that this would enhance future social and career opportunities for the patient. This belief was ..... on the marketing methods used by orthodontists.2 They also tangentially investigated factors ... cities of Dallas, Houston, and San Antonio. ... Edwards DT, Shroff B, Lindauer SJ, Fowler CE, Tufecki E. Media advertising effects on.
Factors Affecting Patient Selection of an Orthodontic Practice
Thesis
Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in the Graduate School of The Ohio State University
By
Craig Ross Elgin, D.M.D. Graduate Program in Dentistry
The Ohio State University 2012
Thesis Committee: Allen Firestone, Advisor F. Michael Beck Katherine Vig
Copyright by Craig Ross Elgin 2012
Abstract It is valuable for orthodontists to know what factors are important to prospective patients in selecting an office at which to begin treatment. Objective: To determine the relative importance placed upon different factors for selection of an orthodontic practice by prospective patients. Methods: In a previous study5, St. Louis et al. developed a patient questionnaire that was determined to be both valid and reliable (able to accurately measure the intended target repeatedly). Two versions of the questionnaire were developed: one for adult patients and one for parents of adolescent patients. Questionnaires were mailed to participating orthodontics offices where they were made available to prospective adult patients, and the parents of prospective adolescent patients, on their first visit to that office. Subjects returned completed surveys directly to the investigators. Data were analyzed by a repeated-measures analysis of variance (ANOVA) and the Tukey-Kramer procedure. Results: In total, 210 surveys were analyzed: 66 from adult patients and 143 from parents of adolescent patients. The 10 most important factors for all subjects were predominantly factors such as being made to feel comfortable, a caring attitude of the doctor/staff, clear communications from the doctor/staff, and a clean office. The 10 least important factors were predominantly “office amenities” (refreshments, play area, parties, school pick-up/drop-off, TV, Wi-Fi, video games, etc) and “doctor demographics” (age, gender, religion, and ethnicity of the orthodontist). Conclusion: Certain factors were consistently important, and others unimportant, for patient selection of an orthodontic practice.
ii
Dedication
Dedicated to my wonderful wife Sara and our amazing daughters, Mara and Fiona
iii
Acknowledgements
I would like to thank the following:
The offices and subjects who participated in this study
Brian St. Louis, Tamer Bedair, and colleagues, for conducting the pilot studies that made this one possible
My thesis committee, Allen Firestone, Katherine Vig, and Michael Beck, for their feedback and guidance during this endeavor
My research assistants, Caroline Pawlak and Rashelle Delli-Gatti, for their input and numerous contributions
Delta Dental for the research grant that funded this project
The faculty, staff, alumni, and patients of The Ohio State University, College of Dentistry, Section of Orthodontics, who provided me with the best orthodontic education available anywhere
My fellow residents, from whom I learned more than anyone
My family, for their boundless support and love
iv
Vita 2000 .............................. B.A., Mathematics and Computer Science, Lewis & Clark College 2009 .............................. D.M.D., Oregon Health & Science University 2009-2012 ..................... Resident, Graduate Orthodontics Program, The Ohio State University
Fields of Study Major Field: Dentistry Specialty: Orthodontics
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Table of Contents
Abstract .................................................................................................................... ii Dedication ............................................................................................................... iii Acknowledgements ................................................................................................. iv Vita .......................................................................................................................... v List of Tables ........................................................................................................... vii List of Figures .......................................................................................................... viii Chapter 1: Introduction and Literature Review ....................................................... 1 Chapter 2: Materials and Methods .......................................................................... 23 Chapter 3: Manuscript ............................................................................................. 27 Chapter 4: Conclusions ............................................................................................ 55 Appendix ................................................................................................................. 58 Bibliography ............................................................................................................ 72
vi
List of Tables
Table 1: ANOVA for parents of prospective adolescent patients ........................... 38 Table 2: ANOVA for prospective adult patients ...................................................... 38 Table 3: The Top 10 Most Important Factors for Each Subject Type ...................... 43 Table 4: The Bottom 10 Least Important Factors for Each Subject Type................ 44 Table 5: Questionnaire items for parents of prospective adolescent patients ...... 58 Table 6: Questionnaire items for prospective adult patients ................................. 61 Table 7: Responses for mothers of adolescent prospective patients ..................... 64 Table 8: Responses for fathers of adolescent prospective patients ....................... 66 Table 9: Responses for adult female prospective patients ..................................... 68 Table 10: Responses for adult male prospective patients ...................................... 70
vii
List of Figures
Fig. 1: Mothers of Prospective Adolescent Patients (124)...................................... 40 Fig. 2: Fathers of Prospective Adolescent Patients (17) .......................................... 40 Fig. 3: Female Adult Patients (57) ........................................................................... 41 Fig. 4: Male Adult Patients (12)............................................................................... 41
viii
Chapter 1: Introduction and Literature Review
For orthodontists currently practicing in the United States, the past several years have been unprecedented within their professional history. The “Great Recession” has brought with it declines in mean net practice income for the first time in at least 30 years, as reflected in the 2011 edition of the Journal of Clinical Orthodontics Practice Study.1 Furthermore, while hundreds of new orthodontists continue to graduate and enter into practice every year, many senior practitioners are remaining in practice longer, with the result that the population of practicing orthodontists continues to age.1
Many potential patients and their families have several orthodontic providers from whom to choose within a reasonable distance. Indeed, it appears that the trend to “shop around” at several offices before entering into treatment may be increasing – previous studies have put the figure at 30-41%.1,2
Particularly given the current practice climate, there is great need for the orthodontist to know how best to focus finite resources to maximize patient selection of his/her practice.
1
Fundamentally, before beginning treatment at a given office, prospective patients must meet four conditions21:
1. They must be aware that an orthodontic need exists.
2. They must have both the desire and the resources to pursue resolution of that need.
3. They must be aware of that particular practice and its ability to meet their need(s).
4. They must choose to be treated at that particular practice, over all others available.
Perception of orthodontic need and motivation for treatment
The perception of orthodontic need and the desire for its resolution via treatment are intimately linked and have been explored extensively in the literature.
