Insurance status and provision of dental services in Australian private general practice

Abstract Annual expenditure on dental care in Australia amounts to ADD 1.9 billion. Approximately one-third of this expenditure involves private dental insurance, yet little is known about the impact of insurance on the provision of services. The aim of this analysis was to examine differences in dental service provision between insured and non-insured patients. Data collected from a random sample of dentists from a survey conducted in 1993-94 were used, providing 817 responses (response rate 74%). Logistic regression analysis controlling for patient age and sex and reason for visit indicated that in private general practice insured patients were more likely to receive preventive (OR=1.37), crown and bridge (OR = 2.25), and endodontic services (OR=1.27), but less likely to receive extraction services (OR=0.52). However, no significant differences by insurance status were found for diagnostic, restorative, or prosthodontic services in the multivariate models. These differences in service provision by insurance status indicate a more favourable pattern of services for insured patients, and point to equity issues in the provision of services.     

Service provision trends between 1983–84 and 1993–94 in Australian private general practice

Patterns of service provision are expected to change over time, reflecting the dynamics of factors such as oral health status and trends in population demographics. The aim of this study was to identify trends in service provision over time. Data were collected from a random sample of Australian dentists in 1983–84, 1988–89, and 1993–94. Changes observed between 1983–84 and 1993–94 included a trend towards increased proportions of patients in older age groups, restorative care (from 40.2 per cent to 37.7 per cent) and prosthodontic care (9.3 per cent to 8.0 per cent) and increases in diagnostic (from 38.7 per cent to 46.0 per cent), preventive (20.9 per cent to 7.1 per cent), and crown and bridge services (3.1 per cent to 4.7 per cent) per visit. Other services such as orthodontic and general/miscellaneous services showed increases over the first half of the study period, but these did not continue between 1988–89 and 1993–94. The total number of services per visit increased over the study period for adult patients. These findings indicate changing patterns of practice over time, consistent with an increasing orientation towards prevention of disease and maintenance of a natural dentition.     

Service provision trends between 1983–84 and 1993–94 in Australian private general practice

Patterns of service provision are expected to change over time, reflecting the dynamics of factors such as oral health status and trends in population demographics. The aim of this study was to identify trends in service provision over time. Data were collected from a random sample of Australian dentists in 1983–84, 1988–89, and 1993–94. Changes observed between 1983–84 and 1993–94 included a trend towards increased proportions of patients in older age groups, restorative care (from 40.2 per cent to 37.7 per cent) and prosthodontic care (9.3 per cent to 8.0 per cent) and increases in diagnostic (from 38.7 per cent to 46.0 per cent), preventive (20.9 per cent to 7.1 per cent), and crown and bridge services (3.1 per cent to 4.7 per cent) per visit. Other services such as orthodontic and general/miscellaneous services showed increases over the first half of the study period, but these did not continue between 1988–89 and 1993–94. The total number of services per visit increased over the study period for adult patients. These findings indicate changing patterns of practice over time, consistent with an increasing orientation towards prevention of disease and maintenance of a natural dentition.     

The role of dentist, practice and patient factors in the provision of dental services

