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J Am Dent Assoc, Vol 140, No 2, 229-237.
© 2009 American Dental Association
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TRENDS

The Development and Testing of a Survey Instrument for Benchmarking Dental Plan Performance

Using Insured Patients’ Experiences as a Gauge of Dental Care Quality



San Keller, PhD, Col. Gary C. Martin, USAF, DC, Christian T. Evensen, MS and CAPT. Robert H. Mitton, DC, USN


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 References
 
Background. There is no standard, nonproprietary method for providing national benchmarks of dental care quality as described by patients. The purpose of this research was to develop such a tool following guidelines of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) initiative.

Methods. The authors identified domains of dental care quality via qualitative methods, including a literature review, stakeholder interviews and focus groups with beneficiaries, and they cognitively tested draft questions with patients to yield a pilot survey. Psychometric analyses of pilot data (n = 3,264) identified summary indexes and guided survey revisions. The authors used two waves of subsequent data collection (n = 4,221) to test the validity of the revised survey.

Results. The mean response rate across three rounds of data collection was 51 percent. Statistical analysis indicated that 17 questions could be reliably collapsed into three composite measures: "Care From Dentist and Staff" (reliability = 0.89, scaling success = 100 percent); "Access to Dental Care" (reliability = 0.78, scaling success = 100 percent); and "Dental Plan Coverage/Service" (reliability = 0.84, scaling success = 100 percent).

Conclusions. The validity of the survey was supported in mail and Internet modes for the American English language, and the instrument was approved by the CAHPS consortium for distribution as the CAHPS Dental Plan Survey.

Practice Implications. A tool is available now for assessing dental care quality by measuring adult patients’ experiences with their dental care and coverage. The authors tested this instrument only in a population with third-party coverage, however, which is a potential limitation that should be considered.

Key Words: Dental care quality; dental plan quality; CAHPS; patient surveys; patient satisfaction; quality benchmarking

Abbreviations: AHRQ: Agency for Healthcare Research and Quality. • AIR: American Institutes for Research. • CAHPS: Consumer Assessment of Healthcare Providers and Systems. • CFA: Confirmatory factor analysis. • CFI: Comparative fit index. • EFA: Exploratory factor analyses. • GED: General Educational Development. • NNFI: Nonnormed fit index. • RMSEA: Root mean square error of approximation.

The goal of dental care is to improve the health and meet the functional needs of patients. However, there is no standard, non-proprietary method for providing national benchmarks of dental care quality based on patient reports, and dentistry has little systematic information about delivery system outcomes.1,2 However, it is difficult to create a survey that provides actionable results and covers all topics important to various stakeholders while being short enough for practical use. The purpose of this research was to develop such a tool.

Although investigators can use clinical and administrative data to obtain some performance indicators, some aspects of dental care can be captured only by surveying patients.3 On the basis of a literature review of patient-reported outcomes in dental care, we determined that the topics studied most frequently were in three areas: communication and interaction with the dental care provider4–9; patient anxiety, fear in anticipation of pain, and comfort during treatment3,10–12; and technical aspects of care, such as comfort, functionality and esthetics of dental work.13–21 Instruments that do focus on patients’ experiences tend to use satisfaction-type items to measure their experiences.8,9,19,22 Such reports may tell researchers about patients’ experiences, but they also can be subject to the emotional state of the respondent and provide little in the way of actionable information. Our goal was to develop a survey based on design principles that would provide scientifically sound, actionable results.

The design and testing of this tool were informed by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) initiative. CAHPS is a public-private initiative begun in 1994 and continuing through 2012 to develop a standard set of surveys of health care quality as experienced and reported by patients.23,24 Widespread adoption of these surveys by providers and/or systems is facilitated by the quality of the methods used to develop, test and disseminate them. These methods include rigorous scientific peer review of results, the involvement of key stakeholders in the design and testing of the surveys, and the distribution of surveys and supporting material free of charge at the Agency for Healthcare Research and Quality (AHRQ) Web site.25

The objective of this project was to develop a dental plan quality survey that, as part of the CAHPS family of surveys distributed and supported by AHRQ, could be used to provide national benchmarks for dental insurance plan performance, especially with regard to the delivery of care. To that end, we followed a program of research that addressed the CAHPS survey design principles shown in Table 1Go.