In 1977, Doery et al. published the results of a survey conducted in the Saint Louis, MO area.8 The subjects consisted of “177 persons from the Saint Louis University orthodontic clinic, … 37 persons from the practice of a black orthodontist with a lower-middle-class clientele… [and] 85 persons from the upper-middle-class practice of a suburban white orthodontist.” The patients were mostly female, the decision for treatment was made mainly by the patient’s mother, and
2
the need for treatment was perceived as greater by the mother than by the child. The most important factor motivating treatment was the desire for improved appearance, with the belief that this would enhance future social and career opportunities for the patient. This belief was more prevalent among the “lower-middle-class” subjects, whom the investigators found “to be more child oriented and to have better relationships with their children.” The cost associated with treatment determined whether patients went to the university or to a private clinic; however, there were no differences in satisfaction with treatment.
Sheats et al. interviewed 1155 eighth-grade students in Alachua County, FL during orthodontic screenings at area middle schools in 1994 by the University of Florida Department of Orthodontics.9 In addition to clinical diagnostic information, investigators recorded the subjects’ perceptions of their dental appearance and desire for treatment. Twenty-five percent of interviewees had a history of previous orthodontic treatment; of the remainder, 74% were satisfied with their dental appearance, 64% felt no need for orthodontic treatment, and 57% were judged by clinicians to have “optional or no orthodontic needs.” Subject parameters associated with perceived treatment need were: sex, soft tissue profile, overjet, anterior crowding, and molar classification. Subject parameters of race and overbite had no significant association with perceived treatment need. Judgment of treatment need by the clinical investigators differed significantly from the subject’s satisfaction with their teeth. Overall, most of the untreated eighth graders were satisfied with their dental appearance and felt less need for orthodontic treatment than did the clinicians.
3
In a study published in 1999, Birkeland et al. examined orthodontic treatment uptake in Norwegian children between ages 11 (T1) and 14 (T2).10 At T1, 359 children and their parents answered separate questionnaires on their attitudes towards their (children’s) dentition and on several aspects of orthodontic treatment. Models were made and the subjects’ occlusions assessed using the Dental Health Component (DHC) and Aesthetic Component (AC) of the Index of Treatment Need (IOTN). At T2, 293 families participated in the follow-up study. The rate of referral varied by dental clinic from 40% to 71%, with a mean of 56%. At T2, about 44% of children had finished, or were undergoing orthodontic treatment. Esthetic concerns were most frequently cited as motivating orthodontic treatment. Sex of the subject was not significantly associated with treatment uptake. The best predictors at T1 for subsequent treatment uptake were DHC scores, followed by the parents’ level of concern for their child’s teeth and their attitudes towards orthodontics. At T2, untreated subjects reported less desire for treatment than at T1; these individuals were associated with favorable AC changes from T1 to T2. Subjects coming from dental clinics with higher referral rates were more likely to begin orthodontic treatment. However, variation in family perceptions of treatment need and attitude towards braces greatly influenced treatment uptake even among subjects with great objective treatment need (as indicated by IOTN score).
In their 2005 study, Reichmuth et al. reported on their survey of orthodontic perceptions and motivations.11 Several groups of children (and their guardians) were interviewed: those who were seeking or undergoing orthodontic treatment at publically funded clinics (150 in the Bronx, NY and 100 in Seattle, WA) and those seeking or receiving treatment at private offices (84 total
4
in Seattle, WA; Anchorage AK; and Chicago, IL). They found greater desire for treatment in children at public versus private clinics, and among blacks versus whites and Asians. Children at public clinics, as well as those of Hispanic and mixed ethnicity at any location, had worse perceptions of their dental appearance relative to objective measures of anterior crowding, increased/decreased overbite, overjet, and diastema. Bronx children were more accepting of a wider range of occlusal variations. The investigators concluded that both socioeconomic and ethnic background influence children’s perception of dento-facial harmony and their desire for orthodontic treatment.
Hamden and colleagues reported in 2007 on their study of perceived orthodontic need among 3 groups in Jordan: 100 patients, their parents, and 23 dental specialists.12 There were equal numbers of male and female patients, whose overall mean age was 14.7 years. Subjects were given 10 numbered photos (each of which had been scored by their IOTN Aesthetic Component, “AC”) and asked them to sort them from “the one that looks best” to “the one that looks worst”. Subjects were then given the same photos sorted by their AC score and asked to place a line between those that needed orthodontic treatment and those that did not. All three groups performed similarly in both tasks: In the sorting task, the mean responses placed cards 1,2,3,4 and 10 identically to their AC score. Further, in the “cut-off” task, all groups had no significant differences with mean threshold for treatment at AC = 4.
In their 2008 study, Fleming et al. surveyed 500 new patients who presented for treatment at their hospital orthodontic clinic in Kent, UK.13 Their response rate was 66%. Patients had been referred by their general dentist 81% of the time. Most of these (87%) were motivated for 5
treatment out of concern about the appearance of their teeth and 38% reported being teased by peers about their dental appearance.
Marques and colleagues reported on motivations for orthodontic treatment among Brazilian adolescents and their parents in 2009.14 They surveyed 403 subjects selected at random from 182,291 students in Brazil, aged 14-18. While 78% of subjects wanted orthodontic treatment, 69% of their parents said they were not receiving treatment due to high cost. Most types of malocclusion were significantly associated with desire for orthodontic treatment, while no significant association was found between treatment desire and subject gender or age. The factors most strongly associated with the subject’s desire for treatment were maxillary anterior crowding of 2mm or more and the parents’ perception of the child’s treatment need.
In their 2010 article, Wedrychowska-Szulc et al. reported on their survey of 674 Polish children and their parents, as well as 86 adult orthodontic patients. As age increased, female subjects became more aware of their malocclusion, while the motivating influence of external/social factors decreased with age for all subjects. Less than 5% of juvenile subjects reported starting treatment due to teasing by peers. Improvement of oral health was a treatment motivation for 6. Over 80% said they gave patients multiple options, but about 75% said they usually recommended 1 option over the others. Eighty percent (strongly) preferred solo practitioners over orthodontic clinics.
