J Dent Educ. 73(2): 218-224 2009
© 2009 American Dental Education Association
From the Students' Corner |
Behavior-Associated Self-Report Items in Patient Charts As Predictors of Dental Appointment Avoidance
Kevin C. Lin, B.S., B.A.
Key words: patient-provider interaction, patient-dentist relationships, dental anxiety, anxiety measures, behavioral dental science, compliance, patient satisfaction, character, personality, temperament
Submitted for publication 07/17/08;
accepted 11/01/08
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Abstract
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Dentally anxious patients with long-term avoidance behavior may experience treatment complications and induce stress in the dentist. Since dental anxiety scales are seldom used clinically, it is valuable to investigate the strength of behavior-associated items in the current patient chart in predicting canceled or missed appointments. Charts from a sample of patients (N=357) who visited the UCLA Dental Center January 2006 to June 2006 were examined for self-reports of depression, moodiness, nervousness, and anxiety. Multivariate regression indicated that reported feelings of depression, moodiness, and prior appointment avoidance due to fear were strong predictors for canceled or missed appointments. Reported anxiety or nervousness did not predict missed appointments. Although studies have shown that anxious patients who have completed behavioral-cognitive therapy were more likely to maintain regular dental care, the lack of prediction from anxiety or nervousness implies that dental anxiety may not play a direct role in patient compliance with attending dental appointments. By examining the relation of additional temperaments to appointment avoidance, a self-report questionnaire can be developed to identify patients with emotional distress and tailor interventions to decrease missed appointments.
Dentally anxious patients tend to present with long-term avoidance behavior and seek treatment only when severe pain is experienced.1–4 This avoidance pattern often complicates the patient’s required dental procedures, induces stress in the dentist, and interferes with the dentist’s ability to provide comprehensive care.5 More importantly, the patient’s oral health is significantly compromised due to avoidance. Reports have indicated that, in comparison to control groups, phobic patients present with more missing teeth, more tooth decay, fewer filled surfaces, more periradicular lesions, and more bone loss.1,5 In addition, because dental providers lack sufficient knowledge in addressing anxiety-related psychological issues, dentist-patient rapport and the quality of care often suffer as a result.6 Considering the ramifications of this problem, dental care providers need to acquire the ability to recognize and adequately manage patient anxiety.
Assessment tools such as the Dental Anxiety Scale (DAS), Dental Anxiety Inventory, and Spielberger’s State-Trait Anxiety Inventory are commonly used for research purposes in screening dentally anxious patients.2–4,7–11 These measures have been shown to have high validity and reliability, but they are seldom used clinically due to the perceived time constraints and sensitive survey contents. Clinicians are also reluctant to administer the surveys to patients because of the surveys’ emphasis on negative dental experiences.12,13 However, regardless of the reasons, without addressing the patient’s fear of dentistry, dentists would encounter difficulty in building rapport and managing treatment compliance. Given the challenging circumstances, it is valuable to investigate whether current patient chart information can serve as an assessment tool to reflect appointment avoidance pattern without introducing additional anxiety measures into the clinical setting.
In order to identify the questionnaire items pertinent for this research, several studies were investigated. Roy-Byrne et al. and Berggren et al. suggest that dental fear may be related to a history of major depression, substance abuse, and panic disorder and that depressed moods seem to influence the cognitive behavior of fearful patients.14,15 In addition, researchers have reported that long-term avoidance behavior appears to play a significant role in fearful patients’ treatment-seeking patterns.1–4 In the current health questionnaire adopted by the UCLA Dental Center, there are seven items presented to patients under the behavioral category. Because there appear to be indirect relationships among depression, anxiety, avoidance pattern, and general dental fearfulness, it would be reasonable to hypothesize that, among the seven items, behaviors identified by the three specific health questionnaire items (items 117, 118, and 120 in Table 1
) are likely to play a role in patients’ canceling or missing dental appointments.
