Patient-centred care in general dental practice - a systematic review of the literature

Patient-centred care (PCC) is recognised as a key dimension of quality within health care according to the Institute of Medicine [1]. The importance of patient-centred care has also been recognised by the Australian Commission on Safety and Quality in Healthcare [2], the King’s Fund [3], Agency for Healthcare Research and Quality [4] and the Picker Institute [5]. PCC is relevant throughout the world irrespective of the system of healthcare or the cultural differences [6]. The International Alliance of Patients’ Organizations (IAPO) represents patients of all nationalities and has a vision to ensure delivery of patient-centred care around the world.

Health services research suggests that PCC leads to enhanced patient satisfaction, improved outcomes, enhanced health status and reduced utilization of care [7‐10]. It is also claimed that PCC can result in greater work satisfaction for professionals and reduced levels of medical litigation [11]. Such benefits are extremely desirable for patients, health professionals and commissioners and fully justify the current enthusiasm for the delivery of patient-centred care.

Recent healthcare reforms in the UK have focussed heavily on quality management, with assessment of quality incorporated into both primary and secondary care services. Quality has been defined in terms of patient safety, clinical effectiveness and the experience of patients[12]. These features have laid the foundations for indicators which will be used to measure improved quality of healthcare [13] with patient feedback playing an increasingly important role in measuring the level of quality delivered [14, 15].

PCC is just as relevant within dentistry, although this may not be reflected in terms of the volume of current literature. The FDI World Dental Federation recognises the importance of quality assessment and improvement in dentistry, but reports that there is considerable variation across member countries in the approach to quality management [16]. The lack of an agreed definition of “quality in dentistry” is reported as a barrier to measuring quality and this is highlighted as key to future developments. The Dental Quality Alliance (DQA) is a group of professional organisations in the United States with a mission of advancing performance measures as a means to improving oral health, patient care and patient safety [17]. The DQA have embraced the definition and domains of quality as described by the Institute of Medicine and focus substantially on the importance of patient-centred care within dentistry [1].

In the UK, provision of quality care within the general dental services has been a long held aspiration, but designing an effective method of remuneration to ensure that this is delivered has proved a considerable challenge. In 2006 a new system was introduced which aimed to improve patient access, promote prevention and deliver quality. It is now generally agreed that the system failed to deliver on its key objectives [18, 19]. These failings have been recognised [20, 21] and there is now a greater emphasis on ‘quality’ in the UK. In February 2014 the Chief Dental Officer for NHS England launched “Improving Oral Health – A Call to Action” aimed at developing a long-term strategic plan for NHS dentistry. One of the key objectives within this plan is the delivery of high quality dental care [22]. A Dental Quality and Outcomes Framework (DQOF) to measure quality has already been developed in England and is currently being evaluated [23]. The current DQOF measure is based around 3 dimensions of quality: Clinical Effectiveness, Patient Experience and Safety.

Almost two-thirds of the literature identified following stage 1 screening was based on opinion or review, with the remainder of the articles published as primary research. Many of the opinion papers identified within this literature review describe features of PCC as reported by Gerteis [41] and published in the seminal text “Crossing the Quality Chasm” by the Institute of Medicine in 2001 [1]. The opinion papers identified within this literature review reveal a strong correlation with the dimensions of PCC as described by the Institute of Medicine, although it is important to appreciate that the views expressed have not been formulated on evidence based dental research.

Of the nineteen primary research papers, only three described PCC and its dimensions through original research. The other sixteen research papers were excluded as they did not explore the nature of PCC. Eleven of the excluded articles were concerned with investigation of “patient-centred” outcome measures rather than PCC and were therefore not relevant to this review. Four articles assessed the delivery of PCC, or a dimension thereof, by using measurement tools previously described in the medical literature. The remaining article used the term “patient-centred” purely as a descriptor and was not concerned with the investigation of any aspect of PCC (See Table 2).