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  		TABLE 1 CAHPS Dental Plan Survey developmental steps.

 

   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 References
 
We constructed a conceptual framework to develop the survey content by using multiple qualitative methods, including a literature review, stakeholder interviews and focus groups with patients. The figureGo shows how the various steps in this process fit together.


Figure 1
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  		Figure. Process of developing the Consumer Assessment of Healthcare Providers and Systems (CAHPS) dental plan pilot test survey.

 
The institutional review board of the American Institutes for Research (AIR), Washington, reviewed and approved all data collection tools (such as interview guides used in the focus groups, the various versions of the survey), consent forms, privacy statements and protocols. We obtained signed consent from all participants in the stakeholder interviews, focus groups and cognitive interviews. A privacy statement appeared on the cover page of the survey (or the introduction section of the online version of the survey), and completion of the survey was accepted as consent.

Literature review. We conducted a search of the MEDLINE and PsycINFO (American Psychological Association, Washington) databases for articles published from 1966 to 2007 by using these key words: dental patient experiences, satisfaction with care, domains, measurement and surveys. Two of us (S.K., C.T.E.) sorted the survey items that we extracted from the reviewed publications into domains. We then evaluated information regarding the reliability and validity testing of the surveys. We supplemented the pool of survey items with several unpublished surveys designed specifically to target the dental plan. We incorporated this information into the protocols that we designed for the stakeholder and focus-group interviews.

Stakeholder interviews. The objectives of the interviews (conducted by S.K., C.T.E. and other employees of AIR) with stakeholders were as follows:

– identify domains of dental care quality of greatest interest;
– determine preferred survey operations;
– determine preferred data-reporting formats;
– obtain advice about ensuring the relevancy of the CAHPS Dental Plan Survey to a variety of stakeholders.

The 12 participants included an expert in dental care policy, an expert in dental services research, dental care insurance plan purchasers and dental care insurance plan providers.

Patient focus groups. A total of 72 dental plan enrollees (recruited by a professional recruiting firm from lists provided by patients’ insurance companies) participated in 12 focus groups conducted on the east and west coasts (North Carolina and California). The objectives of the focus groups were to identify domains of dental care quality that were important to dental plan enrollees but were not covered by the literature review or key informant interviews; determine which domains of dental care quality were of greatest interest to participants; and determine participants’ preferred survey mode (that is, mail, telephone, Internet).

We performed qualitative analyses of the literature, the audiotaped interviews with stakeholders and the audiotaped focus groups with dental patients. We drafted questions to address each of 117 unique features of dental care, which we then organized into 20 topic areas. To decrease the burden on respondents, we created a shorter version of this question list by choosing the subsets of questions addressing topic areas that both dental care experts and dental patients identified as being the most critical aspects of care.

Cognitive testing. We evaluated the comprehensibility of the survey items as well as participants’ ability to navigate the survey by conducting cognitive interviews with 16 dental patients who varied in age, education and health. During each two-hour, one-on-one interview (with an employee of AIR), participants verbalized their thoughts as they responded to survey questions. A trained cognitive interviewer asked scripted, probing follow-up questions to gain additional information about the clarity of the questions and the ease of completing the survey. We rewrote or eliminated questions according to the results of the cognitive testing.

Pilot survey. This process resulted in a 50-item pilot survey that included 20 items to describe the characteristics of respondents and 30 questions about patients’ interactions with dentists and staff members, ease of finding a dentist and obtaining appointments, office waiting times, and quality of the dental plan, including coverage of services and perceived value. The objective of the pilot test was to determine how the responses to the survey could be summarized into a smaller set of indexes (that is, composite measures); to evaluate the measurement properties of items, composite scores and overall ratings of dental care; and to identify modifications that should be made to the pilot test instrument on the basis of these evaluations. The objective of the two subsequent data collections was to field the revised survey and evaluate its reliability and validity.

