37 (1) 417 (8) Information about Information About Procedure 3,701 (70) 947 (18) 667 (13) procedure. For the quesMaterial Choice 3,396 (64) 736 (14) 1,183 (22) tion regarding informa* The dentist’s response is congruent with the patient’s response (for example, the patient was not satisfied tion about the procedure, with the dentist’s friendliness, and the dentist responded that the patient did not perceive him or her as 3,701 (70 percent) of friendly). † The dentist’s response is not congruent with the patient’s response (for example, the patient was not satisthe 5,315 patients rated fied with the dentist’s friendliness, and the dentist responded that the patient did perceive him or her as themselves as satisfied. friendly). For the 1,614 patients who were not satisfied, dentists correctly perceived 947 patients (18 percent) as However, little information has been collected about having an interest in information about the restorative dentists’ views of their patients’ experiences or patients’ procedure and incorrectly perceived 667 patients (13 overall satisfaction with dental treatment. We found that most dentists believed their patients viewed them as percent) as not having an interest. Among patients who friendly and were satisfied. However, in cases in which were not satisfied, dentists were more likely to be aware patients were not satisfied, dentists seldom were aware. that the patient was interested in information about We also found large discrepancies between patients’ lack the restorative procedure if the dentist was in a private of satisfaction with regard to several domains of commupractice model (that is, SGP or LGP) (odds ratio [OR] = 0.8; 95 percent confidence interval [CI], 0.6-0.9); the nication and dentists’ awareness of their patients’ desires, dentist had not placed the original restoration (OR = 1.3; suggesting that some dentists need to better assess their patients’ expectations with regard to a treatment visit. 95 percent CI, 1.1-1.5); the dentist was female (OR = 1.7; Regardless of patients’ viewpoints, if they were satis95 percent CI, 1.2-2.4); multiple surfaces were involved (OR = 1.2; 95 percent CI, 1.1-1.3); the restoration was in fied, we presume that their desires and expectations were a molar tooth (OR = 1.2; 95 percent CI, 1.1-1.4); or there met. Even if the dentist was not aware of the patient’s were complications during the procedure (OR = 1.4; 95 needs, yet met or exceeded them, we arbitrarily defined percent CI, 1.1-1.6). this as a desired outcome. Therefore, we focused on Restorative material choice. For the question perthe dentist’s view of the patient’s experience during the taining to material choice, 3,396 (64 percent) of the 5,315 restorative visit when the patient was not satisfied. The patients rated themselves as satisfied. For the 1,919 padentist could be aware or unaware of the patient’s distients who were not satisfied, dentists correctly perceived satisfaction. A dentist who is aware of a patient’s lack of 736 patients (14 percent) as having a strong preference satisfaction but does not address it may lack the skills, for the restorative material and incorrectly perceived time or interest to rectify the situation. Nothing can be 1,183 patients (22 percent) as not having a strong preferdone when a dentist is not aware, regardless of the denence. Among patients who were not satisfied, dentists tist’s intention. Thus, the dentist needs to do a better job were more likely to be aware that the material choice was of perceiving the patient’s expectations and desires with important if the dentist was female (OR = 1.3; 95 percent respect to treatment.22 Little attention has been paid to this distinction. CI, 1.2-1.5); the patient was female (OR = 1.4; 95 percent Overall satisfaction. Overall, patients were satisfied CI, 1.1-1.7); the procedure involved a replacement reswith dental treatment and the visit, and dentists correctly toration (OR = 1.3; 95 percent CI, 1.1-1.7); or there were predicted this outcome most of the time. Among the 726 complications (OR = 1.4; 95 percent CI, 1.1-1.6). Dentists patients who were not satisfied, there was a substantial were less likely to be aware of patients’ dissatisfaction if subset of cases (684 [94 percent]) in which dentists were the replacement material was composite (OR = 0.2; not aware. This survey measure asked about overall 95 percent CI, 0.1-0.3). satisfaction with all aspects of the treatment and visit; DISCUSSION consequently, we do not know the specific nature of the Researchers in a number of studies have documented dissatisfaction. Dental patients seek not only technical patient ratings of satisfaction with their dentists, with competence in a dentist but also interpersonal skills to dental care in general or with their last dental visit.1 reduce their anxiety and, ultimately, to be satisfied with JADA 145(4) http://jada.ada.org April 2014 359 Copyright © 2014 American Dental Association. All Rights Reserved.