As for the factors motivation the choice of orthodontic offices, Guymon et al. found that referring dentists thought that the convenience of the office for the patient was more important than the treatment cost. Nearly all items in the “quality” category were important to general 7
dentists, making it the highest rated category. Good communication by the orthodontist was valued by general dentists, 85% of whom felt it important that the orthodontist responded promptly to their calls. The category of “reciprocation” was generally of low importance to general dentists, with 29% saying it was important for orthodontists to refer them patients, and only 10% saying it was important to receive lunch or gifts from the orthodontist. However, 94% said it was important for the orthodontist to send patients back for regular check-ups and cleanings. Overall, the six categories were ranked by dentists as: quality > communication > convenience > reciprocation > cost > relationship. Ninety-four percent of dentists were “satisfied” with their orthodontic referrals, with 66% “very satisfied.”
In 2009, Hall and colleagues noted that while previous studies had identified “past treatment quality” as a primary motivating factor for general dentists in their choice of orthodontic referrals, what was meant by “quality” was generally not well defined.16 To further clarify what motivates dentist referrals to specific orthodontists, the investigators therefore created a 35 question survey containing different aspects of orthodontic treatment quality and sent them to 1000 randomly selected general dentists around the Midwestern US. Twelve were returned due to incorrect address, while 358 were returned completed, for a rate of 358/987 = 36.3%. Seventy-five percent of responders said that the occlusal/functional result (as judged by the dentist) and patient satisfaction with their result/experience were equally important. Of the remainder, 18% said occlusion/function was most important and 7% said patient satisfaction was most important. In particular, the most important occlusal factor was “canine guidance”,
8
followed by “Class I molar and canine relationships, even contact of all teeth in centric occlusion, amount of overjet and overbite, absence of spacing, and absence of balancing interferences.”
As Hall et al. found patient satisfaction to be highly important in the general dentists’ choice of orthodontic referrals,16 multiple studies have examined what factors produce patient satisfaction with an orthodontic office:
In 1991, Sahm and colleagues reported on their survey of 254 school age patients (92 questions) and their parents (66 questions) at 9 orthodontic practices in Germany.17 They identified 2 basic areas of patient satisfaction: ‘interpersonal satisfaction’ and ‘perceived treatment efficacy.’ “As patients are rarely able to determine the professional’s technical competence, they are prone to confuse perceived efficacy with their interpersonal contentedness” – this was especially true for younger children and adults with lower levels of education. The investigators identified 3 basic types of practices: (1) 22.8% of the sample practices had above average patient compliance and above average treatment satisfaction (although patients felt the treatment “lacked observable progress”). The orthodontist/patient relationship, however, was perceived as poor, with patients dissatisfied with the doctor’s practice atmosphere, social skills, and communication. Patients found the treatment to be effective, but did not enjoy their office visits. (2) 58.4% of sample practices had patients who were generally satisfied and exhibited adequate cooperation with treatment. The orthodontist and patients generally got along well. (3) The remaining 22.8% of practices had “many complaints about the appliances” among patients, who generally felt that “the orthodontist’s requirements seem[ed] to be too difficult.” Compliance with treatment was perceived by the orthodontist to be poor, while patients thought the 9
orthodontist was “unfriendly and aloof,” with “and insecure and difficult personality” who did “not care about his patients.” The overall finding of the report was “that if – and only if – the orthodontist successfully conveys the proper impression of spending considerable time in caring for his patients, he can expect them to respond to exacting requirements with sufficient compliance and general treatment satisfaction.”
Similarly, in their 1996 paper, Sinha et al. sought to evaluate the effects orthodontist behaviors, as perceived by the patient, upon (1) the patient-perceived relationship with the doctor, (2) patient satisfaction, and (3) doctor-perceived patient adherence to treatment prescriptions.18 A questionnaire was developed and filled out by 199 patients at the University of Oklahoma orthodontic resident clinic, with the treating doctor filling out an evaluation of each subject. Responses did not significantly differ with age of the patient. Eight out of the 24 doctor behaviors studied were correlated with patient satisfaction; “the orthodontist paid attention to what [the patient] had to say” was responsible for 63% of the variance. Two factors significantly predicted patient adherence to treatment; taken together they represented 10% of the total variance in patient compliance score: “the orthodontist was polite to me during my visit” (positive correlation) and “the orthodontist criticized my teeth or how I have been taking care of them” (negative correlation). The researchers concluded that (1) patient satisfaction was important for compliance with treatment and that (2) orthodontist behaviors influence patient satisfaction. The doctor should be polite, calm, confident, unhurried, and provide good verbal communication.
10
Selection of an office
With an awareness of the orthodontic offices available for care, and perhaps having visited several, the prospective patient must choose one at which to begin treatment (whether active or observational). The factors affecting consumer selection of a provider for professional services has been examined in past studies. These studies have examined consumer choices of physicians and other non-dental professionals, of dentists generally, and of dental specialists in particular, including orthodontists.
The medical literature contains numerous studies in which patient selection of physicians is explored. Bornstein et al. (2000) created a 23 question survey that was filled out by subjects in 3 settings: a medical group practice waiting room; a large, general purpose store; and meetings of a local women’s organization. 22 In this way, a sample representing a wide cross-section of the local population was represented, with 636 surveys completed. The highest rated items implied professionalism and competence of the doctor (board certification, clean/neat appearance of office and doctor, friend/family recommendation). Convenience and logistical factors were of moderate importance (which hospital the doctor uses, waiting time for appointments, waiting time at office visits, which insurance plans are accepted, and proximity of the office). Inherent characteristics of the doctor were relatively unimportant (age, gender, ethnicity, religion, marital status). Validity and reliability of the survey were not addressed.