Survey administration. The sampling frame for the pilot test consisted of 436,180 patients residing in the 48 contiguous states who had been enrolled in their dental plans for at least 12 consecutive months and had had at least one dental visit in the six-month period before the pilot test. These patients were members of three dental insurance plans, the membership of which currently represents approximately 2.9 million covered lives. We drew a stratified random sample—in which each plan represented its own stratum—of 6,488 members from the sampling frame, with the goal of obtaining 2,100 completed surveys (700 for each of the three plans).

We employed Synovate, a certified CAHPS vendor, to collect the survey data. The vendor mailed survey packages (cover letter, copy of the survey and a return envelope) to the sampled plan members in March 2006. We gave respondents the option of completing the survey online. The vendor mailed a reminder postcard one week later, followed by a second mailing of the survey package to nonrespondents approximately three weeks after that. One week later, the vendor sent a final reminder postcard. Collection of pilot test data ended on May 31, 2006. We followed the same administrative procedures for the two subsequent data collections that took place in the first (wave 1) and third (wave 2) quarters of 2007. Table 2Go characterizes the three samples.


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  		TABLE 2 Description of data sets.

 
Data analysis. Although the pilot survey contained 30 questions about dental care and dental plan quality, 11 of these could not be summarized into composite measures, either because they asked about the totality of the patient’s care experience or they were "screener" items designed so that respondents skipped inapplicable questions. (For example, one question asked respondents if they had a regular dentist. If they responded "no," the survey instructed them to skip questions pertaining to patients’ experiences with their regular dentist.) Table 3Go shows the paraphrased content of the questions we evaluated for inclusion into composite measures and the questions concerning the totality of the patient’s care experience.


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  		TABLE 3 Paraphrased questions in pilot and final CAHPS* dental plan surveys.

 
We used standard psychometric analyses to summarize the 19 pilot survey items into composite measures, as detailed in the technical note in the boxGo.26–30


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  		BOX Technical note detailing analyses conducted to identify composite measures.

 
Reliability. We computed Cronbach {alpha}31 as our measure of internal consistency reliability. Internal consistency reliability refers to the amount of systematic variance in scale scores. Scales with reliability coefficients above 0.70 are recommended to provide precision for use in statistical analyses of group-level comparisons.32

Validity. We evaluated the validity of the questions as indicators of a specific composite by examining the Pearson product moment correlations of each question with each composite score (corrected for overlap)33 to determine if those correlations exceeded 0.40 and were higher than the correlation of the question with the two alternative composites (see Results section). We assessed the validity of the composite scores by examining the Pearson product moment correlations of the composite scores with overall ratings of quality.

Variability. We evaluated the variability in the data by examining the distribution of scores for each question and composite, particularly noting the percentage of respondents who gave the highest (that is, the ceiling effect) and lowest (that is, the floor effect) possible responses for the composite. Ceiling effects indicate the percentage of people for whom it would be impossible to assess improvement over time or to distinguish among. Floor effects indicate the percentage of people for whom it would be impossible to assess decrements over time or to distinguish among.

Stability of measurement properties. We evaluated the validity and reliability of the survey data collected through the Internet to determine whether the measurement properties of the survey were comparable across data collection modes. Moreover, at the conclusion of the pilot test, stakeholder representatives from the dental plans requested that additional questions be tested for relevance to the Dental Plan Coverage/Service composite. As a result, we added four questions to the pilot test survey targeted toward aspects of the dental plan. We conducted psychometric analyses, as described above, on data collected from both wave 1 and wave 2 to evaluate the modified version of the survey for comparability to the original (the pilot test).