Furthermore, in past dental anxiety studies, the association between individual behavior-associated behaviors and patient compliance has not been investigated separately.6,14,15 Since temperaments such as impatience, excitability, short attention span, impulsiveness, dominance, and uncooperativeness have all been shown to contribute to the development of dental anxiety,6,9 it would also be worthwhile to examine if a direct relationship exists between the specific personality traits and dental appointment compliance.
The primary aim of this study is to investigate the strength of the three behavior-associated items from the existing questionnaire in predicting the number of canceled or missed appointments. The secondary aim is to examine whether the extent of responses to these items reflects the prevalence of dental anxiety in the general population.
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Materials and Methods
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All study procedures were approved by the UCLA Institutional Review Board (IRB #G07-070104-01). For the study, 2,731 patients treated in the UCLA undergraduate dental clinic between January 2006 and June 2006 were indiscriminately included in the selection process irrespective of the extensiveness of dental treatment needed. New patients were obtained from the patient pool marked by Fast Track (a treatment plan for patients who have simple to intermediate periodontal needs, ten or fewer fixed units, "simple" three-unit bridge, or single tooth implant with reasonable occlusion and no temporomandibular disorder) and Advanced Treatment Planning (defined by patients with treatment needs greater than Fast Track criteria). Patients already in treatment were obtained from the existing patient pool. To control for selection bias, a randomized patient pool was generated from the combined groups of patients with varying dental needs. The first 400 patients of that randomized pool were selected for chart review. The clinic’s electronic record system (Software of Excellence, SOE) was used to identify and randomize the patient pool for the study.
Data Collection
The patient charts were held in the chart room at the UCLA Dental Center. Electronic records on SOE were available via the dental school intranet. Both the patient charts and the matching electronic records were accessed simultaneously at the Dental Center during the data collection process. The information was then recorded on an Excel spreadsheet assigned a research case number not linked to the actual patient number. For patient confidentiality, the charts were not revisited.
The items from the UCLA Dental Center self-reported health questionnaire used in the study are shown in Table 1
. There are seven items in the behavioral category of the existing health questionnaire. Items 117, 118, and 120 (boldfaced in Table 1) were selected based on relevance to dental fear and the treatment-seeking pattern described above.
The patient’s "no" response was assigned a "1" in the Excel spreadsheet, while a "yes" response was assigned a "2" in the spreadsheet.
The patient’s number of canceled or missed appointments was documented for the study by examining the student dentist’s notes recorded on the electronic patient record between January 2006 and June 2006. The study included the number of missed (no-show) appointments and appointments that were canceled within twenty-four hours of the scheduled time. Student dentists have the incentive to record patient no-shows and appointments canceled by patients within twenty-four hours because it allows the clinic director and faculty to evaluate each patient’s compliance with clinic policy and management issues and to discharge patients in extreme cases. There is no incentive for a student to record his or her own cancellation of a patient since that would reflect negatively on the student’s organizational skills.
Data Analysis
Data were analyzed using SPSS 15.0 and Excel 2002.
Among the 400 patients originally selected for chart review, seventeen charts were excluded from the selection because they were either missing from the chart room or filled out incompletely. Additionally, after two attempts were made to retrieve the patient chart, twenty-six charts were excluded because they were either in use by student dentists or specialty clinics in the Dental Center. Finally, 357 patients were included in the data analysis.
A t-test (two samples assuming unequal variances) was used to compare the number of appointments missed by patients responding "no" to all three targeted items versus the number of appointments missed by patients responding "yes" to some or all of the items. Another t-test was used to compare the responses to behavior-associated items from patients who attended all appointments with responses from patients who canceled or missed appointments.
Pearson correlation was performed to explore the association between the three behavior-associated items and the number of canceled or missed appointments. Multivariate regression was employed to analyze associations between the behavior-associated items and the number of canceled or missed appointments.
The prevalence of patients responding "yes" to each behavior-associated item and the number of canceled or missed appointments were calculated separately. The prevalence was calculated based on the sample population size of 357.