Similarly, Hickson et al. (1988) investigated how parents choose a primary care physician (PCP) for their children.23 A questionnaire was developed based on the potential decisional factors 11
gained from open-ended interviews with 108 mothers in Nashville, TN. This questionnaire was then mailed out to 750 families on a mailing panel at the University of Arkansas. Six hundred thirty surveys (84%) were returned, of which 229 currently had a PCP for their youngest child: pediatrician (43.3%), family practitioner (26.7%), or general practitioner (25.3%). In making their selection, these families had received information from an average 1.2 sources; they rarely chose between more than 2 physicians. The more important factors were (1) access to, and ease of communication with, the doctor, and (2) recommendations from friends or other physicians. Cost and convenience factors were less important to parents. Validity and reliability of the survey instrument were not addressed.
Freed et al. (2010) likewise examined factors affecting parent selection of a PCP for their child, with a focus on the importance of board certification.24 A 59 question web-based survey was developed, pilot tested, then given to 3621 adults from a panel enrolled by a private research firm. This sample was recruited to be representative of the nation-wide population for peerreviewed health care studies. The response rate was 62%, with most of these believing it was important (or very important) for PCPs of children to be evaluated on their quality of care, pass a written examination periodically, and receive high satisfaction ratings from patients. Most also felt that friend/family recommendations and board certification were important (or very important). Validity and reliability of the survey instrument were not addressed.
Hanna et al. (1994) investigated whether patients placed different weighting on selection factors when choosing a PCP versus a specialist.25 A survey was designed incorporating physician selection factors from previous studies. This was mailed to 300 adult subjects “in a large mid12
west metropolitan area”; 124 of these (41%) were returned. Subjects placed different weighting upon selection factors when choosing a generalist than when choosing a specialist. For the PCP, subjects placed most importance upon fees charged, quality of explanations provided by the physician, and waiting times at office visits. For the specialist, the most important factor was the type of specialty itself – secondary to this were PCP referrals, accessibility of the physician by phone (by married and parent subjects), and quality of the hospital used (by more highly educated subjects). Validity and reliability of the survey instrument were not addressed.
Nowak et al. (1998) examined the factors influencing patient selection of cosmetic surgeons.26 A questionnaire was designed and sent to 438 patients of plastic surgeons; 182 of these were anonymously filled out and returned in a usable form. Subjects reported whether they were in treatment for “medical” or “cosmetic” reasons, as well as their age, gender, and level of education. Both “medical” and “cosmetic” groups most commonly went to the surgeon’s office for their initial visit/consultation due to physician referral. However, the most important factor for deciding to begin care was “board certification” for the “cosmetic” subjects, while “medical” subjects placed the most importance upon the physician referral. The second most important selection factor for both groups was “personality of the physician.” Validity and reliability of the survey instrument were not addressed.
Two studies compared how consumers prioritized the same set of selection factors when they sought the services of different types of professionals. In 1993, Hill et al. published their study “Investigating differences in choice decisions for physicians, dentists and lawyers.”19 Nineteen criteria for selecting professional services were identified and place into a questionnaire. Three 13
hundred adults in Eastern Kentucky were interviewed, and their selection preferences recorded. Each subject responded for 2 out of the 3 types of professions under investigation – thus, a total of 600 surveys were collected, 200 for each of physicians, dentists, and lawyers. The top overall selection item was “knowledge” for all 3 types of professionals; however, it was less important for physicians than for the others. Discussions regarding the nature of the subject’s problem, and its proposed resolution, were both less important for dentists than for the others (perhaps because the nature of dental health and its treatment are perceived by lay people as less complex than medical or legal conditions and procedures). The top 6 selection criteria for each profession were as follows:
Physicians: seems interested in my problem, explains what they are doing and why, seems knowledgeable, offers practical solutions to my problem, asks appropriate questions about my problem, prices are reasonable
Dentists: seems knowledgeable, seems interested in my problem, explains what they are doing and why, offers practical solutions to my problem, prices are reasonable, asks appropriate questions about my problem
Lawyers: seems knowledgeable, seems interested in my problem, offers practical solutions to my problem, explains what they are doing and why, asks appropriate questions about my problem, prices are reasonable
14
Similarly, Crane et al. (1988) reported the result of their survey on patient selection preferences for physicians and dentists.20 They enlisted 100 adult subjects via random digit telephone dialing. Those people agreeing to participate were then questioned regarding their gender, socio-economic status, and preferences in selecting dentists and physicians. Selection was tailored to include equal numbers of males and females who were experienced in selecting both physician and dentist offices, and who represented a range of different socio-economic groups. The top selection factors for both professionals included the same items, although in slightly different order of importance:
Physicians: personal referral, physical facilities, demeanor, other patients present, physical location, dress, price
Dentists: personal referral, demeanor, physical facilities, physical location, price, other patients present, dress
Patient preferences in selecting orthodontic services may differ from selecting professional services generally, or even from selecting non-specialist dental offices. Several prior studies1-4 have attempted to elucidate those factors that most strongly influence patient selection of an orthodontic practice. Each of these studies had limitations. Some were conducted in a limited geographic area: a single state3, or in other cases, a single2 or small number of4 metropolitan areas. Some of the studies were retrospective in nature2,3: subjects included those who had already selected into a practice and had been in treatment for some time; they were thus potentially subject to recall bias. Most importantly, however, none of the prior studies addressed the validity and reliability of the survey instruments they used.
15
In their 1999 study, Walley and colleagues surveyed 589 patients in their first 12 months of treatment private orthodontic offices in Mississippi3. The 3 most influential factors were: 1. dentist referral (20.5%), 2. payment plan (16.1%), and 3. caring attitude (14.7%). Proximity of the practice to the subject’s home was important, and parents were less concerned by the total fee than by the presence of a good payment plan. Further, Walley et al. were able to determine who within the family is responsible for choosing the orthodontic office: Mother (37.8%), mother + father (34.9%), entire family (18.5%).3 The overall conclusion was that, “It is important to the female parent that the practitioner is qualified and caring, the office is convenient, and is willing to work out a payment plan.” No indication was given that the survey used was valid or reliable.
