Normative Evaluation of Dental Specialty Centers and the Relationship with Service and Context AspectsABSTRACT
Objective: To normatively evaluate the Dental Specialty Centers (CEO) and investigate the relationship with service and context aspects.
Material and Methods: This was an evaluative, normative, quantitative, descriptive, and analytical study based on data from the External Evaluation of the 2nd cycle of the Program for Improving Access and Quality of CEOs. A total of 1026 CEOs were evaluated using a Logical Model with evaluative dimensions (Structural, Organizational, Production), subdivided into evaluative sub-dimensions (Human Resources, Structural Resources, Developed Activities, Accessibility, Referral and Counter-referral, Productivity) and indicators classified as poor/regular/good. Classifications were calculated, and a multivariate analysis was performed using Generalized Linear Models and Poisson Regression with robust variance to assess the set of variables related to service (CEO type; Manager presence; Manager tenure; Manager additional training; Planning execution) and context (Geographical region; Population size; HDI; Oral Health Coverage) that are explanatory predictors for the classification of subdimensions. A significance level of p<0.05 was adopted.
Results: The majority of the CEOs were classified as regular (41.1%). The best-evaluated dimension was structure, with 86.5% of the CEOs classified as good. The best-evaluated sub-dimension was Structural resources, with 86.9% of the CEOs classified as good. Statistically significant associations were found between all sub-dimensions and the considered variables.
Conclusion: Service-related variables, especially CEO type, Manager additional training and time of Manager presence, and Planning execution, are determinants for the evaluation. In parallel, contextual factors such as region, Population size, HDI, and Oral Health Coverage also reveal inequalities that affect the CEOs` results. It is concluded that service and contextual factors influence CEOs' classification results.
Keywords:
Health Services Research; Secondary Health Care; Oral Health.
Introduction
Interventions in the health field can be the object of normative evaluation, which seeks to verify if the intervention performed meets expectations by comparing it with pre-established criteria and standards. This type of evaluation is closely associated with the management processes of organizations [1], can assist managers in performing their functions [2], and has been the subject of initiatives to institutionalize it in health in Brazil to consolidate management processes. The dissemination of an evaluative culture, incorporated into the routine of management instances of the Unified Health System (SUS), aims to qualify the actions of the actors responsible for decision-making [3].
The Program for Improving Access and Quality of Dental Specialty Centers (PMAQ/CEO) is an example of an institutional evaluative program by the Ministry of Health. However, due to its cross-sectional data collection and analysis and the cycle's duration, it can be considered sporadic and slow to produce timely results, especially those originating from the External Evaluation stage [4].
In this context, the CEOs are the reference establishments in the National Oral Health Policy (PNSB - Brasil Sorridente) for providing secondary oral health care in the SUS. Advances have been achieved since its implementation [5-7], but challenging issues related to access and quality [5,8], organizational flaws in patient flow [8-10], and meeting production targets [11] persist.
Considering that the purpose of the evaluation is to issue a value judgment for decision-making and to evaluate CEOs' practices and work processes for improvement, this study aimed to conduct a normative evaluation of these establishments and analyze their associations with service and context factors.
Material and Methods
Study Design and Sample
The study conducted was of a normative evaluative type, with a quantitative, descriptive, and analytical nature, based on the analysis of consolidated secondary data from the External Evaluation stage (Modules I - Observation at the CEO; and II - Interview with the Manager and a Dentist) of the second cycle of the PMAQ/CEO, which consisted of collecting information through on-site visits to the services to analyze access and quality conditions [12]. The sample for this study consisted of 1,026 CEOs participating in the External Evaluation, representing 93.53% of the CEOs accredited by the Ministry of Health in 2018. The theoretical-methodological model followed was the Logical Model for the normative evaluation of CEOs (Figure 1), which presents three evaluative dimensions, subdivided into six subdimensions and 24 indicators. All are part of the Evaluation Matrix and are classified based on scores that generate value judgments of poor, regular, and good [13].
