Changes and factors associated with dentists’ willingness to treat patients with severe disabilities
Introduction
Taiwan is currently experiencing a steady increase in the number of people with physical or mental disabilities. As of the end of 2004, there were 908,000 people with a physical or mental disability, or 4.01 disabled people per 100 people [1]. Due to their impairments, people with physical or mental disabilities may not be able to accurately communicate their physical complaints to health care providers, making it considerably more difficult for the disabled to seek medical care than for the general population. There is also a need for longer consulting times due to the increased complexity of treatment of the disabled, resulting in delay or even neglect of necessary treatments.
The need to protect the rights of minority groups has only been slowly realized in our society. To act on this realization, the National Health Insurance (NHI) system has promulgated guidelines regarding medical care for the disabled population. In addition, the NHI's capped global budget payment system allocated an additional amount of dental insurance budget specifically for treating severely disabled population since July 2002. This increase (approximately 130 million NT dollars per year) was allocated under an independent target global budget payment system and was not included in the regional dental global budget distribution. The increase was used to pay for the provision of dental care exclusively for severely physically or mentally disabled people who were defined by the Department of Health (DOH). It was called “the Dental Outpatient Care Payment Scheme for Patients with Severe Disabilities”, which was provided by Bureau of NHI (BNHI). It was intended to act as a financial incentive to encourage dentists to provide oral hygiene and dental care services for severely disabled people [2]. Only severely disabled patients who require dental care are eligible for these special dental care services, and only dentists in teaching hospitals are qualified to provide those services for the severely disabled patients under this rewards program.
In Taiwan, the oral hygiene status and dental condition were poor in the disabled group. Therefore, their first dental treatment was complicated and most of them needed full mouth reconstructed under general anesthesia in the teaching hospitals, especially in medical centers. In the follow-up dental treatment, the qualified dentists then take the responsibility of routine dental caring using physical restrainer or behavior control technique. The nitrous oxide sedation is seldom used in Taiwan. Most of the teaching hospitals in Taiwan offer a private room or space for the severely disabled patients to provide dental care with physical restrainer or behavior control.
Because physically or mentally disabled people are sometimes restricted by difficulties in verbal expression and present with multisystemic diseases, the maintenance of oral health is more difficult for physically or mentally disabled people than for the general public. Thus, the physically or mentally disabled population is one of the groups at high risk of having dental diseases [3], [4]. A study from the United Kingdom indicated that the average number of teeth with dental caries in patients with Down syndrome was 10.95, and for epileptic patients who also had another physical or mental disability, the average number of teeth with dental caries was 11.19 [4]. Beside this, the periodontal health in both groups of patients presented with severe problems, and the majority of the problems had gone untreated. When a group of disabled people with an average age of 30 was considered, 13% of them were already toothless [4]. Children with Down syndrome were more likely to develop periodontal disease than normal children [5], [6], [7]. In Taiwan, the prevalence of dental caries in mentally retarded patients under the age of 12 was as high as 87.5%, and it was 80.59% in patients older than 12 [8]. A study found that the majority of mentally retarded teenagers in northern Taiwan did not receive adequate assistance from their parents or other caregivers in brushing their teeth, showing that these teenagers lacked sufficient preventive dental care [9]. A similar study found Taiwan children with a disability had a significantly higher number of extractions than other relatively normal children [10]. The U.S. studies found that disabled people who were poorer than average had worse oral hygiene status than the general public [11], [12], [13], and the percentage of physically or mentally disabled people with satisfactory overall dental health was only 15.7% [14]. In Melbourne, Australia, 56% of disabled children in special developmental schools required simple preventive and/or periodontal treatment deliverable in the dental chair with or without local anesthesia; 18% required complex restorative and/or periodontal treatment performed best under general anesthesia [15]. Patients with different disabilities may have particular behavioral manifestations of their disabilities. When dentists are treating physically or mentally disabled patients, it may be necessary to control their behavior during the treatment [16]. Therefore, the disabled people might have inequalities in dental treatment and oral health [17], [18].
Now that increased attention is being paid to the rights of minority groups, what are the opinions and attitudes of the dentists with regard to the provision of dental care services to physically or mentally disabled people? Taiwan's medical delivery system consists of three-level hospitals including medical centers, metropolitan hospitals, and local hospitals. Since the medical center cannot reject any patients, only metropolitan hospitals and local hospitals might refer or even “dump” patients to other hospitals for medical treatment. So, was there any difference among dentists in different level of hospitals for accepting the severely disabled patients for dental care due to cost, reimbursement, or other reasons? The barriers to care for the disabled constitute a problem that deserves our attention and that should be actively investigated. Therefore, this study aims to investigate the willingness of dentists to provide dental care for physically or mentally disabled patients, as well as their opinions regarding the rewarding payment program—“the Dental Outpatient Care Payment Scheme for Patients with Severe Disabilities”.
Section snippets
Study samples
Because only treatment for patients with severe disabilities was eligible for special reimbursements for dentists, and only dentists in teaching hospitals were eligible to apply for this type of medical claim, only dentists fulfilling these criteria were surveyed via mailed questionnaires. Using the 2004 dentist registry filed by the Department of Health, a total of 1193 dentists from all 131 teaching hospitals (including medical center, metropolitan teaching hospitals and local teaching
Descriptive analysis of dentists
We compared our study subjects with the general study population, using the 2004 distribution of Taiwanese dentists among different hospital levels (medical centers 59.55%, metropolitan teaching hospitals 33.05%, local teaching hospitals 7.40%) and the distribution of the 184 surveyed dentists in this study among different hospital levels (medical centers 57.61%, metropolitan teaching hospitals 29.89%, local teaching hospitals 12.50%). As for goodness-of-fit testing, we calculated the 95%
Discussion
In order to encourage dentists to provide dental care for the severely physically or mentally disabled population in Taiwan, the BNHI has introduced a special global dental budget. This study found that approximately 60% of dentists said that the medical reimbursement amount of this rewards program was reasonable. Also, 50.4% of dentists clearly showed a willingness to treat severely physically or mentally disabled patients. When combined with those who held a neutral opinion on the rewards
Acknowledgements
This study was supported by a grant from the Taiwan National Science Council (NSC92-2614-B-039-002), and the authors are grateful for National Science Council's assistance in the successful completion of this study.
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