Evaluation of the Practice of Patient Centered Care among Saudi Dentists in Central Region of Saudi Arabia: A Cross-sectional Study

Reham AL Jasser^*

^*Correspondence: Reham AL Jasser, Department of Periodontics and Community Dentistry, College of Dentistry, Riyadh, Saudi Arabia, Email:

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Introduction

Safety and improvements in patient’s health serve as the integral aspects of the quality healthcare services. Components such as; timely care, proper treatment guidance, along with the treatment interventions provided through patient’s centered approach serve as the integral part of the quality care services [1]. In the field of dentistry, services that are provided through patient’s centered approach are recognized as the fundamental dimensions of quality treatment. Such a service stimulates patient’s satisfaction leading towards improved treatment outcomes [2].

According to the Institute of Medicine (IOM), patient-centered care is referred as “Providing care that is respectful of and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions [3]. This type of care includes healthcare practices that are meaningful or valuable for patients. It further includes listening to and informing patients about the developments undertaken during their healthcare process. Al Muammar, et al. [4] described patient centered care as the amalgamation of eight different dimensions, as highlighted by the Picker institute. These dimensions include; i) Respect for patient’s needs, values and preferences ii) Coordination with respect to healthcare integrations iii) Patient’s ease followed by physical comfort iv) Communicating, and educating patients with respect to their problem or disease v) Eliminating the emotions of anxiety and fear through constant support vi) Family and friends involvement vii) Continuity and transition viii) Patient’s access to care [5-6].

In the recent time, studies [2,4,6] have provided greater support to patient centered care, as the idea is connected to high level compliance of patients with treatment procedures leading towards positive treatment outcomes and timely recovery from the disease [4]. However, in the view of Walji, et al. [7] patient centered care is more focused towards the treatment methods and interventions provided with respect to the nature of disease rather than centering focus towards patient’s individual characteristics. Since patients and dentists invest long time while expecting the effective results through quality treatment, it is emphasized to follow the patient’s centered approach as it results in high level of patient’s satisfaction [2]. Al-Madi et al. [8] provided an important stance in this regard. According to the study, the educational institutions of Saudi Arabia are now providing special considerations towards the changes in educational curriculum of dentistry. The study further outlined that educational curriculum must be effective enough, where young dentists must be aware of usefulness of patient centered care and leadership attributes essential for the effective treatment outcomes.

The study of Al Agili, et al. [9] revealed that young population of Saudi Arabia has should greater prevalence of dental problems, leading towards the increased burden of oral disease. In such circumstances, dentists in Saudi Arabia are expected to be highly skilled in providing high quality care, treatment plan, and instructions, based on their knowledge, skills, and experience, to achieve the best dental treatment outcomes. Patient’s perspective during the dental visit is critical here, which is often missed by the dental professionals. Another study [10] indicated that use of technology during the dental treatment is of critical value, as it stimulates maximum patient centeredness, quality of care leading towards the reduction in healthcare cost [11]. Despite of the growing interest of researchers regarding the concept of patient centered care, a little information is provided for the existing conditions of dental treatments. In addition, the growing prevalence of dental problems among Saudi population makes it critical to present a proper evaluation regarding the current practices of patient-centered care among dentists, along with its proper utilization during dental visits. The idea is crucial to increase dental treatment outcomes and patient satisfaction. Considering this, the present study aims to:

1. Assess the practice of patient-centered care among dentists in Saudi Arabia, and

2. Analyze the influence of gender and years of experience on dentist ability to conduct proper patient-centered care to their patients.

The study is of greater significance specifically for Saudi dentists as it will help them in providing a proper understanding of the current modes of treatment along with the level of contribution provided by the existing approach. The study is of further value for patients in providing the necessary education regarding the value of patient centered approach in the present era. Finally, academicians belonging to the field of study may highly benefit from this study to assess the existing practices of patient centered care along with the influence of involved variables.

Methods

IRB approval number

The research was approved by the Institutional Committee of Research Ethics at the King Saud University, Riyadh, Saudi Arabia (NF 4263).

Research Project No. E-19-3638.

Design and population

This study follows a cross-sectional, descriptive, correlational study design, where a self-reported survey, and modified Patient-Practitioner Orientation Scale (PPOS) was quantitatively assessed [12]. The targeted population included dentists that are fresh or experienced dentists that are currently practicing in Riyadh, Saudi Arabia. Sample size of the study was determined by G Power software, where a confidence level was set at 95%, a power level of 80% was set with a moderate effect size. However, to avoid a low response rate, which may affect the sample size, a larger sample i.e. 300 dentists were recruited leading towards a final sample of 272 dentists.