Data Analysis
The data analysis was carried out in two stages. Primarily, absolute and relative frequencies derived from the classifications of poor, regular, and good based on the Logical Model [13] (classifications of indicators, subdimensions, dimensions, and overall CEOs) were calculated. In the subsequent stage, multivariate analysis was conducted to evaluate the set of independent variables (Table 1) [14] as explanatory predictors of the dependent variable "Classification of subdimensions." Generalized Linear Models were applied to evaluate the main effects of the predictor independent variables on the response variable, and Poisson Regression analysis with robust variance, which allows inferring the Prevalence Ratio (PR) of the event, based on the Exp(B) values, with the respective Wald Confidence Intervals (CI). The PR highlights the strength of the association between the variables by comparing the variable's analyzed categorization with the standard used by the software, which is shown as "1" in the results. The omnibus test - Likelihood Ratio Chi-square was used to evaluate the explanatory capacity, i.e., the adequacy of the model used to verify what is proposed when confronted with the theoretical model based on the CI. A significance level of 5% was adopted to reject the null hypothesis in all statistical tests, and the data were exported, organized, and analyzed in Microsoft Excel (version 2019). The statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) software, version 28.0.1.1 (14) (SPSS Inc., Chicago, IL, USA).
Independent variables related to the service and context are included in the statistical analyses.
Based on the obtained frequencies, the classifications considered for the second stage were regular and good for the subdimensions of Human Resources, Structural Resources, Developed Activities, Accessibility, and Reference; and the three judgment groups were considered for Productivity.
Since the data used in the study are secondary and publicly available, containing no individual identification data, this study did not require submission to the Research Ethics Committee (CEP), according to the ethical principles contained in the Resolution of the National Health Council No. 510, dated April 7, 2016, and is also not subject to the Declaration of Helsinki by the World Medical Association.
Results
The normative evaluation classified the majority of CEOs as regular (54.1%), and the evaluation of dimensions showed that the Structural dimension was the best evaluated, with 86.5% of CEOs classified as good. Analyzing by subdimension, within the Structural dimension, the Structural Resources subdimension stood out, with 86.9% of CEOs classified as good; within the Organizational dimension, its Referral and Counter-referral subdimension obtained 58.7% of CEOs classified as good; and the worst results were obtained for the Production dimension and its Productivity subdimension, where 10.90% of CEOs were classified as good (Table 2).
Absolute and relative frequencies of indicators, sub-dimensions, dimensions, and CEOs, according to the classification obtained.
The multivariate analysis relating the variable "Classification of Subdimensions" and the exploratory variables (Table 3) showed that for the Structural Resources subdimension, there was an association only for the regular classification, with a 2.09 times higher probability when the CEO was from the North region compared to the South region, 96% higher when OH/FH Coverage was >=82% compared to lower coverage, 54% lower when the Manager was qualified compared to unqualified Managers, and 89% lower with planning activity being carried out compared to its absence. For good classification, the analytical model was inadequate for identifying the predictors of the outcome.
Classification of the CEOs' evaluative subdimensions and the predictor variables of the multivariate explanatory model, based on Poisson Regression analysis with robust variance.
Regarding the Accessibility subdimension, there was an association only for the regular classification, with a 22% lower probability when the Manager had been in the position for less than a year compared to a tenure of ≥5 years, and the analytical model used was not adequate to identify the predictors of the good classification outcome.
Regarding the Developed Activities subdimension, there was an association for the good classification with a 23% higher probability when the CEO was from the Midwest region compared to the South region, 12% higher when the Manager was qualified compared to unqualified Managers, 38% higher with planning activity being carried out compared to its absence, 22% lower for Type 1 CEOs, and 14% lower for Type 2 CEOs, both compared to Type 3 CEOs. There was an association for regular classification with an 89% higher probability for Type 1 CEOs, 64% higher for Type 2 CEOs, both compared to Type 3 CEOs, 13% lower when the CEO was from the Midwest region compared to the South region, 32% lower when the Manager was qualified compared to unqualified Managers, and 72% lower with planning performed compared to its absence.