Only 3 papers [42‐44] fulfilled the predetermined inclusion criteria and provided data and evidence describing the key features of patient-centred care within dentistry. The literature review demonstrates that there have not been any published studies on patient-centred care within general dental practice. The 3 relevant papers are included in Table 3 with a brief summary of the nature of the study conducted and the key findings.

The three eligible papers all used qualitative research methods and were considered to be of acceptable quality in terms of methodology, analysis, interpretation and relevance when appraised using the CASP framework for qualitative research [38]. A summary sheet providing an overview of the quality assessment is shown in Table 4. None of the studies sampled patients to assess PCC, and instead favoured recruitment of dental care professionals as their participants. All three studies used semi-structured in-depth interviews to collect data, with Scambler [44] also using focus groups. Kulich used video to record consultations, and this information was then used to enrich the data, promote reflection by the dentist involved and stimulate discussion during the interview.

The first of the three papers, Kulich et al. [42], undertook research to identify the important elements of delivering a patient-centred approach while managing patients with dental anxiety. The research team used qualitative research methods based on semi-structured interviews and video recording of consultations. The participant group included 5 dentists specialising in the treatment of ‘odontophobia’, who were recruited by convenience sampling as part of the dental team working at a clinic treating ‘phobic’ patients in Sweden. Fifteen patients were recruited for treatment from the clinic waiting list and attended on two separate occasions, which provided the background for the interviews with the dentists responsible for their care. This resulted in a total of thirty interviews, which were audio-recorded and transcribed verbatim. The video recording was used to promote discussion and enrich the data provided during the interviews. The video data were not formally analysed, but were used in the style of “action research” to stimulate discussion during the interviews and encourage self reflection and verbalisation on the part of the participant dentist. The authors considered this approach to be beneficial and provided “significant impact” in the generation of data.

Grounded theory was used as the conceptual basis of the study and data were collected until saturation was considered to have been achieved. Content analysis was undertaken and a model of a patient-centred consultation developed. This was defined in terms of one overarching core principle - “holistic perception and understanding of the patient” and two underlying categories of “the dentist’s positive outlook on people” and “the dentist’s positive view of patient contact”. The categories described were underpinned by the following aspects of care: empathy, equality, dignity, emotional understanding, respect and engagement.

The second paper, by Loignin and co-workers [43], examined the concept of PCC within a different context. They investigated what skills and approaches dentists in Canada used to overcome barriers to dental care for people living in poverty. They undertook a qualitative study with a group of dentists experienced in delivering care to people living in poverty in Canada. Data were collected by conducting semi-structured interviews with 8 dentists identified as a subgroup of an existing research sample. The subgroup was recruited based on their experience of treating patients living in poverty within Montreal. Content analysis was undertaken which revealed three main themes: “dentists’ experiences with low income patients, perception of poverty and strategies to overcome difficulties with this clientele.” The authors reported the key aspects of successful delivery of dental care to this group of patients and although they use the term “socio-humanistic approach”, they also refer to this as a “patient-centred approach” within the text. The key features highlighted are:

Finally, Scambler [44] conducted a qualitative study to explore attitudes of staff within Special Care Dentistry towards disability and the provision of dental care. The research was concerned with the social model of disability in terms of dentistry and although the study was not directly concerned with PCC, the findings are closely linked. The authors report that patient-centred care was “at the heart of the model”, and PCC is highlighted as one of the key themes to emerge from the research. The study involved recruitment of thirty staff from a Salaried Dental Service Department in London (England), which included clinicians, dental care professionals and administrative staff. Data were collected through interviews and focus groups and initially analysed thematically. Retroductive analysis was then conducted using a framework based on the social model approach to disability. The authors describe several key features of PCC and detail the importance of a holistic approach allowing delivery of individualised care by providing appropriate information and support. The importance of trust, time and communication were also highlighted as important factors in providing patient-centred care.

