Development of a measure for orthodontists to evaluate patient compliance

Transcription

1 ORIGINAL ARTICLE Development of a measure for orthodontists to evaluate patient compliance Minna-Maria Tervonen, a Pertti Pirttiniemi, b and Satu Lahti c Oulu, Finland Introduction: Interruption of treatment and poor compliance are problems in orthodontics, especially when the patient does not pay for treatment. The aim of this study was to develop a measure for orthodontists, regardless of type of practice, to assess their opinions about patient compliance. Methods: A questionnaire, based on an orthodontic patient cooperation scale, was modified in 2 pilot phases. The piloted version was tested among 249 respondents. A principal component analysis was performed that included factors with an eigenvalue greater than 1. Reliability was assessed by means of internal consistency with Cronbach s alphas and by test-retest (n 5 40) measures, using an intraclass correlation coefficient. To assess construct validity, the responses of private and public practitioners were analyzed with chi-square and t tests. Results: The response rate was 77%. The final questionnaire showed good reliability: Cronbach s alpha coefficient was 0.878, and the intraclass correlation coefficient after the test-retest was The participation rate was good, there were few missing values, and the study was multifaceted; thus the questionnaire also showed good validity for face, content, and construct. The differences between private and public practitioners were statistically significant. Five factors describing the different aspects of compliance were shown. Conclusions: Observed differences between public and private orthodontists and dentists performing orthodontics indicated clearly the need to develop a specific measure for countries with a publicly funded system of oral health care. The measure showed good reliability and validity for face, content, and construct among Finnish orthodontists and dentists performing orthodontics. The predictive validity of the measure to assess actual patient compliance remains to be tested. (Am J Orthod Dentofacial Orthop 2011;139:791-6) Ageneral problem in orthodontics is that patients can interrupt their treatment. There are, however, few reported ways to predict patient cooperation. 1-4 Interruption of orthodontic treatment could be a different problem in countries where the public sector provides the treatment, compared with countries where patients or parents pay for treatment in private clinics. In most Nordic countries, there is a publicly funded system in which children are entitled to free comprehensive oral health care that is orientated toward prevention. 5 If needed, this also includes orthodontic treatment provided not only by specialists but From the Institute of Dentistry, University of Oulu, Oulu, Finland. a Junior researcher, Department of Oral Development and Orthodontics. b Professor, Department of Oral Development and Orthodontics; Oral and Maxillo-Facial Department, Oulu University Hospital. c Senior research fellow, Department of Community Dentistry. The authors report no commercial, proprietary, or financial interest in the products or companies described in this article. Reprint requests to: Minna-Maria Tervonen, Department of Oral Development and Orthodontics, Institute of Dentistry, University of Oulu, PO Box 5281, FI Oulu, Finland; , minna.tervonen@fimnet.fi. Submitted, May 2009; revised and accepted, October /$36.00 Copyright Ó 2011 by the American Association of Orthodontists. doi: /j.ajodo also by general practitioners. 5 In these countries, the need for orthodontic treatment is mostly defined by a dentist, not by the patient or his or her parents. Since orthodontic treatment requires relatively extensive oral health resources, it is important that, to prevent disturbances and disruption of treatment, patient compliance can be evaluated and, if needed, enhanced. Of the different measures of compliance, some have been developed to monitor compliance based only on the reports of orthodontists and others by both patients and orthodontists. 1,2,4,6-8 The general finding in these studies was the role of orthodontists in maintaining compliance by encouraging the patient, giving positive feedback, and communicating with the patient. 1,6-10 It has even been stated that the relationship between patient and orthodontist is the most important factor in compliance. 6,8,10 Of the practitioner-orientated measures of compliance applied in orthodontics, some are related to a special appliance. 9,11-14 Compliance in wearing headgear has been measured, for example, by using a headgear timer or a headgear calendar In studies with a broader and more general aspect, the overall compliance of the patient has been evaluated. 6,9,13-16 According to Bartsch et al, 9 compliance is associated 791