Regarding the Human Resources subdimension, there was an association with good classification: a 22% lower probability for population size 2 than for size 4, and a 25% lower probability for Type 1 CEOs than for Type 3. There was an association with the regular classification: a 54% higher probability for Type 1 CEOs compared to Type 3, a 35% lower probability when the Manager was qualified compared to unqualified Managers, and a 67% lower probability when planning activity was carried out compared to its absence.Regarding the Referral and Counter-referral subdimension, there was an association for the good classification with a 61% lower probability when the CEO was from the Northeast region, 41% lower when from the North region, 19% lower when from the Southeast region, all compared to the South region, and 27% lower for population size 1 compared to size 4. There was an association for regular classification with a 2.60 times higher probability when the CEO was from the Northeast region, 2.23 times higher when from the North region, 68% higher when from the Southeast region, all compared to the South region, 42% higher for population size 1 compared to size 4, and 32% lower when the Manager was qualified compared to unqualified.
Regarding the Productivity subdimension, there was an association between good classification and a 2.27 times higher probability when the CEO was from the North region compared to the South region. There was an association between regular classification and a 14% higher probability when the Manager was qualified, a 39% lower probability when the CEO was from the Northeast region compared to the South region, and a 32% lower probability for population size 1 compared to size 4. There was an association between poor classification and a 67% higher probability when the CEO was from the Northeast region compared to the South region, a 60% higher probability for population size 1 compared to size 4, and a 37% lower probability when the Manager was qualified compared to when it was absent.
Discussion
Proposals for alternatives to address challenges in evaluating CEOs to improve the evaluation process and encourage their implementation in these establishments have been reported [4,13,15-17]. The Logical Model used in this study is an example of an alternative proposal that proved effective in its goal (to evaluate CEOs normatively) because it was proposed based on scientific literature and legal documents, used quality standards from the PMAQ/CEO, related to the classic Donabedian Systemic Model for health service evaluation (structure-process-outcome triad), which still serves as a model for evaluation studies due to its advantages [18], and provided valuable judgments on the services. Additionally, this Logical Model can be applied by the CEOs' own teams for a local evaluation to understand the territory's reality for planning and to support better decision-making.
The overall classifications obtained by the CEOs from the normative evaluation conducted in this study were similar to the previous evaluation performed with the same Logical Model based on data from the first PMAQ/CEO cycle, where most CEOs were classified as regular (68.1%), followed by good (21.3%) and poor (10.6%) [13]. However, there may have been an improvement in the second cycle, with an increase in the percentage of CEOs classified as good and a decrease in the percentages classified as regular or poor.
The detailed evaluation of subdimensions showed that the Structural Resources subdimension was better evaluated than in the first cycle, where 58.9% were classified as good [13], indicating improvements related to the CEOs' structure. However, the analysis of predictors for this subdimension's outcome showed a deterioration for CEOs in the North Region, as they were among the best evaluated in terms of structural and environmental characteristics in the first PMAQ/CEO cycle [5,19], yet showed a higher probability of being classified as regular rather than good.
The higher probability of regular classification in cities with higher OH/FH coverage may be related to investments in primary care equipment and structures at the expense of secondary care, compared to cities with lower coverage. It is recommended to conduct studies investigating this possible relationship, considering that there are institutional financial incentives provided for primary care through the Requalification UBS Program [20] and for the implementation and funding of CEOs [21].
Understanding issues related to building infrastructure, the maintenance of health units, equipment, and instruments [22] is inherent to the effective performance of the Manager's role. Yet, few studies have examined structural aspects [19], which appear closely linked to service functionality [23]. The results of this study may demonstrate that Managers lack knowledge of these aspects, hindering planning aimed at improving CEOs, as qualified Managers tend to engage in planning [14]. Therefore, it is important to conduct more evaluative studies on the structure of CEOs and seek to relate it to process and outcome aspects, as a good structure does not always necessarily imply a good process or outcome [24].
The Accessibility subdimension was better evaluated than in the first cycle, in which 71.8% of CEOs were classified as good [13]. Providing care to people with special needs is mandatory for CEOs, and accessibility to the service can be achieved through equipment that facilitates physical access, minimizing access barriers as much as possible [25,26]. Improvements have been made in this regard [7].