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 References
 
Confirmatory factor analysis (CFA) of the pilot test data indicated that the new structure (BoxGo), consisting of 15 questions measuring three aspects of dental care ("Care From Dentist and Staff," "Access to Dental Care" and "Dental Plan Coverage/Service") demonstrated excellent fit to the data in both the mail and Internet collections (mail respondents: {chi}279 = 350; comparative fit index [CFI] = 0.97; nonnormed fit index [NNFI] = 0.96; root mean square error of approximation [RMSEA] = 0.05; Internet respondents: {chi}279 = 116; CFI = 0.96; NNFI = 0.95; RMSEA = 0.05).

Reliability. With one exception (the "Access to Dental Care" composite in the pilot data set), these aspects of dental care demonstrated high internal consistency reliability, with Cronbach {alpha} coefficients greater than 0.75.27,32

Validity. The median Pearson product moment correlations in Table 4Go summarize the validity of the survey questions as measures of their respective composites (that is, scaling success). A comparison of the magnitude of the convergent and discriminant validity supports the overall validity of the items as indicators of their respective composite scores. Each composite includes items more highly correlated with their own composite than they are with the two competing composites (100 percent scaling success).


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  		TABLE 4 CAHPS* dental plan composite measurement properties in three data sets.

 
The second row of Table 4Go ("Convergent Validity") shows that median correlations of items with their own composite far exceed, for the most part, the criterion of greater than 0.40, which supports the validity of the survey questions as indicators of their respective composite scores.27,32 The only observed correlation that was lower than 0.40 was for the question in the pilot data set regarding whether someone explained to the patient why there was a delay in the appointment (data not shown but available on request). The influence of this item is reflected in the median correlation of 0.44 for the "Access to Dental Care" composite in the pilot data set, which is lower than the rest of the median correlations in that row.

The third row of Table 4Go shows that the discriminant validity of the three composites is good. The median correlations of items with the competing composites are, with one exception, lower than 0.40.27,32 The "Access to Dental Care" composite in the pilot data set is the one exception.

The correlations in rows 4 ("Overall Rating of Dental Care") and 5 ("Overall Rating of Dental Plan" (Table 4Go) provide further evidence of the validity of the composite measures by demonstrating how the composite scores are related to respondents’ overall ratings of quality.34 Across all three data sets, "Overall Rating of Dental Care" is highly correlated with the "Care From Dentist and Staff" composite. Similarly, "Overall Rating of Dental Plan" is highly correlated with the "Dental Plan Coverage/Service" composite. Finally, the "Access to Dental Care" composite is correlated more highly with "Overall Rating of Dental Care" than it is with "Overall Rating of Dental Plan".

Variability. None of the three scales exhibited floor effects, and two of the three scales had ceiling effects that were less than 10 percent in two of the three data sets. We observed the greatest problem with the lack of variability for the "Care From Dentist and Staff" composite in all three data sets; more than 50 percent of respondents reported the highest possible score on this composite.

Stability of measurement properties. The measurement properties of the mail data were the same as those of the Internet data (data not shown but available on request) and improved, for the most part, in the wave 1 and wave 2 data sets. The ceiling effect for the "Care From Dentist and Staff" composite did not improve from that which we observed in the pilot sample.

We presented the results of the pilot test for peer review by the consortium of CAHPS scientists. In November 2006, the consortium approved the CAHPS Dental Plan Survey for inclusion into the CAHPS family of instruments. Subsequently, we presented the results from waves 1 and 2 to the consortium for evaluation of the modifications made to the pilot survey and the impact of those changes on the three composites. The consortium approved the changes. This modified version of the CAHPS Dental Plan Survey is available to users free of charge.35


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 References
 
Summary of results. We can reliably summarize responses to 17 questions on the survey into three composite measures to indicate "Care From Dentists and Staff," "Access to Dental Care" and "Dental Plan Coverage/Service." The observed internal consistency reliabilities of the composite scores ranged from 0.67 to 0.90 and were comparable to or better than those of established CAHPS measures. Although the reliability of the access composite in the pilot data was slightly lower than the recommended value, it compared favorably with internal consistency reliabilities reported for other CAHPS instruments.36,37 Moreover, the reliability estimates for the scores from this composite passed acceptable levels in the two subsequent data collections (waves 1 and 2). The "Access to Dental Care" and "Dental Plan Coverage/Service" composites demonstrated good variability in their scores, but we observed substantial ceiling effects for the "Care From Dentist and Staff" composite. The size of this ceiling effect, however, is not unusual for questions that ask respondents to evaluate their direct care providers.38,39