2 792 Tervonen, Pirttiniemi, and Lahti with many variables, such as characteristics of the patient, family background, duration of treatment, and influence of the treatment provider. Sergl et al 3 found that compliance in orthodontics can be predicted by the amount of initial pain and discomfort experienced. There are also reports that, in orthodontic treatment, female patients are generally more compliant than male patients. 15,17,18 A comprehensive and validated measure for testing patient cooperation in orthodontics was developed by Slakter et al 2 in the United States. The orthodontic patient cooperation scale is based on a list of indicators related to patient compliance. 2 Compliance in orthodontics has been relatively widely studied. To our knowledge, however, no measure of compliance has so far been developed for a context with emphasis on publicly funded orthodontic care. The list of indicators introduced by Slakter et al 2 was chosen as the basis for this study because it is multifaceted and carefully developed, and it had been used previously in other studies. 3,4,6 The aim of this study was to develop a measure for orthodontists, regardless of type of practice, to assess their opinions about patient compliance. MATERIAL AND METHODS The development of the measure, which was also to be suitable for the public health context, comprised several phases (Fig). In the first phase, the original 12-item indicator list of Slakter et al 2 was translated into Finnish, and some items were edited (Fig). The following openended questions were included from the original indicator: Can you name other indicators of noncooperation? Please list them below. Be as specific as possible. Also, if you believe that poor attitude is a major indicator of noncooperation, please list below some specific patient behaviors from which an orthodontist might infer poor attitude. Other comments? The indicator was then tested with 8 orthodontists (Fig), who were asked to rank these 12 items in terms of their importance as indicators of cooperation and response to open-ended questions as in the original indicator study. In the second phase, the items were modified based on the qualitative comments provided. Existing items were rephrased and edited. New items were added based on the comments of the respondents (Fig). In this phase, the modified indicator with 16 items and the openended questions of Slakter et al 2 were tested among orthodontists and orthodontic residents (n 5 5) as well as by public health care dentists (n 5 8). The participants were again asked to rank these 16 items in terms of their importance as indicators of cooperation and to provide comments. In the third phase, and after the second pilot test, the indicator was further modified (Fig). At this point, to determine how much each item described a noncompliant patient according to the respondents, 6 Likert-scale reply alternatives were introduced for every item (1, not at all; 2, slightly; 3, somewhat; 4, quite a lot; 5, very much; and 6, I have no experience of this kind of behavior). In this phase, the following background variables concerning the participants were also added to the questionnaire: sex, age in years, information on specializing in orthodontics (yes or no), and type of practice (private or public health care). The participants in the final study were members of the Orthodontic Section of the Finnish Dental Society Apollonia. The questionnaires were sent to all members (n 5 249). Three sets of reminders were sent; finally, 192 (77.4%) questionnaires were returned. Of these questionnaires, 13 (6.8%) were not properly filled out, and the final number of questionnaires included in the analyses was 179 (72%). The mean ages were 51.9 years (SD, 10.7; range, years) for all participants, 54.4 years (SD, 11.3; range, years) for men, and 51.5 years (SD, 10.6; range, years) for women (Table I). In addition, the test-retest questionnaires were collected from 40 respondents by using a 3-week mailing interval. Statistical analysis Reliability was assessed by means of internal consistency with Cronbach s alphas and by test-retest measures with intraclass correlation coefficients. In the missing-value analysis, 6 items with missing replies were observed among the 179 participants and the total of 3043 items on the scale. To assess the construct validity, the responses of private and public practitioners were compared in cross tabulations. Statistical significance was evaluated by using chi-square and t tests. To determine whether there were any underlying constructs in this questionnaire, a principal component analysis was performed that included factors with an eigenvalue over one. RESULTS The distribution of the participants is presented in Table I and the distribution of the responses in Table II. The most frequently reported characteristic of a noncompliant patient was that the appliance seemed to be unusable. Additional reported characteristics of a noncompliant patient were failure to wear the appliance at night and failure to wear intermaxillary elastics. These 3 characteristics, all of which describe a noncompliant patient, were related to appliances, whereas the 4 least important items were related mainly to appointments (Table II). Most respondents did not consider June 2011 Vol 139 Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics

3 Tervonen, Pirttiniemi, and Lahti 793 Fig. Development of the questionnaire. the patient looking untidy to be a characteristic of a noncompliant patient (Table II). The internal consistency of the total scale (17 variables) described with Cronbach s alpha coefficient was The alphas of deleted items varied from to 0.880, indicating that all items contributed almost equally to the scale. After the test-retest, the intraclass correlation coefficient was The response rate was 77.4%, and, for the replies included in the analysis, there were only 6 missing values. During the pilot-testing phases, many responses were obtained for the open-ended questions as well as various extensive written comments. When different subgroups of respondents were compared, statistically significant differences were found between men and women as well as between private and public practitioners in responses to items. Compared with men, women significantly more often considered that distorted wires and loose bands described a noncompliant patient very well (46% vs 72%, P ). Public dentists had more experience (98%) of patients not asking about treatment procedures and not answering when asked a question (P ), and also more experience of those patients (98%) with behavior indicating that orthodontic appointments were an inconvenience, or treatment procedures were painful (P ), compared with private practitioners (89% and 91%, respectively). The 5 factors extracted with the principal component analysis were named according to the content of each factor. These factors were (1) indifference, which consisted of items related to lack of interest in treatment and appointments; (2) hostility, which included items related to the patient s hostile attitude toward treatment American Journal of Orthodontics and Dentofacial Orthopedics June 2011 Vol 139 Issue 6

4 794 Tervonen, Pirttiniemi, and Lahti Table I. Characteristics of the respondents Men, n (%) Women, n (%) All combined, n (%) 28 (15.6) 151 (84.4) 179 (100.0) Specialized in orthodontics 24 (85.7) 106 (70.2) 130 (72.6) General practitioners or other specialists, or specializing 4 (14.3) 45 (29.8) 49 (27.4) in orthodontics at that moment Working at private clinics, hospitals, or universities* 12 (42.9) 32 (21.2) 44 (24.6) Working at public health centers 14 (50.0) 114 (75.5) 128 (71.5) *There were 7 missing values. Table II. Means and standard deviations of the responses on items describing characteristics of noncompliant patients (range: 1, does not describe at all, to 5, describes very much) and percentages of respondents with no experience of that behavior Item Mean SD No experience (%) Failure to wear appliance at night Poor oral hygiene Patient s behavior is sullen, hostile, belligerent, or rude Lack of interest in treatment Patient does not clean his or her appliances Failure to bring headgear or removable appliance to appointments Appliances are often broken Distorted wires and loose bands Late for appointments Failure to wear rubber elastics (with fixed appliance or cross-elastics) Frequent broken appointments or cancellations Parent takes no interest in child s treatment Patient asks nothing about treatment procedures and does not answer when asked something Patient s behavior indicates that orthodontic appointments are an inconvenience or treatment procedures are painful Patient thinks that appointments are too long Appliance seems to be unusable Patient looks untidy and appliances; (3) poor hygiene, when the patient had poor oral and appliance-related hygiene; (4) neglect, which consisted of failure to wear appliances; and (5) nonuse, which meant indifference to appointments. The first 2 factors explained over half of the common variance of the total scale. These factors and their loadings as well as the percentages of common variance explained are presented in Table III. The values of Cronbach s alpha for each factor were the following: factor 1, 0.790; factor 2, 0.749; factor 3, 0.697; factor 4, 0.535; and factor 5, No statistically significant differences in the total scale or factor subscale scores were found between the subgroups. DISCUSSION Among the respondents in this