Patient Satisfaction Surveys in Dental School Clinics - Semantic Scholar

Review Article

Patient Satisfaction Surveys in Dental School Clinics: A Review and Comparison Arezoo Ebn Ahmady, PhD; Mina Pakkhesal, DDS, PhD; A. Hamid Zafarmand, DDS, MSD, PhD; Harry Alan Lando, PhD Abstract: Health care is becoming more patient-centered and, as a result, patients’ experiences of care and assessment of satisfaction are taken more seriously. Patient satisfaction influences treatment cooperation, and better cooperation leads to healthier patients in the long term. This generalization clearly applies in the dental school clinic setting. Furthermore, dental school clinics’ administrators and clinicians should know about the dimensions of their patient satisfaction in order to provide the highest quality of care. The aim of this study was to review studies published between 1980 and March 2014 to identify the dimensions used to measure patients’ satisfaction when they receive services in dental school clinics. The PubMed database was used to access published studies using patient satisfaction surveys in dental school clinics, and the dimensions used in these surveys were then categorized. Through several stages of searching in PubMed, the authors selected 41 articles from a total of 730; after further critical appraisal, nine articles were retained. Five dimensions included in patient surveys were identified: quality, interaction, access, environment, and cost. Determining the dimensions used in patient satisfaction surveys in dental school clinics can assist academic dental institutions in providing the highest quality of care. Dr. Ebn Ahmady is Associate Professor, Community Oral Health Department, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran; at the time of this study, Dr. Pakkhesal was a PhD candidate, Community Oral Health Department, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran; Dr. Zafarmand is Associate Professor, Community Oral Health Department, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran; and Dr. Lando is Professor, Epidemiology and Community Health Department, School of Public Health, University of Minnesota. Direct correspondence to Dr. Mina Pakkhesal, Community Oral Health Department, Dental School, Shahid Beheshti University of Medical Sciences, Daneshjoo Blvd., Evin City, Tehran, Islamic Republic of Iran 1983963113; [email protected]. Keywords: dental education, dental school, dental school clinics, patient satisfaction Submitted for publication 6/7/14; accepted 9/3/14

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atient satisfaction is regarded as an important outcome of care and is one of the major factors that contribute to better patient compliance and consequently to improved clinical outcomes.1 Today, health care is being transformed from a providercentered approach to a patient-centered approach in which satisfaction of the patients’ needs is part of the definition of quality.2 Hence, a commitment to providing high-quality service and to achieving patient satisfaction is important for the oral health care provider.3 As teaching facilities, dental school clinics must constantly strive to find a balance between meeting the needs of the patient and meeting the needs of the student, all the while knowing that “patients and their satisfaction are critical to the education of our students.”4 Also, dental school clinics play a prominent role in promoting oral health care. Furthermore, in a dental school setting, the focus on meeting requirements for graduating must be balanced with patients’ satisfaction. Though both care 388

providers and patients benefit from their interaction, patient satisfaction is prioritized. In other words, educational and clinical experience gained by academic dental care providers should be patient-centered.4 Kotler defined satisfaction as “a person’s feeling of pleasure or disappointment resulting from comparing a product’s perceived performance or outcome in relation to his or her expectations.”5 One study regarding patient satisfaction concluded that satisfaction is a multidimensional concept addressing many aspects of care.6 Though the dimensions differ slightly, our research emphasizes that since satisfaction is multidimensional, patients can be satisfied with some areas of care but not with others. Despite the fact that there was a great degree of commonality among the dimensions explored in these studies, no one standardized survey instrument was generally employed. This appears to be especially so in the case of satisfaction with dental school clinics. The findings from these clinics may Journal of Dental Education ■ Volume 79, Number 4

not be adapted to another setting as every health care setting is unique. Thus, we decided to review the surveys used at dental school clinics. Although a number of patient satisfaction studies were conducted in the 1960s and 1970s, social, business, and professional environments have changed dramatically since then. This review therefore focuses only on studies conducted between 1980 and March 2014. According to Lafont et al., there is very little in the literature about patient satisfaction in a dental school setting.4 Those authors also noted that, unfortunately, “while there is vast literature describing patient satisfaction with private providers, we know very little about what satisfies patients and how to attract them to academic health centers.” The aim of our study was to identify dimensions of patient satisfaction in dental school clinics that form a framework for further development of questionnaires in this area. Eventually, administrators could use these questionnaires in order to improve the quality of care provided in their clinics.

