Effects of the Hospital Gradation System on Patient Behavior and Satisfaction: An Investigation of Dental Health Care

Dear Editor-in-ChiefHospital gradation systems are used to examine the performance of hospitals to promote the efficient use of medical resources (1). Patient-perceived service quality may differ for differing grades of medical institutions under gradation system, which has been rarely reported. The aim of the present study was to explore the relation between the hospital gradation system and patient perceptions under Taiwanese hospital gradation system. The specialty of dentistry was investigated due to dental care being significantly different from other medical services (2). Dental care is more personal, intimate, and lasting contact with the patient (3). Nevertheless, quality assessment of dental service remains relatively primitive (4). To explore more accurately and objectively assessment of service quality of dental care is necessary. In Taiwan, the National Health Insurance (NHI) system has provided universal and comprehensive health care to the residents at affordable costs since 1995. It utilizes a gradation system that integrates classification with accreditation to promote efficient medical resources utilization. Medical institutions are classified and divided into four grades based on the level of services provision and size of care providers: medical centers, regional hospitals, area hospitals, and basic-level institutions. Medical institutions other than basic-level institutions are required accreditation to provide quality service to obtain subsidization from Bureau of NHI (5). Dental care, excluding cosmetic services, is covered as part of the benefit package in the comprehensive NHI program of Taiwan. Dental services are provided by dental care centers in the four grades of medical institutions. Patients have freedom of choice of dental service providers with the same co-payment, regardless of the grade of the dental care center. However, in medical centers, dentists are not only tasked with providing clinical services but also participating in teaching and academic research. This has raised the question of whether the dentists' technical skills and the service quality are better at higher-grade dental care centers.Patient satisfaction is a key determinant of the service quality and can be conceptualized as the difference between a patient's perceptions and their expectations. The SERVQUAL model (6) is commonly used to examine the service quality of health care (7). In this study, the modified SERVQUAL instmment which comprises 21 attributes was used to explore differences in patient-perceived service quality between two types of dental care centers with different grades, namely dentistry departments in medical centers (DMCs) and basic-level dental clinics (DCs). The questionnaire contains three sections. The first two sections measure the patient's expectations and percep- tions on a 7-point Likert scale from 1 ("strongly disagree") to 7 ("strongly agree"). The third section of the questionnaire comprises demographics-related questions.The study population included patients over 20 years of age who visited the dental care center for the first time for any type of treatment and had visited another dentist at least once in the past year. A total of 600 patients from five DMCs and ten DCs participated in the study. The questionnaire covered patient expectations regarding their respective dental care provider before treatment and their ratings of that particular dental service provider after treatment immediately. The difference between patient expectations and their perceptions was termed the quality gap or satisfaction gap.Data analysis was performed using the SPSS (Version 20.0. IBM. USA). Cronbach's alpha coefficients were calculated using the valid questionnaires (n = 562) and revealed high levels of internal consistency for the items surveyed. Table 1 shows the comparison of the patient expectations (E), perceptions (P), and the quality gaps (P? E) between grades of dental care centers. …