In a study conducted at 8 orthodontic clinics in Richmond, Virginia, Edwards et al. gave subjects a 20 question survey whose main aim was to determine perceptions of treatment quality based on the marketing methods used by orthodontists.2 They also tangentially investigated factors that influence patient selection of a practice. 510 surveys were returned, with respondents primarily female (80%), married (81%), parents (87%), in their early 40s (mean 42.8). They reported that the top factors in selecting an orthodontic office were: the caring attitude of orthodontist (53%), good reputation of the orthodontist (49%), general dentist referral (38%), convenient office location (38%), affordable fees and convenient payment plan (27%), the atmosphere in the office (18%), and use of current treatment techniques (11%). No indication was given that the survey used was valid or reliable.
16
In their study, “Factors involved in choosing an orthodontist in a competitive market,” Longoria and colleagues created a survey with 43 items in 7 categories, developed largely from the survey of Walley et al.4 These were given to subjects at 27 private orthodontic offices in the Texas cities of Dallas, Houston, and San Antonio. 66 surveys were returned. The category that was most important was “Fees”, while “Competency and personality of the orthodontist” also had multiple high-scoring items. Board certification of the orthodontist was also found to be “highly important”. Most subjects (85%) came to the office where they received the survey due to a referral. Sixty-three percent of these referrals came from pediatric dentists, and 73% of these subjects said that referral was “important” or “highly important”. No indication was given that the survey used was valid or reliable.
The aim of the present study was to determine the relative importance placed upon different factors for selection of an orthodontic practice by prospective adult patients and parents of prospective adolescent patients across the United States, using a valid and reliable survey instrument:
H01.0: For parents of adolescent prospective patients, no significant differences exist between the questionnaire items for selection of an orthodontic practice.
H01.1: For parents of adolescent prospective patients, no significant differences exist between their motivations for selection of an orthodontic practice with respect to gender (male, female) of the subject.
17
H01.2: For parents of adolescent prospective patients, no significant differences exist between their motivations for selection of an orthodontic practice with respect to the practice location (urban, suburban, rural) of the practice at which the subject received the survey.
H02.0: For adult prospective patients, no significant differences exist between the questionnaire items for selection of an orthodontic practice.
H02.1: For adult prospective patients, no significant differences exist between their motivations for selection of an orthodontic practice with respect to gender (male, female) of the subject.
H02.2: For adult prospective patients, no significant differences exist between their motivations for selection of an orthodontic practice with respect to the practice location (urban, suburban, rural) of the practice at which the subject received the survey.
References
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2. Edwards DT, Shroff B, Lindauer SJ, Fowler CE, Tufecki E. Media advertising effects on consumer perception of orthodontic treatment quality. The Angle Orthodontist 78, no. 5 (September 2008): 771-777.
3. Walley EK, Silberman SL, Tuncay OC. Patient and parent preferences for orthodontic practices. Clinical Orthodontics and Research 2, no. 3 (August 1999): 110-123.
4. Longoria JM, English J, O’Neill PN, Tan Q, Velasquez G, Walji M. “Factors involved in choosing an orthodontist in a competitive market.” Journal Clinical Orthodontics, Vol. XLV, no. 6 (June 2011): 333-337.
5. St Louis BL, Firestone AR, Johnston W, Shanker S, Vig KW. Prospective patients rate practice factors: development of a questionnaire. Am J Orthod Dentofacial Orthop. 2011 Feb;139(2):235-41.
6. Members' report. Research and Planning Group, American Association of Orthodontists. Consumer orthodontics study with patients and non-patients. 1997.
7. Members' Report. AAO Qualitative Research: Moderator’s Full report. Schupp Company 2005.
8. Dorey J, Korabik K. Social and Psychological Motivations for Orthodontic Treatment. Am. J. Orthod. 1977 Oct;72(4):460. 19
9. Sheats RD, McGorray SP, Keeling SD, Wheeler TT, King GJ. Occlusal traits and perception of orthodontic need in eighth grade students. The Angle Orthodontist. 1998;68:107–114.
10. Birkeland K, Katle A, Løvgreen S, Bøe O, Wisth PJ. Factors influencing the decision about orthodontic treatment. A longitudinal study among 11- and 15-year-olds and their parents. Journal of Orofacial Orthopedics. 1999;60(5): 292-307.
11. Reichmuth M, Greene KA, Orsini MG, Cisneros GJ, King G, Kiyak HA. Occlusal perceptions of children seeking orthodontic treatment: impact of ethnicity and socioeconomic status. Am J Orthod Dentofacial Orthop. 2005;128:575–582.
12. Hamdan AM, Al-Omari IK, Al-Bitar ZB. Ranking dental aesthetics and thresholds of treatment need: a comparison between patients, parents, and dentists. European Journal of Orthodontics. 2007;29:366–371.
13. Fleming PS, Proczek K, DiBiase A T. I want braces: factors motivating patients and their parents to seek orthodontic treatment. Community Dental Health. 2008 Sep;25(3): 166169.
14. Marques LS, Pordeus IA, Ramos-Jorge ML, Filogonio CA, Filogonio CB, Pereira LJ, Paiva SM. Factors associated with the desire for orthodontic treatment among Brazilian adolescents and their parents. BMC Oral Health 9 (2009):34.
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15. Guymon G, Buschang PH, Brown TJ. Criteria used by general dentists to choose an orthodontist. Journal of Clinical Orthodontics. 1999 Feb;33(2): 87-93.
16. Hall JF, Sohn W, McNamara JA. Why do dentists refer to specific orthodontists? The Angle Orthodontist. 2009 Jan;79(1): 5-11.
17. Sahm G, Bartsch A, Koch R, Witt E. Subjective appraisal of orthodontic practices. An investigation into perceived practice characteristics associated with patient and parent treatment satisfaction. European Journal of Orthodontics. 1991 Feb;(13)1: 15-21.
18. Sinha PK, Nanda RS, McNeil DW. Perceived orthodontist behaviors that predict patient satisfaction, orthodontist-patient relationship, and patient adherence in orthodontic treatment. Am J Orthod Dentofacial Orthop. 1996 Oct;(110)4:370-377.