Although we do not present the data in this article, we conducted patient-mix analyses to identify characteristics of patients that might affect the way they responded to the survey but that are not a consequence of their experiences with their care or with their dental plan. We assessed an item asking how many dental visits the patient had had in the previous 12 months, an item asking about the respondent’s overall dental health and several other items (regarding, for example, age, education, sex, race, overall physical health) as possible patient-mix adjusters. The final version of the instrument approved by the CAHPS consortium contains several questions that can be used as patient-mix adjusters. We have recommended that age, education and overall dental health be used as patient-mix adjusters, but users of the survey may find it useful to test their own potential adjusters.

Implications of results. The results of this research suggest that users of this CAHPS Dental Plan Survey can be confident about the quality of the data provided by the survey. The content validity of the survey questions was supported by a review of the literature, key informant interviews and focus groups with patients. The construct validity of the CAHPS Dental Plan Survey composite scores was supported by the results of CFA and by the relationship of the composite scores to patients’ overall ratings of their dental care and dental plan. In addition, we found the measurement properties of the mail and Internet survey to be comparable and stable when assessed across three data sets. These findings support administration of the survey in either or both of two modes: mail and Internet.

Possible study limitations. Potential users of the survey should note that the measurement properties of the CAHPS Dental Plan Survey have been studied when administered via mail or Internet. No data address the survey reliability and validity when administered via telephone or interactive voice response. While the measurement properties of the American English–language version of the survey are supported by the study findings, the validity of the survey when translated into other languages has not been studied. For example, it is not known whether a Spanish translation of the survey would have comparable measurement properties. Finally, all of the data reported here come from patients who participated in one of three dental plans. A thorough evaluation of the measurement properties of the survey awaits the implementation of the survey by other dental plans or purchasers of dental insurance. This instrument was not designed to assess the experiences of patients who do not have dental insurance.


   CONCLUSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
References
 
The primary objective of the CAHPS Dental Plan Survey was to produce information that enables the comparison of plan performance, as evaluated by dental patients. In terms of practice implications, the instrument was not designed to be used by individual dental practices, and many of the items on the survey would be inapplicable to patients in such a context. The instrument would, however, be useful to various purchasers of dental care plans, whether they be employers or other organizations responsible for assessing the performance of their dental plans. The rigorous testing of the instrument’s reliability and validity demonstrates that this is a high-quality survey, and that users of the survey and readers of the results can have confidence that the data collected via this instrument are scientifically sound.


   FOOTNOTES
 

Dr. Keller is a principal scientist, American Institutes for Research, Chapel Hill, N.C.


At the time this study was conducted, Col. Martin was the director, Dental Care Division, TRICARE Management Activity, Falls Church, Va. He now is an assistant professor, Uniformed Services University of the Health Sciences, Bethesda, Md. Address reprint requests to Col. Martin, Tri-Service Center for Oral Health Studies, Building 141, Room 221, USUHS, 4301 Jones Bridge Rd., Bethesda, Md. 20814-6975, e-mail "gary.martin{at}usuhs.mil".


Mr. Evensen is a senior research analyst, American Institutes for Research, Chapel Hill, N.C.


CAPT. Mitton is the chief, Dental Care Branch, TRICARE Management Activity, Falls Church, Va.


Disclosure. The authors did not report any disclosures.


The development of this dental care quality benchmarking tool was made possible by a contract from the TRICARE Management Activity, Falls Church, Va., to the American Institutes for Research.


Data for this study were collected by the survey research firm Synovate, a vendor certified to collect data for the Consumer Assessment of Healthcare Providers and Systems surveys.


   References
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 References
 

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