Patient Satisfaction in Military Dental Clinics—Findings From the Department of Defense Dental Patient Satisfaction Survey

The results were presented at the Association of Military Surgeons of the United States Annual Meeting in February 2019. The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Navy, U.S. Air Force, the DoD, or the U.S. Government.

Copyright Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Associated Data

The data underlying this study were provided by the Uniformed Services University TSCOHS by permission. Data will be shared on request to the corresponding author with permission from TSCOHS.

ABSTRACT

Introduction

An objective of the Military Health System is to deliver an improved health care experience. Patient satisfaction affects the patient experience, health outcomes, and treatment compliance. The purpose of this study is to identify indicators of high and low patient satisfaction within a military dental setting.

Materials and Methods

De-identified data from 248,342 responses to the DoD Dental Patient Satisfaction Survey conducted from October 2014 to March 2016 were used. The overall satisfaction and other related outcomes were analyzed by age, sex, beneficiary status, current rank, current Service, type of dental treatment, clinic location, and clinic size. Unpaired t-tests and logistic regression modeling were used to ascertain relationships between various aspects of patient satisfaction and variables of interest.

Results

Overall, 96% of patients attending military dental clinics were satisfied, whereas 72% of patients were satisfied with the number of days waited for an appointment. Air Force patients were the most satisfied compared to their Army, Navy, and Marine Corps counterparts. Patients treated in small dental clinics (less than 5 dentists) were 74% more satisfied than patients treated at large dental clinics (more than 12 dentists). Patients seeking routine dental treatment were significantly more satisfied with the number of days waiting for an appointment (odds ratio = 8.03; 95% CI: 7.64–8.43) compared to patients waiting for an emergency dental appointment.

Conclusions

There were important differences in patient satisfaction by military Service and clinic size, suggesting that improvement in satisfaction may need to be Service specific. These differences warrant further research that could inform policy changes directed at improving service members’ dental care and readiness.

INTRODUCTION

Customer service and patient satisfaction have a significant impact on the oral health of service members. Factors that increase the likelihood of compliance are patient satisfaction, level of supervision, patient’s view of the disease, patient’s compliance strategy, and family influence. 1 Customer service requires a systemized approach to every patient every day. 2 It can be defined as a way of demonstrating care and concern for the consumer and building lasting and collaborative relationships. 3 An important element of this relationship, or interaction between the health care provider and patient, is building trust with the patient through good customer service. Relationships characterized by trust often result in long-term commitment. 3 By making a concerted effort for the service member to feel appreciated and valued as a patient, the dental provider and dental staff will demonstrate good customer service, thus increasing the likelihood of patient compliance.

Several studies have reported on patient satisfaction with the civilian dental health care system. Based on findings from the National Dental Practice-Based Research Network, Mitchell et al. reported that patient satisfaction did not differ between patients receiving invasive dental treatment compared to those not receiving invasive treatment. 4 Furthermore, in 2012, the National Dental Practice-Based Research Network recommended for dentists to take a patient-centered approach and seek to understand how patients evaluate and rate the service provided, facilitating a focus on what each patient values most. 4 A review of dental school patient satisfaction studies by Ebn Ahmady et al. found five indicators that are related to high patient satisfaction: Quality, interaction, access, environment, and cost. 5

There are many intertwining variables that contribute to assessing and understanding patient satisfaction, and this also includes provider perception. For example, it has been reported that several studies in medicine have focused on patient’s perceptions and demonstrated that there is a discrepancy between medical professionals’ and patients’ perception about the treatment they receive. 4 Therefore, measuring patient satisfaction is an important activity to inform actions directed at improving the patient experience. One important characteristic of professionalism is self-monitoring and accountability; hence, it benefits dental professionals to encourage a culture of self-evaluation through measurement. 6

The use of an anonymous survey instrument as a way of gathering data is more effective than asking in person, as patients are more prone to be honest in their replies to questions related to satisfaction. Patients may feel awkward expressing their real views when asked verbally by front desk staff 7 ; thus, an anonymous online survey may reflect a truer indication of their level of satisfaction. Additionally, the timing of sending out a survey has important ramifications. The cognitive process of satisfaction takes time, and if a survey is administered too early, a patient will not have had time to go through the process of evaluation. 8