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Results
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In the patient group that responded "yes" to some or all of the behavior-associated items, more canceled or missed appointments were apparent. In the first t-test, the statistical significance (P
0.05; Table 2) suggested that the appointment avoidance pattern was clearly distinct in the two sample groups that were separated based on the positive/negative responses to behavior-associated items. The significance of the second t-test results (P0.05; Table 3) indicated that when the sample population was divided into two groups based on the presence or absence of canceled/missed appointments, there was, once again, a distinction in each group’s tendency to respond positively to the behavior-associated items. Thus, the results of the two t-tests demonstrated a relationship between canceled or missed appointments and the three behavior-associated items.
Five of the Pearson correlations indicated a significant relationship between the behavior-associated items and the number of missed/canceled appointments and among the behavior-associated items themselves. The number of canceled or missed appointments noted on SOE positively correlated with the patient response to "depressed or moody" (R=.117) and "avoid dental appointment" (R=.109) at the significance level of P0.05. The anxious/nervous item did not reach the same level of significance with canceled or missed appointments; however, it did exhibit a strong association with depressed/moody (R=.455) and previous appointment avoidance (R=.212) at a significance level of P0.01 (Table 4).
The multivariate linear regression analysis included the three behavior-associated items as the independent variables and the number of recorded canceled or missed appointments as the dependent variable. When examining all three predictors together, the regression indicated that "depressed or moody" (B=.158; P=.115) and "avoid dental appointment" (B=.144; P=.105) exhibited a trend for the number of canceled or missed appointments; however, the regression slope was disturbed by the "anxious or nervous" variable (B=.023; P=.809) (Table 5). When "anxious or nervous" was excluded, "depressed or moody" and "avoid dental appointment" items yielded a predictive strength that is statistically significant (B=.100; P=.062 and B=.090; P=.094) for the number of canceled or missed appointments (Table 6). In the linear regression examining each predictor individually, "depressed or moody" and "avoid dental appointment" were significant at the level of .027 and .04 respectively; "nervous or anxious" demonstrated a significance level of .152 (Table 7).
Finally, the prevalence of canceled or missed appointments and positive response to behavior-associated items are presented for better visualization in Table 8.
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Table 8. Prevalence of canceled/missed appointments and positive responses to behavior-associated items (total sampled population n=357)
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Discussion
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The population for this study was drawn from a teaching clinic at a large urban dental school and may have an inherent bias towards more extensive treatment plans and medical conditions. However, the study tried to minimize bias by choosing patients based on their recorded appointment attendance between January 2006 and June 2006 within the same patient pool. New patients with varying degrees of dental needs and existing patients with similar variability were all included in the pool for random selection.
Dental anxiety studies have shown that anxious patients who have completed behavioral-cognitive therapy were more likely to experience fewer cancellations, complete more fear-provoking treatments, and more able to maintain regular dental care.3,5 Other studies have also grouped depression or moodiness with anxiety in examining a patient’s avoidance and compliance patterns.14,15 The findings in this study, however, indicate that it is necessary to distinguish the influence of the specific behavioral characteristics rather than observing the general impact of anxiety alone.
In this study, the series of statistical analyses reveal two significant findings. First, it demonstrates that the depressed/moody item and the prior appointment avoidance item predict patients’ tendency to cancel or miss dental appointments. Secondly, it shows how anxiety may strongly correlate with other behavior-associated characteristics but lack individual predictive strength for patient appointment compliance at the same time. This latter finding is consistent with a dental anxiety study done at the UCLA Dental Center fifteen years ago. Stewart et al. screened anxious patients using the DAS and found that the reported depression and prior avoidance history on the self-report admission questionnaire did not significantly discriminate between patients with high and low DAS.10 By comparing Stewart et al.’s finding with the present study, it is apparent that the degree of anxiety (high and low) may not strongly reflect the patient’s compliance in attending dental appointments. This relatively weak correlation between these two factors was demonstrated in several other research articles as well. In Sergl et al.’s study on orthodontic patient compliance, anxiety did not seem to predict cooperative behavior as strongly as other personality traits such as impulsiveness and dominance.16 Berggren et al. found that patients with high general fear who failed to engage in behavioral therapy were able to complete the dental treatment without significant reduction in anxiety.8 McCracken et al. found that reduction in depression throughout chronic pain treatment was more strongly related to patient satisfaction than reduction in pain-related anxiety.17 And lastly, Sohn and Ismal found that, among patients without dental insurance, dental anxiety may not influence regular dental visits because of the expectation that dentists were only to be visited for urgent oral care.9 In sum, anxiety is shown to correlate with depression, moodiness, and high avoidance history; however, it does not reflect a patient’s appointment compliance as effectively as the aforementioned behavior-associated characteristics.