19. Hill CJ, Garner SJ, Hanna ME. Investigating differences in choice decisions for physicians, dentists and lawyers. Health Marketing Quarterly. 1993;3(10):147-161.
20. Crane FG, Lynch JE. Consumer selection of physicians and dentists: an examination of choice criteria and cue usage. Journal of Health Care Marketing. 1988 Sep;8(3):16-19.
21. Kelley SW, Schwartz RW. A marketing-oriented perspective on physician selection. Surg Innov. 2005 Dec;12(4):357-63.
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22. Bornstein BH, Marcus D, Cassidy W. Choosing a doctor: an exploratory study of factors influencing patients' choice of a primary care doctor. J Eval Clin Pract. 2000 Aug;6(3):255-62.
23. Hickson GB, Stewart DW, Altemeier WA, Perrin JM. First step in obtaining child health care: selecting a physician. Pediatrics. 1988 Mar;81(3):333-8.
24. Freed GL, Dunham KM, Clark SJ, Davis MM. Perspectives and preferences among the general public regarding physician selection and board certification. J Pediatr. 2010 May;156(5):8415, 845.e1. Epub 2010 Feb 6.
25. Hanna N, Schoenbachler DD, Gordon GL. Physician choice criteria: factors influencing patient selection of generalists versus specialists. Health Mark Q. 1994;12(2):29-42.
26. Nowak LI, Washburn JH. Patient sources of information and decision factors in selecting cosmetic surgeons. Health Mark Q. 1998;15(4):45-54.
22
Chapter 2: Materials and Methods
The Institutional Review Board of The Ohio State University approved this study as Protocol #2010B0206.
In a previous study by St. Louis et al.3, two versions of a questionnaire were developed and determined to be both valid and reliable. The surveys were initially developed by a panel of orthodontists in academics and in private practice thereby establishing content validity. Furthermore, construct validity was established by including questions from previous, well regarded questionnaires.1,2,5,6 Finally, face validity was achieved by soliciting and incorporating feedback from the field test subjects as to the relevance of the questions. The result was two versions of a survey, one for parents of prospective adolescent patients, and one for prospective adult patients. These surveys were then checked for reliability in a second field test involving 53 subjects (41 parents and 12 adults), using test-retest methodology. All 53 subjects demonstrated excellent reliability (ICC = 0.88, range = 0.61-1.00). 21 questions had excellent reliability (ICC > 0.75), 29 had fair-to-good reliability (ICC = 0.41-0.75), and no questions had poor reliability (ICC < 0.40).3 Summary scores of all questions showed that the overall reliability of the questionnaire was acceptable (ICC = 0.70, range = 0.45-0.88). 23
In a second study4, Bedair et al. compiled a list of 450 orthodontists in private practices across the United State from the membership directory of the American Association of Orthodontists. Practices were randomly selected from each state in approximate proportion to the total number of listings in that state. These practitioners were then contacted and asked to participate. They were sent both versions of the survey and asked to answer them as they expected a new prospective patient (or parent of adolescent patient) in their office would answer. They also were also asked if their offices would participate in the final phase of the study; 123 surveys were returned and evaluated.
The final questionnaires, used in the present study, consisted of 44 items for adult patients, and 50 items for parents of child patients (see Appendix, Tables 5 and 6). For each item, the subject would place a mark on a 100mm visual analog scale (VAS) indicating the importance placed upon that item in the selection of an orthodontic practice, with 0 being “not important at all” and 100 being “most important”.
Those orthodontists who agreed to further participation were each mailed 10 copies of each version of the survey (20 surveys). These were displayed for prospective adult patients and parents of prospective adolescent (subjects) on their first visit to that location. In each office, potential subjects were made aware of the option to fill out surveys, but were not actively recruited (in order to eliminate potential bias from differing recruiter and methods in different offices). After completing the surveys, the subjects mailed them directly to the investigators. Incentive for participation was provided in the form of a $5.00 gift card, which was sent to each participant upon receipt by the investigators of the completed survey. 24
With a non-directional alpha risk of 0.05 and assuming a correlation of 0.5 and a standard deviation of 24.4mm6 a sample size of 50 subjects would be required to demonstrate a difference of ±10 mm on the VAS scale with a power of 0.81. With 100 subjects, power would increase to 0.98.
Data were recorded by 3 individuals using digital calipers to measure the VAS score for each response and rounding to the nearest 0.5mm. After all data were entered, 20 questions were randomly selected out of all the measured surveys and were re-measured to determine reliability of the data measurements. These were compared to the original measurements and an intra-class correlation coefficient was calculated.
The results for the adult patient and parent surveys were analyzed separately. Mean VAS scores were analyzed using a factorial, repeated-measures ANOVA with question, office location (urban, suburban, rural), and gender as the factors. Post hoc testing was done using the TukeyKramer procedure.
References
1. Edwards DT, Shroff B, Lindauer SJ, Fowler CE, Tufecki E. Media advertising effects on consumer perception of orthodontic treatment quality. The Angle Orthodontist 78, no. 5 (September 2008): 771-777. 25
2. Walley EK, Silberman SL, Tuncay OC. Patient and parent preferences for orthodontic practices. Clinical Orthodontics and Research 2, no. 3 (August 1999): 110-123.
3. St Louis BL, Firestone AR, Johnston W, Shanker S, Vig KW. Prospective patients rate practice factors: development of a questionnaire. Am J Orthod Dentofacial Orthop. 2011 Feb;139(2):235-41.
4. Bedair TM, Thompson S, Gupta C, Beck FM, Firestone AR. Orthodontists’ opinions of factors affecting patients’ choice of orthodontic practices. 2010 Jul;138(1):6.e1-7; discussion 6-7.
5. Members' report. Research and Planning Group, American Association of Orthodontists. Consumer orthodontics study with patients and non-patient. 1997.