There are a number of similarities between the three papers in terms of the research topic, sampling methods, data collection and findings. However there are contrasting styles in terms of data analysis, particularly between Kulich and Scambler. Kulich used grounded theory to analyse their data and develop theory generation. Data collection, coding and analysis were conducted simultaneously and continued until saturation had been reached. In contrast, Scambler used mid range theory with retroductive analysis. The objective was to undertake theory testing in contrast to Kulich who was theory generating. Although very different in approach, both studies provide insight into the important features of PCC according to the participant samples.

There was a degree of commonality between the findings of the three studies, with each highlighting the need to treat the patient as a person or as an individual in their own right. This reflects the key principles of PCC as described by Gerteis [41]. Each article also reported the importance of a clear focus on delivering a holistic, non-judgemental approach which represented the findings of previous reports on PCC in other areas of healthcare. The importance of communication was highlighted as a key feature of PCC, and this also featured frequently within the rest of the dental literature. The three articles all detailed the importance of breaking down perceived barriers to allow establishment of a dentist-patient relationship through “direct contact”, “patient contact” or “overcoming social distance”.

Two of the eligible papers highlighted the importance of empathy and understanding, which was again representative of the overall dental literature. Other features that were also reported were the importance of information and support, individualised care, trust and the impact of time.

Certain aspects of PCC that feature within the rest of the dental literature have not been described within the evidence-based papers. These include patient satisfaction [45‐47], oral health promotion/self care [48] and physical comfort [49].

The results across the three studies show a degree of congruity and tend to highlight similar themes within their findings. This could be indicative of a degree of conformity in terms of PCC across different areas of dentistry, or it could simply be due to the homogenous nature of the participant groups, the study design or the similarities in the area of research investigated.

The studies recruited dentists, dental care professionals and administrative staff to understand the key features of PCC, with none of them engaging with patients directly. This is considered by the authors to be a key finding of this literature review, and highlights the importance of understanding PCC from a “patients” perspective. Health professionals have a wealth of knowledge and experience, but ultimately it is patients’ views, which need to be considered and adequately represented when we wish to understand “patient-centred care”. This has recently been recognised by the Cochrane Collaboration with the importance of involving patients in developing “patient-centred outcome measures” highlighted as a key factor in delivering informed healthcare decisions [50].

The studies were not based in general dental practice and focussed on “specialised’ areas of dentistry concerned with the treatment of vulnerable patients. Although such patients may attend general dental practices for routine care, they are likely to have more specific needs, which are not necessarily representative of the rest of the population. It needs to be recognised that although the features identified within these studies could be highly relevant, there may be distinct differences within a group of patients attending a general dental practice. Kulich et al. suggested in their concluding remarks that their findings may be generalisable within the scope of treating dental phobic patients, but the basic principles “should also be applicable to wider areas of dentistry” when dealing with anxious patients.

The recurring themes within this limited body of literature highlight the importance of a humanistic, non-judgemental approach based around good communication, empathy and understanding. (See Tables 3 & 5) The need to see the patient as a person or as an individual in their own right was a strong theme throughout the research articles and aligns closely to the patient-centred clinical method (PCCM) described by Stewart et al. [31]. This framework is based on the concept that ill health has two components – disease and illness. Stewart et al. recognised that history taking and clinical examination provides information on the disease, but it is equally important to understand and appreciate the patient’s perspective and experience of the illness. An understanding and appreciation of the patient’s feelings can only be achieved by engaging with the patient through communication and developing the patient-doctor (dentist) relationship, and this was highlighted repeatedly within the three articles identified within this review. These concepts also reflect the findings within Kitson’s narrative review of the nursing literature [51] which described three main themes; patient involvement, relationship and context.

Despite a close correlation with previous work on PCC, some distinct differences within the dental literature are evident. The most obvious difference was the lack of emphasis within the dental literature on the dimensions of “involvement of family and friends”, “co-ordination and integration” and “physical comfort” as described within the Picker Principles of PCC [5], The NHS Patient Experience Framework [32] and the Institute of Medicine [1].