Unlike the civilian dental health care system, information on patient satisfaction after dental visits in military clinics, including foreign military clinics, is limited. Reporting findings from a survey of over 7,000 Army dental patients, Chisick reported that patients’ age was strongly associated with overall satisfaction. 9 A follow-up study by Chisick and Poindexter of over 12,000 Air Force, Army, Marine, and Navy patients showed high overall satisfaction and little mean satisfaction variance across branches of service. 10 Results from a Tri-Service Center for Oral Health Studies (TSCOHS) survey from 2000 to 2004 found that patients treated by hygiene providers were highly satisfied in both the dental clinic environment and in their beliefs about dental care. 11

Increasing awareness of contemporaneous factors contributing to patient satisfaction within a military setting can inform health care policy discussions and improve decision-making. Given that nearly two decades have elapsed since the publication of any information related to service member satisfaction with receipt of dental care, this study’s objective is to report findings from a multi-service patient survey of active duty military assessing their health care experience.

METHODS

Data Source and Sample Selection

This is a cross-sectional study using de-identified data from the DoD Dental Patient Satisfaction Survey (DDPSS) from October 2014 to March 2016. The DDPSS is administered by the TSCOHS, which is affiliated with the Postgraduate Dental College at the Uniformed Services University. The survey was developed in 1999, and instrument validation was conducted by the Consumer Assessment of Healthcare Providers and Systems organization. A total of 248,342 responses from the standardized surveys were analyzed. Survey response rates were 10.0%, 8.1%, and 8.6%, respectively, among Air Force, Army, and Navy clinic encounters. Data were compiled from an online patient satisfaction survey emailed to adult dental patients (aged 18+ years) after completion of their dental appointment. It is possible that some patients completed the survey more than once because of multiple appointments, so we define these patient encounters as “clinic encounters” for the sake of clarity. For the survey, “dentists” refers to general dentists or specialists seen by the patient. Routine treatment includes general dentistry or specialty care, in contrast to emergency treatments, which are unscheduled “sick call” walk-in appointments that address acute issues.

The survey collected information anonymously from Air Force, Army, Navy, and Marine Corps dental patients. Data for “Other” military Service, for example, Coast Guard, Merchant Marines, and others, were not included because they represented less than 2% of survey responses. The intent of the surveys was to collect patient satisfaction data for the completed dental appointment. The date of the appointment is listed on the survey to remind patients of which dental appointment the survey is specifically targeting. Data regarding clinic size and location are not collected by the survey. Data for the study were released by Army, Navy, and Air Force leadership and TSCOHS upon approval from the Uniformed Services University’s Institutional Review Board. TSCOHS also assisted with survey data management. The study was conducted upon approval from the National Institutes of Health’s Institutional Review Board.

Analytical Variables

The survey assessed dental patient satisfaction using two Likert (six-level) scales: “Very poor to very good” or “completely dissatisfied to completely satisfied.” Six questions from the survey were selected for this analysis (Supplementary Material File 1). For this study, the overall satisfaction was ascertained from the question asking, “In general, how satisfied are you with the clinic’s overall ability to take care of your dental needs,” which was assessed on a Likert scale of “completely dissatisfied to completely satisfied.” For analytical purposes, we categorized responses dichotomously as “satisfied” (completely satisfied, very satisfied, and somewhat satisfied) and “not satisfied” (completely dissatisfied, very dissatisfied, and somewhat dissatisfied).

The other five questions included in the analysis were assessed by a Likert scale of “very poor to very good” and asked the patient to evaluate parts of the dental appointment. These were as follows: Friendliness and courtesy of the dentist; attention given to what you had to say; explanation of dental procedures; how much you were helped by the care you received from the dentist?; and how do you rate the number of days you waited for your appointment? Survey responses of “neither satisfied nor dissatisfied” and “undecided” were not included in the analysis.

The six key explanatory (independent) variables of interest were beneficiary type, service member rank, current Service, type of dental treatment, clinic size, and clinic location. Four of the six variables of interest (beneficiary type, military rank, Service branch, and type of dental treatment) were derived from the DDPSS. Clinic size and clinic location were linked to the survey answers via the individual clinic code that was included with each survey response. Additional independent variables included age and sex.