Methods Our study approach consisted of two phases. First, we used the PubMed database to identify studies done on patient satisfaction surveys in dental school clinics. Then, we categorized the dimensions used in those articles. Initially, we used PubMed to identify studies that evaluated patient satisfaction with dental school clinics. This database was searched for English-language articles published between 1980 and March 2014. The following combinations of keywords were used: patient satisfaction, dental school clinic, dimension, and dental school. We selected the questionnaires in the articles that had the following characteristics: standardized (i.e., all respondents should be asked identical questions, with questions being presented in the same order and with the same response formats); valid; reliable; multidimensional; generic rather than pertaining to a specific disease; and focused on the direct users’ attitudes towards dental care. The selected studies should not measure any of the following: non-patients’ satisfaction (e.g., university students, dental school staff, parents or caregivers of children); satisfaction related to specific dental treatments (e.g., prosthodontics, orthodontics, implants, esthetics); satisfaction limited to one gender; satisfaction in a special system or framework (e.g., the National Health System); satisfaction in private

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dental settings; or satisfaction with urgent oral care. Editorials, personal views, and lectures were also excluded. Following preliminary rater training on dimension analysis methods regarding dimensions definition, the raters were asked to categorize 18 dimensions that were extracted from patient satisfaction surveys in dental school clinics. The categorizing was done independently and without consultation. While dimension analyses were performed, interrater agreement (the extent to which independent raters evaluate a characteristic of variables and reach the same conclusion) was assessed for each category. Interrater agreement was evaluated for three raters by calculating kappa statistic. The range of interrater kappa was from 0.83 to 0.95, indicating a high level of agreement. The kappa statistic may range from -1 (perfect disagreement) to 1 (perfect agreement). When a variation in the categorizing occurred, the principal investigator resolved any disagreement between the two reviewers by discussion and made the final decision. After collecting the dimensions from the eligible articles, we categorized them. This resulted in five main dimensional categories from the 18 collected dimensions inventory obtained from the nine selected articles.

Results The results of the primary search in PubMed identified 730 articles through the following keywords: dent*[ti] OR oral*[ti]; satisfaction*[ti] OR expect*[ti] OR percept*[ti] OR desir*[ti]; and patient*[ti/ab] OR custom*[ti/ab] OR consum*[ti/ ab] OR client*[ti/ab]. After that, we excluded 450 articles that used the following words in their titles and did not support our purpose: denture, implant, job, occupation, student, child, elder, cancer or carcinoma, women, contraceptive, HIV, present, pain, esthetic, anesthesia, surgery, peridont, orthodont, prosthodont, restorat, pediatric, teeth or tooth, facial, arch, edentul, parent, overdenture, anxiety, stress, hygienist, and wear. We next applied additional filters that selected English-language articles published between 1980 and March 2014, with available abstracts. These procedures resulted in 280 articles. Then, we excluded surveys implemented in other dental settings unless these were dental school clinics. We retained 76 articles after using this strategy. Subsequently, from these articles we selected those that had one of the following words in their titles or

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abstracts: dimension, item, factor, or variable. After this stage, we retained 41 articles. Finally, after two reviewers critically appraised the abstracts to exclude articles about specific groups, nine articles were retained (Table 1). The excluded articles focused on specific ages, specific ethnic

groups, specific income groups, specific payment systems, specific health care systems and public dental services, emergency oral health care, and studies that did content analysis using open-ended questionnaires. The total search strategy and results are shown in Figure 1.

Table 1. Nine articles included after critical appraisal First Author

Year

Country

Study Population

Questionnaire

Dimensions

1

Lafont

1999

United States

Louisiana State University School of Dentistry

N/A

Facility Services received Treatment received

2

White

2001

South Africa

Patients attending dental training hospital

Modified version of Parasuraman SERVQUAL model

Reliability Tangibles Responsiveness Empathy Assurance

3

Karydis

2001

Greece

200 adult patients of dental clinic, University of Athens

Quality

Assurance Empathy Reliability Responsiveness

4

Sakalauskiene

2005

Lithuania

53 adult patients visiting dental clinics at Kaunas University

Pilot questionnaire

Professional competence of dentist Personality of dentist Organization of dental surgery (availability, access, equipment, fees)

5

Hashim

2005

United Arab Emirates

135 patients with dental services at Ajman University

DSQ

Access Convenience Quality

6

Imanaka

2007

Japan

Patients of dental hospital of Tsurumi University

Construct questionnaire for dental school setting

Facilities Treatment Communication Staff appearance

7

Orenuga

2009

Nigeria

100 patients at Lagos University Teaching Hospital

Modified DSQ

Pain management Accessibility Quality Availability/convenience Cost

8

Adeniyi

2013

Nigeria

Lagos State University Dental Clinic

Modified DSQ


9

Lopez-Garvi

2014

Spain

217 patients attending dental clinic of University of Valencia

DSQ


DSQ: Dental Satisfaction Questionnaire Note: See references for full source information for articles.

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Initial search in PubMed N=730

Excluded articles that used inapplicable words in their titles N=450

Included eligible articles N=280 Excluded surveys in other dental settings and additional filters N=204 Included based on dental school clinics with defined additional filters N=76 Excluded based on lack of dimensions N=35 Included with dimensions N=41 Excluded based on critical appraisal N=32 Included after critical appraisal N=9 Figure 1. Search strategy and results

The articles that fulfilled all of the selection criteria were analyzed to identify the assessed dimensions of satisfaction. An 18-dimension list was developed from the nine articles, and those dimensions were then organized into five main categories (Table 2): 1) quality (technical competence, treatment received, reliability, responsible, assurance, professional competence of dentist, pain management, etc.); 2) interaction (information, communication, understanding, acceptance, tangible, empathy, personality of dentist and interpersonal factors, etc.); 3) access (availability, accessibility, convenience, organization of dental surgery, etc.); 4) environment (staff appearance, services received, facilities, etc.); and 5) cost.


Discussion Patient satisfaction is a multidimensional concept, and each study addressed some of the relevant dimensions. For more than three decades (from 1980 to 2014), many studies assessed satisfaction with dental care, attempting to determine factors that motivate patients to seek dental treatment.4,7-14 In our study, we analyzed the dimensions used to assess patient satisfaction in dental school clinics and identified five main categories: quality, interaction, access, environment, and cost. It is clear that understanding the dimensions used in patient satisfaction studies is important. They can help dental school

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Table 2. Description of categories and identified dimensions related to dental school patients’ satisfaction Category

Identified Dimensions Inventory

Quality

• Treatment received • Reliability • Responsiveness • Assurance • Professional competence of dentist • Pain management

Interaction

• Tangible • Interpersonal factor • Empathy • Personality of dentist

Access

• Availability • Accessibility • Convenience • Organization of dental surgery

Environment • Staff appearance • Services received • Facilities Cost

• Cost

clinic decision makers collect comprehensive data concerning patient satisfaction for modifying service delivery to meet patient expectations, and they can help administrators actively manage patient expectations to ensure they coincide with the services to be provided. In this context, Lafont et al. asked whether the patient would recommend the school to others seeking dental care.4 A comparison of the selected articles showed that most of the surveys used the Dental Satisfaction Questionnaire (DSQ) for assessing patient satisfaction in dental school clinics.10,12-14 This questionnaire consists of the following dimensions: quality, accessibility, availability/convenience, pain management, and cost. The DSQ was developed by the Rand Corporation based on data from a health insurance study involving both metropolitan and low-income areas, although the use of the DSQ in general population studies is also supported by these results.15 Validation studies confirmed the internal consistency and reliability of the factor structure of this instrument. Skaret et al. used the DSQ, which was originally developed in the United States, for Norwegian populations.16 It is noteworthy that some dimensions such as interaction and quality were not mentioned in the DSQ. According to the Holt and

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McHugh study, the main reason for changing dentists among patients they surveyed was the dentist’s interpersonal attributes.17 In our study, we identified five main dimensions. White et al. and Karydis et al. used the SERVQUAL questionnaire to assess patient satisfaction.7,8 Parasuraman et al. and Parasuraman and Berry concluded that customers perceive service quality by comparing their expectations of performance to actual experience in five dimensions: reliability, tangibles, responsiveness, empathy, and assurance.18,19 This is why superior quality is desirable in the sensitive field of health care and why most authors suggest that satisfying patients should be a key task for all dental providers.20 The key to achieving this is in ensuring good service quality that meets or exceeds patients’ expectations.8 It is important to emphasize that these tools measure patients’ perception of quality and not the technical quality of the services provided. Also, these tools measure only the performance of services and not the cost. Finally, this study used revealed dimensions that should be attended to in developing questionnaires for assessing patient satisfaction and did not evaluate the importance of each dimension separately. The 1999 review article by Newsome and Wright found the same dimensions with another name.20 The results from our study indicate that other surveys carried out after their review followed the same dimensions on patient satisfaction and this was true even in the dental school clinics. The limitations of our study include using only one database and thus acknowledging that there may be some surveys we failed to access. Using additional databases to address our research questions may help to identify overlooked surveys and other dimensions in the future.

Conclusion This study extracted the dimensions that were used in studies of patient satisfaction surveys regarding dental school clinics. The information gained in this study was beneficial for the manager of the clinic to determine what dimensions should be assessed for strategic planning efforts. By satisfying patients, administrators increase the chance of attracting more patients and retaining existing patients and therefore create opportunities for dental students to obtain optimal clinical experiences.

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