OBJECTIVES: Service provision varies by dentist, practice and patient factors. However, limited subsets of these potential influences on service rates have been explored. More comprehensive models could improve our understanding of the factors influencing the pattern of care delivered. The aim of this study was to examine variation in dental services by dentist (treatment choice, practice beliefs, preferences for patients, demographics), practice (type, location, size and volume of practice) and patient (visit, demographic, oral health and socio-economic) characteristics. METHODS: A random sample of Australian dentists was surveyed in 1997-98 (response rate=60.3%). Private general practitioners (n=345) provided dentist and practice data, and service provision and patient variables were collected from a log of a typical clinical day (n=4,115 patients). Multivariate negative binomial regression models were fitted for diagnostic, preventive, restorative, extraction and prosthodontic services. RESULTS: Significant dentist factors included (P<0.05; RR=rate ratio): lower diagnostic rates (RR=0.78) for dentists with stronger practice beliefs for giving information about cost and treatment options; preventive rates were lower (RR=0.74) for male dentists and higher (RR=1.48) for younger dentists aged 20-29 years; restorative rates were higher (RR=1.27) for dentists that rated patient preferences more highly in treatment choice and in the dentist age group 30-39 years (RR=1.25); extraction rates were lower (RR=0.61) for dentists with stronger preferences for patients that would adhere with treatment but higher (RR=1.57) for dentists with stronger preferences for sociable patients; and prosthodontic rates were lower (RR=0.38) for dentists with stronger preferences for adaptable patients who were willing to cooperate when expected to do so. Practice factors included: higher preventive (RR=1.28) and prosthodontic rates (RR=2.07) in solo practice; higher preventive (RR=1.34) but lower prosthodontic rates (RR=0.42) in capital cities; lower diagnostic (RR=0.82) and extraction rates (RR=0.55) in practices with fewer other dentists; higher diagnostic (RR=1.33) and extraction (RR=1.62) rates but lower restorative rates (RR=0.84) in practices with lower patient visits per year. Patient factors included: lower preventive (RR=0.76) but higher extraction rates (RR=1.45) for emergency visits; lower extraction rates (RR=0.60) for the insured; higher diagnostic rates (RR=1.17) for new patients; higher restorative (RR=1.31) but lower prosthodontic rates (RR=0.46) for patients with decayed teeth; higher prosthodontic rates (RR=2.14) for those with dentures; and lower preventive (RR=0.66), but higher extraction (RR=2.22) and prosthodontic rates (RR=1.82) for patients from lower socio-economic status areas. CONCLUSIONS: Dental service rates were influenced by large number of small effects from a wide range of dentist, practice and patient factors. Socio-economic and geographic barriers may need broad policy innovations to be addressed, but factors such as insurance and visit type have the potential to be altered to achieve better service outcomes and there is scope for research into clinical outcomes to improve the knowledge upon which treatment decisions are based.     

Trends in service provision among Australian private general dental practitioners over a 20-year period

AIM: To-investigate time trends in service provision. DESIGN: Five cross-sectional surveys across a 20-year period. SETTING: Australian private general practice PARTICIPANTS: A random sample of dentists. METHODS: Mailed questionnaires were collected in 1983, 1988, 1993, 1998 and 2003 (response rates 71%-76%). MAIN OUTCOME MEASURES: Services per visit, annual services per dentist; annual services per patient. RESULTS: Total services per visit increased over the study period from 1.78 to 2.37 (Poisson regression; P<0.05). However the annual number of services provided per dentist did not vary significantly, reflecting a trend among dentists to supply fewer patient visits per year. The annual number of services provided per patient increased from 3.47 to 5.50 (OLS regression; P<0.05), reflecting both increased service rates per visit and increased numbers of visits by patients. Dentists provided less restorative, prosthodontic and extraction services per year, but more diagnostic, preventive, endodontic and crown and bridge services. The annual care received per patient also included more diagnostic, preventive, endodontic and crown and bridge services but differed from the dentist pattern through increased rates of restorative services over the study period. CONCLUSIONS: The content of dentist workloads has changed to include less emphasis on removal and replacement of teeth and more effort on diagnosis and prevention aimed at retention of natural dentitions.     

Opinions among Norwegian dentists on specialization and/or general practice

abstract – Three special areas of dental practice are recognized by the Norwegian Dental Association: oral surgery, orthodontics, and periodontics. A representative, nationwide sample comprising 50 dentists in Norway was surveyed through personal interviews concerning opinions about specialists and further specialization. Two dentists in the sample were specialists, the remaining general practitioners. Two-thirds of this group thought that the specialization of dentistry would continue. Only 11 dentists, however, considered this development to be desirable. Every second stated nevertheless that there was a shortage of specialists, particularly orthodontists, in the district where they practiced. Most respondents had good experiences cooperating with specialists but they were against establishing new specialities; they were concerned about their own scope of activity. Some pointed out that it requires greater skill and ability to be a solo general practitioner in a rural district than to be an urban, centrally located specialist. However, only 13 dentists considered it right to make general practice a "specialty".     