study, the validity and reliability of the scale were good. According to the results of the test-retest measures, the test gives similar results when repeated. The internal consistency of the total scale was on the same level as in the original study of Slakter et al. 2 The alphas of deleted items were relatively high, and all items contributed almost equally to the scale. Thus, this measure, as in the original scale, is relatively homogenous and seems to measure essentially the same dimension: patient cooperation. The study group broadly represented practitioners involved with orthodontics from different locations, of different ages, and with different types of practice such as specialists, general practitioners, private practitioners, and public health care dentists. The respondents thought that this type of study was important, and they were committed to it, as can be concluded because there were few missing values. Based on the effective sample, the rate of participation was also good; many openended responses were received, thus indicating good face validity. 19 June 2011 Vol 139 Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics

5 Tervonen, Pirttiniemi, and Lahti 795 Table III. Factors describing the characteristics of noncompliant patients (factor names, factor loadings, and percentages of common variance explained [% var] by each factor and the total scale) Factor item Loadings to the factor Total % var 1. Indifference 18.2 Patient asks nothing about treatment.741 procedures and does not answer when asked a question Parent takes no interest.694 in child s treatment Patient thinks that appointments.666 are too long Patient looks untidy.605 Behavior indicates that orthodontic.580 appointments are an inconvenience or treatment procedures are painful Appliance seems to be unusable Hostility 15.9 Patient s behavior is sullen, hostile,.748 belligerent, or rude Appliances are often broken.714 Distorted wires and loose bands.701 Lack of interest in treatment.548 Late for appointments Poor hygiene 11.0 Poor oral hygiene.833 Patient does not clean his.710 or her appliances 4. Neglect 10.4 Failure to wear elastics (with fixed.786 appliance or cross-elastics) Failure to wear appliance at night Nonuse 8.9 Failure to bring headgear or removable.754 appliance to appointments Frequent broken appointments.422 or frequent cancellations Total 64.4 The content of the final indicator was multifaceted. During the pilot phases, all final items were found to be important. The saturation point was also reached when items were no longer excluded or added. Several phases were necessary for development of the measure, and the contents of the items were determined based on the judgment of experts. 19 The measure revealed 5 factors describing the different aspects of compliance. The construct validity can also be considered to be good, since this measure seems able to find differences between the responses of practitioners working in the public and private sectors. 19 Private practitioners, more than public practitioners, considered different characteristics (eg, appointments as an inconvenience and painful treatment procedures) to describe a noncompliant patient. One reason for this could be that in private clinics the patient is paying for the treatment, and the publicly offered treatment is free of charge. It could be assumed that the motivation for treatment might be lower if the patient or the patient s parent does not have to pay for it. Because no measure of compliance has so far been developed for a context with emphasis on publicly funded orthodontic care, in this study we were also able to develop a measure to assess the opinions of orthodontists and dentists performing orthodontics about patient compliance to be used in countries with a publicly funded system of oral health care. Most respondents reported that some items described well the action of a bad complier (appliance seems to be unusable) compared with other items (patient looks untidy or patient is late for appointments). Interestingly, all 3 of the best characteristics for describing a noncompliant patient were related to appliances. On the other hand, 4 less important items were related mainly to appointments. The final questionnaire was further developed from the scale developed originally by Slakter et al. 2 The original list of indicators was changed to fit the public health context. The list of indicators changed somewhat from the original: 4 items remained the same, 8 were rephrased and edited, and 4 new items were added. The inclusion of this public health care context required more items than did the original list. This was probably because the environment for providing treatment is different, as is the basis of the funding for treatment, but also patients in public health care differ from private patients. The aim of this study was to develop a measure for orthodontists, regardless of the type of practice, to assess patient compliance. The scale proved to be valid with these respondents and in this context, and this measure can be used as a basis for studying compliance. 