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the visit.23,24 Experiencing anxiety during dental treatment is a common problem,25 and fear of pain is one of the most commonly cited factors associated with dental anxiety.26 On the basis of dentists’ reports, approximately 18 percent of patients in this study experienced anxiety, and for 12 percent, the procedure was painful. Surprisingly, pain and anxiety, as reported by the dentists, were not associated with patients’ reports of overall satisfaction. We speculate that because patients understood the potential for negative experiences (such as pain) during dental treatment and because of other overriding positive factors, such as a high level of rapport and trust, patients were satisfied with the treatment and dental visit. Relationship factors. The results of studies of patient-physician encounters generally show that patient-caregiver pairs more frequently were similar in affiliation than they were on other dimensions, with both groups expressing friendliness and cooperation, including greater nonverbal ‘‘interaction synchrony.’’10 In our study, patients overwhelmingly reported that their dentists were friendly.2 Ross and Duff27 also found that dentists generally were friendly, but that when patients were not satisfied with the dentist’s friendliness, the dentists often misinterpreted the patient’s preferences for treatment. Dentists in our study also perceived themselves as friendly, agreeing with the friendliness statement for 97 percent of the restorative visits. As with the overall satisfaction rating, when patients were not satisfied, dentists seldom were aware. None of the practice, patient or procedure variables were associated with accurately predicting the dentist’s awareness of a patient’s lack of satisfaction with their friendliness. Communication. One finding from this study involved direct communication between dentist and patient (that is, the information provided by the dentist about the procedure before it started and the patient’s having input into the choice of restorative material). Ratings of satisfaction among dental patients were considerably lower for these measures than they were for other measures. In addition, although the percentages for dentists’ lack of awareness were lower than those for the satisfaction or friendliness variables, misunderstanding their patients’ level of interest occurred at a higher frequency for the dentist-patient communication behaviors. Our finding is consistent with those of studies in which investigators compared patients’ views of ideal and actual behaviors of dentists.28-30 In these studies, the largest discrepancies occurred for the communicative and informative factor. We speculate that because dentists are so familiar with the restorative procedures, they forget the importance of explaining them to patients. Network dentists rated patients’ interest in information as relatively low, with only 33 percent agreeing with the statement that the patient was interested in information about the procedure. A dentist’s misinterpretation of the patient’s interest could explain why patients’ satisfac-
tion was relatively low (70 percent). It is surprising that when patients were not satisfied, dentists more often than not were aware of this dissatisfaction. This finding supports an assumption that dentists either did a poor job of communicating or made a conscious decision not to provide more details of the procedure or provide a review of the details already covered. Our study findings show that when the restorative procedure involved complications, dentists were more likely to be aware of the patient’s interest in information. Similarly, awareness among dentists was more likely if the procedure involved multiple surfaces or was performed on a molar tooth, both situations making for more complicated cases. Consequently, in situations involving higher risk, dentists appeared to take greater care to review with the patient what might occur than they did for simpler procedures. A lack of awareness of the need for information also was associated with the dentist’s having placed the original restoration. One possible explanation is that with long-time patients, dentists presumed that patients simply trusted them and no explanation was needed.31 Patients were least satisfied with respect to having a choice regarding the restorative material. Moreover, dentists often were not aware of their patients’ lack of satisfaction. Dentists’ awareness was associated with the procedure having been a replacement and involving complications. As discussed earlier, dentists may have been more likely to cover restorative materials with patients in more complex cases. Our study findings show that more dentists were aware of patients’ interest in the material choice when the original restorative material was an amalgam, but awareness was not associated with the choice of replacement material. We should note that amalgam was not the main restorative material used for either repairs or replacements, and dentists were much more likely to replace the restoration when the original restoration was amalgam.32 There was an interesting finding related to the sex of the dentist. Male dentists were less likely than female dentists to be aware of the importance to patients of both procedural information and a discussion of the restorative material choices. There are two possible explanations, which are not mutually exclusive. The first is related to sex differences in health care provider communication patterns. Research findings indicate that female providers generally conduct longer consultations with patients, provide more information and are more explicitly reassuring and encouraging than are male clinicians.33-35 Second, study findings show that both male and female patients often vary their responses depending on the clinician’s sex.36,37 In addition, the sex makeup of the patient-provider dyad may influence overall patient satisfaction.38 A patient sex difference effect also occurred, but only for the restorative material choice variable, as dentists were less likely to be aware of dis-
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satisfaction when the patient was male. Evidence shows that health care providers may provide more information and support to female patients, not because of presumptions about the health care needs of women, but because female patients express their feelings, concerns and questions more openly.39 Patients’ involvement. Findings from research among physicians indicate little agreement between patients’ and physicians’ perceptions of the physicianpatient relationship.33,40,41 Dentists have reported that they are aware of patients’ preferences regarding treatment42,43; however, our results suggest that often they are not aware. The results of several reviews indicate that patients vary in the extent to which they want to be involved in their health care, with some patients wishing to become active in treatment decision making and others preferring to adopt a more passive role.44-46 Neufeld and colleagues47 found that increasing patients’ knowledge of available options increased their willingness to participate in treatment decisions, but when a mismatch occurred, it involved patients who had less active roles than they preferred.10 It is possible that the patients in our study, as has been documented in other studies, failed to match their desire for information and participation in decision making with their overt behavior (that is, communicating clearly with the dentist).13,48 CONCLUSIONs
The primary finding of this study was that when dental patients were not satisfied with some aspect of restorative treatment or the visit, dentists often were unaware of it. This was most common with regard to patients’ desire for greater communication and, surprisingly, occurred most often during less complicated restorative procedures. The main implication is that for improved patient-centered care, dentists need to determine patients’ desires, expectations and perceptions of the dental care experience and then manage the care of patients or correct behavior as needed for all cases. Reaching a mutual understanding of the nature of the problem and its solutions requires dynamic communication during dental visits. It appears that for some dentist-patient dyads, this does not occur. n Disclosure. None of the authors reported any disclosures. This work was supported by grants U01-DE-16746, U01-DE-16747 and U19-DE-22516 from the National Institutes of Health, Bethesda, Md. Opinions and assertions contained herein are those of the authors and are not to be construed as necessarily representing the views of the respective organizations or the National Institutes of Health. All participants in this investigation provided informed consent after receiving a full explanation of the nature of the procedures. The National Dental Practice-Based Research Network Collaborative Group includes practitioners, faculty and staff investigators who contributed to this network activity. A list of these people is available at http:// nationaldentalpbrn.org/collaborative-group.php under the title “Patient satisfaction with dental restorations.”
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