Patient satisfaction with intraoral examination in a Nigerian tertiary hospital

INTRODUCTION

Intraoral examination (IOE) is a routine and frequent procedure performed on dental patients globally.^[1] All known orodental diseases are diagnosed following IOE. It is the examination of the oral cavity (mouth) with mouth mirror and dental probe to detect orodental problems.^[2] However, there are various barriers toward patient acceptance of IOE. One such barrier pertains to patient dissatisfaction toward the procedure. Patients who are dissatisfied are less likely to comply with management plan or more reluctant to continue utilizing a particular healthcare service.^[3] Providing best possible care is the most important goal of any health-care facility. In recent years, patient satisfaction has become an increasingly important outcome measurement in medical practice. Not only does patient satisfaction establish performance standards but it also increases the accountability of physicians and staff and, most importantly, can lead to improvements in the quality of care.^[4] Furthermore, satisfied patients are theoretically more likely to be compliant and to maintain a relationship with one specific care provider, which is more conducive toward continuity of care.^[5]

Several measurement scales for measuring satisfaction are available in the literature but Group Health Association of America (GHAA) instrument is most widely used due to its simplicity and easy to use. The original GHAA instrument, a commonly used patient satisfaction survey, consists of 60 items in the following section: Satisfaction with health-care services and providers, general satisfaction with care, satisfaction with health plan, health insurance and use of services, and personal characteristics.^[6] The GHAA was modified by American Society of Gastrointestinal (GI) Endoscopy to GHAA-9 to make it applicable to measurement of patient satisfaction with GI endoscopy. The GHAA-9 is a 9-item subscale with following sections: Waiting time to get appointment, waiting time before the procedure, personal manner (courtesy, respect, sensitivity, and friendliness) of the physician, personal manner (courtesy, respect, sensitivity, and friendliness) of the nurses and support staff, technical skills (thoroughness, carefulness, and competence) of the physician performing the procedure, and adequacy of explanation of procedure. The remaining three questions include on overall rating of the visit and inquiries into whether the patient would have the procedure done again by same physician or at the same facility.^[6]

Although there are several studies on patient satisfaction using GHAA-9 in medical practice,^[7-12] there seems to be limited related studies in dental practice. This study, therefore, aimed to determine the level of satisfaction with IOE among dental patients attending a Nigerian teaching hospital. Furthermore, the factors influencing the level of satisfaction were determined. It is expected that the study will generate evidence-based information for decision-making to mount interventions that would improve patient satisfaction with regard to dental treatment.

MATERIAL AND METHODS

This was a prospective cross-sectional study design performed on consecutive dental patients at the Department of Oral Diagnosis of the University of Benin Teaching Hospital, Nigeria, from April 2020 to September 2020. Informed consent was obtained from the patients while ethical permission was granted by the Institution Ethical and Research Committee. Patients that refused to participate in the study were excluded. The data collected were age, gender, occupation, place of residence, level of education, dental condition, and patient satisfaction.

The minimum sample size for statistically meaningful deductions was determined using the statistical formula of Fisher for calculating sample size: n = Z²P (1-P)/d². Where, n is the minimum sample size for a statistically significant survey, Z is normal deviant at the portion of 95% confidence interval (C.I) = 1.96, since this is preliminary study in Nigeria, a best guess prevalence of 50% was chosen for the estimation of sample size,^[13] and d is margin of error acceptable or measure of precision = 10%. Using this formula, the minimum sample size (n) was 96. Therefore, the study of 96 respondents was to give meaningful statistical deductions. However, the sample size was increased to 103 to compensate for any attrition.

The patient satisfaction was measured with GHAA-9 questionnaire. This survey was pre-validated in the previous study.^[14] The questionnaire was modified for this study. The original question on technical skill of the endoscopist was replaced with a question patient comfort during the IOE. It comprised 10 sections. The first six questions assess aspects relative to patients satisfaction: (1) Waiting time before IOE, (2) personal manner(courtesy, respect, sensitivity, and friendliness) of the physician, (3) personal manner (courtesy, respect, sensitivity, and friendliness) of the nurses and support staff, (4) comfort of patient during the procedure, (5) adequacy of explanation of procedure, and (6) overall satisfaction of the patient. Patients were asked to score each question with a score of 1–4 with one representing a poor and 4 representing excellent score. Each score of the questions were summed up. The total satisfaction score was 6–24. A score of 6–9 points was graded as poor, a score of 10–14 points was graded as fair, a score of 15–19 points was graded as good, and a score of 20–24 points was graded as excellent. The last four questions of the questionnaire were: (7) Would like to be examined by same physician again, (8) would you like to be examined in the same facility, (9) would you recommend same facility to your relation, and (10) was this your first visit and their responses were either “Yes” or “No.” The dissatisfaction rate or problem rate was calculated by adding all poor or fair responses in all questionnaires, dividing them by the total number of questions asked, and multiplying the result of this division by 100. The questionnaire was pretested in a pilot study on 10 respondents who were not part of the study. This was done by test-pretest method and using Cronbach’s alpha coefficient to evaluate the reliability.

Simple descriptive statistics were used to define the characteristics of the study variables by counting and calculating percentages for the categorical variables. For the inferential statistics, we used Chi-square test for univariate analysis of the categorical variables. P < 0.05 was taken to indicate statistical significance. All statistics were performed with SPSS version 21 (IBM corps, Armonk, New York, US). P < 0.05 was considered statistically significant.