Data Analysis

Clinic encounter satisfaction was described by select demographic and clinic-related variables of interest using frequency and proportion measures. We calculated the least squares mean for each category of the independent variables and assessed the difference between groups, adjusted by Tukey test for multiple comparisons. We developed generalized linear models for each of the six clinic patient satisfaction questions, using overall satisfaction as a dependent variable and the demographic, dental treatment, and clinic characteristics as independent variables (age, sex, beneficiary type, Service, rank, type of dental treatment, clinic size, and clinic location). Unadjusted and adjusted logistic regression models were produced to assess the relationship between independent variables and overall patient satisfaction, as well as satisfaction with days waited for a dental appointment. All analyses were conducted using statistical software (STAT-SAS, Version 9.4, SAS Institute, Cary, NC).

RESULTS

From a total of 248,342 responses, Army and Air Force users each represented more than one-third of the responses analyzed (38.5% and 39.6%, respectively), whereas one-fifth identified with Navy and Marine Corps (20.5%). More than three out of five responses came from enlisted service members and more than three out of four were male. For less than 5% of clinic encounters, emergency dental treatment was sought. Almost half (45.7%) of the clinic encounters were at medium-sized clinics with 5 to 12 dentists, whereas 41.3% and 13% were at large (more than 12 dentists) and small (less than 5 dentists) dental clinics, respectively ( Table I ).

TABLE I.

The Distribution of Patient Satisfaction Outcomes for the Total Population of Survey Respondents in U.S. Military Dental Clinics, October 2014 to March 2016

a The total number for some variables is less than the total number because of some missing sample data.

c Navy and Marine Corps.

Data source: TSCOHS.

Although overall satisfaction was generally very high (∼96.0%) with military dental clinic encounters, there was somewhat less satisfaction with the friendliness of the dentist (84.3%), attention given to what patients had to say (83.9%), explanation of dental procedures (83.0%), how much patients were helped by the care received from the dentist (82.1%), and the number of days waited for an appointment (72.0%). For these five patient satisfaction domains, patient satisfaction was particularly less prevalent for Navy and Marine Corps clinic encounters (70.9%, 71.0%, 69.5%, 68.8%, and 69.0% patient satisfaction, respectively) ( Fig. 1 ).

The percentage of patient satisfaction outcomes for the total population and military services among survey respondents.

Patients expressed satisfaction in three-quarters of clinic encounters (73.9%) with the number of days waited for routine care but were satisfied with access to care at just 28.6% of emergency dental treatment clinic encounters ( Table I ). Patients aged 40 years or older expressed satisfaction with the number of days waited for routine dental care in 80% of visits compared to 68% of clinic encounters among patients aged 30 years and younger. There were significantly fewer Army, Navy, and Marine Corps clinic encounters where patients were satisfied with their wait time for an emergency appointment (only 10.6% and 24.2%, respectively), compared to the Air Force (52.6%) ( Table II ).

TABLE II.

Patient Satisfaction Outcomes for Numbers of Days Waited for Routine and Emergency Dental Treatment in U.S. Military Dental Clinics, October 2014 to March 2016

a The total number for some variables is less than the total number because of some missing sample data.

Data source: TSCOHS.

Results from the multivariable logistic regression models indicate that at Air Force clinics, patients were nearly twice as likely (odds ratio [OR] = 1.98; 95% CI: 1.86–2.11) to express overall satisfaction with their encounter compared to patients with visits at Navy and Marine Corps clinics ( Table III ). Although patients at Army clinics were more likely to express overall satisfaction with their visit (OR = 1.19, 95% CI: 1.12–1.27) compared to Navy and Marine Corps responses, the magnitude was not as high as it was for Air Force encounters. For clinic encounters among patients aged 40 years and older, they were two and a half times more likely to be satisfied overall with their visit compared to patients younger than 30 years (OR = 2.49; 95% CI: 2.34–2.65). Patients with small-clinic encounters (less than 5 dentists) were 74% more likely to be satisfied overall with their care (OR = 1.74; 95% CI: 1.60–1.89) compared to encounters at large clinics (more than 12 dentists).

TABLE III.

Association of Select Characteristics with Being Overall Satisfied and Satisfied with Number of Days Waited for Dental Care, Among Patients in U.S. Military Dental Clinics (Results of Multivariable Logistic Regression Model), October 2014 to March 2016

Abbreviation: OR, odds ratio.

Patients with routine dental care visits were 73% more likely to be satisfied overall with their dental care than those with emergency dental care encounters (OR = 1.73; 95% CI: 1.58–1.91). Among routine dental clinic encounters, patients were eight times more likely to be satisfied with the number of days waited for an appointment (OR = 8.03; 95% CI: 7.64–8.43) compared to emergency dental encounter wait time experiences. Among clinic encounters for patients aged 40 and older, they were two times more likely to be satisfied with days waited for an appointment (OR = 1.94; 95% CI: 1.89–1.99) than among clinic encounters for patients aged 30 years or less. At Air Force clinic encounters, patients were 64% more likely (OR = 1.64; 95% CI: 1.59–1.69) and at Army clinic encounters they were 23% more likely (OR = 1.23; 95% CI: 1.20–1.27) to be satisfied with days waited for an appointment compared to those at Navy and Marine Corps clinic encounters.

DISCUSSION

Overall satisfaction was defined as the clinic’s overall ability to take care of a patient’s dental needs in our analyses, and at 96% of clinic encounters, those surveyed indicated that they were satisfied with their overall military dental clinic experience. However, patient satisfaction can be “multidimensional,” meaning that no “one” indicator is strictly correlated to patient satisfaction. 5,12 Patients can be satisfied with some areas of care but not with others. When a patient self-assesses satisfaction, an emotional state is reached that indicates whether a person’s experience has met, exceeded, or has failed to reach expectations of an ideal experience. 8 However, the difference between expectation and experience accounts for only 20% of the variance in satisfaction ratings. 8 Patients’ decisions and evaluations of situations are often derived from the values they attach to the different aspects of their health care experience. 13

When assessing findings from patients at military dental clinics, Mangelsdorff et al. found that patient satisfaction differed by Service. In general, patient satisfaction scores were highest for the Air Force, followed by the Navy, Army, and Marines, respectively. 13 In our analysis of patient satisfaction with dental clinic encounters, there was some variance between the three Services in the level of satisfaction reported across the domains assessed, with patients at Air Force clinic encounters more often indicating higher levels of satisfaction compared to the other Services. In contrast, at Navy and Marine Corps clinic encounters, patients were consistently lower in reporting patient satisfaction for all six questions evaluated. This suggests that there is a need to further inquire why Navy and Marine Corp satisfaction differs from their Air Force and Army counterparts. One possible explanation is that the different branches of service have different missions (air, land, and sea) requiring some difference in care delivery systems, and it is possible that these different situations and experiences affect patient assessments. 14 Perhaps, these differences may be a result of the demographic characteristics of the Service members and their families. Among active duty service members, patient satisfaction is moderated by patient sociodemographic characteristics, and addressing patient characteristics can provide an added measure of increased patient satisfaction. 15 According to the normative decision theory, which explains the incorporation of individual expectations, values, and preferences into the decision-making process, patients’ decisions and evaluations of situations are derived from the values they attach to the different aspects of their health care experience. 14 Further studies are needed that assess the differences in the health care experience between Services and what factors of each Service affect patient satisfaction.

In an article entitled “Transforming the Military Health System,” three overarching goals are laid out for the military’s way of delivering health care: To ensure trained and ready military medical personnel, to deliver an improved health care experience to beneficiaries, and to perform both functions as one efficient enterprise. 16 The DoD plans to improve the patient experience so that each military treatment facility is the first choice for beneficiaries where available and appropriate. 16 Patient satisfaction surveys are the DoD’s most direct method for evaluating the quality of the patient experience. The ability to measure the quality of dental services provided is a key to monitoring and improving dental care. 6,12

Our findings illustrate that although patients may not be as satisfied with the individual parts of the dental appointment, dental patients were generally satisfied with the overall patient experience of the dental appointment. This raises the question regarding what part of the dental appointment is the most important. Consequently, should we target areas to improve overall satisfaction? Or, at a minimum, should we intervene in areas of the appointment that will maximize the investment of resources? In a review of dental school patient satisfaction studies from 1980 to 2014, Ebn Ahmady et al. found five indicators that are related to high patient satisfaction: Quality, interaction, access, environment, and cost. 5 Chaffin et al. also concluded that “beliefs about care” are the most important factors associated with patient satisfaction. 11 Furthermore, patients’ evaluation of the health system characteristics suggests that access, communication, outcomes, and quality predict 42% of the variation in patients’ satisfaction scores. 17

It has been suggested that we focus on the demographic characteristic of the Service members, branch of Service, and the geographic location of the assignment. 13 Differences in satisfaction for the number of days waited for a routine and emergency appointment show that the Air Force is more successful at minimizing appointment wait times compared to the other services. Only 5% of clinic encounters were for emergency services, yet Air Force satisfaction for emergency wait time was two and five times more than Navy and Marines and Army, respectively. In their analysis of Navy dental clinics, the Center for Naval Analysis suggested that Navy dentistry reduces unnecessary variation across dental commands and uses its current resources more productively and efficiently. 18 Moreover, the Navy could consider reallocating personnel from OCONUS to large CONUS commands, which are under-resourced and have greater difficulty meeting command-wide patient health benchmarks. 18 Clinic location was found to not have a significant effect on overall patient satisfaction and satisfaction with the number of days waited for an appointment across all variables analyzed in our study although a previous study found that patients assigned in overseas locations tended to be more satisfied than patients assigned in the continental United States. 13

Among clinic encounters, patients were most satisfied in small clinics for both overall satisfaction and satisfaction with the number of days waited for an appointment, and patient satisfaction in smaller clinics was consistently higher throughout our study compared to medium- and large-sized clinics. It has been found that dentists in small-group practices had the most-satisfied patients. 19 This may be because small-group practitioners are more prone to offer alternative treatments and are not required to follow certain pre-approved treatment protocols, creating a discussion with patients that leads to goodwill even though the same end point is achieved. 19 The Center for Naval Analysis found that the largest commands are below their targeted patient-care benchmarks but smaller (typically OCONUS) commands exceed both average and targeted patient benchmarks. 18 Adopting a more patient-centered approach could lead to changes in policy for patient management and improve the patient’s health care experience. The National Committee for Quality Assurance recommends involving patients and family members in practice management and believes that measuring patient experiences can identify and address needed areas for improvement. 20

The DoD has transitioned to the Patient-Center Medical Home (PCMH), where the model of primary care combines teamwork and information technology to improve care, improve patient-care experiences, and reduce health care costs. 20 Patients treated in PCMHs have increased satisfaction to include improved access to care, continuity of care, higher levels of staff and patient satisfaction, better quality of care, lower health care costs, and improved overall health status. 20 Initiating Patient-Center Dental Home throughout the military dental community can match the PCMH approach and improve the health care experience by bringing a small-clinic atmosphere into larger dental clinics. The dental-home-port model emulated a portion of civilian private practice, where chairside care is generally provided by the same dentist and hygienist. 18 This model increases patient convenience and can have the added benefit of increasing patients’ oral health through the continuity of care. 18 Additionally, the most important outcome of this increased patient satisfaction is that it typically promotes patients’ adherence to treatment, which yields better health outcomes. 20 A smaller clinic atmosphere typically improves patient/provider interaction and communication, and continuity of care may be preserved. The quality of communication between staff members and patients has the greatest influence. Thus, if personal interactions fall short, an office’s ability to earn high marks for customer service is jeopardized. 21 Dental providers should remain aware of the human and psychological aspects of care and remain cognizant that they are integral components of the quality of care provided. 19 Patients are able to distinguish between courtesy and genuine interest. 22 Thus, with an improvement in customer service and increased patient satisfaction, military clinics may experience an increase in compliance with dental treatment therapies with their patients and subsequently an improvement in dental health outcomes.

The strengths of our study were its large respondent participation size and the incorporation of supplemental information on clinic size and location. We had to assume that each observation was independent, thus introducing a weakness of the study. An individual may have submitted multiple surveys that span the course of multiple appointments for certain dental procedures. Additionally, the survey was not mandatory to complete, so not all clinic encounters resulted in a completed survey. Thus, it is not possible to determine why a patient did not submit a survey. This may have introduced selection bias.

CONCLUSION

There were important differences in patient satisfaction by Service branch, with dissatisfaction in the number of days waited for emergency dental care being the most evident. This suggests that improvement in satisfaction may need to be Service specific and warrants further evaluation to inform decision-making directed toward improving service members’ dental care and readiness. Clinic size can also negatively affect patient satisfaction, suggesting that adjustments to clinic staffing, dental facility design, and patient management should be considered to improve the patient’s dental care experience. Addressing the availability of dental emergency appointments is paramount since access to emergency care was the most concerning of this survey.