Title:Effectiveness of a quality management program in dental care practices

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1 Author's response to reviews Title:Effectiveness of a quality management program in dental care practices Authors: Katja Goetz (katja.goetz@med.uni-heidelberg.de) Stephen M Campbell (stephen.campbell@manchester.ac.uk) Bjoern Broge (bjoern.broge@aqua-institut.de) Marc Brodowski (marc.brodowski@aqua-institut.de) Michel Wensing (M.Wensing@iq.umcn.nl) Joachim Szecsenyi (Joachim.szecsenyi@med.uni-heidelberg.de) Version:3Date:5 March 2014 Author's response to reviews: see over

2 Dear Editoral board of BMC Oral Health Please find attached our revised manuscript Effectiveness of a quality management program in dental care practices (MS: ). We appreciate the opportunity to revise our manuscript; thereby the comments of the reviewers were very helpful in order to improve the clarity of the paper. Our responses to the comments are given below. We hope that this revised version can contribute to the contents of BMC Oral Health. Sincerely The Authors Reviewer's report Title:Effectiveness of a quality management program in dental care practices Version:2 Date:3 March 2014 Reviewer: Jan Clarkson Reviewer's report: I have reviewed the changes and content that the authors have addressed the referees comments. If the decision is to publish there needs to be some grammatical corrections and I suggest they check for consistency eg when referring to general medical practice that the authors use the word medical. On different parts into the manuscript we checked for consistency and improved the wording. Furthermore, we had a native speaker who improved the language within the manuscript. I suggest also that the abstract is amended to include the exploratory nature of the work and more clearly describe the two groups. Thank you for these suggestions. We added following sentence for the exploratory nature: This was an exploratory study with a before-after-design. Furthermore, we described more clearly the two groups as follow: The mean interval between the before and after assessment was 36 months. The comparison group comprised of 56 dental practices that had undergone their first assessment simultaneously with follow-up assessment in the intervention group. Level of interest: An article whose findings are important to those with closely related research interests Quality of written English: Needs some language corrections before being published Statistical review:no, the manuscript does not need to be seen by a statistician. Declaration of competing interests: I declare that I have no competing interests

3 Reviewer's report Title: Effectiveness of a quality management program in dental care practices Version:2 Date: 25 February 2014 Reviewer: Paul Batchelor Reviewer's report: Major Compulsory Revisions As the authors have identified, the term 'quality' of healthcare is a multidimensional term. While the authors have provided a framework on how quality could be measured, the finer aspects of what should be need a greater explanation. For example, it would be helpful to provide a more detailed description of what exactly was included in the german system and, since it has been a requirement (? to practice) since 2006, what impact it has had. Thank you for this advice. We added following paragraph in the introduction: Although, to date, there are no formal sanctions, so participation remains voluntary. The result has been that different quality management systems have become available for health care providers in primary care settings [15]. These different quality management systems measure structure and process of care as well as non-clinical outcomes of patients. I would also like to see more details of the differences between the initial medical assessment tool and the dental tool. While agreeing with the authors that differences exist, there are a number of areas which would be consistent. For example, are the finance issues any different, and if yes, how and why? We have the following paragraph in the method. However, if we reported more details between the initial medical assessment tool and the dental tool the focus of the manuscript would be changed. A new publication which only compares these to tools is necessary but not relevant for the current manuscript. Some indicators for dental care practices are different to those for general medical care. The domain infrastructure was expanded by dimensions material management and laboratory management ; the domain quality and safety by dimensions safety of staff and patients, hygiene, infection control and provisions for emergency situations ; and the domain information by dimensions communication with other health care providers and information for patients on practice, practice policy and community resources. Detailed information about the European Practice Assessment for dental care settings on a website is under construction. Third, I am not sure I agree with the authors that their work is not about patient outcomes (page 10 limitations). There is an important distinction to be made between clinical outcomes, for example has disease reoccurred within a particular time period, and nonclincialoutcomes, for example the patient is very happy with the care they received. Thank you for this advice. We added that we evaluate no clinical patient outcomes.

4 This leads onto the last issue which I think needs greater discussion; the difference between statistical and clinical significance. While differences between the numerical values derived are tested for significance, I am struggling to understand what exactly does this mean in clinical terms if anything. Please find an explanation in the manuscript, as follow: Because this was the first study evaluating effectiveness of a quality management program in primary dental care settings in Germany, we have no experience on which to base our assessment as to how clinically relevant our results are. At this time, we have no reference standards. This study provides preliminary results as basis for further studies. Minor Essential Revisions There are a number of revisions required to the current text. In the Background section of the abstract, do the authors mean 'improve dental care', or 'improve the provision of dental care'? Page 3 after reference 11. 'Already' should be 'Since'. Page 4 (i) do the authors mean 'quality management' or 'quality assurance'? (ii)just before references (18.19) I think the word 'the' should be inserted between improving and management. (iii) Line 2 of the methods section, change general practice care to general medical care. Page 7 Last paragraph, drop 'Significant' and start the sentence 'Improvements'. Page 8 Last line: 'data are' not 'data is'. Page 9 Lat line of first paragraph the authors use the wording 'for private practice'. I think 'private' could be dropped. Thank you for the different suggestions which improved the wording in the manuscript. Page 10. The issue of 'pay for performance' (3rd sentence) is much more complex than highlighted. After all isn't a fee-for-service system a form of pay-for-performance? I think this paragraph should be rewritten highlighting the very valid sentiment expressed by the authors in the remaining sentences in the paragraph. Thank you for this advice. We rewrite this paragraph as follow: One opportunity (enabler) would be the introduction of performance-based reimbursement to incentivize good quality of care. The potential role of performance-based reimbursement for dentistry is currently under discussion in the United Kingdom and it is being piloted [3,32].

5 However, performance-based reimbursement is also associated with unintended consequences [33,34]. For example, the introduction of performance-based reimbursement in general medical care practices has shown short-term gains, but the evidence for its effectiveness long-term is not compelling [35,36]. Discretionary Revisions Level of interest: An article whose findings are important to those with closely related research interests Quality of written English: Needs some language corrections before being published We improved the language within the manuscript. Statistical review: Yes, but I do not feel adequately qualified to assess the statistics. Declaration of competing interests: I declare that I have no competing interests

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