RESULTS

A total number of 103 consecutive dental patients were recruited as they all agreed to participate in the study. The Cronbach’s alpha was 0.89 indicating good reliability in this study. The age range was 18–77 years with a mean age of 35.8 ± 14.3 years. Patient clinic demographic characteristics regarding age, gender, occupation, place of residence, level of education, dental conditions, and referred department is found in Table 1. More than half of the patients were in the age group if <36 years. There were more males (51.5%) compared to their female counterparts. Only 2 (1.90%) patients were unemployed. Majority (81.6%) of patients were urban dwellers. Around two-third (72.8%) of the patients had tertiary level of education. Most (19.4%) patients presented with acute apical periodontitis (AAP) followed by acute pulpitis (16.5%) and chronic marginal gingivitis (14.6%). Highest number (45.6%) of patients was referred to the department of oral and maxillofacial surgery.

The minimum and maximum satisfaction scores were 12 and 24, respectively. The mean score was 18 ± 3.10. Table 2 shows overall percentage of favorable and unfavorable responses for each of the question. Just more than half (60.2%) of the respondents said that they are satisfied with the time waited to get IOE performed on them as majority (93.2%) of them were satisfied with the doctor’s manner during the procedure. Higher number (89.3%) of the respondents was satisfied with the manners of the support staff. Less than half (21.4%) of the patients responded that they were unsatisfied with the explanation given to them before the IOE. A two-third (80.6%) of the patients acclaimed that they were comfortable during the procedure. In overall, just a few patients (17.5%) were not satisfied with their visit to our facility. The majority (96.1%) of the patients said that they would like to have IOE done again by same physician. Only 5 (4.90%) of the patients said that they will not like to have IOE done in our facility. More than two-third (95.2%) answered that they will recommend our facility to their relatives. Fifty-two (50.5%) patients were visiting our facility for the 1^st time. The problem rate was 16.0%. The occupation of the patients, type of dental condition, waiting time, doctor’s manner, staff manner, adequate explanation, and comfort during IOE were only found to be significantly associated with the unfavorable responses, as shown in Table 3.

DISCUSSION

Patient satisfaction has come to the forefront of health-care outcomes measure in recent years. Although patient satisfaction is variably defined, there is agreement that it represents a patient’s cognitive or emotional evaluation of a health-care provider’s performance and is based on^[10] relevant aspect of the health-care experience.^[3] The perceptions and experiences of the patient are increasingly recognized as critical measures of performance and have become a central focus of health-care delivery and quality assurance efforts.

The health plan employer data and information set, HEDIS, a report card system for health maintenance organizations in effect since 1991, incorporates patient satisfaction with care experience among its eight major quality indicators.^[5] The ability to accurately measure and improve patient satisfaction, however, is limited by a lack of understanding of those aspects of the care experience most important to this outcome. Patient satisfaction measurement can help establish performance standards, improve risk management, increase in accountability of physicians and staff, and the quality of care.^[6] Studies have shown that satisfied patients are more likely to continue to use medical care services, to comply with prescribed treatments, and to maintain a relationship with a specific care provider.^[5,9] The satisfied patient is more apt to disclose important medical information to caregivers and to participate in his or her own treatment. Dissatisfied patients, on the other hand, are more likely to doctor shop, at allow their health insurance to expire, and to be non-compliant.^[15]

This is the first study using GHAA-9 survey to inquire about patient satisfaction with IOE. The use of the modified GHAA-9 patient satisfaction survey has been recommended because it has been validated in numerous patient populations and has been in existence for more than 20 years.^[16] Patient satisfaction surveys provide mechanism whereby patients can alert providers to their needs, concerns, and perceptions of treatment. Such feedback is helpful in the quality assessment process because it highlights specific areas in need of improvement. A well-designed and implemented patient satisfaction measurement system can improve the quality of clinical and administrative practices.^[17]

Seven factors affecting overall rating were identified in our population: Occupation, dental condition, waiting time, doctor’s manner, staff manner, adequate explanation, and comfort during IOE. Of these waiting time and adequate explanation ranked the highest in terms of unfavorable responses. These factors were also reported by the previous studies to be related to the level of satisfaction.^[7,9] However, Ko et al. did not identify waiting time as an associated factor in relation to satisfaction.^[11]

The rate of satisfaction with the waiting time before IOE in the present study was 60.2%. This finding is in contrast with the previous studies among the Caucasians and Asians.^[7-12] The differences among the studied population could be attributed to this variation in the studies. The finding in the present study as regard the waiting time is a clarion call to improve in waiting time and hence raise patient level of satisfaction. Although the 93.2% rate of satisfaction as regard doctor’s manner was encouraging, it was, however, lower than 99.1% and 98.7% reported by Rasool et al.^[10] and Del Rio et al.,^[7] respectively. This finding was higher than 79.2% reported by Chan and Goh.^[9] In the present study, the rate of satisfaction from the support staff ’s manner was 89.3%. This was, however, lower than that reported from the previous studies [Table 1]. The rate of satisfaction as regard adequate explanation in our study was 78.6%, which was lower compare to the previous studies.^[11,12] This indicates the level of patient-doctor relationship which is not encouraging in developing countries. Patient satisfaction rate regarding comfort during IOE in the present study was 80.6%. This finding was lower than that reported in the previous studies but higher than that reported by Chan and Goh.^[9]

This study has few limitations that can be considered in the interpretation of the results. To the best of our knowledge, this is the first study on dental patient’s satisfaction using GHAA-9 and this limited comparison of our findings with studies on dental population. More so, future studies may recruit larger sample size. This study was also a single-center study.

CONCLUSION

Although waiting time and adequate explanation ranked the highest in terms of unfavorable responses, the overall satisfaction of patients following IOE was generally good. The factors that influence satisfaction were occupation of the patients, type of dental condition, waiting time, doctor’s manner, staff manner, adequate explanation, and comfort during IOE.