The analysis of predictors for the outcome of this subdimension showed a significant association only for CEOs with Managers who have held the position for less than a year, with a lower probability of regular classification compared to those who have held the position for longer. However, no evidence was found to support a relationship between the Manager's tenure and changes in structural accessibility. Additionally, structural aspects have already been shown to be poorly governed by local managers, and governance is essential for implementing interventions [27]. Therefore, more specific investigations are suggested.
The Developed Activities subdimension was better evaluated than in the first cycle, where 60.0% were classified as good [13]. The analysis of predictors for the outcome of this subdimension showed a higher probability of good classification in the Midwest compared to the South, which can be explained by improvements related to the provision of minimum specialties and the minimum operation of 40 hours per week compared to the first PMAQ/CEO cycle, where approximately 30% did not offer the five minimum specialties, or four were offered below expectations [28]. This may be linked to the presence of qualified Managers in these CEOs, as adequate training positively impacts the implementation of a care model and its actions, influencing the adequacy of workload and the provision of specialties. Qualified Managers tend to engage in planning [29], which also serves as a reference for implementing actions [30].
The higher probability of poorer classifications for Type 1 and 2 CEOs compared to Type 3 may indicate that smaller structures hinder compliance with required standards, suggesting investigations to relate adherence to regulations and structural aspects of CEOs.
The Human Resources subdimension was the only one that worsened in the evaluation compared to the first cycle, where 78.1% were classified as good [13], compared to 43.9% in the second cycle. The main issue is the imbalance in workload between Dentists and Oral Health Assistants/Technicians, with only 26% of Brazilian CEOs having an adequate ratio [28]. This shows that Dentists often work alone, taking on multiple functions, which can negatively impact the provision of care. The role of Assistants/Technicians is essential for providing dental services [31].
The analysis of predictor factors for this subdimension showed a lower probability of good classification for CEOs in size 2 cities than for those in size 4 cities. This can be explained by the inadequate distribution of services and professionals according to the population's needs, which may reflect in the relationship between the working hours of Dentists and Assistants/Technicians, as they tend to be concentrated in larger cities [29,31,32], where training centers are also concentrated [29]. Therefore, it is suggested that policies be strengthened to encourage professionals to move to regions with greater needs, thereby improving service provision.
The lower probability of a regular classification when the Manager is qualified, and planning is carried out accordingly, may suggest that the managers of these CEOs are well-trained and educated, leading them to conduct planning [14] and invest in continuous education for their workers [32].
The Referral and Counter-referral subdimension was better evaluated in the second cycle than in the first, with 33.5% of CEOs classified as good [13]. The execution of this process is essential to the organizational dynamics of Health Care Networks (HCN) to overcome fragmentation in care and management, thereby improving the political-institutional functioning of the SUS [33] and the quality of services offered [9]. The result of this subdimension was consistent with studies in which most patients accessed the CEO through a referral term [9,10]. Still, the considerable percentage of access not carried out through referenced demand may indicate spontaneous demand, weakening the Network's dynamics, and suggesting this be investigated.
The analysis of predictor factors for the outcome of this subdimension showed a higher probability of a regular classification and a lower probability of a good classification for the Northeast, North, and Southeast Regions, compared to the South. Size 1 cities, compared to size 4 cities, where problems have been reported, such as the lack of a guarantee of referral to specialties [34], issues related to the use of physical referral guides [35], and weaknesses in communication between Primary and Secondary Care [15]. The use of computerized systems may be a solution to these problems, capable of providing benefits, but has been little explored, especially in smaller cities, making it necessary to invest in their dissemination and in the training of professionals and users for their use [36].
The failures in the organizational arrangement may be related to the lack of professionals or even services, as there is low availability of these when evaluating the distribution of professionals in relation to the population [37], who tend to be concentrated in more populous cities [32], which can hinder the referral and counter-referral process of patients in smaller cities. In this sense, the consolidation of regionalized HCN can overcome this obstacle, as it establishes organizational arrangements for different health actions and services to ensure continuous care through the referral and counter-referral mechanism [33].