In order to better understand the pattern of patient compliance, it would be helpful to investigate additional patient temperaments (impatience, excitability, short attention span, impulsiveness, dominance, and uncooperativeness) and personality traits beyond the conventional anxiety assessment. If correlational strength between a patient’s appointment cancellation and additional temperaments/traits was established, a compliance assessment scale might be developed and incorporated into the self-report admission questionnaire. Dental providers would then be able to screen for potentially noncompliant patients and better meet their needs before cancellations occur. To enhance the patient’s dental experience, the score compiled from the compliance assessment scale could indicate the utilization of different strategies ranging from behavioral-cognitive modification, oral sedatives, conscious sedation, to general anesthesia. A seminar focusing on the application of the assessment scale might be provided to students and practicing dentists by bridging the information learned in existing didactic courses on behavioral science, patient management, dental pharmacology, and dental anesthesiology. Finally, after the providers were taught to employ the strategies of minimizing patient noncompliance, the various modalities could be further evaluated and refined for effectiveness.
The secondary aim of this study was to address whether the extent of responses to the behavior-associated items reflected the prevalence of dental anxiety in the general population. As reflected in multiple studies, the prevalence of dental anxiety ranges from 5 percent to 20 percent.6,8,12 It was demonstrated that, in the UCLA Dental Center, the prevalence of patients with behavior-associated characteristics and canceled or missed appointments did match the prevalence of dental anxiety in the general population. However, although the level of prevalence may be similar among mood disorders (depression, moodiness, anxiety, and nervousness) and other associated behaviors (previous avoidance history), it would be false to identify dental anxiety simply using prevalence as an assessment tool since the multivariate regression analysis in this study indicates the complexity of patient compliance.
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Conclusion
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While the results of this study acknowledged the effect of dental anxiety on dental care, feeling "depressed or moody" and "having prior appointment avoidance due to fear" were stronger predictors for canceled or missed appointments. The lack of correlation between anxiety or nervousness and appointment avoidance in this study implies that dental anxiety may not play a direct role in patient compliance. In addition to anxiety and the specific behavior-associated items selected for this research, appointment avoidance may be a multifactorial issue influenced by other personality traits. Past dental anxiety studies have frequently examined temperaments based on their correlations with anxiety measures.6 However, a direct relationship between these personality traits and dental appointment compliance has yet to be established. Temperaments such as impatience, excitability, short attention span, impulsiveness, dominance, and uncooperativeness have all been shown to contribute to the development of dental anxiety.6,9 Given that anxiety may not be directly related to appointment compliance, examining additional temperaments may help to develop a compliance assessment scale. Dental providers will be able to minimize a patient’s appointment cancellation by enhancing the patient’s dental experience accordingly through the use of behavioral-cognitive modification, oral sedatives, and other sedation techniques.
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Acknowledgments
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The author would like to thank Dr. Karen Lefever at the UCLA School of Dentistry for her assistance in conducting and analyzing this study. Further gratitude goes towards Dr. Jeffrey Goldstein and the chart room staff at the UCLA Dental Center for making the data collection and chart review possible.
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Author Information
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Mr. Lin is a dental student at the School of Dentistry, University of California, Los Angeles. Direct correspondence and requests for reprints to him at the UCLA School of Dentistry, A0-111 CHS, 10833 Le Conte Ave., Los Angeles, CA 90095-1762; 650-799-0829; kevinclin{at}ucla.edu.
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Abstract
Materials and Methods