6. Members' Report. AAO Qualitative Research: Moderator’s Full report. Schupp Company 2005.
26
Chapter 3: Manuscript
Introduction
For orthodontists currently practicing in the United States, the past several years have been unprecedented within their professional history. The “Great Recession” has brought with it declines in mean net practice income for the first time in at least 30 years. Furthermore, while hundreds of new orthodontists continue to graduate and enter into practice every year, many senior practitioners are remaining in practice longer, with the result that the population of practicing orthodontists continues to age.1
Many potential patients and their families have several orthodontic providers from whom to choose within a reasonable distance. Indeed, it appears that the trend to “shop around” at several offices before entering into treatment may be increasing – previous studies have put the figure at 30-41%.1,2 Particularly given the current practice climate, there is great need for the orthodontist to know how best to focus finite resources to maximize patient selection of his/her practice. Fundamentally, before beginning treatment at a given office, prospective patients must meet four conditions9:
27
1. They must be aware that an orthodontic need exists.
2. They must have both the desire and the resources to pursue resolution of that need.
3. They must be aware of that particular practice and its ability to meet their need(s).
4. They must choose to be treated at that particular practice, over all others available.
The focus of the present study is on the fourth point. Factors affecting consumer selection of a provider for professional services have been examined in past studies. These studies have examined consumer choices of physicians and other non-dental professionals, of dentists generally, and of dental specialists in particular, including orthodontists.
The medical literature contains numerous studies in which patient selection of physicians is explored. Bornstein et al. (2000) created a 23 question survey that was filled out by subjects in 3 settings: a medical group practice waiting room; a large, general purpose store; and meetings of a local women’s organization. 10 The highest rated items implied professionalism and competence of the doctor (board certification, clean/neat appearance of office and doctor, friend/family recommendation). Convenience and logistical factors were of moderate importance (which hospital the doctor uses, waiting time for appointments, waiting time at office visits, which insurance plans are accepted, proximity of the office). Inherent characteristics of the doctor were relatively unimportant (age, gender, ethnicity, religion, marital status). Validity and reliability of the survey were not addressed. 28
Similarly, Hickson et al. (1988) investigated how parents choose a primary care physician (PCP) for their children.11 A questionnaire was developed based on the potential decisional factors gained from open-ended interviews with 108 mothers in Nashville, TN. This questionnaire was then mailed out to 750 families on a mailing panel at the University of Arkansas. The more important factors were (1) access to, and ease of communication with, the doctor, and (2) recommendations from friends or other physicians. Cost and convenience factors were less important to parents. Validity and reliability of the survey instrument were not addressed.
Freed et al. (2010) likewise examined factors affecting parent selection of a PCP for their child, with a focus on the importance of board certification.12 A 59 question web-based survey was developed, pilot tested, then given to 3621 adults from a panel enrolled by a private research firm. This sample was recruited to be representative of the nation-wide population for peerreviewed health care studies. The response rate was 62%, with most of these believing it was important (or very important) for PCPs of children to be evaluated on their quality of care, pass a written examination periodically, and receive high satisfaction ratings from patients. Most also felt that friend/family recommendations and board certification were important (or very important). Validity and reliability of the survey instrument were not addressed.
Hanna et al. (1994) investigated whether patients placed different weighting on selection factors when choosing a PCP versus a specialist.13 Subjects placed different weighting upon selection factors when choosing a generalist than when choosing a specialist. For the PCP, subjects placed most importance upon fees charged, quality of explanations provided by the physician, and waiting times at office visits. For the specialist, the most important factor was the type of 29
specialty itself – secondary to this were PCP referrals, accessibility of the physician by phone (by married and parent subjects), and quality of the hospital used (by more highly educated subjects). Validity and reliability of the survey instrument were not addressed.
Nowak et al. (1998) examined the factors influencing patient selection of cosmetic surgeons.14 Subjects reported whether they were in treatment for “medical” or “cosmetic” reasons, as well as their age, gender, and level of education. Both “medical” and “cosmetic” groups most commonly went to the surgeon’s office for their initial visit/consultation due to physician referral. However, the most important factor for deciding to begin care was “board certification” for the “cosmetic” subjects, while “medical” subjects placed the most importance upon the physician referral. The second most important selection factor for both groups was “personality of the physician.” Validity and reliability of the survey instrument were not addressed.
Two studies compared how consumers prioritized the same set of selection factors when they sought the services of different types of professionals. In 1993, Hill et al. published their study “Investigating differences in choice decisions for physicians, dentists and lawyers.”15 Nineteen criteria for selecting professional services were identified and placed into a questionnaire. The top overall selection item was “knowledge” for all 3 types of professionals; however, it was less important for physicians than for the others. Discussions regarding the nature of the subject’s problem, and its proposed resolution, were both less important for dentists than for the others.
30
Similarly, Crane et al. (1988) reported the result of their survey on patient selection preferences for physicians and dentists.16 Those people agreeing to participate were then questioned regarding their gender, socio-economic status, and preferences in selecting dentists and physicians. The top selection factors for both professionals included the same items, although in slightly different order of importance:
Physicians: personal referral, physical facilities, demeanor, other patients present, physical location, dress, price
Dentists: personal referral, demeanor, physical facilities, physical location, price, other patients present, dress
Patient preferences in selecting orthodontic services may differ from selecting professional services generally, or even from selecting non-specialist dental offices. Several prior studies2-4 have attempted to elucidate those factors that most strongly influence patient selection of an orthodontic practice. Each of these studies had limitations. Some were conducted in a limited geographic area: a single state3, or in other cases, a single2 or small number of4 metropolitan areas. Some of the studies were retrospective in nature2,3: subjects included those who had already selected into a practice and had been in treatment for some time; they were thus potentially subject to recall bias. Most importantly, however, none of the prior studies addressed the validity and reliability of the survey instruments they used.
In their 1999 study, Walley and colleagues surveyed 589 patients in their first 12 months of treatment private orthodontic offices in Mississippi3. The 3 most influential factors were: 1.
31
dentist referral (20.5%), 2. payment plan (16.1%), and 3. caring attitude (14.7%). Proximity of the practice to the subject’s home was important, and parents were less concerned by the total fee than by the presence of a good payment plan. Further, Walley et al. were able to determine who within the family is responsible for choosing the orthodontic office: Mother (37.8%), mother + father (34.9%), entire family (18.5%).3 The overall conclusion was that, “It is important to the female parent that the practitioner is qualified and caring, the office is convenient, and is willing to work out a payment plan.” No indication was given that the survey used was valid or reliable.