Stability of practice beliefs and preferences for patients among private general dentists: a comparison of 1997 and 2007

Background:  Practice beliefs and dentist preferences for patients have been related to service rates and appropriateness of care. If practice beliefs and preferences for patients are stable then they could restrain long-term changes in practice styles and service rates. The aim of this paper was to assess the stability of practice beliefs and preferences for patients between 1997 and 2007.
Methods:  Practice beliefs and dentist preferences for patients were recorded on a five-point Likert scale using mailed questionnaires from a random sample of dentists in 1997 (response rate = 60 per cent) and 2007 (response rate = 77 per cent).
Results:  In both 1997 and 2007, n = 215 dentists provided data. For practice beliefs, 1 out of 8 items were significantly different (p < 0.05; McNemar's test) between the two observations (12.5 per cent of practice belief items) while 5 out of 37 dentist preferences for patient characteristics items were significantly different (13.5 per cent of items).
Conclusions:  The majority of items were not significantly different over time. This demonstrates a generally high degree of stability over time in the level of agreement with dentist practice beliefs and preferences for patients. Given that it may be difficult for clinicians to change practice beliefs and behaviours that have become established, it is important for policy makers to understand the relationship between provider characteristics and service patterns and for educators to positively shape beliefs and behaviours through undergraduate and continuing education.     

Service patterns associated with coronal caries in private general dental practice

OBJECTIVES: To describe the pattern of dental services associated with dental caries by level of carious lesion severity. METHODS: Data were collected by a mailed survey from a random sample of dentists from each State/Territory in Australia in 2003-2004. Dentists provided service data on patients treated on a typical clinical day for patients attending with a diagnosis of dental caries. RESULTS: Restorative rates were higher for insured patients, radiograph rates were higher for emergency visits, prophylaxis and topical fluoride rates were higher for non-emergency visits and at capital city locations with topical fluoride also higher for patients from higher socio-economic status areas, endodontic rates were higher for emergency visits and at non-capital city locations, while extraction rates were higher for males, uninsured patients and for emergency visits. Poisson regression models compared the rates of services from different service areas for initial and cavitated carious lesions with gross carious lesions, controlling for patient demographics, visit type, location and socio-economic status. Restorative services were provided at higher rates (P<0.05) for cavitated carious lesions (RR=2.38), radiographs were provided at lower rates for both initial (RR=0.28) and cavitated carious lesions (RR=0.31), both prophylaxis and topical fluoride services were provided at higher rates for initial carious lesions (RR=2.33 and 3.00, respectively), endodontic services were provided at lower rates for both initial (RR=0.03) and cavitated carious lesions (RR=0.07), and extractions were provided at lower rates for both initial (RR=0.23) and cavitated carious lesions (RR=0.16) compared to the reference category of gross caries. CONCLUSION: Service patterns varied by level of carious lesion severity with initial carious lesions managed by more preventive services, cavitated carious lesions with more restorative services, gross carious lesions with more radiographic, endodontic and extraction services. However, initial carious lesions tend to be managed with restorative rather than preventive service, suggesting scope for increased management by minimum intervention approaches.     