The Productivity subdimension was better evaluated in the second cycle than in the first, with 8.9% of CEOs classified as good [13]. The Brazilian time-series profile [11] showed an increasing trend in the proportion of CEOs who met the targets. Still, for the Northeast and North Regions, the decreasing trend for Basic Care procedures is noteworthy, which historically tend to be met, and endodontics, where the minimum required percentages are commonly not achieved [38-42]. In addition, lower target compliance has been observed in smaller cities [29,38]. It is suggested that practices be reorganized to achieve better results, and, therefore, the higher probability of a regular classification and lower probability for poor classification when the Manager was qualified seems to be a positive aspect, as the weaknesses may reveal the need for more incisive management committed to the better effectiveness of care actions.
This study evaluated CEOs normatively, and classifying these establishments as good does not mean they do not need improvements and advances. However, failing to meet the minimum requirements indicates that management needs to devote more attention to improving them.
Strengthening the importance of qualified managers is recommended, as they can affect service outcomes [41]. It is also necessary to adopt a differentiated approach for the Northern region, such as implementing a specific policy to increase supply, and for small cities, which face greater difficulties in meeting established goals and achieving higher quality. This study reinforces the importance of recognizing that, in the HCN, references are usually found in these cities, even if of lower quality.
Additionally, it is emphasized that the incorporation of Information Technology has already been shown to improve the quality of care, productivity, and problem-solving in secondary oral health care [15]. Recently, the Ministry of Health has been promoting the institutionalized computerization of Dental Specialty Centers with financial incentives to assist in evaluating and reviewing care line protocols, including the continuity and comprehensiveness of care [43].
There has been a significant increase in the number of studies evaluating secondary oral health care in Brazil in recent years, but some gaps remain. These include evaluations conducted by actors not linked to the service, characterized as external evaluations, whose purpose may be seen as solely to produce knowledge recognized by the scientific community and not always used to support decision-making [43], and the use of data from the External Evaluation PMAQ/CEO stage, which has underpinned a significant portion of evaluative studies on the CEOs [4,7,13,28]. Based on these assumptions, this study has a limitation: there was no linkage to the evaluated services, and data from the External Evaluation were used.
Other limitations may be related to the use of secondary data, which are subject to underreporting or inadequate recording that cannot be identified; subject to exploratory variables, where their categorizations are not always similar to other studies, lacking a more precise parameter for comparison; and subject to the modeling adopted for analysis, which did not prove robust enough to explain the outcome of two sub-dimensions (Structural Resources and Accessibility).
It was not the objective of this study to analyze all aspects of CEO evaluation. The possibility of exploring each of the 24 indicators related to the six subdimensions and three evaluative dimensions may lead to the elucidation of questions that are still unanswered, suggesting future studies to analyze the relationships between exploratory variables and each indicator, subdimension, and dimension, aiming to consider the specificities of the local scenario to support decision-making.
Conclusion
The evaluation of Dental Specialty Centers in Brazil is strongly influenced by service-related variables, particularly organizational and managerial aspects. The CEO type, the Manager's additional training, the time the Manager spent in the position, and the implementation of Planning execution were determinants in the evaluation. These elements reveal that strengthening managerial capacity and institutionalizing planning appear as essential strategies to improve the quality of specialized care.
In parallel, contextual conditions also exerted substantial influence on the evaluation of the CEOs. Regional differences, municipal population size, socioeconomic conditions expressed by the Human Development Index, and oral health coverage highlight persistent territorial inequalities. In this sense, the findings reinforce the interdependence between service organization and municipal conditions.
The results indicate that both service-related and contextual factors must be considered in the outcomes CEOs achieve. Internal improvements, especially in management, professional qualifications, and planning, tend to enhance evaluations, but their effectiveness depends on the context in which each service is embedded. Thus, strengthening the CEOs requires recognizing that internal organization and contextual equity are inseparable dimensions, and that advances in specialized oral health care depend on both.
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Financial SupportNone.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Edited by
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Academic Editor: Wilton Wilney Nascimento Padilha