The Patient-Practitioner Orientation Scale (PPOS)

PPOS was used to measure whether the practitioner leans toward patient-centered care or disease/doctor-centered care [12,13]. PPOS is divided into two sections, the sharing and caring subscales. The sharing subscale measures how important the practitioner feels. The scale is important to share power and information with patient while involving them in treatment decisions. The caring subscale measures the extent to which the practitioner considers their patient’s emotions and thus aims for a more holistic approach to patient care, with the patient rather than the disease being the focus of attention. The PPOS has been previously validated for use in a health care setting, [14,15] as well as in the dental environment [16-18].

A modified validated PPOS in English version was used in this study. The original PPOS [18-20] is a self-administered paper-pencil instrument that contains eighteen statements regarding various aspects of doctor-patient relationship and communication. The responder expresses his or her level of agreement with each item on a six-point Likert scale; from strongly agree to strongly disagree. Most of the items are expressed in dentist-centered terms and hence scored directly from 1 to 6, while items 9, 13, and 17 are patient-centered statements and, hence, are scored in reverse. The scale has two subscales of nine items each. The “sharing” subscale contains nine statements (items 1, 4, 5, 8, 9, 10, 12, 15, and 18) describing the extent to which the respondent believes that the patient should receive information and be involved in decision-making.

The rest of the items constitute the “caring” subscale, which rates the extent to which the patient’s expectations, feelings, and lifestyle are considered important in the treatment process. To adapt the instrument for the dental practice, following changes were made to the original instrument. Item 3, which reads “the most important part of the standard medical visit is the physical examination,” was rephrased as “The most important part of the standard dental visit is the intra-oral and extraoral examination.” In items 3 and 4, the word “medical” was substituted with “dental”. In items 1, 5, 6, 7, 9, 11, 12, 15, and 17, the word “doctor” was replaced by “dentist” and in 4 and 16; the words “medical condition” and “illness” were replaced by “dental condition,” respectively. Finally, in items 2 and 18 the word “dental” was added with no modification to the original question. Completion time is approximately 10 minutes.

Scoring method

Scores were reported as mean scores to allow dentists’ responses to be used even if one or two scale items are deleted. One total mean score can be calculated for the 18 items, and two subscale scores can also be calculated. The total score ranges from “patient-centered” to “dentistcentered” or “disease-centered.” The higher the score, the more patient-centered the orientation.

Subscale scores

I. Sharing scores: reflect the extent to which the respondent believes that:

a) Dentists and patients should share power and control on a relatively equal basis.

b) Dentists should share as much information with their patients as possible.

Related items: 1, 4, 5, 8, 9, 10, 12, 15, & 18.

II. Caring refers to the extent that respondents believe that:

a) Caring about emotions and good interpersonal relations is a key aspect of the medical and dental encounter.

b) Dentists should care about the patient as a person, rather than as a dental condition.

Related items: 2, 3, 6, 7, 11, 13, 14, 16, & 17.

A 6-point scale was laid out from left to right as “strongly disagree” to “strongly agree.” Strongly disagree (far left) was scored 6, and strongly agree (far right) was scored 1. Three items (9, 13, and 17) were reverse worded, and scoring needed to be reversed. Therefore, a high score indicated an orientation toward patientcenteredness.

Ethical considerations

The protocol used in this series was approved by the Institutional Committee of Research Ethics at the College of Dentistry Research Center, King Saud University, Riyadh, Saudi Arabia (E- 193638). Permissions for data collection were granted by the institutional review board at King Saud University. However, requirement for patient consent was eliminated as the names of study participants were replaced by numeric codes to ensure confidentiality. The purpose and procedures involved in this study were explained in a cover letter, followed by a copy of informed consent form, which emphasized the right to self-determination, confidentiality and anonymity, benefits, and risks of the study.

Data entry and statistical analysis

Data entry was performed using SPSS version 24.0 (IBM, Armonk, NY, USA), and cross-verified by two independent operators. Descriptive statistics (frequencies, percentages, mean (M) and standard deviations [SDs]) was computed to characterize the study sample. The summary statistics was calculated for each item, for the sharing and caring subscales, and for PPOS as a whole. The D’Agostino and Pearson omnibus test was used to test the normality of distribution of the analyzed data. The independent sample t-test was used for gender-based comparisons. Differences within age groups, as well as years of experience were evaluated with one-way analysis of variance (ANOVA) followed by the post-hoc test. The alpha level for all tests was kept at 0.05 for level of significance.

Results

A return of 272 usable forms out of total 300 forms corresponds to a response rate of 90.66%. According to the findings of Table 1, majority of the participants were males (N=148, 54.40%) in contrast to females (N=124, 45.60%). Majority respondents i.e. (N=122, 44.90%) fall in the age group between 25 to 34 years. Findings in relation to years of dental practice indicate that most of the participants were reported to have ≥ 10 years of dental practice (N=106, 39.00%). While, the least reported dental practice experience was less than one year (N=26, 9.60%).

Table 1: Distribution of participants by gender, age, and years of dental practice.

Analysis of the gender-based differences using independent samples t-test revealed statistically significantly higher sharing subscale among female dentists (3.24 ± 0.78) in comparison to males (3.13 ± 0.59) with a statistically significant value of p=0.001. On the other hand, there was no statistically significant difference in either the caring subscale or overall scale. Nonetheless, females were more patient-centered than males (3.11 ± 0.57 vs. 3.06 ± 0.50), p=0.037 (Table 2).

Table 2: Total and subscale PPOS mean scores by gender using independent sample t-test.

Other findings are related to the Post-hoc comparisons using the Tukey HSD test. Findings of Table 3 indicate that the mean score for sharing subscale in dentists with less than 1 year of dental practice (M=2.56, SD=0.47), was significantly less than the other three groups. This also applied to the overall PPOS score for the same group (M=2.72, SD=0.38). However, no significant difference was shown between the other groups in any of the subscales. Altogether, these results suggest that dentist with less than 1 year of practice were significantly less patientcentered than dentists practicing for a longer period (p=0.002). This was also significant for the sharing subscale of the same group (p=0.000). The differences for other comparisons were not statistically significant at p<0.05 (Table 3).

Table 3: Total and subscale PPOS mean scores by years in dental practice using post-Hoc Turkey test.

Discussion

The present study evaluated the practice of patient-centered care among Saudi dentists in Riyadh, Saudi Arabia. The mean PPOS score observed in the present study was 3.08 ± 0.53. This represents a lower score than those reported by other comparable studies conducted in different regions. A study conducted among medical physicians in Nigeria showed a mean PPOS score of 3.98 [18], while other studies in the United States of America reported a score of 4.80 [19] and 4.97 in Malaysia in a similar population [20]. In India, comparison of other studies revealed mean scores of 3.38 and 4.66 among postgraduate orthodontic [16] and medical [21] students, respectively. This shows that the orientation of doctors toward patient care in clinical practice, followed a doctorcentered approach, which was traditionally called paternalistic role orientation. Parsons [22] described this approach as “an asymmetrical relationship in which the doctor occupies the dominant position by virtue of his or her specialist knowledge and the patient merely cooperates”. The study conducted by Scambler, et al. [23] outlined that patient catered approach in the field of dentistry is followed at an initial level where patients is provided with necessary information about the disease, followed by their choice of treatment.

In this study, female gender was significantly associated with patient-centered attitudes. A similar finding was revealed in other studies [19,21], where mean PPOS scores were significantly higher among females. Only two studies [18,16], revealed that the mean PPOS score was slightly higher among females with no significant difference compared to their male colleagues. In the present study, female dentists had a higher mean score than males in the two dimensions of “sharing” and “caring”, with significant difference observed in the sharing subscale than in the overall PPOS score. In all other studies, mean scores were higher among males in the caring and sharing subscale, with significant difference in the sharing, as seen in a study conducted in Brazil [21]. However, studies conducted in America [19], Brazil [21], and India [16] showed significant differences in the caring subscale between gender. This may be because female dentists use the patient-centered approach when communicating with patients by using more encouraging talks, emotional talks, and in soliciting for patients input in decisionmaking about the patients’ management [24].

Dentists with more years of practice showed higher PPOS score than those with less than 1 year of dental practice (fresh graduates). Similar findings were observed in a study in Nigeria [18]. In the American study [19], the mean sharing scores of the newer and older clinicians were similar, and physicians with an intermediate duration of practice (11–20 years) had the highest PPOS score. Thus, with increase in years of practice, dentists gain experience in several clinical situations, which modifies their patient’s communication skills, making them more patient-centered in their approach. Several limitations were pointed out in the present study such as; the measurement of PPOS in only one region of Saudi Arabia, which makes the generalizability of the results to the whole region impossible, and the relatively small sample size.

Conclusion

This study provides an in-depth analysis the practice of patient centered care in Saudi Arabia, while analyzing the influence of gender and years of experience on the ability of dentists in following the given approach. According to the findings, female gender and increased years of dental practice were significantly associated with patient-centered-approach. Patientcentered approach is least practiced in Saudi Arabia specifically in the field of dentistry and it is highly recommended to enhance patient outcomes and satisfaction. This give rise to the need of further multicentric studies to delineate the effective methods for improved patientcentered orientation in dentistry from early years of clinical practice.

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