Service provision trends among Australian private general dental practitioners: 1983/84 to 1998/99

AIM: To investigate time trends in service provision. DESIGN: Four cross-sectional surveys across a 15-year period. SETTING: Australian private general practice. PARTICIPANTS: A random sample of dentists. METHODS: Dentists were surveyed by mailed questionnaire in 1983, 1988, 1993 and 1998 (response rates 71%-75%). Data were weighted to provide representative estimates for the age by sex distribution of private general practitioners in 1983, 1988, 1993 and 1998. MAIN OUTCOME MEASURES: Services per visit, annual services per dentist, annual services per patient. RESULTS: Total services per visit increased over the study period from 1.78 to 2.14 (Poisson regression; p < 0.05). However the annual number of services provided per dentist did not vary significantly, reflecting a trend among dentists to supply fewer patient visits per year. The annual number of services provided per patient increased over the period from 3.47 to 5.22 (OLS regression; p < 0.05), reflecting both the increased service rate per visit and increased numbers of visits by patients. Dentists provided less restorative, prosthodontic and extraction services per year, but more endodontic and crown and bridge services. The pattern of annual care received per patient also included more endodontic and crown and bridge services but differed from the dentist pattern through increased service rates over the study period in areas such as restorative, diagnostic and preventive. CONCLUSIONS: While dentists are providing a similar number of services annually, the content of their workload has changed to include less emphasis on removal and replacement of teeth and more effort on maintenance and retention of natural dentitions.     

Hours worked and patient visits provided by dentists in Australia

Background

The aim was to examine the numbers of hours worked and patient visits provided by age and gender of dentists in Australia, and compare with previous estimates to describe trends.

Methods

Data were collected from a random sample (N = 2961) of Australian dentists. Private sector dentists working in clinical practise were included in the analysis.

Results

The response rate was 49% (N = 1345 dentists). Hours per year worked and number of patient visits per year were lower for dentists aged 65 years and older compared with younger dentists, and were higher for male compared with female dentists aged 35–45 to 55–64 years. Hours per year worked were lower in 2013–2014 than reported in 2009–2010, but the number of patient visits in 2013–2014 was similar to the previously reported estimate from 2009–2010.

Conclusions

Hours worked and visits provided were only lower among older dentists aged 65 years or more. Male dentists tend to work more hours per year and provide more patient visits per year than female dentists. Over the last decade, Australian dentists maintained a stable output of visits per year despite a trend towards fewer hours worked per year.     

Variations in Australian dental therapy practice by practitioner and workplace characteristics

Introduction: Understanding dental therapy practice across clinical settings is useful for education and service planning. This study assessed if dental therapy service provision varied according to practitioner and workplace characteristics. Methods: Members of professional associations representing dental therapists (DT) and oral health therapists (OHT) were posted a self-complete survey collecting practitioner and workplace characteristics, together with clinical activity on a self-selected typical day of practice. Differences in service provision according to characteristics were assessed by comparing mean services per patient visit. Negative binomial regression models estimated adjusted ratios (R) of mean services per patient. Results: The response rate was 60.6%. Of practitioners registered as an OHT or a DT, 80.0% (n = 500) were employed in general clinical practice. Nearly one-third of OHT and nearly two-thirds of DT worked in public sector dental services. Patterns of service provision varied significantly according to practice sector and other characteristics. After adjusting for characteristics, relative to private sector, public sector practitioners had higher provision rates of fissure sealants (R = 3.79, 95% confidence interval [95% CI]: 2.84–5.06), restorations (R = 3.78, 95% CI: 2.94–4.86) and deciduous tooth extractions (R = 3.58, 95% CI: 2.60–4.93) per patient visit, and lower provision rates of oral health instruction (R = 0.86, 95% CI: 0.76–0.98), fluoride applications (R = 0.43, 95% CI: 0.33–0.56), scale and cleans (R = 0.39, 95% CI: 0.34–0.45) and periodontal services (R = 0.20, 95% CI: 0.14–0.28) per patient visit. Conclusion: Differences in service provision according to sector indicate that OHT and DT adapt to differing patient groups and models of care. Variations may also indicate that barriers to utilising the full scope of practice exist in some settings.Key words: dental therapists, oral health therapists, dental practice, dental practitioners, mid-level dental providers, dental practice management     