In a study conducted at 8 orthodontic clinics in Richmond, Virginia, Edwards et al. gave subjects a 20 question survey whose main aim was to determine perceptions of treatment quality based on the marketing methods used by orthodontists.2 They also tangentially investigated factors that influence patient selection of a practice. 510 surveys were returned, with respondents primarily female (80%), married (81%), parents (87%), in their early 40s (mean 42.8). They reported that the top factors in selecting an orthodontic office were: the caring attitude of orthodontist (53%), good reputation of the orthodontist (49%), general dentist referral (38%), convenient office location (38%), affordable fees and convenient payment plan (27%), the atmosphere in the office (18%), and use of current treatment techniques (11%). No indication was given that the survey used was valid or reliable.
In their study, “Factors involved in choosing an orthodontist in a competitive market,” Longoria and colleagues created a survey with 43 items in 7 categories, developed largely from the survey of Walley et al.4 These were given to subjects at 27 private orthodontic offices in the Texas 32
cities of Dallas, Houston, and San Antonio. 66 surveys were returned. The category that was most important was “Fees”, while “Competency and personality of the orthodontist” also had multiple high-scoring items. Board certification of the orthodontist was also found to be “highly important”. Most subjects (85%) came to the office where they received the survey due to a referral. Sixty-three percent of these referrals came from pediatric dentists, and 73% of these subjects said that referral was “important” or “highly important”. No indication was given that the survey used was valid or reliable.
The aim of the present study was to determine the relative importance placed upon different factors for selection of an orthodontic practice by prospective adult patients and parents of prospective adolescent patients, using a valid and reliable survey instrument.
Materials and Methods
The Institutional Review Board of The Ohio State University approved this study as Protocol #2010B0206.
In a previous study by St. Louis et al.5, two versions of a questionnaire were developed and determined to be both valid and reliable. The surveys were initially developed by a panel of orthodontists in academics and in private practice thereby establishing content validity. Construct validity was established by including questions from previous, well regarded 33
questionnaires.2,3,7,8 Finally, face validity was achieved by soliciting and incorporating feedback from the field test subjects as to the relevance of the questions. The result was two versions of a survey, one for parents of prospective adolescent patients, and one for prospective adult patients. These surveys were then checked for reliability in a second field test involving 53 subjects (41 parents and 12 adults), using test-retest methodology. All 53 subjects demonstrated excellent reliability (ICC = 0.88, range = 0.61-1.00). 21 questions had excellent reliability (ICC > 75), 29 had fair-to-good reliability (ICC = 0.41-0.75), and no questions had poor reliability (ICC < 0.40). Summary scores of all questions showed that the overall reliability of the questionnaire was acceptable (ICC = 0.70, range = 0.45-0.88).
In a second study6, Bedair et al. compiled a list of 450 orthodontists in private practice across the United State from the membership directory of the American Association of Orthodontists. Names were randomly selected from each state in approximate proportion to the total number of listings in that state. These practitioners were then contacted and asked to participate. They were sent both versions of the survey and asked to answer them as they expected a new prospective patient (or parent of adolescent patient) in their office would answer. They also were also asked if their offices would participate in the final phase of the study; 123 surveys were returned and evaluated.
The final questionnaires, used in the present study, consisted of 44 items for adult patients, and 50 items for parents of child patients. For each item, the subject would place a mark on a 100mm visual analog scale (VAS) indicating the importance placed upon that item in the
34
selection of an orthodontic practice, with 0 being “not important at all” and 100 being “most important”.
Those orthodontists who agreed to further participation were each mailed 10 copies of each version of the survey (20 surveys). These were displayed for prospective adult patients and parents of prospective adolescent (subjects) on their first visit to that location. In each office, potential subjects were made aware of the option to fill out surveys, but were not actively recruited (in order to eliminate potential bias from differing recruiter and methods in different offices). After completing the surveys, the subjects mailed them directly to the investigators. Incentive for participation was provided in the form of a $5.00 gift card, which was sent to each participant upon receipt by the investigators of the completed survey.
With a non-directional alpha risk of 0.05 and assuming a correlation of 0.5 and a standard deviation of 24.4mm6 a sample size of 50 subjects would be required to demonstrate a difference of ±10 mm on the VAS scale with a power of 0.81. With 100 subjects, power would increase to 0.98.
Data were recorded by 3 individuals using digital calipers to measure the VAS score for each response and rounding to the nearest 0.5mm. After all data were entered, 20 questions were randomly selected out of all the measured surveys and were re-measured to determine reliability of the data measurements. These were compared to the original measurements and an intra-class correlation coefficient was calculated.
35
The results for the adult patient and parent surveys were analyzed separately. Mean VAS scores were analyzed using a factorial, repeated-measures ANOVA with question, office location (urban, suburban, rural), and gender as the factors. Post hoc testing was done using the TukeyKramer procedure.
Results
Forty-eight offices were each sent 20 surveys (10 of each version), for a total of 960 surveys sent. Part way into the data collection period, the response rate was found to be lower than anticipated. This was possibly due to several offices not, in fact, making surveys available. Eight additional offices were recruited and each was sent a packet of 20 surveys. This brought the total number of surveys sent out to 1120.
In total, 218 surveys were received within the time window available for data collection. Of these, 64 from adult patients and 154 from parents of adolescent patients, for a response rate of 19.5%. Eight of these did not include subject demographic information, so were not included in the analysis, leaving a total of 210 surveys.
Reliability of the measurements was excellent (ICC = 1.00). ANOVA analysis (as seen in the tables below) revealed a statistically significant main effect for question (p0.05).
37
Table 1: ANOVA for parents of prospective adolescent patients
Effect
Num DF
Den DF
F Value
Pr > F
QUESTION
49
6500
62.47
F
QUESTION
43
2657
43.9