“Involvement of family and friends” was not considered to be an important feature within dentistry, other than in relation to consent. In contrast, “Involvement of family and friends” is considered one of the most important features of PCC according to Cronin [52] who undertook a review of PCC in 2004.

“Co-ordination and integration” of care was not highlighted within the dental literature as an important feature of PCC, which may reflect the more solitary nature of work as a dentist compared to our medical colleagues who tend to work in larger teams. With the increasing development of skill mix, specialisation and team working, co-ordination and integration is likely to become an increasingly important feature within primary care dentistry.

“Physical comfort” did not feature as an important aspect of patient-centred care within the dental literature. This would appear surprising as fear of pain is considered to be a common barrier to dental attendance for a significant proportion of the population. As highlighted previously, sampling for the three research articles was restricted to dental care professionals with no patients selected as participants. It is conceivable that this aspect of patient-centred care may have featured if patients had been included within the interviews.

These differences highlight the importance of understanding the features of PCC within the contexts of setting, sampling and the area of health investigated. The dimensions described by the Picker Institute [5], the Institute of Medicine [1] and The Kings Fund [3] focus on the secondary care setting, predominately with in-patient care. This would explain the importance of “involvement of family and friends” and “co-ordination and integration”, which would be less relevant to the delivery of dental care in a general dental practice.

Little et al [24] investigated patient preferences in attending general medical practice, based on a questionnaire designed to assess patient-centredness. The authors identified three important domains of patient-centredness from the patients’ perspective: communication, partnership, and health promotion. Communication and partnership were key aspects reported in the dental literature, although health promotion did not feature. General dental practice may be considered to be more closely aligned to general medical practice than it is to secondary care in terms of continuity of care, familiarity and their role within the community. This will obviously be dependent on the practice, the setting and the healthcare system. There are, however, many differences between general dental practice and medical practice and one should not assume that the key features of PCC would be the same for both.

The importance of communication and relationship was highlighted repeatedly throughout the dental literature and would appear to be a cornerstone of PCC. The overarching theme of the features reported was around the importance of “soft skills” of the clinician. Empathy, equality and emotional understanding were considered to be particularly important and this would appear to support the work of Burke and Croucher [53], and Holt and McHugh [54] on patients’ views of the important features of a good dentist.

The primary aim of the general dental practitioner is to improve and maintain the oral health of their patients and this is normally based on a long term relationship rather than episodic care [55]. This relationship is crucial and success is based on trust, respect and mutual understanding [56, 57]. Communication is key, but must not be considered as simply an act of giving and receiving information. Communication is about establishing a “connection” on a human level in order that we can understand the beliefs, needs and preferences of the individual. This is an important theme, which has been repeatedly identified within this literature review and highlights the importance of “putting the patient first” and taking a holistic approach to care.

Delivery of patient-centred care is an important aspect of providing quality dentistry, but there appears to be a poor understanding of the term within the existing literature. This paper demonstrates that there is only limited evidence to provide an understanding of patient-centred care within dentistry and the research, which has been published, does not relate to general dental practice.

The NHS Patient Experience Framework states that “it is possible to apply a single generic framework....to a wide range of health conditions and settings.” [32] The results of this review, albeit from a limited evidence-base, would appear to indicate that there are some distinct differences within the domains of PCC in dentistry when compared to other areas of health. In view of this it may not be appropriate to simply use a generic medical framework to assess PCC as an effective indicator of quality in dentistry.

These findings are equally relevant on an international perspective, for countries striving to implement quality management systems within general dental practice. This lack of evidence-based research must be addressed if we wish to measure PCC within general dental practice and deliver quality improvement. Research needs to be undertaken within primary care and must be developed from a patients’ perspective if we wish to understand patient-centred care within dentistry.