Service provision patterns by main diagnoses and characteristics of patients

Service provision patterns may be influenced not only by clinical oral health status leading to a diagnosis and treatment plan, but also by other variables such as patient characteristics. The main aim of this study was to investigate whether associations between services provided and patient factors would persist after controlling for the main presenting diagnosis or condition. A random sample of dentists surveyed in 1993-94 provided a response rate of 74%. Private general practitioners recorded service provision data from logs of 1-2 typical days of practice. Caries (26.5%) was the most prevalent diagnosis, followed by recall/maintenance care (19.0%), pulpal/periapical infection (10.9%), and failed restorations (10.4%). Diagnoses were associated with variation in the percentage of patients receiving services in main areas of service, and also with insurance status, sex and age distributions of patients, and type of visit (chi-square; P< 0.05). Logistic regressions of receipt of services indicated statistically significant associations with patient characteristics and diagnosis categories. Controlling for diagnosis, uninsured patients and those visiting for emergencies had less favourable service patterns (e.g., higher odds of extractions, but lower odds of preventive and crown and bridge services) compared to patients who had dental insurance or visited for check-ups or other non-emergency dental problems. The influence of these factors on services provided has implications of public health importance in terms of appropriateness of care and social inequality.     

Development and testing of revised practice belief scales among private general dental practitioners

BACKGROUND: Practice beliefs have been related to service rate variation and appropriateness of care. The aim of this paper was to further develop practice belief scales by adding new items to an existing set and testing associations with dentist and practice characteristics, and services provided. METHODS: Practice belief items were recorded on a five-point Likert scale using mailed questionnaires from a random sample of dentists in 2004 (response rate = 76.8 per cent). RESULTS: Factor analysis yielded five factor-based scales, with three having adequate or near adequate internal consistency: Professional Autonomy (alpha = 0.72), Patient Focus (alpha = 0.71) and Preventive Orientation (alpha = 0.59). Responses were skewed towards strongly agree (scores 1-<2) for Professional Autonomy (60.6 per cent), Patient Focus (71.7 per cent) and Preventive Orientation (46.3 per cent). Higher percentages of dentists with strong agreement on Patient Focus were aged 30-39 and 60+ years, while lower percentages of dentists with strong agreement on Preventive Orientation were male (Chi-square, P < 0.05). Those strongly agreeing with the scales (scores 1-<2) had (Poisson regression; P < 0.05): lower rates of restorative, a rate ratio (RR) of 0.93, dentures (RR = 0.72) and extractions (RR = 0.63) for Professional Autonomy; higher rates of dentures (RR = 1.32), crowns (RR = 1.46) and extractions (RR = 1.47) for Patient Focus; and lower rates of restorative (RR = 0.88), dentures (RR = 0.78), crowns (RR = 0.72), extractions (RR = 0.50), endodontics (RR = 0.80), but a higher rate of scaling (RR = 1.13) for Preventive Orientation. CONCLUSIONS: The findings confirmed some of an earlier factor structure of practice beliefs, extended the potential practice belief domains, and demonstrated associations with service rates.     

The involvement of Iowa dentists in hospice care

The relationships between dentist characteristics and professional education with involvement of Iowa dentists in hospice care were investigated. Using the 1999 Iowa Health Professional database, a survey requesting information regarding involvement in and training for care of hospice patients was mailed to all licensed dentists (N = 1,210). Two mailings yielded a 54.6% response rate. Of the 638 dentist respondents, the mean age was 47, 86% were male, 88% general dentists, and 295 (46%) reported providing some treatment for hospice patients. At least one dentist reported providing hospice patient care in 72 of Iowa's 99 counties. About 90% of dentists treating hospice patients were general practitioners. Males were more likely to provide treatment (p < 0.0313). Neither dentist age nor years in practice were significant predictors. Dentists were more likely to treat hospice patients in the office (IO, 40%). The most prevalent treatments were denture relines (31% IO; 71% OO), examinations (16% IO; 68% OO), and emergency treatment (12.5% IO; 53% OO). More than 86% of surveyed dentists indicated that their professional education did not adequately train them to meet the clinical, psychosocial, communication, or spiritual needs of hospice patients.