19 Patient compliance appears to be a complex issue. 20 According to Mandall et al, 21 age, sex, socioeconomic status, type of appliance, and clinical treatment need are not useful in helping a clinician to designate potentially cooperative patients. To examine the ability of this new questionnaire to predict and evaluate actual patient compliance during treatment, further studies with this questionnaire are needed. This is important from the clinical point of view, since the final outcome and the quality of treatment depend on patient compliance. If compliance can be predicted, it might also help in directing scarce resources, especially in the public sector. CONCLUSIONS The observed differences between public and private orthodontists and dentists performing orthodontics indicated clearly the need to develop a specific measure American Journal of Orthodontics and Dentofacial Orthopedics June 2011 Vol 139 Issue 6

6 796 Tervonen, Pirttiniemi, and Lahti for countries with a publicly funded system of oral health care. The measure showed good reliability and validity of face, content, and construct among Finnish orthodontists and dentists performing orthodontics. The predictive validity of the measure to assess the actual patient compliance remains to be tested. REFERENCES 1. Mehra T, Nanda RS, Sinha PK. Orthodontists assessment and management of patient compliance. Angle Orthod 1998;68: Slakter MJ, Albino JE, Fox RN, Lewis EA. Reliability and stability of the orthodontic patient cooperation scale. Am J Orthod 1980;78: Sergl HG, Klages U, Zentner A. Pain and discomfort during orthodontic treatment: causative factors and effects on compliance. Am J Orthod Dentofacial Orthop 1998;114: Sergl HG, Klages U, Pempera J. On the prediction of dentist-evaluated patient compliance in orthodontics. Eur J Orthod 1992;14: Stenvik A, Torbjørnsen TE. Team-work in orthodontic care: orthodontist, dentist and other dental personnel. Nor Tannlegeforen Tid 2007;117: Nanda RS, Kierl MJ. Prediction of cooperation of orthodontic treatment. Am J Orthod Dentofacial Orthop 1992;102: Bos A, Hoogstraten J, Prahl-Andersen B. Towards a comprehensive model for the study of compliance in orthodontics. Eur J Orthod 2005;27: Sinha PK, Nanda RS, McNeil DW. Perceived orthodontist behaviors that predict patient satisfaction, orthodontist-patient relationship, and patient adherence in orthodontic treatment. Am J Orthod Dentofacial Orthop 1996;110: Bartsch A, Witt E, Sahm G, Schneider S. Correlates of objective patient compliance with removable appliance wear. Am J Orthod Dentofacial Orthop 1993;104: Nurminen L, Pietil a T, Vinkka-Puhakka H. Motivation for and satisfaction with orthodontic-surgical treatment: a retrospective study of 28 patients. Eur J Orthod 1999;21: Cureton SL, Regenitter FJ, Yancey JM. The role of headgear calendar in headgear compliance. Am J Orthod Dentofacial Orthop 1993;104: Doruk C, Agar U, Babacan H. The role of the headgear timer in extraoral co-operation. Eur J Orthod 2004;26: Agar U, Doruk C, Bicakci AA, Bukusoglu N. The role of psycho-social factors in headgear compliance. Eur J Orthod 2005;27: Egolf RJ, BeGole EA, Upshaw HS. Factors associated with orthodontic patient compliance with intraoral elastic and headgear wear. Am J Orthod Dentofacial Orthop 1990;97: Cucalon A, Smith RJ. Relationship between compliance by adolescent orthodontic patients and performance on psychological tests. Angle Orthod 1990;60: Bos A, Hoogstraten J, Prahl-Andersen B. The theory of reasoned action and patient compliance during orthodontic treatment. Community Dent Oral Epidemiol 2005;33: Southard KA, Tolley EA, Arheart KL, Hackett-Renner CA, Southard TE. Application of the Millon personality inventory in evaluating orthodontic compliance. Am J Orthod Dentofacial Orthop 1991;100: Bos A, Vosselman N, Hoogstraten J, Prahl-Andersen B. Patient compliance: a determinant of patient satisfaction? Angle Orthod 2005;75: Steiner DL, Norman GR. Health measurement scales. A practical guide to their development and use. 4th ed. New York: Oxford University Press; p. 82-3, Lee SJ, Ahn SJ, Kim TW. Patient compliance and locus of control in orthodontic treatment: a prospective study. Am J Orthod Dentofacial Orthop 2008;133: Mandall N, Matthew S, Fox D, Wright J, Conboy F, O Brien K. Prediction of compliance and completion of orthodontic treatment: are quality of life measures important? Eur J Orthod 2008;30: June 2011 Vol 139 Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics