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Dentists and the institutionalized elderly : issues in long term care dental services Weiss, Rachel Tobiasz 1986

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DENTISTS AND THE INSTITUTIONALIZED ELDERLYUSSUES  IN LONG  TERM CARE DENTAL SERVICES by RACHEL TOBIASZ WEISS A THESIS SUBMITTED IN PARTIAL F U L F I L M E N T OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE  in THE F A C U L T Y OF GRADUATE STUDIES Department of Interdisciplinary Studies  (Department  of  Health  Care  (Department  of  Restorative  and  Dentistry)  We accept this thesis as conforming to the required standard  'THE UNIVERSITY OF BRITISH COLUMBIA October  1986  ® Rachel Tobiasz Weiss,  1986  ,  .  Epidemiology)  In p r e s e n t i n g  this thesis  r e q u i r e m e n t s f o r an of  British  it  freely available  in partial  advanced degree a t  Columbia,  Library  shall  for reference  and  study.  I  f o r extensive copying of  understood that for  h i s or  be  her  g r a n t e d by  f i n a n c i a l gain  s h a l l not  the  be  of  further this  r c U T e g P \^Q\  this  The U n i v e r s i t y o f B r i t i s h 1956 Main Mall V a n c o u v e r , Canada V6T 1Y3  Date  OcJ\  °l , I ^  g>&  Columbia  my  thesis  a l l o w e d w i t h o u t my  P L j uA^<  thesis  It is  permission.  Department of  make  head o f  representatives.  copying or p u b l i c a t i o n  the  University  the  f o r s c h o l a r l y p u r p o s e s may by  the  I agree that  agree t h a t permission  department o r  f u l f i l m e n t of  STUIPl £  ^  written  ABSTRACT  A  recent  elderly dental by  a  in  Greater  problems  dentist  issue  in  dentists  interest model,  of  the  Vancouver  amongst  since  the  their  admission  services  t h e o r e t i c a l models in  long  term  care  emphasizes  on  a  number  of  belief  and  the  ungrateful  or  socialization  dentistry  on  the  disabled,  the  chronically  opportunity  The  prejudices  and  studies  focused  model  is, private  the  decision  dentists'  elderly,  the  uncommunicative  on  of  professional of  training  predicted  treat  of  atmospheres  practice  to  major  the  l i m i t e d treatment  economic  seen  socio-cultural  i d e o l o g i c a l focus  of  A  predict  of  depressing  the  been  of  facilities.  towards  e l d e r l y are  model  perception  that in  care  therapy(eg.undergraduate  i l l ) . The  critical  term  practice.  to  had  willingness  dental  the  number  and  the  with  options  for  that  leisure  time,  institution-  elderly.  survey  the  the  costs,  Questions a  or  the  to  professional  reparative  is  a  facilities.  developed  aversion  training  despite  were  that  The  institutionalized  i l l , few  the  long  attitudinal  facilities). and  the  cultural  profession(eg.the  alized  to  the  that  chronically  in  provide  of  revealed  to  which  be  health  services  based  would  oral  establishing dental  Three  was  survey  relating  to  questionnaire.  greater  experience  Vancouver and  each  The  area,  interest  in  of  these  survey, asked working  i i  models  mailed  dentists with  to  were 603  about  both  the  included  dentists their well  and  in  in  disabled survey, best  elderly. and  the  the  interest  at  a  facility  classification not  and  most  with  to  dental  training had  of  the  beginning  dentists  most  practice  to  who  busy  were  training  in  forces  at  an  medically  guide  in  to  term  the  The  findings  indicate  appropriate  this  elderly  education,  as  and  a  practised  multiple  and  economic,  decisions  elderly  the  not in  was  Those  young busy,  who  i l l , were  was  and  dentists were  who  the  dentists  little  least  likely  area.  that in  both  in  order  nursing didactic  to  homes and  extend and  dental  hospitals,  clinical,  who  their  had the  of  dentists  extending  and  the  availability  experience  and  practice,  chronically  but  of  satisfaction  patients.  were  had  the  f a c i l i t i e s . C o n v e r s e l y , those  private  in  those  such  interested  care  their  treating  be  the  This  experience, who  by  service.  interest.  and  from  treating  compromised  model  definite  upon  servicing  care  factors,  practice  likely  long  term  the  delivery.  professional the  to  which  indicated  concluded  both  of  dental  respondents  institution,  interest  to  was  institutional a  determine  if called  survey  long  show  services  facility  that  enabling  operatory  extensive  were  a  to  to  responded  dentists  s a t i s f a c t i o n in  several  with  the  at  analysis  respect  analyzed  of  significant predictor  linked  to  19%  population  institutional  previously.lt  Professional  a  37%  socio-cultural,  dentists  in  practising  administrator,  the  were  interest  findings,  in  half  results  predicted  In  Over  and  an  an  acceptable should  be  financial introduced  arrangement into  the  f o r such  dental  i v  specialized  community.  services  TABLE OF CONTENTS  TITLE  .  i  Abstract List  i i  of Tables  v i i  ACKNOWLEDGEMENTS 1.  2.  Introduction  4.  .  1  1 .1 O v e r v i e w  1  1.2 S t a t e m e n t o f t h e Q u e s t i o n  3  1.3 T h e s i s  4  Outline  T h e o r e t i c a l Models  of D e n t i s t s '  Interests  6  2.1 O v e r v i e w  6  2.2 The S o c i o - c u l t u r a l M o d e l  6  2.3 The P r o f e s s i o n a l M o d e l  9  2.4 E c o n o m i c  3.  ix  Model  11  2.5 H y p o t h e s e s  15  METHODS FOR DENTISTS' SURVEY  19  3.1 D e v e l o p m e n t  19  of the Survey  3.2 The Q u e s t i o n n a i r e  22  3.3 A d m i n i s t r a t i o n  29  3.4 C o d i n g  30  3.5 R e c o d i n g  31  3.6 S a m p l i n g B i a s  33  INTERESTS OF DENTISTS IN TREATING ELDERLY:RESULTS  37  4.1  37  Overview  4.2 F i r s t  Stage:Frequency D i s t r i b u t i o n s of V a r i a b l e s  v  ....  37  4.3 S e c o n d S t a g e : P r e d i c t i n g Analysis 4.4 T h i r d  Dentists'  Interest:Bivariate 47  Stage:Multivariate  Analysis  56  4.5 A Summary o f t h e F i n d i n g s 5.  DENTISTS WHO  60  PRACTICED AT LTCS-A SECONDARY  5. 1 O v e r v i e w  of Secondary  5.4 C o n c l u s i o n s 6.  62 62  5.2 M e t h o d s f o r t h e S e c o n d a r y 5.3 R e s u l t s  STUDY  Study  of the Secondary  DISCUSSION  63 64  Study  72 74  6.1 L i m i t a t i o n s 6.2 P r a c t i c a l  Study  o f the Survey  Applications  74 75  REFERENCES  80  Appendix  A  84  Appendix  B  87  Appendix  C  95  vi  LIST OF  TABLES  Table  Page  1  Independent V a r i a b l e s  2  Coding of Continuous V a r i a b l e s  30  3  Recoding of P r a c t i c e C h a r a c t e r i s t i c s  32  4  Recoding of Importance of S p e c i f i c C o n s i d e r a t i o n s f o r LTC S e r v i c e  33  5  i n the Three Models  Demographic C h a r a c t e r i s t i c s of Respondents  27  and  Population 6  Interest  7  P e r c e p t i o n s of Work with E l d e r l y  39  8  G e r i a t r i c Dental T r a i n i n g of Respondents  41  9a  P r a c t i c e C h a r a c t e r i s t i c s of Respondents  42  9b  P r a c t i c e C h a r a c t e r i s t i c s Relevant to E l d e r l y  42  10  Common Proceedures f o r E l d e r l y P a t i e n t s  43  11  Important C o n s i d e r a t i o n s f o r LTC  44  12  Threshold Variables  13  Reasons f o r Not  14  S o c i o - c u l t u r a l V a r i a b l e s S i g n i f i c a n t l y A s s o c i a t e d with Interest P r o f e s s i o n a l V a r i a b l e s S i g n i f i c a n t l y A s s o c i a t e d with Interest  51  Economic V a r i a b l e s Interest  54  15 16 17  in LTC  35 Service  i n LTC  Providing  38  service  Decision LTC  45  Services  S i g n i f i c a n t l y Associated  46  49  with  Multiple C l a s s i f i c a t i o n Analysis:Socio-cultural Variables  57  18  Multiple C l a s s i f i c a t i o n Analysis:Professional  19 20  M u l t i p l e C l a s s i f i c a t i o n A n a l y s i s : Economic V a r i a b l e s Questions and Responses of LTC P r a c t i t i o n e r Study  vii  Variables  .  ....  58 59 65  21  Geriatric Training  22  Interest  23  Home V i s i t s  24  Considerations  C:1  Interest  by P e r c e p t i o n s  C:2  Interest  by S e l e c t e d  to  Among  i n LTC S e r v i c e Among  Three  o f Time  Three Among  Sub-groups Two  68  Sub-groups  69  Sub-groups L o s s Among o f Work  Practice  70 Three  with  Sub-groups  the Elderly  Characteristics  Elderly  71 96  Relevant 97  C:3  Interest  by G e r i a t r i c T r a i n i n g  C:4  Interest  by Age a n d Y e a r s o f P r a c t i c e  C:5  Interest  by S t a t u s  C:6  Interest  by C o n s i d e r a t i o n s  C:7  Interest  by R e a s o n s  of Practice  of D e n t i s t s  99  and Busyness  f o r LTC S e r v i c e  f o r Not P r o v i d i n g  viii  98  Services  100 101 101  ACKNOWLEDGEMENTS  I  would  members  o f my  MacEntee, James  U.B.C.  t o acknowledge  thesis  Dr. Brenda  Thornton.  Extended  I  like  Care  fortheir  am d e e p l y  this who  thesis.  who  I would  i t s design,  College this for  t o my  taught  me  my  year  British  like  elderly  operation  Columbia  of the  Hospital at  of research  there.  the theoretical  t o thank  foundations of  of every  Dr. Michael health  chapter i n MacEntee,  of the  Vancouver,  i n the research  forgiving  me  a t a l l the stages  and a n a l y s i s .  Health  Surgeons  and I extend  and Dr.  s u p e r v i s o r , D r . Nancy  i n Greater  to participate  of Dental  project  also  staff  Centre  of the  Dr. Michael  Waxier-Morrison  Sciences  during  and support  Hill,  to the nursing  t h e s t u d i e s on t h e d e n t a l  opportunity  The  D r . Nancy  at the Health  indebted  institutionalized  of  P r o f . Mary  s o c i o l o g y , a n d who was t h e m i d w i f e  initiated  the  Morrison,  guidance  Waxier-Morrison, medical  committee-  I am g r a t e f u l  Unit  the teachings  have my  Care  Research  provided  Foundation  financial  gratitude to these  their contributions.  ix  and the  support f o r  organizations  1  CHAPTER  INTRODUCTION  1.1  Overview  In  1984,  an  i n v e s t i g a t i o n of  institutionalized conducted at  by  several  UBC(19). T  previously Extended  elderly  was  a  in  assisted  the  members member in a  of  of  Unit  at  the  Forty-one  long  term  and  North  West  Vancouver  and  653  oral  greater the  the  pilot  Care  the  needs  Vancouver  Dental  and  health  Sciences  of  area  survey Centre  faculties  and  in  the was  Medical  i n v e s t i g a t i v e team  oral  Health  health  had  the  Hospital  at  UBC(20).  nursing their  As  and  facilities  representing  care  examined  dental  was  needs  found  residents  of  the  41  were  had  and  in  the  not  involved  administrators  had  little and  a  residents  to  his/her  residents  and  their  the a  health  a  care  dentist  than  dentist office  in  in  the  unit 5  affairsd9).  1  at  study,  a l l levels  interviewed  years  of  about  to  to  For  look  majority  more.  arrangements  community  left  or  the  programs,  necessary.  f a m i l i e s were  major  study,  dental  formal  when  and  Burnaby  history.  structured  more  the  population  dentist  extended  seen  facilities  by  oral  in Vancouver,  participated in  residents  of  these  care  and  Only  9  most  between  transport the  after  most  part,  dental  of  The  inadequacy  findings  of  complained  the of  Oral  mucosal  most  of  the  wearers. had  A  their  of  this  study.  About  pathoses lesions  own  were  were  relatively  and  periodontal  Other  studies  periodontal noted  that  89%  of  geriatric  institution  reporting  on  the in  aged the  their  stated  Neither  are  the  revealed a  lesions,  often  elderly.  In  a  of  health  the  status  dentures  of  the  In  their  survey  without group  over  frequency with  a  of  to  and  of  and  denture residents  these  pulpal  dentate  lesions,  of  caries  and  study,Banting i n an  three  et  al.(2)  Ontario and  Leake,  O n t a r i o homes  for  exception, a l l individuals i n need  In  age  a  edentate the  of  restorative,  of  of  cancerous  70  noted  1980  elderly  American  history  study  state's 60  sample  elderly  Martinello  were  of  Osterberg(25)  the  root  caries.  review  longitudinal  of  the  dentures.  specific the  the  interviewed  to  majority(59%)  denture-wearing  sample.  of  in  treatment"(22).  associated  study  and  individuals  health  higher  Gothenburg,Sweden,  relating  increased risk  root  d i s e a s e . Smith's(29)  cancer  21%  the  edentulous surgical  residents  i n 37%  commonly  "almost  and  apparent  disease(l9).  had  periodontal  oral  the  dentate  oral  that  partially  usually  i n o l d age.  the  the  p r o p o r t i o n of  most  confirm  disease  became  inflammatory  t e e t h ( 4 1 % ) , but caries,  of  observed  high  had  had  1/3  d e n t a l problems,  individuals 18%  situation  Iowa  of  year  2  studies and  olds  examined  of a  were  of  oral  amongst  the  in  homogenous survey  from  precancerous  smoking,  population, over group  free  leukoplakia the  half  oral of  i n need  the of  in  repair  or  reline.  denture  wearers  in  age  this  1000  for  In the  the  in  B.C.  to  regularly  elderly,  appointments  treatment. dental  dentist  before  legal  care  group.  major  a  of  question  no  the  This  this  determinants  of  care  to  mechanics dentures), and  able  issue  is  per  look  at  the  who  exception  institution,  i n s t i t u t i o n . The  when  arises and  we  to  and  arrange  recognize  one  a l l  of  the  diagnose  and  treat  i t to  is  a  need  subject  only dental  prescription  crucial  undertake  the  a  institutionalized  are  have  dental  accessibility  dentists  must  of  frail  must  is  to  46  subsidized  dentists  with  us  authority  willing  the  provincially  rest  Because  to  institutionalized  the  mobility,  population,  contrast  lesions  to  limited  which  mucosal  the  imperative  residents,  of  amongst  i t was  special  veteran's  making  special  such  of  marked  psycho-geriatric  dental  are  Statement  and  individuals.  they  The  a  this  whether  1 .2  no  question  even  in  services  treat  like  to  with  problems(eg. a  are  and  The  care  homebound  profession  dental  whom h a v e  just  1000,  lesions  rate  findings,  elderly  of  per  overall  these  Hospital,  many  the  mucosal  population(34).  Hospital,  Shaughnessy  of  state  There  the  and  140  of  diagnose  Valleyview  and  was  entire  light  incidence 32%,  a v a i l a b i l i t y of  services  of  was  group  the  elderly  for  The  to  determine  treatment of  from  this  of  this  thesis.  Question  study  attempts  interest  in  3  to  long  answer term  is,"What  care(LTC)  are  dental  the  service?".  Three  been g l e a n e d  m o d e l s of  from  the  literature,  rationale  f o r the  patients.  These models a r e  dentists  servicing  i n t h e LTC  q u e s t i o n n a i r e asks in  1.3  working  with  interest  oral  i n LTC  each  dental service  with a  have  different  d e c i s i o n s of p r o v i d e r s r e g a r d i n g tested  by  a s u r v e y q u e s t i o n n a i r e of  h e a l t h survey  dentists  about  t h e w e l l and  LTC  study  their  disabled  area. This  e x p e r i e n c e and  interest  elderly.  Thesis Outline  Chapter  2 is a literature  review  t h e p e r c e p t i o n s of  the e l d e r l y  professionals.  socio-cultural,  theoretical which w i l l  models a r e o u t l i n e d be  Chapter  The  tested  3 i s an  q u e s t i o n n a i r e . The q u e s t i o n s and itemized  by  under  the  of the  s t u d i e s conducted  d e n t a l and  medical  professional  and  on  and  the hypotheses  economic i n each  model  are defined.  account format  of t h e e v o l u t i o n  of t h e  survey  of the q u e s t i o n n a i r e i s d e s c r i b e d .  independent  variables  they  the t h r e e models e x p l a i n i n g  represent  interest  in  The  are LTC  service.  Chapter conducted of  the  4 p r e s e n t s the data  to determine  respondents  population  differ  of d e n t i s t s  in  t h r e e s t a g e s of  of  determining  whether  the  increasing  survey. A b i a s study  the demographic  significantly  i n the  w h i c h model  from  study  from  a r e a . The  complexity,  i s the  4  is  characteristics  the  total  data are  w i t h the  analyzed  specific  strongest in predicting  goal  interest  i n LTC  Chapter practised  facilities.  practice  conclusions  study of those d e n t i s t s The  incentives  a r e examined  of the p r i m a r y  Chapter practical  5 i s a secondary  i n LTC  LTC d e n t a l  service.  have  and d i s i n c e n t i v e s  i n order to v a l i d a t e  of  the  study.  6 is a discussion  applications  who  of t h i s  of the t h e o r e t i c a l l i m i t a t i o n s and study.  5  CHAPTER 2 THEORETICAL MODELS OF DENTISTS'  2.1  Overview  There  are three  potentially providing  useful  to  with  be d i s c u s s e d  term  degree  "youth  was  poor,  isolated  between  them.  Butler(24)  broadly  and  economic  amongst  by Robert  them.  These  paragraphs.  and the subsequent  where  i s actively  or powerful,  to  refer  social  of the e l d e r l y  the culture  the stereotype  o r unhappy  Butler(24)  The d e g r a d a t i o n  society,  described  young  be  i n the following  coined  o r i e n t e d " , and aging  Neugarten(18)  may  of d e n t i s t s i n  Model  against  i n Western  They  of overlap  the stereotyping of the e l d e r l y  pervasive  that are  the interests  professional,  individually  "ageism"  discrimination  gap  some  The S o c i o - c u l t u r a l  The  perspectives  i n understanding  as s o c i o - c u l t u r a l ,  perspectives, will  theoretical  services to the e l d e r l y .  classified  2.2  INTERESTS  i s regarded  as  camouflaged. of the o l d as rigid  and o l d i s p e r p e t u a t e d  either  o r r e a c t i o n a r y . The  by s u c h  stereotypes.  stated;  Ageism allows the younger g e n e r a t i o n s t o see o l d e r people as d i f f e r e n t from themselves. Thus, they s u b t l y c e a s e t o i d e n t i f y w i t h t h e i r e l d e r s a s human b e i n g s .  6  i s  As  The  socio-cultural literature  studies study  on  by  lay  Signori,  Department  descriptive volunteers to  be  rigid,  the  of  studies which  focus  on  the  Nonetheless,  more  patients  the  in  than  medical  handed  out  school a  geriatric as  to  commonly,  no  on  a  health  negative general  small  number  of  of  questionnaire  clinical  have  differences  and/or before  experience  were  found  7  in  with the  subjects  sensitivity, in the  exaggerate  claim  that  these  traits  elderly.  approach  scale  other  believe  been to  studies(3,5,7,14,15,30,31,32),  and  the  found  to  be  elderly  p o p u l a c e ( 8 , 17,23,35) . Most  descriptive  less  the  preselected  the  professionals their  On  ageism  They  were  more  by  authors  views.  failings"  in  and  persistence  reveal  456  poorer,  impression  which  to  elderly  populace.  The  A  societal  traits, The  and  elderly.  bipolar  understanding,  objectives.  group's  gauge  point  30  general  broader  studies  knowledge  courses  a  to  7  the  of  Psychology  gossipy  contribute  "natural  bipolar,  gerontological  the  plethora  unhealthy,  and  humanity,  sampled  the  significantly  frigid  noted  attitudes  of  d e l i c a t e and  than  attitudinal  rate  a  age.  40  greater  the  provided  years  worthwhile  misconstrue  conducted  and  willingness of  UBC  on  stubborn,  a  the  focusing  more  researchers  attainment  surveys  of  a  towards  scale,  orientated  recognized  majority  14  yielded  attitudes  Kozak  researchers  weaker,  experience,  and  The  and  of  adjective  subjectively  that  Butt,  between  powerful,  hand,  professional  is typical  "ageism"(28).  rated  and  has  commonly,  students  were  dichotomous and the  after elderly.  perceptions  of  Just  students, by  which  Neugarten  were  above,  period(3,14,15). image  similar the  didactic  Indeed,  the  impressions  functional  loss  treatment  encounters  may  age  the  students  The  two  studies  1967,  and  the  these  two  generalized  perceptions  other  of  the  dentists'  15  years  elderly.  prosthodontic  orientation  of  characteristics or  negative  the  highest  most no  Kiyak  negative  of  impact  significance  were  elderly  Kiyak(l7)  that  delineate  in  concluded  that  appraisal  of  attitude.  Beck(3)  the  noted  training  deteriorating  from  limited  negative  a l . on  image  of  of  the  elderly  the  on  elderly aged  their  various  and  that  8  either  those  of  the  positive  dentists  with  produced  elderly.  patterns  to  attempted  to  surveys.  "more  initial  a  for  the  the  geriatric dentistry  correspondingly,  hypothesized  on  practice  authors  a  a  questionnaires  predict  response  have  employed  dentists'  displayed  focus  professional  dentists and  in  al.(l7),  in  therapy.  evaluations  age-specific and  and  elderly, in  Coe(8)  psychological  would  Training the  a  by  dental  knowledge  to  which  et  assess  and  aging,  led  one  studies,  et  medical-dental  the  of  to  geriatric  evaluations.  significant  the  Kiyak  in  dentists  stereotypes number  both  physiological  stereotypes  of  by  scales  In  concomitants  of  of  attitudes,  later  attitude  as  reliance  clinical  patients  heightened  of  deterioration  revelation  elderly  and  impressions  held(3).  regarded  the  of have  professionals  The  stereotypical  over  and  old  to  had  Of the  Kiyak  realistic" more  favourable  responses  to  the  visibly  poor  nursing  homes  students. run  contrary  clients the  the  most  losses  aged  professional  The  ageism  of  to  of  the be  chronically i l l  the  antipathy Miller  thought.  et  Here,  incompetent  and  years.  form  al.(23)  of  incontinent  overlooked  in a  of  that  elderly the  exposure  encounters  study  speculated  denial The  dental  older  institutionalized  personal  in  amongst  the  t r e a t . Walk(35)  advancing  in  in  the a  the  stronger  mentally  reflect  cannot  with  by  threatening  to  reminders  debilitated,  discussion  of  ageism.  majority  of  stream  of  of  findings  evaluations  mortality  advanced  even  difficult  professionals  one's  lack  this  status  an  the  considered  functional  the  engender  to  negative  older  health  However,  physicians  of  oral  of  endemic  experience  physiological  studies in  this  with  and  of  psychological  society  and  fear  psychological  and  of  motive  emphasize  its reaffirmation  the  in  the  complicated  treatment  responses  of  the  elderly.  2.3  The  Professional  This  social  examining  perspective  dentistry's  predominant  focus  on  chronic  conditions  elderly  remain  phase.  Only  Model  of  does  be  taken  "occupational cosmetic  and  c a r i e s and  unattended  then  can  the  until  one  ideology".  reparative periodontal  these  specific  9  step  With  in  a  technologies, disease  problems  disease  further  reach  oriented  the  amongst an  the  acute  therapy  with  its  massive  with and  i n f r a s t r u c t u r e become  understandably degenerative  large  regarded  trained  of  a  when  their  in  home(23).  maintenance  In The  the  measure, Lower  large  number of  the  emergence  the  European  s o c i e t i e s , such  constituencies insurance American  The  pushed  programs  in  dentists,  practices affluent  supported middle  trend  the as  the  on  a  state  late  fee  data  indicate  casting  aside  the  for  have  that  by  proportion  of  to  service  in  in a  working  not  aversion  to  profession the  dentistry. class  century.  by  In  political  dental)  North  establish private basis  be  nursing  outlines of  a  residents  should  health(including  able  p r i n c i p l e of  groups  the  persisted  institutionalized  vulnerable  the  nineteenth  were  accrued  dental  ideology  and  highly  their  they  , Davis(9)  Denmark,  through  that  organized  social  i s by  a  solo  growing  and  class.  utilization  the  Dentistry  however,  service  indulged  of  large  and  chronic  the  been  occupational  tracing  development  has  the  i l l .  of  a  of  placement  chronically  Context  the  after  highlights  of  waste  homes and  believed  care  of  group,  physicians(85%),  nursing  State,  patient's  this  in medicine  status  of  the  Soc i a l  a  elderly constitute  York  finding  elderly  of  historical  and  of  skills.  evaluations  their  This  A  to  r e s u l t s . Treatment  palliative  the  Westchester,New  involved  in  as  practice(35).  survey in  conditions  professional's  professionals their  limited  available  where  to  "user  inequalities in the  present.  pay"(9),  e l d e r l y along  i t became  10  the with  politically  fee  for  Without profession the  has  dependent  expedient  to  do  so, t o appear  response the  delivery  inequities  system  groups  culture  dental  restorative  mouth  to the exclusion i l l ,  Economic  issues  and/or  literature  economists utility  live  on  adult  having  dentures  profession  becomes  t h e needs  and  young  e l d e r l y and the  limited  has minimized the supply  have  means.  psychological  behaviour  compared  maximizing  firms.  dental With  to replace  practices  the  models(4,13,27).  the concept  the c l a s s i c  Evans(l2)  and  of d e n t i s t s .  and s e l f - r e g u l a t i n g p r o f e s s i o n a l  s i t u a t i o n began  adjusting  proposed  o f whom  in analyzing  price-fixing  price  many  and  to service  of the f r a i l  strata  more  Model  economic  monopoly  of d e n t i s t s  class  receiving  lower  extractions  of the dental  of the  social  strata  and  of the a f f l u e n t and h e a l t h y  Traditionally,  of  ideology  in the training  chronically  profit  the higher  of complete  populations,  social  with  strata  i n the  t o the predominant  number  predominantly  The  according  of  the e l d e r l y .  are evident  and bridge)  translated  2.4  the indigent,  ( i . e . crown  The  restructure  the r e s p o n s i b i l i t y  work  filled(16,26).  to  and to a t t r i b u t e s o c i a l  of treatment  clientele,  overall  a t t i t u d e s and m o t i v a t i o n s  - the poor,  philosophies  professional  greater  health  The  pressures  to stress  to the problematic  Contrasting  their  own  of access.  to external  has been  for their  disadvantaged  a  the problem  of the p r o f e s s i o n  individuals  of  t o ease  as  establishment bodies,  a  supply/demand  and o t h e r s  have  of the " n o t - o n l y - f o r - p r o f i t " provider  1 1  firms  where  other  efficiency targets,  considerations guide  concluded  medicine  over  i s t h e outcome  provider's  the  discrepancy income  targets  controversial response  between  issue.  t o an  the profession,  to  maintain  of Dental  decline  i n incomes  means  of  levels  Surgeons  and promotion  importantly  to this  as  demand  responsibility.  by  behaviour  hopes  with  This  of t h i r d  argument,  by  an  behaviour.  The  degree  i s currently  hypothesis,  the  capital the  oversupply  product  lines  losses.  The  perceived of providers  insurance,  transforming  and p r o s t h o d o n t i c  a  provider's  i s t o be a c h i e v e d  party  to  i s not t o opt out  his/her  to redress  in  attributable to  incomes.  to readjust  of  utilization,  are partially  Evan's  i n Canada,  pattern  and p r o v i d e r  and t a r g e t  workload  Expenditures  determined  "demand"(10).  orthodontic  emerges.  and minimize  associated  advertising  such  a clear  of p r o f e s s i o n a l s  but rather  increasing  periodontic,  decades  supplier  Following  activity  College  been  actual  "oversupply"  of  four  responses  guide  behaviour,  and t e c h n i c a l  the h i s t o r y of medicine  of patient  servicing  minimization  and p r o f e s s i o n a l  organization  and d e n t i s t r y have  The  which  on  the past  economic  cost  servicing  requirements  in writing  that  professional  which  dentists'  leisure  Evans(l2),  than  by  by  more  b u t more  "unmet  treatment  need" f o r into  demand.  The  issue  assessed a  great  of a c c e s s i b i l i t y  within deal  specialty  such  an economic  o f human  training  of s e r v i c e s  and  context.  and p h y s i c a l in setting  12  capital up a  to the elderly Dentists  have  may  invested  i n undergraduate  practice.  be  Therefore  and  general  practitioners  are interested  life-span  earnings  by d e v e l o p i n g  clientele  who  the a b i l i t y  of  a general  services their  have  or specialized  over  a  children,  orthodontics  period  into  the dentist's  short  of  clients  through  of  greater  concern.  do not have  treatment. party  social  Approximately Pension may  market  to practise  i n mind  cannot  bear  the services  may  t o be a  temporary  established.  there  income  For r e t i r i n g  flow  investment labour  in a  because  sophisticated  a r e no g o v e r n m e n t unless 65th  they  or t h i r d  have  birthday.  subsist  in lost  they  on  t h e Canada  income  potential  to consider  an  facilities.  of product  of a high  prices,  until  for their  t h e r e f e r r a l network i s  their  dentists,  13  lines  per capita  when t h e number o f  the i n s t i t u t i o n a l i z e d elderly  sufficiently profitable source  rates  and the optimal  to receive  elderly cost  For specialists in  higher  to their  the substitution  at fee schedule  a  practice.  of p r a c t i t i o n e r s  i n LTC  providers prove  mostly  f o r the e l d e r l y ,  f o r the bulk  either  others,  and s p e c i a l i z e d  The o p p o r t u n i t y  services  and r e c r u i t  charge  prior  regular  these  a r e a poor  Columbia,  assistance  a  utilize  through  50% o f t h e s i n g l e  be t o o h i g h  Keeping  office  time  schemes  Plan(6).  arrangement  who  their  will  t h e f i n a n c i a l means  In B r i t i s h  insurance  received  of time  i l le l d e r l y  practitioner's  a n d who  c l i e n t s are the rule,  their  chronically  dental often  term  with  t o pay f o r d e n t a l  long  expertise,  The  a practice  nature  and endodontics,  i n maximizing  market  private  LTCs  may  f o r novices  practice represent  is a  as  part-time  p r a c t i c e opportunity  of a u x i l i a r i e s of  the  dental  leisure  and  In p u t t i n g  that  place  health  care,  health  care  and  across  i . e . the on  the  the  of  qualities  orthodox  illness  the  and  the  the  limits of  o r t h o d o x m o d e l , but e x i s t s an  individuals social  issue  care  status  come under have no  as  in acquiring  along  e f f e c t s of  access  to  of  i t . As  the  part  the  improvement  i n d i v i d u a l s , and the  of  not  plan.  s i g n i f i c a n c e in health  are  s o c i e t y to  Davis points  to  dental  national health  e f f e c t s of  the  i t s underlying  "needs" to  normative  external  o b l i g a t i o n on  out(9),  the  such  that  assist the  major  i n d e n t i s t r y i s i n c r e a s i n g l y the r e l a t i o n s h i p  between  t h o s e who  receive  them. At  dentistry  the  disease  differential  and  of i t s  external  d e l i v e r y system has  health  need may  care  of i n d i v i d u a l s ( 9 ) .  m a t c h i n g of h e a l t h  of  and  health  between p r o v i d e r  g r o u p s ; and  end  economic  distribution  of  either  practioners.  of  intrinsic  costs  in professional  the  community  s y s t e m doe*s not  concept  there  groups at  " w i l l i n g n e s s " to p a y ( l 2 ) . U n f o r t u n a t e l y ,  delivery  overhead  the  effect  the  of  information  age  two  costs  bulk  high  argument, I acknowledge  differential  m a i n t e n a n c e of  their  The  the  the  the  these  r a n g e of  uncertainty  Canadian medical  objective and  the  assymetry of  the  lines  The  unlike  forth this  i t outside  insurability; class  low,  importance of  analysisrthe consumer;  equipment. For  practice, opportunity  time are  fundamental  without  provide present  s e r v i c e s and there  i s no  social  t o m a t c h s e r v i c e s t o need and  1 4  t h o s e who  this  have a r i g h t  contract issue  in  will  to  undoubtedly access  2.5  to  arise  dental  i n an  attempt  resolve  the  inequities  in  services.  Hypotheses  Each  of  development  these of  accessibility  three  several of  perspectives working  dental  perspective  perceptions  the  of  professional, provide asking  dental  and  age  the  to  most  groups,  to  they  this  questions  have  second  inquiry.  It  dentists  does  would  dental  not  of  to  lend  in  the  in  dental  facilities  to  treat  accustomed  to  the  the  the  age  factors  working  may  overt  be  in  of the  that  of  the  the  the  motivation  introducing  the  to  questions  relationship with  the  e l d e r l y and  examined.  suggestion  opens  to  with  in  up  of  several  the  Because ageism,  about  the  this  operations  the  and  the the  institutionalized. i n f r a s t r u c t u r e of  15  of  the  lack  chronically  group,  areas  socialization  treatment  concerns  massive  issue  hypothesized as  the  e l d e r l y . From  occupational  itself  treatment of  the  to  the  phrased d e l i c a t e l y .  dealing  complications  on  e l d e r l y . By  their  the  be  that  evident  training  limitations  the  t h e o r e t i c a l model  states  be  well  hypothesis  precludes  The  be  itself  d i s t i n g u i s h between  professionalism would  the  critical  describe  whether  to  i t may  e l d e r l y , as  services  dentists  elderly other  are  lends  hypotheses  services  socio-cultural  This  to  of of  frail of  elderly.  geriatric  i l l , the  possible  medical  inappropriate Dentists their  have  private  grown  office, For  without  example,  portable  equipment,  lead  financial  are  enter  the  into  in  regarding  -  the  be  may  that  in handling  their  treating their  new,  interest  asked the  The  patients.  in  they  the  dental costs  using  may  loss  will  busyness  of  gauged  practice  practice of  a  predict  However,  be  of  would  e s t a b l i s h e d or  practices  importance  outrightly.  elderly for  whether to  of  opportunity  concern  an  issues  practice. be  responses  i t a  gauge  economic  LTC  in deciding  matching  inadequate  to  hypothesis  costs  time  practice  feel  if offered.  reimbursement  questions  and  the  to  opportunity  leisure  there  to  motivation  many  i t i s necessary  Finally, that  which  their  the  with and  in  LTCs,  private  part-time  retired  practice.  2.5.1  Independent  In  and  Dependent  order  to  measure  perspectives  in  the  number  of  or  i n LTC  interest  variable  i s measured  question  on  administrator  In social clients  the  the  such  model,  perceptions will  by  i s the  interest  makes  first  been  of  influence  of  of  the  dental  developed.  in providing  facilities  their  relevance  accessibility  i n d i c a t o r s have  willingness living  the  Variables  broad  health  care,  In  a l l the  services  dependent  response  three  of  in practising  the at  LTC  regarding  the  broad  independent  interest  These  1 6  elderly This  a  a  direct  facilities  if  an  resident.  v a r i a b l e s are  perceptions  in working  analyses,  d e n t i s t s to  request  elderly.  the  variable.  a  the  to  a  i n LTC  of  the  elderly  facilities.  The  social  concept,  perception  may  be  variables:the experience  perception in  their  In  of  the  may  facilities, elderly,  of the  of  with  care,  of  concrete  elderly  clients,  enjoyment  of  clients,  and  the  between  elderly  or  age  groups  professional  variables, or  are  whether  dentist an  other  this  working of  professional  the and  which  factors  well  time,  and  cost  capital  years  elderly,  equipment  treatment  treating  costs  in  of  the  LTC  the  elderly.  are  importance  less  the  of  the  significantly, distance  outlay  variables  decide  of  the  The  determinant  frail  opportunity  assessed.  and  and  dental  in  as  of  for  which  opportunities  may lost  that  must  be  portable determine are  too  high  to  practice.  study, with  are  loss)  will  with  group  specialization,  limitations  in  leisure  a  training,  satisfaction  such  threshold  LTC  values,  appropriate  of  model,  reimbursement  a  or  perception  equipment  strength  series  elderly  experience  operatory  travelled(i.e.time  in  a  amorphous  with  used:geriatric  practice  financial  In  rather  by  term  professional  economic  independent  initiate  long  distinctions  practice  and  the  of  in  a  experience  communicating  be  availability  loss  measured  age,  elderly  model  practice,  In  and  elderly,  practice.  variables of  and  the  defined  dentist's  with  socializing  of  the  the  analysis  of  institutionalized elderly  three the  empirical  models:the economic.  dentists' will  socio-cultural,  Specific  17  hypotheses  test  interests the  the under  each  model  are presented  2.5.2  List  1: Explicit  Soc i o - c u l t u r a l  Professional  1 .  Hypotheses  of  the  Three  Models  model  Hypotheses:Dentists w i l l be: 1) t h o s e who patients 2) t h o s e who 3) t h o s e who problems of  in List  enjoy  who  indicate  interest  i n LTC d e n t a l  s o c i a l i z i n g and communicating  with  services  elderly  do n o t d i s t i n g u i s h between t h e e l d e r l y a n d o t h e r s a r e o l d e r a n d by a s s u m p t i o n more e m p a t h e t i c w i t h t h e the elderly  model  Hypotheses:Dentists w i l l be:  who i n d i c a t e  interest  i n LTC d e n t a l  services  O t h o s e who h a v e s p e c i a l i z e d t r a i n i n g a n d / o r e x p e r i e n c e i n g e r i a t r i c and s p e c i a l care d e n t i s t r y 2) t h o s e w i t h a h i g h p r o p o r t i o n o f e l d e r l y i n t h e i r practice 3) t h o s e who i n d i c a t e p r o f e s s i o n a l satisfaction i n treating the elderly 4) t h o s e who make home v i s i t s 5) t h o s e who d o n o t v i e w t h e o r a l h e a l t h p r o b l e m s o f t h e a g e d a s having l i m i t e d treatment potential 6) t h o s e who a r e w i l l i n g t o u s e p o r t a b l e e q u i p m e n t a n d l e s s concerned with the a v a i l a b i l i t y of a stationary operatory  Economic  Model  Hypotheses:Dentists w i l l be:  who  indicate  interest  i n LTC d e n t a l  services  1) t h o s e who a r e b e g i n n i n g a p r a c t i c e o r r e t i r i n g a s o p p o s e d t o t h o s e w i t h an e s t a b l i s h e d practice 2) t h o s e f o r whom t h e o p p o r t u n i t y c o s t s i n l o s s o f p r i v a t e p r a c t i c e and l e i s u r e time a r e low 3) t h o s e who a r e l e s s c o n c e r n e d w i t h f i n a n c i a l r e i m b u r s e m e n t a n d c a p i t a l expenses(such as p o r t a b l e equipment)  18  CHAPTER 3 METHODS FOR  3.1  Development  A  mail  different  in  economical  The  order  even  The  the  test  multiple  the on  of  a  the  acquiring discussed  of  Dr.  of  professionals  J.  the  any  As  requests  negotiates well,  which  elderly  were  expeditious  professional  president and  and  and  for on  from  of  the  several  Dentistry.  I  their  intrude  dental College  professors  was  financial  d e n t i s t s are may  an  information  Silver,  Restorative  which  for  three  dentists.  personal with  the  dentist-disabled  health  group  choice  s i g n i f i c a n c e of  socio-cultural,  from  questionnaires  advised  information,  behalf  with  reluctant  to  on  that  their  answer  private  schedule.  goal  was  for  dentists  less  multiple  of  discard CDS,  a  establish guidelines  agencies.  requests  brevity  were  often  government  practice  of  to  of  surveys  Surgeons(CDS),  from  lengthy  to  department  dentists  form  constructs  acquisition  problems  the  the  chosen  information  Dental  from  was  Survey  Previous  professionals of  in  theoretical  relationship.  economic  the  survey,  questionnaire,  examined  of  DENTISTS' SURVEY  and  an  anonymous  financial than  clarity  10  questionnaire,  information, minutes  the  to  which  complete.  questionnaire  choice.  19  was  lacking  would For  take the  almost  any  direct  most  sake  of  exclusively  The The  questionnaire  first  section  was s u b d i v i d e d  (henceforth  measure d i f f e r e n t  attitudinal,  variables  which c o u l d  to  i n a LTC d e n t a l  engage  (henceforth  i n t o two s e p a r a t e  SECTION  1) was c o n s t r u c t e d t o  structural,  equipment of v a l u e  p r o g r a m . The s e c o n d  in  (financial  reimbursement, d i s t a n c e e t c ) . This  i n the f u t u r e development a brief  I t asked  travelled,  information  was t h o u g h t  of treatment  d e s c r i p t i o n of current  for logistical  t o be  programs, and i n  LTC d e n t a l  practices  Vancouver.  3.1.1  Pretesting  The  faculty  of  completed  supervisors  register.  the p i l o t  questionnaire  was s e n t  to the  a n d s e v e r a l members o f t h e d e n t a l  test  a t random  This p i l o t  questionnaire  was m a i l e d  from t h e C o l l e g e  study  began  of Dental  were m a i l e d  o f D e n t i s t r y . T h e s e were e x a m i n e d  which d i d not e l i c i t  This pretest questionnaire  Surgeons'  r e s u l t e d i n some f u r t h e r c h a n g e s B ) . Question  back t o  for questions  r e s p o n s e s o r were m i s l e a d i n g  (See A p p e n d i x  o u t t o 50  i n November,1984, a n d by  1985, t w e n t y - n i n e q u e s t i o n n a i r e s  Faculty  question  Questionnaire  two p a r t  of t h e study  dentists picked  January,  the  f o r comment. A f t e r some m i n o r a l t e r a t i o n s i n w o r d i n g a n d  structure,  the  section  SECTION 2) was d i r e c t e d t o d e n t i s t s who were now o r  availability,  furnishing  and f i n a n c i a l  be d e c i s i v e i n t h e w i l l i n g n e s s o f d e n t i s t s  who p r e v i o u s l y h a d p r a c t i s e d a t L T C s. information  sections.  and ambiguous.  i n the  7, an o p e n - e n d e d  on t h e l o c a t i o n o f p r a c t i c e was now a m u l t i p l e - c h o i c e  20  listing  because  precision.  the answers  Question  16 o f f e r e d  estimates  of the time  per  days  a  year,  single  confusing place  hours  i t was  questionnaire sentence  The  p e r month,  table  who  presents  this  dentists  p e r week. T h i s  often  left  in correctly.  2 was  i s now  that  separate  i n the d e n t i s t ' s  be  proved mark  the  options.  information portion facilities  changed  in regular  response repeated  i n weeks to too  in  abandoned  Instead,  entirely  multiple choice  was  a question  i n SECTION  section  of  options in  the options  logistical three  degree  t o LTC p r a c t i c e  because  format  filled  with  interested  or hours  seldom  format  in their  c o u l d devote  f o r the d e n t i s t s ,  o f number.  because  they  p e r month,  format,  had v a r i e d  three  final linear The  times  experience  so may  accounted f o r .  3.1.2  The  population  A population of  603  the  LTC  survey  and  West  time  oral  Vancouver),  constraints  survey. pilot  This  those  program  pedodontics  or o r a l  and with  whose  any  were  f o r t h e LTC  elderly t h e CDS,  were  have  were  21  and  provincial  chosen  with  a .  i n mind.  little  omitted.  in  North  Financial  larger  facilities  situated  Burnaby,  specifically  who  88  for a  r a d i o l o g y , and they  study.  were  f o r the survey.  ambitions  groups  offices  area(Vancouver,  selected  specialty  registered  study  of d e n t i s t s  the handicapped  dentists  were  quashed  group  treatment  Therefore, with  health  dentists,  Of  o r no  contact  t h e 691  in orthodontics,  were  e l i m i n a t e d from  the  There  were  population. Secretary  the  Earlier  of  requesting  the  poor  errors. would  data  plan  of  not  to  opportunity  The  might  to  of  so  the the  low  population i f the  and  to  number  was  of  sample have  small  introduced  the  dentist  by  the  services of  were  other  be  responses  chosen  high  that  standard that  be  concept  to  names.  positive  would  would  4  and  enough  e n t i r e group  each  offer  response  might  remaining  Association  profession  if a  population  entire  circulated  Dental  yielded a  that  be  parent  LTCs,  letter  the  the  costs  surveyed.  of  a  given  pilot the  participate.  Questionnaire  3. 2. 1 St r uct  ur e  Appendix  The be  part  questionnaire  service  a  dentists willing  the  the  surveying  District  elderly  excessive  the  for  year,  suggested  the  be  the  of  on  Secondly,  Thirdly,  may  names  some q u e s t i o n s  estimates  See  in  Vancouver  showing  preliminary  3.2  the  reasons  institutionalized  This  on  three  B  first divided  sect ion(SECTION into  four  1),  parts.  which  These  applies  parts  to  will  a l l dentists,  be  outlined  below.  The  first  educational and  part  data  requests  from  the  demographic,  respondents.  s p e c i a l t y p r a c t i c e , average  location  of  p r a c t i c e , and  working  geriatric  22  practice,  The  age,  hours  dental  and  years  per  of  week,  training  general type  (ranging  and  from  formal  university  education)  are  income  considered  was  substituted actual  The and by  too  "busyness"  a  Thus,  the  his/her practice  i s "busy  enough".  elderly  clientele.  patients are and  elective  are  asked  part  measuring  the  A  of  perusal  measuring  clientele,  D e n t i s t s are  I was  recent  common  to  particularly  reviews  of  typically  out  several  Kogan(l8)  address amongst  the these  instruments  imply  that  elderly(the  fewer  the  one's  attitude  toward  lack  of  more  incorrect them.  In  r e s e a r c h e r s assume  part  p e r c e i v e r s of  the  the  they the  a  and  one's  23  is a  component  the  of  elderly.  attitude  they  between  semantic  of  and  knowledge  have  fallen  and  knowledge  Many  of  and  these  knowledge  s t e r e o t y p e s ) , the  meaning  home  means  McTavish(2l)  there  made  of  emergency  i n the  accurate  that  make  treating  instruments.  using  training,  impressions  about  attitude  distinction  measuring the  with  Both  the  percentage  revealed that  reasons.  asked  "attitudinal"  employed  2)  techniques, of  the  is  of  patients.  concerned  satisfaction  i n Chapter  for  elderly  traditionally  studies(discussed favour  a  most  instruments  what  list  investigator  proximity  the  whether  from  hourly  dentist  65),  choose  dentist's  and  asked  to  i n c l u d e s the  study.  the  questionnaire addresses  elderly(over  procedures  This  the  for  a d v i s o r s the  incomes.  with  attitude  by  continuing  request  target  experience  of  a  of  of  the  Because  gauge  to  as  part  visits,  post-graduate  audacious  second  their  to  rough  elderly  of  included here.  incomes  whether  courses  more  of  the  positive  differential consensus  certain  on  adjectives  the such  as  "happy"  criticism and  or  "independent".  leveled  by  controversial  elderly  as  whole  homogenous status  or  Signori  traits  group  of  without  instruments to  sets  and  pressure  social health  any  event,  verbal  toward  few  the  of  elderly(18).  questions.  The  and  specific  issues.  e l d e r l y and  status  of  because  follow-up  asks  the  of  is  into  race, of  of  the  continuous  as  an health  such  doubt  because  e f f e c t s , such  one's  limited  the  treated  class,  ageism,  as  they  response  particularly  of  age  and/or  to  weigh  both  congruent  own  measuring  dentists work  lack  ungrateful  of  24  the  elderly  on  socializing  and  of  distinction  between  or  with  of  oral  or  finally,  time  the  work.  medical  uncommunicative  intervention  the  with  report  the  of  in  improvement  such  instrument  to  with  difficulties  to  between  elderly patients  enjoyment  and  nature  behaviours  their  l i m i t a t i o n s to therapy  and  asks  groups, the  links  with  e l d e r l y , the  unrewarding  dentists  of  substantiated  my  question  elderly, barriers  preventive  financially  created  include  the  other  have  aspects  These  confusion  behaviours  disguise  use  the  description  validity  response  attitude  I  first  with  are  put  satisfaction  negative  communicating  problems,  to  the  importance  The  further  in the  socio-economic  studies  expressions  positive  the  preclude  mentioned  professionals(36).  personal/professional two  al.(28),  greater  artificial  care  already  e l d e r l y , who  is  themselves  the  Of  the  lend  In  et  individual differences.  attitudinal  amongst  have  which  people.  overgeneralization  I  The  p o s i t i v e and  lack  health of  consuming  second the  and  question  negative  aspects  they  have  noted,  categories  predominates  manner,  evaluation  an  dentistry, as  an  independent  The  third  interest is  although  in  posed,  drive  the  part  important  reflects  one  professional and/or  of  private  operatory;  the  to  practice  or  as  the  the  the  two  e l d e r l y . In from  in depth,  can  main  how  this  geriatric later  to  . After hours  such  a  be  used  not  at  on  a  or  models.  time;  and  and  as  government  They  distance  of  such  a  of  treat  the  seven scale  these  with  are:loss to  others,  of  and  as  taken  of  dental  in  working  in  this  treating table,  payment  capital  account.  financial  of  training  preferred  into  leisure  facility;  satisfaction  underwriting  25  to  ordinal  availability  personal  are  long  the  table  point  Each  experience  the  how  decision  c h r o n i c a l l y i l l e l d e r l y . Below  well  question  the s o c i o - c u l t u r a l ,  expenses;  and  the  in conjunction of  this  includes  four  important.  variable,  service.  is primarily a  ranked  capital  independent  many  in arriving  qualifying conditions,  arrangements CDS  and  of  derived  questionnaire  hypotheses  professional  diasabled  with  facilities  give  the  are  elderly patients;  certain  the  of  to  economic  and  the  LTC  itself,  the  and  reimbursement  with  by  on  elderly. It  which  considerations  work  limited  i s asked  involved  considerations  which  satisfaction  focuses  is willing  institutionalized  their  somewhat  dentist  fourth  very  of  determine  variable.  part  considerations  from  in  p r a c t i s i n g at  he/she  The  to  expenses  by  Finally, service  has  the not  been  response  options  refer  the  to  to  the  a  SECTION  service  request  barriers  first  at  the  to  the  reasons  practice  the  proper  such  before.  considerations, by  why  The  but  also  administration,  treatment.  and  This  section.  is  LTC  mark  his/her  of  which  practised  of to  the  2,  part  to  similar  lack  ends  i s asked  are  administrative  question  have  dentist  filled  out  facilities,  only  by  those  consists  of  dentists  two  who  parts.  t The is the  asked  to  part  mark  facilities.  closely of  first  the  of  off  value  in  The  next  the  This  dentist policy  this  positive  and  the  lists  and  appraisal  is  Following  this  incentives incentives, service;  first  and  B).  the of  may  practice  and/or  query  The  listed  two  of  of  note  semi-retirement  26  how  may  be  again  the  two  the  separate  must  weigh  retrospective this  probe  practice.  social contacts;  opportunity;  to  the  case,  two  questions a  at  instrument  this in  This  such  as  answers  institutionalized elderly  inquiry,  dentist  program.  In  dentist  The  undertaken  extensions  predominates.  dentist  private  LTC  are  are  The  disincentives  the  responsibility  of  line  a  a  guide.  questionnaire.  aspects  which  only  for  questions  Appendix  decide  fee  by  s a t i s f a c t i o n measuring  negative  questions(See  procedures  followed  the  guidelines of  is descriptive.  common is  followed  series  for  most  listing  professional/personal developed  section  time.  into  the  Amongst  the  public  professional practice.  Amongst  the  a  disincentives,  the  dentist  following:administrative loss;  private  practice  to  in  deducing  the  dental  interplay  The  of  second  questions These  of  and  As  linear  the  the  is a  name o r  service  available,  and  earlier,  the  elements long  leisure  of  in  term  three  time  adjuncts  the  care  series with  patients.  repetition  each  facility,  visits,  models  in  LTC  combination  of  independent  the  Table  the  important  of  facility.  time  distance  reimbursement  interest  three  are  structure  type  of  personal/professional  and  practice  of  and  underlying  2  one  f i n a n c i a l or  questions  SECTION  the  any  span  of  travelled,  arrangements.  es  discussed  summarizes of  of  frequency  i abi  variable,  of  profession  include  equipment  3. 2. 2 Var  series  describing  questions  practice type  part  off  commitments;  This  1  mark  difficulties;  disatisfaction. SECTION  may  service,  independent  theoretical  which  one  independent  is predicted  variables.  variables  of  under  The  the  by  a  following  umbrella  of  models.  1:Independent  Question  consist  Variables  number  in  the  i s denoted  Socio-cultural  by  Three  (Q  Model  Independent variable: Age(Q1) Personal/professional satisfaction:(Q13) a) e n j o y s o c i a l i z i n g w i t h e l d e r l y b) d o n ' t s e e a d i s t i n c t i o n b e t w e e n e l d e r l y and others d)elderly often ungrateful or uncommunicative  27  )  Models  table each  e) do n o t f o l l o w up p r e v e n t i v e therapy Summary o f p o s i t i v e a n d n e g a t i v e a s p e c t s ( Q 1 4 ) Considerations:(Q18) f) P r o f e s s i o n a l / p e r s o n a l s a t i s f a c t i o n i n working elderly  Professional  with the  Model  Independent v a r i a b l e : Type of p r a c t i c e ( Q 6 ) Training in geriatric dentistry:(Q9) a) f o r m a l u n i v e r s i t y c o u r s e w i t h c l i n i c a l experience b) f o r m a l u n i v e r s i t y c o u r s e only c) c l i n i c a l institutional experience d) o c c a s i o n a l l e c t u r e s i n c u r r i c u l u m e) p o s t - g r a d u a t e c o n t i n u i n g ed f ) no f o r m a l training Percentage elderly i n practice(Q10) Home v i s i t s ( Q 1 1 ) Professional/personal satisfaction:(Q13) c ) e l d e r l y present d i f f i c u l t i e s due t o m e d i c a l complications e) e l d e r l y d o n o t f o l l o w up p r e v e n t i v e therapy f) d i f f i c u l t t o improve o r a l h e a l t h ( l i m i t e d treatment options) Summary o f P o s i t i v e a n d n e g a t i v e a s p e c t s ( Q 1 4 ) Considerations:(Q18) e) a v a i l a b i l i t y o f d e n t a l o p e r a t o r y f) p r o f e s s i o n a l / p e r s o n a l s a t i s f a c t i o n i n working with e l d e r l y g) e x p e r i e n c e / t r a i n i n g w i t h c h r o n i c a l l y i l l o r d i s a b l e d Reasons f o r non-provision:(Q21) b)inadequate t r a i n i n g and e x p e r i e n c e e)lack of appropriate treatment facilities  Economic  Model  Independent v a r i a b l e : Age(Q1) Years i n practice(Q2) Years i n s p e c i a l t y practice(Q3) Status of practice(Q4) H o u r s worked p e r week(Q5) Business(Q8) Professional/personal satisfaction(Q13) g ) g e r i a t r i c work t i m e c o n s u m i n g a n d f i n a n c i a l l y Considerations(Q18): a) l o s s o f p r i v a t e p r a c t i c e time b) l o s s o f l e i s u r e time c) d i s t a n c e t o f a c i l i t y  28  unrewarding  d ) f i n a n c i a l reimbursement and c a p i t a l e x p e n s e s I m p o r t a n c e of c o s t of p o r t a b l e equipment(Q19) Importance of form of reimbursement and preferences(Q20) Non-provision of d e n t a l services:(Q21) a ) t o o busy i n p r i v a t e p r a c t i c e c ) f i n a n e i a l l y c o s t l y and unrewarding  3.3  Administration  The cover  mail-out  letter  package  introduced  complemented(See out in  the a  dentist's white had  pre-paid  name o n  i t was  envelope.  more  services. project  i f agreed  a v a i l a b l e to  slip,  the  inform  LTC  LTC  his/her  the  A  me  as  dental  whether asked  were  listed  added  would  for in  to  a d d i t i o n , on i n an  elderly  s/he  dental  be  the  not  i f s/he  will  participate  them  the  or  demand  In  mail  f i l l  pre-paid  to  administrators.  with  with  needs  names  experience  and  requesting  favourably  to  i n s t r u c t e d to  slip  to  A  i t  i n another  facilities  invited  research  blue  d e n t i s t was  their  anonymity.  questionnaire  returned  the  match  upon,  d e n t i s t was  overviewing  to  responded to  the  be  slip,  who  of  ensure  d e n t i s t was  to  this  on  The  to  and  envelope.  was  information Those  survey  A).  This  in progress  Further, file  On  prepared  sections  brown  replied.  like  the  Appendix  appropriate  large  was  a  pilot  LTCs. a  current  the  blue  interview  at  his/her  convenience.  The  mail-outs  beginning had  in February,  returned  return  were  rate  sent  out  1985.  questionnaires, than  was  expected  By  over  a  July,  which for  29  was a  two 334 a  study  month or  55%  period of  the  substantially of  this  dentists larger  nature.  3.4  Coding  When returned  the  statistical  frequency years LTC  of  hours  were  and  of  the  recoded  was  of  by  t o have  been  Subsequent  continuous variables,  hours  Such  appeared  initiated.  practice,  f o r the  recoded  commitment  Table  were  specialty  month(Ql6).  practice  responses  tests  number  i n LTCs  per  of  several  general  2 ) . The  practise  of  run,  service  (Table  majority  purposes  each  from  the  2 tCoding of  hours  of  dentist  was  i . e . age, committed  willing  data  to  to  calculated  simplifies  dentist(Table  Continuous  a  crosstabulation  orginal  categorization each  and  to  the  in  degree  2).  Variables  Var i a b l e  Coding  Age:(Q1)  a. b. c. d. e.  Years of p r a c t i c e ( Q 2 ) & specialty practice:(Q3)  a. l e s s than b . 6 t o 15 c . 16 t o 25 d . 26 t o 35 e . a b o v e 35  Commitment (hours per  a. l e s s than 8 ( l e s s than a day) b . 8 t o 16(1 t o 2 d a y s ) c . 17 t o 3 2 ( 2 t o d a y s d . 33 t o 5 6 ( 4 t o 7 d a y s ) e. more t h a n 56(more t h a n 7 days)  t o LTC practice: month)(Q16)  30  under 35 36 t o 45 46 t o 55 56 t o 65 65 p l u s  5  3.5  Recodinq  When  the coding  all  the variables  LTC  service.  were  the dependent  many  method,  crosstabulations  using  variable,  of the v a r i a b l e s  Pearson's  the Spss:x  were  chi-square,  of the crosstabulation  computed  initial  against  Because  non-parametric evaluation  was c o m p l e t e d  results.  statistical  run of c r o s s t a b u l a t i o n s ,  i t was  were  run  with  interest in  nominal,  a  was c h o s e n f o r  Chi-square package.  found  tables  After  that  an  frequency  i values these  forcertain variables crosstabulations  The  number  4(Table  group,  because  separate were  grouped  demographic  the  comparison  8 categories  i n t h e economic  practice  (low opportunity  opportunity  costs);  opportunity  costs  time  public  which  fell  categories  were  to reflect  modeKTable costs);  a part-time  than  established  practice(which  31  the study  population.  practice(Q4),  were  an e s t a b l i s h e d  as  fora  opportunity  3 ) . They  a  Burnaby, and  and the  of  22 t o  i n t o one  outside  useful  or associate  full-time,  salaried  united  the Vancouver,  cells.  into  t o o few t o be o f v a l u e  Only  recoded  from  grouped  were  the e f f e c t s of the status were  o f empty  reduced  were  of the respondents  outlined  full  was  Vancouver  A l l locations  Vancouver  and consequently  number  locations  were  together.  determining  a large  a n d West  t h e numbers  categories.  a n d West  In  North  occurred,  locations(Q7)  3 ) . A l l the Vancouver category.  North  included  of o f f i c e  single  area  seldom  costs  now:  a  new  practice(high  practice(lower p r a c t i c e ) ; and  eliminated  their  Table  3:Recoding  of Practice  Recoding  Original  Status of P r a c t i c e : ( Q 4 ) a . New practice= b. E s t a b l i s h e d practice=  c.Part-time  practice=  a.General a l l other  Practice Location:(Q7) a. Vancouver b. B u r n a b y c . N o r t h a n d West Vancouver  Vancouver suburbs  = =  redefined considered  a . no b. y e s , c. yes  f o r LTC  as general t o be  professional  service). practice  sufficient  considerations  categories  a l l areas under Vancouver municipality(d. t o s.) a. Burnaby b. West V a n c o u v e r c. North Vancouver a l l other locations, ex.Richmond,New Westminister,Coquitlam  Home v i s i t s : ( Q 1 1 ) a .No= b.yes =  availability  Coding  b.new p r i v a t e practice b. e s t a b l i s h e d p r i v a t e practice e. f u l l - t i m e p u b l i c s a l a r i e d practice c. r e t i r e m e n t p a r t - t i m e practice d. p a r t - t i m e p r i v a t e practice f. part-time p u b l i c s a l a r i e d practice g. a s s o c i a t e practice  Type of P r a c t i c e : ( Q 6 ) a. G e n e r a l = b. S p e c i a l t y =  d. o t h e r  Characteristics  The  type  only  of p r a c t i c e  or s p e c i a l t y  to delineate o f t h e two  32  i n emergencies  (Q6)  practice.  the economic  groups  This  was was  and  in treating  the  elderly.  Home v i s i t s "yes"  and  "only  willingness The  (Q11) were  i n emergencies"  to practise  interval  the way, at  two  and  last  two  a general statement  LTCs  Table  could  be  used  4iRecoding of  of  in statistical  LTC  considerations  However,  were  importance  Importance  indicating  many  For the purposes  categories  in deciding  computations  empty  of the  combined.  of S p e c i f i c  In  to  Service  a.very  b. n o t  c.minimally important d.not important  coding  important  b.moderately  as  a  important=  In  to find  order  result  statistical  out  i f t h e r e was  of non-response, data  from  t h e CDS  4).  Considerationsfor  a. important=  Bias  study,  this  (Table  Original  Sampling  cells  practise  Recoding  3.6  of  operatory(Table 3).  several  4 values.  in the crosstabulations.  first  of  the responses  thus  of a dental  importance  created  t o combine  to "yes",  outside  ranking of  (Q18) h a d o r i g i n a l l y occurred  recoded  a bias  the investigator on  33  important  i n the study  group  obtained  the demographics  of  the  dentist  population.  The demographic  goodness-of-fit  test  data  was c o n d u c t e d  years  of practice,  order  t o compare  the respondents  3.6.1  Results  the  Of 29  of  only, that  approximately North  currently  data  respondents  The  age 2  (x =6.63,  years was  the total  of practice, i n  form  the first  This  Mainland  would  of dental  with the  section indicate  dentists i n  and Vancouver,  i n those  There  combined  have  service  or  are  delivery to  boundaries.  characteristics  ranged  from  of  the  i n Table  5 below.  26 t o 77 y e a r s ,  was n o s i g n i f i c a n t  with  difference in  population and and the respondents  p=.1).  dentists  i n their  i n t h e study  profession.  goodness-of-fit  X  had p r a c t i s e d  T h e mean  who h a d e m b a r k e d  w a s 1 t o 38 w i t h  population  answered  and the population a r e presented  16. F o r t h o s e  range  study,  sections.  on t h e d e m o g r a p h i c  o f 42 y e a r s .  between  The  dentists  age of t h e respondents  average  and l o c a t i o n  i n t h e major  Vancouver  residing  v a r i a b l e s : age,  to the population.  19% o f t h e l o w e r  i n v o l v e d i n some  four  and a  Study  t o both  a n d West  institutions  The  an  study,271  recoded,  using  of practice  Bias  a n d 63 r e s p o n d e d  Burnaby,  the  type  t h e 305 r e s p o n d e n t s  in the pilot  were  2  an average  showed  a n d t h e sample  number upon  1 a n d 54 of practice  practices the  o f 11 y e a r s . T h e  regards  34  of years  specialty  no s i g n i f i c a n t with  between  differences  t o years  between t h e  of dental  practice  TABLE  2  (x =2.92,  p=.6).  5:Demographic  Characteristics  of Respondents and  Population  Variable  Respondents(%)  Population(%)  120(37) 103(31) 49(15) 41(13) 14(4) 327(100)  216(31) 214(31) 117(17) 105(15) 39(6) 691(100)  61(19) 129(39) 72(22) 44(14) 21(6) 327(100)  125(18) 232(34) 177(26) 92(13) 65(9) 691(100)  277(85) 48(15) 325(100)  586(85) 105(15) 691(100)  224(72) 56(17)  501(72) 120(18)  33(11) 313(100) df = 2  70(10) 691(100)  Agegroup:(Q1) 35 o r l e s s 36-45 46-55 56-65 65 + 2  x =6.63  p=. 1  df = 4  Years of Practice:(Q2) 6 or less 6-15 16-25 26-35 36 + 2  x =2.92  p=. 6  df = 4  Type o f P r a c t i c e : ( Q 6 ) General Spec i a l t y x  2  =0  p=1  df = 1  Location of Practice:(Q7) Vancouver North and West V a n c o u v e r Burnaby 2  x =.15  p=.99  35  About  85%  practice. the  of  the  survey  i s not  percentage  in general  p r a c t i c e found  the  Ten  of  2  areas(x =.15,  There practice,  are  generalize  in  in  general  different  the  from  total  the of  dentists practised in  dentists located  of  West  total  the  in  Kitsilano  Vancouver and  Fairview  dentists practised  Vancouver.  These  Vancouver,  in  Burnaby,  figures parallel  dentist population  in  the  three  the  study  p=.99).  no  and the  significant  of  location  population.  findings  groups  d i f f e r e n c e s i n age,  p r a c t i c e and  the  a l l dentists  specialty  and  the  type  respondents  significantly  Vancouver(10%),  percent  in North  proportions  of  number  Downtown  Slopes(8%). 18%  70%  highest  East(l2%),  were  p=1)  Approximately  of  the  percentage  2  and  in  This  population(x =0,  with  dentists  from  in Greater omitted  Thus  the  the  36  should  (with  survey).  of  p r a c t i c e between  respondents  Vancouver  from  we  of  years  to  the  be  able  the  the  to  population  exception  of  the  CHAPTER INTERESTS  4.1  which LTC  analysis  best  the  with  was  the  bivariate In  IN  TREATING  well  of  ELDERLY:RESULTS  predict  the  the  frail  such  and  rank  as  the  most  stages the  their  in  focus  and  was  of  a  according  second a l l with  the the  through were  singled  multivariate  significant predictors models  a working  between  examined  stage,  of  the  experience  in  analysis.  provided  significant variables complex  model  interest  perceptions  The  training  the  this  data  relationship  variable  the  the  and  select  variable,  of  elderly.  Here,  Stage:Frequency  primary  question going  importance  which  services  Thirty-seven were  and  and  tables  dentists  combined,  to  distinct  to  to  in  each  their  model  ability  to  interest.  First  Of  of  performed  dependent  three  dependent  final  conducted  main  specific.  the  was  frequency  analysis,  the  analysis  4.2  were  variables,  and  data  the  stage,  more  elderly,  was  the  description  independent  out.  There  first  both  stage  of  explained  service.  general  on  DENTISTS  Overview  The  In  OF  4  asked, to  percent  interested,  Distributions  of  to  were  this  "Would  residents of  another  the 37%  of  study you  be  a  long  dentists  the  responses  interested term  sampled  indicated  37  Variables  no  care  in  providing  facility?".  responded  interest  to  and  that 26%  they were  uncertain.  At the f i r s t  distributions who t h e s e elderly This  stage  of analysis, the  of the responses  d e n t i s t s a r e a n d what  and the p o s s i b i l i t y  information  independent  contribute they  c a n be d i s c u s s e d  with  v a r i a b l e s i n the three  Table  6:Interest  t o say about the  term  care  reference  i n LTC  Univariate  views  question  Anal ys i s : Soci o-cul t ur al  of the social  and c u l t u r a l  a r e found  14, w h i c h  asks  the dentist  i n assessing  components  37 26 37 100  83 1 3 24 96 207  40 1 2 1 1 46 100  of professional  13, w h i c h  offers  i n p r a c t i c e t o mark t o use these  satisfaction  38  120 86 j_2J_ 327  Model  i n question  d e s c r i p t i o n s of the e l d e r l y  descriptions  %  service:(Q15)  of the elderly  various  tothe  #(dentists)  Time committment t o LTC s e r v i c e ( h r s . p e r mo.):(Q16) Less than 8 8-16 17-32 33-56 M o r e t h a n 56  Most  service.  i n LTC S e r v i c e  Not interested Uncertain Interested  4.2.1  dental  models.  Variable  Interest  t o o u r knowledge o f  have  of a long  frequency  with  o f f , and  various  the elderly  in their  practice. findings  The r e s u l t s , of Kiyak(l7),  uncovered 5% 31%  fairly  regarded  working and  the elderly  therapy.  with  equally  stereotypes  felt  In t h e i r  both  7, c o n t r a d i c t  Holtzman  as ungrateful  the elderly,  32% c o n s i d e r e d  i n Table  Coe(8),  negative  of the respondents  preventive  listed  that  et al(14,15),  of e l d e r l y  assessment  who  patients.  Only  d i d not follow  up  of s a t i s f a c t i o n i n  positive,  the positive  earlier  or uncommunicative, y e t  the elderly  52% were  the  8% w e r e  and negative  negative  aspects  t o be  balanced.  Table  Descriptions  7Perceptions  o f Work  noted:(Q13)  with  Elderly  #(dentists)  Enjoy s o c i a l i z i n g w/elderly No d i s t i n c t i o n s b e t w e e n e l d e r l y a n d others Difficulties-medical problems Ungrateful/uncommunicative Preventive therapy not followed Limited treatment options Time c o n s u m i n g / f i n a n c i a l l y unrewarding  %  182 125  56 39  109 18 1 02 90 56  33 5 31 28 1 7  n = 334  Summary o f p o s i t i v e a n d n e g a t i v e P o s i t i v e outweigh negative Negative outweigh positive B o t h t h e same Uncertain  39  aspects:(QI4) 167 24 103 2_7 321  52 8 32 8 1 00  These  findings  patients, of  which  service  elderly. working  indicate  leads  with  these  elderly  fairly  positive  us t o q u e s t i o n  i s attributed  Whether  a  to social  views  a model  will  of  elderly  i n which  the lack  p r e j u d i c e s towards t h e  predict  i n LTCs  view  a dentist's  be t e s t e d  interest in  through  bivariate  analysis.  4.2.2  Univariate  There  a r e two p r o c e s s e s  ideologies training health  and both  and disease  practice  to the oral  ideology. the  well  for  them.  patients, This  and disabled  experience  their  professional  data  respondents clinical  i n Table  8  to the dental  institutional  prosthodontic  clinical  o f t h e sample  lack  commonly,  appraisal  are listed  of  services i n Table  i n Table  i n Table  9 b and  7.  history  of formal  of the courses  the dentists  e x p e r i e n c e ( 1 2 % ) , such  40  and the treatment  of the e l d e r l y  session held  of  in their  of dental  i s summarized  problems  the  and prevention,  the dentists'  and the role  relative  i s  by t h e p r o f e s s i o n ' s  are reported  Most  definitions  of the elderly  on t h e t r a i n i n g  to a  professional  The f i r s t  i s the exposure  develops  t h e aged  views  training(6%).  introduced clinical  with  points  on c u r e  i s guided  data  shape  i n the survey.  outlook  elderly  The t r a i n i n g  ultimately  their  problems which  Model  generates  The second  experience  their  The  which  and t h e i r  and aging.  elderly  which  a r e examined  of dentists,  pathology  of  Anal ys i s: Pr ofe s s i onal  with  were through  as the  at the Health  Sciences  8,  Table  8:Geriatric  Dental  Training  Training:(Q9)  of Respondents  #(dentists)  %  21  6  13 41 107  4 1 2 32  Formal courses and c l i n i c a l experience Formal courses Clinical institutional experience Occasional lectures(undergraduate courses) Post graduate c o n t i n u i n g education No f o r m a l training  Centre  Hospital-Extended  opposed  t o formal  knowledge attended  either  that  last  are a  their  small  constituted  practioner's patients.  had  treated the elderly  lectures(32%),  course  a t home;  9b).  41  university  in training,  program.  i n the light  p o r t i o n of a either  Thirty-six  as  theoretical  48% h a d n o t r e c e i v e d a n y  fairly  the  7 48  7% o f t h e g r o u p h a d  continuing education  i s not s u r p r i s i n g  The e l d e r l y  emergencies(Table  their  About  or informal, during  finding  Occasional  ( 4 % ) , formed  Nontheless,  the elderly  clientele.  Unit.  dentistry.  a post-graduate  formal  This  courses  of g e r i a t r i c  gerodontology.  Care  22 159 n=334  dentist's  10% o r l e s s  percent  12% h a d d o n e  of the fact  o f most o f  of the d e n t i s t s so o n l y i n  Table  9a:Practice  Characteristics  Variable  Status  of  Respondents  #(dentists)  %  48 253 32 333  15 75 10 100  5 20 263 i i 332  2 6 79 11 100  153 170 2 325  46 53 j_ 100  Practice:(Q4)  N e w d e s s than 5 y r s . ) E s t a b l i s h e d or s a l a r i e d Part-time  Average working L e s s t h a n 10 11-25 26-40 M o r e t h a n 40  Busyness of Not busy Busy Uncertain  Table  week(hrs):(Q5)  '  practice:(Q8)  9b:Practice  Characteristics  Variable  Elderly  of  in practice(as  Relevant  to  Elderly  #(dentists)  %  15 140 83 64 331  5 42 25 19 9 100  211 80 4J_ 332  64 24 J_2 100  %):(Q10)  None 5 6-10 11-24 25+  29  Home v i s i t s : ( Q 1 1 ) Do n o t v i s i t Do v i s i t Only i n emergencies  42  The sector  most were  common denture  prosthodontic procedures.  emergency proceedures adjustments(75%)  orientation  Fillings/  relines(65%)  were  i s evident  crowns(65%),  closely  i n frequency  the  commonly  were  number(44%)  elderly  clientele(Table 10).  Proceedures  10:Common  i n the data  on  Proceedures  About  periodontal endodontic  forElderly  Reported:  A  elective  f a b r i c a t i o n s ( 6 7 % ) and  of procedures.  performing  age  and e x t r a c t i o n s ( 7 0 % ) .  denture  treating  similar  Table  were  for this  f o l l o w e d by e x a m i n a t i o n s ( 7 3 % )  prophylaxis(69%), dentists  noted  and  one h a l f  conditions procedures  of  and a on  Patients  #(dentists)  %  234 249 167 79 34 n=334  70 75 50 24 10  242 230 216 224 217 163 148 n=334  73 69 65 67 65 49 44  Emergency:(Q12) Extractions Denture adjustments Endodontics/Periodontics Diagnosis of oral pathoses Biopsies  Elective:(Q13) Examinations Oral hygiene Fillings/crown Denture f a b r i c a t i o n Denture r e l i n e s Peridontal therapy Endodontic therapy  The  emphasis  accompanied  on c u r a t i v e  by i m p l i c i t  deterioration  procedures  assumptions  of the aged  person,  43  in dentistry,  about  the progressive  i s clearly  influential  i nthe  dentists' the  evaluations  respondents  believed  because  of t h e i r  thought  improvement  limited(Table medically  not of  chronic  their  of experience  patient(24%)  clearly  11:Important  were  influenced  dentists' number  decision  of d e n t i s t s  professional patients  requirement  decision  to treat with  11).  f o r LTC  Service  #(dentists)  making  professional  process  gave  and personal  amongst  quite  1 3 ) . The  their  Considerations  of these  who  be  28%  c i t e d as reasons f o r  P r i v a t e p r a c t i c e t i m e l o s s , n=293 L e i s u r e t i m e l o s s , n=292 Distance, n=289 R e i m b u r s e m e n t / e x p e n s e s , n=289 D e n t a l o p e r a t o r y , n=295 Professional/personal satisfaction, n=286 E x p e r i e n c e a n d t r a i n i n g , n=213  prominence  and another  as d i d t r a i n i n g and experience  Considerations ranked important:(Q18)  The  difficulties  in treating the  to LTCs(Table  patients(5l%)(Table  Table  would  1/3 o f  and the absence of  facilities(35%)  in facilities(9l%), care  health  About  presented  and confusion,  oral  practice  operatory  in practice.  the e l d e r l y  problems  of t h e i r  treatment  a dental  that  7 ) . The l a c k  extending  patients  medical  compromised  appropriate  of the e l d e r l y  high  217 163 193 220 269 243  74 56 67 76 91 85  108  51  concerns  i s attested or moderate  interest(85%).  44  listed  in the  t o by  the  importance  satisfaction in treating  the considerations  %  great to  elderly  i n determining  Table  12:Threshold Variables  Variable  i n LTC  #(dentists)  Cost of portable Relevant Uncertain Irrelevant  Use o f g o v t , Wi11ing: Uncertain Unwilling  equipment:(Q19)  portable  Pay p r e f e r e n c e : ( Q 2 0 ) Fee f o r service Fee f o r time Sessional fee Retainer fee  Univariate  I  used  measured behaviour  70 16 100  1 98 24 18 240  83 10 7 100  73 68 1 54 295  25 23 52 100  85 88 31 1 4 n = 295  28 29 10 4  Ii  Anal ys i s : Economi c Model  several  the role  indicators o f income  that  either  expectations  directly  or  i n guiding  indirectly  the  of dentists.  Opportunity of  21 1 48 44 303  equipment:(Q19)  Form o f r e i m b u r s e m e n t : ( Q 2 0 ) Relevant Uncertain Irrelevant  4.2.3  decision  a private  costs  practice.  are directly  related  If a practice  45  to the current  i s at capacity,  state  leaving the  office  will  If  dentist  the  income, by  result  then  The  loss  chooses  any  necessity  in  to  of  avoid  servicing  infringe  dentists  were  on  practice any  loss  conducted  his/her  evenly  leisure  clients.  Over  half  as  "busy"(Table  9a).  "Busyness"  in  their  respondents  as  one  31%  extending time  was  group was  in  their of  high  decision  than the  to or  LTCs(Table moderate  regarding  importance  half  the  of  theory  regarded  office  of  their  13).  the  their  private  interest.  has  the  capacity  The  will  to  take  practice  practice  was  reasons  for  loss  practice  by  Loss  of  74% of  of  11).  some w e i g h t  These in  not  the  leisure  considerations  dentists(56%)(Table  economic  office  time.  importance  amongst  profits.  by  time a  figures  explaining  motivations.  Table  for  of  high  that  professional  Reasons  practice  ranked  more  indicate  the  their  ranked  little  of  group  hence  private  their  new  by  the  in  on  cited  of  and  outside  divided  of  time  no  13;Reasons  for  not  service:(Q21)  Too b u s y i n p r a c t i c e Inadequate t r a i n i n g Financially costly Bureaucratic barriers Inappropriate treatment Not a s k e d f o r services Other  Providing  LTC  Services  #(dentists)  facilities  46  85 64 42 33 95 1 52 28 n = 271  % 31 24 15 12 35 56 10  These  indirect  statements  of  financial  considerations  in  reimbursement or  moderate  25%  of  the  directly quarter  capital  importance dentists  of  the  and  concern.  deciding  and  effect  service,  i n d i c a t o r s are  Amongst  76%  the  preferred number Two  threshold  a  11),  and  the  equipment  (Table  group(Tables  At  this  emphasizes service, such  4.3  a  11  and  were  dental  stage,  financial  appears  to  of  a  response  form  of  per  over fee  to  and would one  for  time  the  purchasing  importance  high  payment  Slightly  fee  of  surveyed,  variables, of  of  distance  to  portable  two-thirds  of  the  12).  preliminary the  Second  12),  cost  a  direct  financial  traditional  preferred  12).  (Table  12).  the  arrangement(Table facility  the  by  list  dentists  that  decision(Table  similar  the  received  of  acknowledged  their  backed  s e r v i c i n g LTCs,  expenses  from  dentists  a  on  further  be  then,  incentives  influential  the and  economic  model,  disincentives  in predicting  of  which LTC  interest  in  service.  Stage:Predicting  Dentists'  InterestiBivariate  Analysis  Ov er v / ew  4.3.1  In  the  first  independent and work  their at  stage  variables,  comments  LTC  of  on  analysis,  i.e.the both  facilities.  In  I  simply  looked  c h a r a c t e r i s t i c s of  the  elderly  the  second  47  in  their  stage  of  at  the  the dentists  practice analysis,  and I  established would  predict  This each LTC  which  their  service.  was a h i g h  detected. around  The f o l l o w i n g  discussion  4.3.2  Bivariate  The  socio-cultural studies  Kiyak's  study(17),  study, under 29%  their  this  35 w e r e  view  i tdoes  working  t ur al  these  of treating  dentists  of personal with  that  being findings  Model  stage  of analysis of  any of those of  f o rthe older  attitudes.  In  i n determining  the dentists the  o f o l d a g e a n d t h e more the elderly.  55 y e a r s empathy  48  over  services  of age(Table and concern  a g e , h a s no impact  the group.  However  In f a c t ,  i n LTC d e n t a l  over  10% o r  on which t h e  and p r o f e s s i o n a l  was n o t d i s p l a y e d .  increase  with  perception  interested  the issue  variable  a g e was a s i g n i f i c a n t f a c t o r  their  a  C.  not resemble  of the elderly,  interest in  as t h i s ,  organizes  i n Appendix  student  relating  s i g n i f i c a n t t o ensure  i n the second  does  on d e n t a l  trend  of those  then, if  views  favourable  positive  emerges  variables  earlier  more  a r e found  that  such  crosstabulations  Anal ys i s: Sbci o-cul  pattern  dentists'  Specific  tables  variable,  of a predictor  discussion  models.  i s based  analysis  was c o n s i d e r e d  probability  the three  up b i v a r i a t e  t o t h e dependent  In an e x p l o r a t o r y level  perspectives  i n LTC p r a c t i c e .  by s e t t i n g  variable  probability  there  c h a r a c t e r i s t i c s and  interest  was a c h i e v e d  independent  less  of these  in this  50% o f those  i n comparison t o 16). Clearly f o r the elderly,  on i n t e r e s t i n  Table  14;Socio-cultural  Variables  Significantly Associated  with  Interest  Variable  x  2  Sig. level  1.Professional/personal satisfaction:(Q13) a. E n j o y s o c i a l i z i n g w i t h 12.46 elderly b . no d i s t i n c t i o n b e t w e e n 5.84 e l d e r l y and others 2. Summary o f p o s i t i v e a n d 14.81 negative aspects(Q14) Source:Appendix C - Table C:1  Two  other  related  to  socio-cultural  interest  in  variables  treating  the  crosstabulations(Table  14).  the  elderly(Q13)  by  was  2  interest(x =12.46, between  whether  elderly  from  Those the  who  that from  professional weight the to for  not  chronically  elderly  of  treat whom  the  the  disabled  45%  did  and  distinguish  of  was  a  or  did  his/her are  rest  behaviour the  clearly  of  society,  as  positive influences  the  disabled  elderly  the  positive  side  6  socializing  who  did  the  in  working  not  previously and  decision  2  (x =14.8l,  weighed  more  service.  of  of  the  a  force  believed.  aspects the  of  in  The  work  with  practitioners  p=.02)(Table indicated  with  finding  negative  been  negative  the  This  separation as  with  association  distinguish  p=.05).  to  express  uninterested  is  49  .02  LTC  stereotyped  had  2  in  2  the  .05  according  significant not  2  interest  i l lelderly(x =5.84, or  in  those  .01  significantly  elderly  Enjoyment  There  dentist  ageism,  either  elderly  p=.0l)  others(Q13)  do  suggests  noted  were  D.F.  14).  interest,  Those and  those  who p l a c e d  indicate  The into  interest.  on t h e n e g a t i v e  only  aspects  d i d not  1  s o c i o - c u l t u r a l model,  difficulty  since  t h e weight  i n explaining  as measured interest  in this  study,  i n LTC dental  1 out of 3 s p e c i f i c hypotheses  falls  service,  a r e supported  (List  1,  p. 1 8 ) .  4.3.3  Bivariate  The  professional  training  In  Analysis  and p r a c t i c e  this  interest  study,  those  interested  (Table  such  2  providing a service  interest  i n LTC s e r v i c e  and c l i n i c a l  curriculum(Q9)  those  medically  LTC s e r v i c e a t present  lectures  i nthe  2  ( x = 7.51, p=.02). training  of service(Q9)  were 2  less  (x =20.69,  who c i t e d  inadequate  compromised  patients  before(Q13)  were  (X =16.42, p=.0l) 2  between  institutional  p=.C)1) o r o c c a s i o n a l  type  tothe  of d e n t i s t s .  who h a d n o f o r m a l  in this  with  Model  was a s i g n i f i c a n t a s s o c i a t i o n  = 9.54,  15).Notably,  experience not  (x  traces  experience  there  undergraduate  Conversely, be  model  i n LTC s e r v i c e  experience(Q9) dental  .Professional  likely  to  p=.0l)  t r a i n i n g and as a reason f o r  not interested i n (Table  15).  ^he weighing of p o s i t i v e and negative aspects followed specific d e s c r i p t i o n s o f work w i t h t h e e l d e r l y w h i c h were t o a c t a s c u e s in the o v e r a l l assessment of p o s i t i v e and negative aspects, and these d e s c r i p t i o n s f e l l into both the s o c i a l and p r o f e s s i o n a l m o d e l s . When t h e s u m m a r y q u e s t i o n o f o v e r a l l s a t i s f a c t i o n was crosstabulated with each of these d e s c r i p t i o n s , s i g n i f i c a n t c o r r e l a t i o n s were found w i t h a l l t h e d e s c r i p t i v e variables e x c e p t f o r t h e v i e w t h a t t h e e l d e r l y d i d n o t f o l l o w up p r e v e n t i v e t h e r a p y . Thus, I have i n c l u d e d t h e summarizing question i n both the s o c i o c u l t u r a l and p r o f e s s i o n a l models.  50  Table  15:Professional Variables Significantly Interest  Associated  2  Sig. Level  Variable  1.  2. 3. 4.  5. 6.  7.  Training in geriatric dentistry:(Q9) c. C l i n i c a l i n s t i t u t i o n a l experience d. o c c a s s i o n a l l e c t u r e s i n curriculum f.No formal training Percentage of elderly i n practice(Q10) Home v i s i t s Professional/personal satisfaction:(Q13) f . d i f f i c u l t t o improve o r a l health Summary o f p o s i t i v e a n d negative aspects(Q14) C o n s i d e r a t i o n s i n LTC service:(Q18) f.professional satisfaction with elderly Non-provision of services:(Q21) b.inadequate t r a i n i n g and experience Source:Appendix C - Tables  The the  to  who  this  who  views  of purpose  were  7.51  .02  2  20.69 14.12  .01 .08  2 8  16.39  .01  2  8.30  .02  5  14.81  .02  6  19.08  .01  2  16.42  .01  2  p r o f e s s i o n have  about  the disabled  informed  elderly.  not i n t e r e s t e d  i n extending  their  LTC service(x =14.12, home  2  the h e a l t h of  p=.02).  However,  the proportion of e l d e r l y  had conducted  .01  t o improving  2  2  9.54  limits  group(x =8.30,  were  have  D.F.  C : 1 , C : 2 , C : 3 , C : 5 , C:6  of the dental  dentists  believed there  elderly(Q13)  between in  ideological  sense  Those the  x  with  p=.08).  was a  i n practice(Q10) As w e l l ,  v i s i t s ( Q 1 1 ) were  51  there  twice  relationship and  a s many  interested  practice  interest dentists  a s were n o t  (x =16.39,  p=.0O  familiarity  with  2  of the  this  curative  treating in  important  15).  These  practical  compromised  ideology  the  interest  the  and  medically  treating in  (Table  of  the  chronically  elderly(Q18)  LTC  service.  group  2  The  findings  was  Those in  professional practice.  the  variables  A l l of  statistically  p=.0l)  at  the  6  supported  may  of  the  offset  profession  a  and  dental the  who  were  (Table  second have  a  such  to  extend  more  15).  stage  barriers  2  p.  of  in  satisfaction of  s a t i s f a c t i o n was  likely  their to  practice  an to  indicate  2  of  analysis  substantial  1,  problems  apprehension  felt  s p e c i f i c hypotheses (List  that  significant predictor  deciding  institutionalized elderly  interest(x =19.08,  knowledge  illustrate  i l l .Finally, professional  the  consideration  findings  effect tested  suggest on  LTC  that dental  were  18).  P r o f e s s i o n a l s a t i s f a c t i o n ( Q 1 8 ) , w h i c h w o u l d p r o v e t o be so c r i t i c a l in p r e d i c t i n g i n t e r e s t , presented a problem at t h i s s e c o n d a r y s t a g e of a n a l y s i s . B e c a u s e t h i s c o n s i d e r a t i o n i n the d e n t i s t ' s d e c i s i o n was b a s e d on b o t h p e r s o n a l a n d professional s a t i s f a c t i o n i n working with the e l d e r l y , t h i s independent v a r i a b l e c o u l d n o t i n i t i a l l y be p l a c e d i n one s p e c i f i c model. It was e s s e n t i a l t h e n , to f i n d out whether t h i s c o n s i d e r a t i o n was l i n k e d t o o t h e r p e r c e p t i o n s of work w i t h the e l d e r l y w h i c h could be c a t e g o r i z e d as e i t h e r s o c i o - c u l t u r a l or p r o f e s s i o n a l . I p e r f o r m e d a s e r i e s of c r o s s t a b u l a t i o n s of t h i s v a r i a b l e w i t h other considerations and p r e d i c t o r s of i n t e r e s t t o f i n d the model t h i s v a r i a b l e most r e a d i l y f i t , i . e . which of the two g r o u p s o f v a r i a b l e s was i t most c l o s e l y a s s o c i a t e d w i t h . The crosstabulations showed t h a t p r o f e s s i o n a l / p e r s o n a l satisfaction was s i g n i f i c a n t l y l i n k e d t o the a v a i l a b i l i t y of a dental o p e r a t o r y and e x p e r i e n c e and t r a i n i n g w i t h c h r o n i c a l l y i l l p a t i e n t s . S u b s e q u e n t l y , i t was included i n the professional model at t h i s secondary l e v e l of analysis.  52  4.3.4  Bivariate  The  anal ys i s : Economi c  economic  theory  has  become  are  n o tpermitted  up  the  increasingly  bulk  likely  t o express  those  potential dismiss stage  for  dentists loss  t o the  practices.  their  These  services. busy,  outthese  with  using  established  practice(Q4)  were  LTC  (x =15.57,  drops  5 years(Q2)  t o 22% f o r  p=.02)(Table under this any with the  1 6 ) . Most  35 y e a r s age group  other  those  group  d.f.=3).  busy  indicated 2  (x =23.54,  were  will at this  chi-square  interest i n  practising  the percentage 2  (x =18.06,  interest  as those  By c r o s s t a b u l a t i n g that  were  and t h ed e n t i s t s i n  these  age groups  i d e n t i f i e d the  i ntheir  with an  o f t h ep r o f e s s i o n  d.f.=6),  o f a l l t h ed i f f e r e n t  analysis  a number o f  t o express  16-25 years  a s much  53  income  51% o f t h o s e  i t was e s t a b l i s h e d  as a factor  with  The f i n d i n g s  interested,  p=.0l).  dentists  and hence  likely  While  p=.01,  twice  predicts  concerned  1 6 ) . Those  o f t h eneophytes  2  The youngest  equipment(Q19)  less  practising  (x =444.65,  busyness(Q8), least  or less  more  also  i nLTC s e r v i c e ,  arose(Table  dentistry  are  make  i s an  theory  Pearson's  interest  p=.0l).  that  assumptions.  associations  2  families  which  practice.  market graduates  new e n t r a n t s  This  time  significant  service  recent  a n d who a r e  practice  crosstabulations variables  working  i n LTC s e r v i c e ,  who a r e  bear  t h ep r o f e s s i o n a l  a n d young,  of institutional  of analysis  economic  access  of private  t h e idea  that  saturated,  interest  market  Through of  easy  of current  alternative that  suggests  variables  decision  age(Q1)  dentists 2  (x =22.50, cost  of  t o extend  from  were p=.01,  portable practice  Table  16:Economic  Variables  Siqnificantly Interest  Associated  Variable  1. 2. 3. 4. 5.  Age(Ql) Years of P r a c t i c e ( Q 2 ) S t a t u s of P r a c t i c e ( Q 4 ) Busyness of P r a c t i c e ( Q 8 ) C o n s i d e r a t i o n s i n LTC service:(Q18) f.Loss of p r i v a t e p r a c t i c e time b. L o s s o f l e i s u r e t i m e Cost of p o r t a b l e equipment(Q19) N o n - p r o v i s i o n of d e n t a l services:(Q21) a.too busy i n p r i v a t e p r a c t i c e c. f i n a n c i a l l y c o s t l y and unrewarding Source:Appendix C - Tables  6. 7.  to  x  2  LTCS(X =19.76,  The  d e n t i s t s who 2  practice(x = indicated leisure  7.26,  either  time  Dentists  because  the  prepared  The  do  direct  institutional theory  has  a  busier(Q8) (Table  2  (x =14.98, not  had was  so  and  great  to  not  6 8 4 2  15.51 14.98 15.82  .01 .01 .01  2 2 4  17.84 14.16  .01 .01  2 2  were  less  Those  C:6  practised in  2  indirect on of  costly  dentists  2  fairly in a  income  the  or  programmable previously  unrewarding  were  not  16).  economic  demonstrates  relevance  54  of  LTC  important  institutions and  in  who  p=.0l)  LTC  , p=.01)(Table  measures  interested  (X =15.51,  were  participate  n o w ( x = 14.16  deal  .01 .02 .01 .02  C:5,  16).  p-,01)  financially  practice  D.F.  23.54 18.06 15.57 7.26  C:4,  private practice(Q18)  who  work  to  were  chose  Sig. Level  d.f.=6).  p=.07)  loss  considerations 16).  P=.01,  2  with  impact  that  the  in explaining  the  of  economic  motivations of d e n t i s t s of  the 3 hypotheses  4.3.5 Results  t o work a t LTC f a c i l i t i e s ,  were s t a t i s t i c a l l y  of Testing  of Hypotheses  supported  since  (List  2 out  1,  p.18).  of the Three Models  Soc i o - c u l t u r a l model Hypotheses:Dentists w i l l be:  who i n d i c a t e  interest  i n LTC d e n t a l  services  O t h o s e who e n j o y s o c i a l i z i n g a n d c o m m u n i c a t i n g w i t h e l d e r l y patients - accepted 2 ) t h o s e who do n o t d i s t i n g u i s h between t h e e l d e r l y a n d o t h e r s i n t h e i r work - r e j e c t e d 3 ) t h o s e who a r e o l d e r a n d by a s s u m p t i o n more e m p a t h e t i c w i t h t h e problems of t h e e l d e r l y - r e j e c t e d  Professional  model  Hypotheses:Dentists w i11 b e :  who i n d i c a t e  interest  i n LTC d e n t a l  services  O t h o s e who have s p e c i a l i z e d t r a i n i n g a n d / o r e x p e r i e n c e i n g e r i a t r i c and s p e c i a l c a r e d e n t i s t r y - accepted 2 ) those with a h i g h p r o p o r t i o n of e l d e r l y i n t h e i r p r a c t i c e -accepted 3 ) t h o s e who i n d i c a t e p r o f e s s i o n a l s a t i s f a c t i o n i n w o r k i n g w i t h the e l d e r l y - a c c e p t e d 4) t h o s e who make home v i s i t s - a c c e p t e d 5) t h o s e who do n o t v i e w t h e o r a l h e a l t h p r o b l e m s o f t h e a g e d a s having l i m i t e d treatment p o t e n t i a l -accepted 6) t h o s e who a r e w i l l i n g t o u s e p o r t a b l e e q u i p m e n t a n d l e s s concerned with the a v a i l a b i l i t y of a s t a t i o n a r y operatory -accepted  Economic  Model  Hypotheses:Dentists w i l l be:  who i n d i c a t e  interest  i n LTC d e n t a l  services  O t h o s e who a r e b e g i n n i n g a p r a c t i c e o r r e t i r i n g a s o p p o s e d t o t h o s e w i t h an e s t a b l i s h e d p r a c t i c e - a c c e p t e d 2 ) t h o s e f o r whom t h e o p p o r t u n i t y c o s t s i n l o s s o f p r i v a t e p r a c t i c e a n d l e i s u r e t i m e a r e low - a c c e p t e d 3 ) t h o s e who a r e l e s s c o n c e r n e d w i t h f i n a n c i a l r e i m b u r s e m e n t a n d c a p i t a l expenses(such as p o r t a b l e equipment)rejected  55  4.4  Third  Analysis  Overv/ew  4. 4.1  In  order  interest for  Stage:Multivariate  a  to determine  i n LTCs,  large  the  strength  of  I chose a m u l t i v a r i a t e  number o f  variables  classification  analysis  which p e r m i t s  the  creation  of  v a r i a b l e s ( 1 ) . The  variable, b a s e d on  interest an  which the or  artificial  test  of  the  MCA  other  of  dependent variables.  changes  variation  in  each model,  (Readjusted the  of  combined in  can  w i t h an  main  be  through  the  dependent  a dichotomy the  or  can  be  variables  for  i n a p r o b a b i l i t y of 1 0 % subsequently  run  MCA  of  that  for  effects  c o - e f f i c i e n t i s s i m i l a r to a  partial  indicates  independent  by  the  the  analysis  strength upon  for a l l other  the  variables f o r the  c o e f f i c i e n t i s an in p r e d i c t i n g  listed  56  and  of  the  independent  i n e a c h model  on  variables  correlation indicator interest.  discussed  a  the  number of  squared m u l t i p l e  model are  the  variable  controlled  e f f e c t of  model,  the  produce  interest, adjusting  i s given  adjustment  within  c o e f f i c i e n t . This  the  regression  to  having  o v e r a l l strength  results  allowed  categories.  each m o d e l , a l l  variables  i n the  variable,  the  which  nominal c a t e g o r i e s  resulted  c o - e f f i c i e n t , and  The  predict  is a multiple  s i g n i f i c a n t , and  i s ordered  beta c o - e f f i c i e n t . This  effects  to  progam.  independent  correlation  In  association  Each v a r i a b l e of  of  service,  interval scale.  l e s s were c o n s i d e r e d  through  analysis(MCA)  i n LTC  analysis  with nominal  Multiple  use  e a c h model  of The  below.  4.4.2  Multi-vari  at e Anal ysi s : Soci o-cul t ural  Table  17:Multiple  Classification  Model  Analysis:Socio-cultural  Variables  Variable:  1 2 3  Beta:  enjoy s o c i a l i z i n g with e l d e r l y positive and n e g a t i v e a s p e c t s weighed no d i s t i n c t i o n b e t w e e n e l d e r l y a n d o t h e r s 2  multiple  At the none  this  elderly  R (adjusted)=.05  stage  of analysis,  i s t h e most  of the three  service.  This  important  substantially  model  only  t h e enjoyment variable  influence  explains  and this  low p r o p o r t i o n a t e  essential  weakness  of this  work  i s not v a l i d  model.  in explaining  of s o c i a l i z i n g  interest  figure  i n LTC variation  Multivariate  Therefore,  the  the dentists'  The  Anal ys i s : Pr of es s i onal  second model,  socialization,  that  socio-cultural  willingness to  includes  Model  of professional  9 variables  below.  57  whose  of  reveals the  i n LTC.  4.4.3  with  i n t h e model, but  5% o f t h e t o t a l  interest,  theory  .138 .132 .103  training ranking  and  i s listed  Table  18 t M u l t i p l e  Classi fication  Analysis;Professional  Variable:  1. 2. 3. 4. 5. 6. 7. 8. 9.  Beta:  professional satisfaction in treating elderly l i m i t e d treatment o p t i o n s t o improve h e a l t h occasional lectures i n undergraduate program proportion of elderly i n practice lack of experience i n dealing with disabled l a c k o f t r a i n i n g a s r e a s o n f o r no s e r v i c e c l i n i c a l i n s t i t u t i o n a l experience only no f o r m a l t r a i n i n g make home v i s i t s t o t h e e l d e r l y  multiple  The  the the  by f a r ,  i n working  variable,  group,  in this with  t h e view  highlights  t o t h e management  model i s  the elderly. of limited  the traditional  of chronic  The  treatment  resistance  conditions  of  amongst  elderly.  model's  power  i n predicting  t o by a m u l t i p l e - R  variation  in interest  2  figure  the variation o f .28, i e .  i s attributable  of interest i s  28% o f t h e  to the variables  within  model.  Multivariate  The the  ranking  forthis  attested  4.4.4  variable,  satisfaction  profession  The  this  2  highest  options  .384 .271 .166 .128 .123 .111 .075 .066 .055  R (adjusted)=.28  strongest  professional second  Variables  third  dentists'  variation  Anal ysi s : Economi c Model  model,  which  interest  i n response.  i s t h e economic  i n LTC s e r v i c e , The r a n k i n g  58  rationalization of  contributes  of the variables  11% t o t h e i s listed  below.  Table  19:Multiple Classification  Analysis;  Economic  Variables  Variable:  Beta:  l . l o s s of l e i s u r e time 2. a g e 3. f i n a n e i a l l y u n r e w a r d i n g a s r e a s o n f o r n o s e r v i c e 4. k i n d o f p r a c t i c e 5. y e a r s o f p r a c t i c e 6. t o o b u s y i n p r i v a t e p r a c t i c e a s r e a s o n f o r n o s e r v i c e 7.loss of p r i v a t e p r a c t i c e time 8.busyness  2  multiple  R (adjusted)=.11  Amongst  these  contributes over  loss  economic When  model,  practice  would  dentists  with  the tables  that  many d e n t i s t s  the  leisure  number  time  study  2  concern dentists  (x =9.56,  with  other  i t was  most  services  office  hours.  strongly  d.f.=2),  the loss  importance.  are willing  59  of interest.  2  thought  i s also  p=.01,  that  i nt h e  (X =10.09, p = . 0 l ,  of p a r t i c u l a r  in this  concern  7th), which,  home v i s i t s ,  outside of regular  of hours  practice(Q16)  showed  time  than  determinant  home v i s i t s ( Q 1 1 )  was a c o n s i d e r a t i o n  reason,  time(ranked  who h a d u n d e r t a k e n  be c o n d u c t e d  leisure  loss(Ql8)was cross tabulated  time  to  over  i n LTC s e r v i c e  be t h e c r i t i c a l  variables,  linked  concern  to interest  of p r i v a t e  independent  For  8 variables,  f a r more  l e i s u r e time  strongly  .215 .171 .155 .141 .132 .131 .131 .116  d.f.=l).  of leisure  I t appeared a t LTCs  were  For this  associated  to contribute  with  t o LTC  and the d i s t a n c e  they  are  willing  The  dentists  time  or  no  leisure  4.5  A  may  be  are  servicing  decisions  professional  working linked  with to  The the  both  his/her  of  of  the  dentists the  enabling  to  a  or  disabled by  with  who  have  had  training  and such  psychological dentistry  as  the  or  an  for  amount  of  whom  model  professional  is  not  model.  of  classification  economic  with  to  respect i s on  forces to  LTC  guide  the  practice.  In  s a t i s f a c t i o n in  s a t i s f a c t i o n has  practise  patient,  this  is a  been  group the  of  this  clients,  amongst  i n managing  this  limited value  60  in  elderly  traditional  tendency  of  successfully  either  training  understanding  complications being  and  outside  There  elderly,  those  economic  multiple  his/her  office.  the  minimal  clearly  variables.  practice  amongst  as  this  dentist  operate  any  a  are  the  emphasis  the  not  .11,  interest  from  experience  ability  of  professional  i l l  only  d.f.=3).  Findings  is predicated  his/her  devote  practice  figure  c a p a b i l i t y of  otherwise,  LTC  e l d e r l y , and  several  chronically  area,  2  model,  the  to  p=.0l,  paramount.  concluded  that  the  R  the  analysis,  facility(x =17.91,  willing  predictor  of  2  the  a l l to  costs  Summary  It  at  multiple a  to  are  time  a  strong  travel  who  time  With as  to  of kind to  the of the  or  specialized and  with  confines  those  chronic  with  of  dentists  conditions physiological  work,  to  elderly  dismiss patient.  While the are  f o r the most p a r t  variables that  independent v a r i a b l e s enabling  v a r i a b l e s , the  i n the economic model r e f l e c t  influence  the d e c i s i o n  b e n e f i t s . I f the c o s t s  that  are  continuation  outweigh these c o s t s , this service  The studies  factors  decision  to  the d e n t i s t weighs the  cost  income or  i s p r e d i s p o s e d to d e c l i n i n g  o p p o r t u n i t y . However, i f the b e n e f i t s r e c r u i t m e n t , and  the p r e d i s p o s i n g  too h i g h i n terms of  l e i s u r e time, then the d e n t i s t  model  independent  to work at LTCs. The  undertake such work r e q u i r e s and  i n the p r o f e s s i o n a l  i n terms of  income, c l i e n t  of a former p a t i e n t ' s  then the d e n t i s t  treatment  i s p r e d i s p o s e d to accept  opportunity.  s o c i o - c u l t u r a l model, which was  employed i n a s e r i e s of  with o f t e n c o n f l i c t i n g r e s u l t s , has  t h i s matter. I t may  be  that  the  little  bearing  e l d e r l y are not  well  r e f i n e d enough to b r i n g out.the s o c i o - c u l t u r a l i n f l u e n c e s s e r v i c i n g behaviours of d e n t i s t s . Nontheless, the  places  and  economic concerns.  The  the  i s s u e of m o t i v a t i o n  d e n t i s t s , who  testing this  undertaken LTC  have d i s c u s s e d  s e r v i c e , are  study's  had  the  61  values,  conclusion. addressed  s e r v i c e . These  incentives  and  the group which v a l i d a t e s or  findings.  the  professional  second s e c t i o n of the questionnaire(SECTION 2) was  to those d e n t i s t s who  LTC  i n the arena of  next s t e p i n t h i s study i s the  in  analysis  conducted i n t h i s study d i s c o u n t s the primacy of s o c i a l and  on  instruments to measure "ageism"  or c u l t u r a l v a l u e s around the d i s a b l e d  The  the  disincentives  invalidates  the  of  CHAPTER 5 DENTISTS WHO  5.1  PRACTICED AT LTCS-A SECONDARY  STUDY  Overview  We but  have  been  shown  that  not s o c i o - c u l t u r a l  professional  factors,  predict  and economic interest  factors,  i n LTC  dental  service.  The those will  second  section  dentists  who  be t h e g r o u p  findings.  These  dentists)  were  their  of the questionnaire  have  who v a l i d a t e  dentists asked  institutional  frequency  of v i s i t s ,  relevance  to the primary  common  emergency  distance  Sixty-three  dentists(l9%  questionnaire,  at present  dentists first  with  provided  was  motivation  h a d some service.  h a d two p u r p o s e s  to evaluate  the reasons  and subsequent  entry  f o r examining  this  sub-group  in  respects  were  similar  they  questions  62  etc.  focusing  Of on  practice.  answered the  involvement  i n the past  The i n f o r m a t i o n  dentists  purpose what  proceedures,  i n the overall  into  equipment  to facility,  of this  o r LTC  the nature of  of the respondents)  having  LTC d e n t a l  about  and e l e c t i v e  a r e four  and consequences  dentists  the study's  arrangements,  travelled  study  These  LTC p r a c t i t i o n e r s  i.e.fee  motivations  separate or  or invalidate  of questions  practice,  t o them,  LTC s e r v i c e .  (henceforth  a number  available  the  undertaken  was a d d r e s s e d t o  gave  study. The  for their  LTC s e r v i c e . of dentists  these  The  second  was t o f i n d o u t  t o or d i f f e r e n t  from t h e  dentists  who  undertaken  this  interested. the  three  models  The  entered  2) w h i c h  LTC s e r v i c e models  liked  incentives  By  analyzing  4 and 5  the responses when  factors  i.e  whether  the primary  Another  issue  discontinuing  In  this  ranked  was  the  assessed.  inquire  about  specialized offered  the reasons  by t h i s what  inquiries, term  was  63  models.  the factors care  i s whether the  would  be  evident,  applications.  model  which  practice  the reasoning f o r  I f , as the economic  have  t o be m a r k e d o f f  2 0 ) . The q u e s t i o n models  question.  The  to the three  has r e a l i s t i c  they  dentists  practice.  as options  of long  in question  A l l three  degree  to investigate  service.  which  i s addressed  of time.  i n the t h e o r e t i c a l study  t h e most  tests  t o some  the question  significant  validate  i n LTCs.  to identify  to these  ascertained(Table  to  were n o t  Study  f o r any l e n g t h  a  who  has the best  f o r work  c a n be s i m i l a r l y a l l o c a t e d  weigh  were  that  statistical  dentists  i n such  never  me  specified  of motivation  and d i s i n c e n t i v e s  respondents  arises  asks  questions  by  dentists  deductive  are covered  and d i s l i k e d  enabled  of the a n a l y t i c a l process  of the issue  addition,  They  but had  the dentists  the model  f o r the Secondary  theoretical In  study.  f o r the motivation  through  crux  7,(SECTION  and from  of a n a l y s i s  and hence,  the v a l i d i t y  Methods  forms  of t h e major  value  i n LTC s e r v i c e  o f work,  two  factors,  predictive manner,  type  These  findings  critical  5.2  are interested  predicts,  opportunity  costs  play  w o u l d be a p p a r e n t The  time  lost  increasingly eventually  a major  when a p r i v a t e  from p r i v a t e diminish  lead  role  practice  practice  5.3  Results  5.3.1  of Secondary  Incentives  and  Those d e n t i s t s practitioners, and  Table  The services  By a n a l y z i n g t h e t h i s s e r v i c e , the  Study  Disincentives  discussion  a t LTC f a c i l i t i e s , focusing  of t h i s p r a c t i c e .  LTC p r a c t i t i o n e r s  The r e s u l t s a r e l i s t e d i n compares t h e s e  results  to the  were a s k e d why t h e y h a d p r o v i d e d  their practice  comments t o t h e i r  and r e l a t i v e s of p a t i e n t s individuals  or a hospital  residency,  reported  that  practice  i n England. Three  LTC f a c i l i t i e s  i n either  and another  individuals  64  o f LTC p r a c t i t i o n e r s  had requested  were p a r t  of the  of t h e i r  r e s p o n s e s wrote t h a t  were s a l a r i e d  position  one h a l f  a t LTCs a s p a r t  r e s p o n s i b i l i t y . The m a j o r i t y  with additional  other  i . e . LTC  on t h e i n c e n t i v e s  t o t h e i n s t i t u t i o n a l i z e d e l d e r l y . Over  professional  Four  would  of the study.  group o r i g i n a t e d  patients  established.  tested.  who h a d p r a c t i s e d  2 0 . The f o l l o w i n g  conclusions  offer  were a s k e d q u e s t i o n s  disincentives  trend  o f LTC p r a c t i c e , a n d  to i t s discontinuation.  o f t h i s t h e o r y was  became  and l e i s u r e  the v i a b i l i t y  r e s p o n s e s o f t h o s e who no l o n g e r relevance  i n i n t e r e s t , then a  their  older services.  a government two d e n t i s t s  of their  salaried  h a d worked a s  public  associates  Table (  )refers  20:Questions  t o p e r c e n t a g e o f LTC p r a c t i t i o n e r s  SOCIO-CULTURAL Why  R e s p o n s e s o f .LTC to  contacts(22)  a)public  about  working  a)socializing(43)  service(40)  a) i n c r e a s e  a)broadened  c)prof.  scope(29)  about  difficult(18)  working  at  care  practice(8) practice(O)  practice(13)  with other(24) workers  LTCs:(%)(Q5)  a) i n a d e q u a t e t r e a t m e n t  faci1ities(67) a)time  unrewarding(8)  b) l i m i t e d  c) f a c i l i t i e s  smell,(18)  c) medical c o m p l i c a t i o n s ( 2 2 )  Why  retired  b)part-time practice(8)  b) p e r s o n a l l y  d e p r e s s i ng  c ) semi  responsibi1ity(65)  health  have you d i s l i k e d  time  a)expand  service(51)  d) i n t e r a c t i o n  a) e l d e r l y  practice(18)  b) p a r t  i n LTCs?:(%)(Q4)  b) p u b l i c  What  Study  n=63  to LTCs?:(%)(Q7)  b)prof.respons ibi1i ty(52)  What h a v e y o u l i k e d  Pract i ti oner statement  ECONOMIC  PROFESSIONAL  d i d you d e c i d e to p r o v i d e s e r v i c e s  a)social  and  responding p o s i t i v e l y  treatment options(50)  d) a d m i n i s t r a t i v e  barriers(13)  a) p r o f e s s i o n a l l y  and p e r s o n a l l y  consuming(41)  b)financial1y  unrewarding(37)  d i d you s t o p : ( % ) ( Q 8 )  a)other(32)  a) i n c r e a s i n g b) l o s s  unrewarding(18) b) admi n i s t r a t i v e d i f f i c u l t i e s ( 1 2 )  commitment t o p r i v a t e , p r a c t i c e ( 3 8 )  of leisure  time(15)  c ) no d e m a n d ( 3 2 ) d) f i n a n c i a l 1 y u n r e w a r d i n g ( 9 )  65  for  dentists  into  their  who  private  took  or p u b l i c  sense  practice,  helped  to define  the  to existing  or as part  of p r o f e s s i o n a l  care  was  This  commitment  increase  by  of a  work term  patients  larger  in  job they  Economic of  The  and  agrees  discussion  majority(65%)  public  was  reasons  finally  practice  with  t h e MCA  of  views  opportunity. with  LTC  their  practice  tells  us  their  practice  that  by only  Less  engaging  of the  chronically  1/3  i l l  i n LTC  to  who 22%  initiated  motivations by  economic  are elaborated service. they  t o LTCs.  on  This  h a d met  their  performed  the scope  This  incorporated an  in  The  c l i e n t s and had  had broadened  patients  were  considerations.  that  of d e n t i s t s  66  8%  hoped  models.  practice  in services  a minority  18% who  followed  satisfied  than  of t h e LTC  the e l d e r l y .  responsibility to elderly  service(51%).  dental  service".  40%  Only  professional  ranking  were  by  by  socio-cultural  on  "public  and another  l i k e s and d i s l i k e s  of d e n t i s t s  cited  practice,  by  a  the  requiring  specified  were  demonstrate,  LTC d e n t i s t s '  professional  duty  LTC  group  to perform  practice  in initiating  opportunities ranking  special  for social contacts  the figures  paramount  as a  their  a part-time  practice  r e s p o n s i b i l i t y towards  the wish  to public  the s i z e  recognized  As  elderly  expressed  practitioners.  a  comments  r e s p o n s i b i l i t y " as a duty  institutionalized  the  These  i n s t i t u t i o n a l i z e d dental  on.  The  the  incorporated  practice.  "professional a  had  ongoing  figure into basis.  of  The by  reluctance  the  Over  to  undertake  identification  2/3  of  the  of  the  dentists  facilities  at  expressed  the  that  belief  reluctance  acknowledging  financially most  institutions.  factors  the  (37%)  identified  i . e . the  profession's  this  line  of  and  more  appropriately  auxilliary  The  be  for  the  explanation was  their  Another  the  32%  too  this  associateship  they  could had  of  specified  that  no  not  with  They  practice.  the of  inadequate  the  limited  this  treatment  work.  were  as  of  costs  group  showed  study  perception  elsewhere,  did  not  were be  room  was  dentists  the in  no and  Then,  the  impediments  to  l i m i t a t i o n s of  time  that  could  reiterated in  of  which off  this  this  willing,  We  patients,  forth  for  predicted  by  the  "other" a  few  LTC  option  found  can  service.  private  included  but  underlined  to  quite  the  was  commitment  stated  response,  mark  LTC  costs  p r a c t i t i o n e r s put  trend  advanced. for  opportunity  increasing  This  dentists  of the  discontinuation  LTC  practice(38%).  locum  this  c o n s u m i n g ( 4 1 %)  opportunity  used  s i g n i f i c a n c e of  service  who  the  by  in  explained  study.  explanations common  time  is partly  Half  only  nature  interest,  work,  were  institutionalized.  unrewarding  critical  dissatisfied  there  for  in  the  the  possibilities  practice  disincentives  were  treatment  LTC  no  "no  a  demand",  that  most  model.  reason.  moved  the  discontinuing  economic  interested  i . e . the  67  had  The  or  Of  left  p r a c t i c e . Because  hypothesize  high.  as  in  the  those a  these  argument  facilities, the  opportunity  new  practice  costs  were  5.3.2  A Comparison  From  of LTC dent i s t s wi t h t he s tudy  the t o t a l  selected:those at  LTCs,  in  LTC s e r v i c e  group o f d e n t i s t s ,  who h a d p r e v i o u s l y  i . e . LTC p r a c t i t i o n e r s  interested  dentists(25%),  21:Geriatric  2  Formal no yes Total 2  x =17.4  Number  those  institutional 44(70) 19(30) 63(100)  practising  who w e r e  interested  t o t h estudy,i . e  not interested,  Three  Sub-groups(Q9)  of Dentists  Uninterested Dentists(%)  Total(%)  102(95) 5(5)  220(86) 35(14) 255(100) 2  107TT00)  d . f .=2  training: 21(28) 42(72) 63(100)  53(62) 32(38) 85(100)  P=.01  that  Among  training: 74(87) 11(13) 85(100)  P=.01  suggests  who w e r e  Ihterested Dentists(%)  68(64) 39(36) 107(100)  142(56) 113(44) 255(100)  d.f.=2  A c o m p a r i s o n between groups  currently  were  1  Training  LTC dentists(%)  x =21.81  (19%),  and those  dentists(32%).  Variable  Clinical no yes Total  o r were  sub-groups  buthad notundertaken i t p r i o r  i.e.uninterested  Table  three  gr oup  t h eLTC p r a c t i t i o n e r s a n d t h e two o t h e r  a crucial  enabling  1  factor  i ndeveloping  a  I o m i t t e d t h o s e d e n t i s t s who w e r e u n c e r t a i n a b o u t L T C s e r v i c e when e x a m i n i n g t h e g r o u p t h a t h a d n o t a t t e n d e d facilities.  68  working formal had  relationship training  clinical  with  the i n s t i t u t i o n a l i z e d elderly  of d e n t i s t s .  While  geriatric training,  30% o f t h e LTC  only  dentists  a n d 5% o f t h e d i s i n t e r e s t e d  training  (X =21.81, p=.01).  dentists  and 62% o f t h e i n t e r e s t e d  2  training,  this  2  (x =17.40, the  study  current  p=.0l) - that  interest  dentists potential who  increased  (Table  fell  in treating  dentists  dentists  data  service:  training  practised  t o 74% amongst  a t LTCs  were  similar  h a d no LTC  formal practioners  the findings  fundamentally  the e l d e r l y .  while  interested  had  supports  Three  significant differences  LTC d e n t a l  practitioners  64% o f t h e d i s i n t e r e s t e d  t o 28% amongst  21). This  professional  exhibited  had never  (Table  percentage  Although  13% o f t h e  i s the  only  effects  groups of  in their  interest in  4 4 % o f t h e 192  interested, 2  of  this  LTC p r a c t i t i o n e r s ( x = 1 4 . 5 2 ,  dentists  percentage p=.0l)  22).  Table  22:Interest  i n LTC S e r v i c e  Among  Two  Sub-groups(Q15)  Variable LTC  Interest yes no Total  2  x =14.52  i n LTC  Dentists(%)  I n t e r e s t e d and Disinterested Dentists(%)  service: 37(74) 13(26) 50(100)  85(44) 107(56) 192(100)  p=.01  d.f.=1  69  Total  122(50) 120(50) 2 4 2 ( 11 0 0 )  Another  difference  home  visits.  only  42% o f i n t e r e s t e d  quite  low amongst  undertake (7,35)  home  have  elderly of  may  experience  69% o f t h e LTC d e n t i s t s dentists  2  visits(x =39.03, that  reinforce  them.  study  This  develops  Table  a more  suggests  23:Home V i s i t s  falls  1/5 o f t h i s  conditions  such  of the  exposure  to this  from  group  studies  are put i n a  that  t o move a w a y  i n the dentist's  Variable:  who  of  visits,  2 3 ) . Some  p o s i t i v e approach  as the a b i l i t y  infrastructure  only  (Table  those  i n the area  percentage  the debilitating  negatively  as well  Home yes no  p=.0l)  was  make home  do s o . T h i s  disinterested dentists;  suggested  treating  care  While  i n s e r v i c i n g behaviour  position and  specialized  dependency  on t h e  office.  Among  Number  Three  Sub-groups(Q11)  of d e n t i s t s  LTC Dentists(%)  Interested Dentists(%)  43(69) 19(31)  36(42) 49(58) 85(100)  Uninterested Dentists(%)  Total(%)  visits:  62(100)  100(43) 133(57)  21(20) 85(80) 106(100)  233(100)  Total d.f.=2  P=.01 2  x =39.03  LTC 2  practioners  (x =13.16, less did  the loss  p=.03) a n d p r i v a t e  critical the rest  glance,  considered  in their  practice  current  appeared  to reaffirm  time  decision  of the dentists(Table  leisure  2  (x =9.95,  to practice  24). This  the role  70  of both  p = . 1 ) t o be  a t LTCs  finding,  of opportunity  time  than  at first costs.  We  Table  24;Considerations  of Time  Variable  Number  LTC Dentists(%) Loss  of p r i v a t e  practice  important not important Total 2  of  have  service be  at  LTCs. Those  have loss.  more  p=.03  d.f = 2  serious  far less  who  a  were  continued  those  and  find  that  loss  of  of  d.f.=1).  either LTC  69(67) 14(33) 83(100)  158(71) 63(29) 221 ( 1 0 0 )  58(70) 25(30) 83(100)  1 18(54) 102(46) 220( 1 1 00)  dentists  leisure  and  than  s t i l l  a t LTCs  practice  for leisure  who  practice  and  analysis  subdivided  into  discontinued  significant differences  loss  those  considerations  chi-square  practitioners  no  to  concern  However,  Total(%)  d.f.=2  indicate  to  Uninterested Dentists(%)  54(63) 27(37) 81(100)  35(43) 46(57) 81(100)  expected  would  Dentists  25(45) 31(55) 56(100)  13.16  would  Sub-groups(QI8)  time:  important not important Total •2 _  Three  time:  p=.1  leisure  of  Among  Interested Dentists(%)  35(61) 22(39) 57(100)  X =9.95  Loss  Loss  or  practitioners,  time  practice  be  when  those  at LTCs,  groups 2  (x =.007,  discontinued  time  work  expected  practice  groups,  two  discontinued  continue  that  service  leisure  71  would  showed  the  had  who  private  between  who  private  those  two  who  to  time the  LTC  who there  were  i n terms of p=.94, service  because  of  the  demands  relate  these  present  regards results  discontinuing  5.4  Within  shows  the  of  role.  which  in  motivation  in  this  does  The  complements  time,  serviced making  the  LTC  currently  current  too  that  stand  model,  in  of  LTC  service, busy  increasing  in  These  at  apparently  involved  has  not  considerations  failed  the  secondary earlier  and  in to  show  to  a  service.  to  for  fulfill  former  there  analysis.  prerequisite  takes  study,  exposure  and  up.  The  This  study  the this  one's  patients  are  at  specialized  professional LTCs  is  professional  satisfaction precedence  model,  effects  in  this  study.  But  alone.  with  i t s emphasis  professional high  did  Study  need  such  service,  not  study  professional  facilities,  processes  discontinued  that  so  the  factors  this  is a  time,  their  service.  this  training  Further, to  LTC  other  validate  leisure  about  Secondary  elderly  LTC  economic  leisure  the  undertaking  indicated  model  to  which  professional  responsibilities implicit  future  point  to  institutionalized dentistry  to  and  asked  l i m i t a t i o n s of  findings  that  practice  when  services  Conclusions  relevant  their  concerns  with  incongruent  on  model.  The  the  priorities  are  less  because  private  commitments  to  new  72  of  those  Those  they  practice, or  opportunity  opportunity  overriding  practitioners.  either  on  in who  have  costs  who the  in  have  not  decision  have moved  realistically  growing  costs,  private  or  are  have  shown  practices  no  longer  make  LTC  service  as a t t r a c t i v e  as  i t had  been  formerly.  Nontheless, s t i l l  interested  positive  manpower  o f LTC  services  Given  appropriate  the c h r o n i c a l l y  effective  number  i f their  conclusion.  prohibitive, for  the large  that  in special  requested  the economic  training  i l le l d e r l y  were  practitioners  may  care  73  increase programs.  leads  costs  and e x p e r i e n c e  who  were  to a  are not  in  dentistry  the p o t e n t i a l  for  CHAPTER 6 DISCUSSION  6.1  Limitations  Social  science  shortcomings social  of the  surveys  which  reality.  limit  This  pitfalls.  To b e g i n ,  reporting  their  honestly The  questions be any  on  meaning  assume  that  may  carry  amongst  through  their  doors',  incomes. Without  interpretation  This  leads  qualifying  enough  ambiguity One  which  i s a continuous  o f how  they  meaningful  such  superficial  a  whether stream  analysis  74  raise  of actual  and  of the  a r e open  to the  the question  can be.  a r e busy  clients  and m u l t i p l e choice  are construed,  term  has  they  of  limitation  to  i s the  potentially  c l a u s e s , answers  of the investigator,  the  to preclude  example  i t i s a matching  to the t h i r d  regardless  Secondly,  this.  p r e - t e s t e d and honed  dentists.  for others  the various  of v e r i f y i n g  evidence.  satifaction",  of  as a c c u r a t e l y and  i s no means  "hearsay"  busyness  reflection  the dentists are  connotations. D e n t i s t s are asked  F o r some  survey.  of their  options, although  as possible  enough.  target  numerous  has not circumvented  but there  "professional/personal different  with  p e r c e p t i o n s and e x p e r i e n c e s  a r e based  universal  the accuracy  I must  and answer  as c l e a r  are fraught  study  as p o s s i b l e ,  results  Survey  answers, of  how  6.2  Practical  The  Applications  r e s u l t s of  applications  in  the  institutionalized defined dental  "needs" service  office.  This  and  financial  Dentists operative  and  have  i s one  mechanics  for  basic  for  this  this  service(37%  reluctance bivariate of  study  and  limited  elderly.  i s to  has said a  dental  shown, no,  and  view  with  the  of  subjectively  of  a  a dental  medical  the  the  and  individuals  impediments  to  the  fullfillment  of  fundamental.  position and  in diagnostic  educational  hygienists,  senior  and  changes  dental  nurses,  denture  work  professionals  who  are  must  service.  dentists  are  reluctant  another  26%  were  based,  analysis,  possibilities  partly  of  r e s t o r a t i v e and  degree  multivariate  the  and  most  legal  dental  group  large  treatment  This  experience  LTC  the  the  s p e c i a l i z e d group  of  service,  the  of  be  this  number  and  confines  account  for  for  elderly require  the  monopoly  use  i t is this a  a  practical  services  constraints  of  Until  forthcoming,  As  into  a  dental  acquired  l e g i t i m i z e the  recruited  are  of  clinically  outside  treatment  a  proceedures.  dental  the  take  There  requirements  number  dental  psychological  such  a  institutionalized  dental  of  of  operates  treatment.  establishment  which  the  p r a c t i c e must  the  have  planning  which  of  manpower  study  e l d e r l y . Both  of  complications  requiring  the  stems  on  for  from  the  their  p h y s i o l o g i c a l changes  75  undertake  uncertain).  according a  to  to  Their  both  generalized  perception  institutionalized limited of  the  training  oral  cavity  and in  age  old  and the o r a l  dentists the  a r e not ready  sophisticated,  accustomed of  pathoses  their  to accept  stationary  t o f o r even  minor  t r a i n i n g . These  broadening  common  the education  t o t h e e l d e r l y . As  a working  environment  equipment  they  have  reparative  work  since  two p r o b l e m s of dentists  may  well, devoid  of  become the beginning  be r e c t i f i e d  in specialized  by  care  dentistry.  As  the federal  Canadian extend  nation(5),  their  distinguish  between  of standard  consequence i l l  professionals.  may  be a b l e  This  changes  patient  techniques,  and t o d e n t i s t s  i nthe of  management a n d  would  through  traditional team  of s p e c i a l i z e d dental  applies  not only  chronically  etc.). Dentists medicine  that  on t h e m e d i c a l  different  therapies.  have  their  a t an i n s t i t u t i o n  knowledge  i l l  care  other  be  valuable  the  continuing  for  the  patients enough  as  and psychological  76  care  welKthe  of a grounding i n  facilitate  F a m i l i a r i t y with  health  to the i n s t i t u t i o n a l i z e d  incorporation  would  to  to  on t h e r a t i o n a l c a r e  i s the interaction with  but other  handicapped,  care  they  involving  treatment  profession  program(11).  chronically  elderly  courses  patients,  of the  i n the p h y s i o l o g i c a l and  and p a t h o l o g i c a l  and c l i n i c a l  undergraduates  education  One  normal  the "greying"  to the dental  i n o l d age so that  compromised  modification both  i t i s of benefit  changes  mouth. D i d a c t i c medically  anticipate  t h e o r e t i c a l background  psychological  to  demographers  into  the health  the exchange of  complications  of  pharmaceuticals and  surgical effects weigh  p r o c e e d u r e s would e n a b l e d e n t i s t s to p r e d i c t i a t r o g e n i c of  the  not  to  their  long or  care  chronically i l l ,  g r o u p s who  I t i s not  are  but  health care therapy  team  may  for  the  fixed  dental  stationary  operatory.  u n i t s with  training  new  or  beds  operatories  to those  In  concern  the  compressed air/water  past  of  their  technology  of d e n t i s t s t o  f o r the  few  syringes  could  be  familiarize  on  presence  decades,  a i r vacuum s y s t e m s ,  have become more t h a n a d e q u a t e This  other  to wheelchairs  similar  is  s u r p r i s i n g d e n t i s t s , when d e c i d i n g  s p e e d hand p i e c e s ,  procedures.  facilities  extends to  confined  s e r v i c e , i n d i c a t e d great  a b s e n c e of a d e n t a l  evacuators  the  the  equipment a t  p r i v a t e p r a c t i c e s that are  term c a r e  low  dental  D e n t i s t s adopt  schools.  portable and  the  facilities.  dental  that  d i s a d v a n t a g e s of d e n t a l  i s s u e of a p p r o p r i a t e  limited  for  so  pathoses.  specialized in  proceedures  b e n e f i t s and  specific  The  specific  and  high  oral  for basic  dental  actively  employed  them w i t h  portable  in  equipment.  The capital  f i n d i n g s of expenditures  interested  in long  establishment available  The the  the  by  of the  study  i s of  importance  term c a r e  a program sponsoring  show t h a t  i s not  the  only  underwriting  t o d e n t i s t s who  s e r v i c e . I t would be  i f these  77  are the  made  bodies(33).  for specialized  remedy  of  h e l p f u l to  u n i t s w o u l d be  government  professional preparation  elderly  the  f o r the  dental  l a c k of  care  current  for  interest  in providing  dentists  have  in  a  identified  LTC f a c i l i t i e s ,  far  more  time  private  arrival,  may  timed  be  have  forgotten  t o treatment  earn  more,  along  arrangement at less  the patient  previously  the c h r o n i c a l l y  fee-for-service  those  performed  cost  with  cannot  may  be  i l l that day, or the s t a f f  or the patient  decided  be  scheduled.  upon.  the longer  may  These  proceedure  i l l patient,  render the  unacceptable  t o many  and l e s s  in  f o r the dentist's  The p a t i e n t  the appointment  circumstances,  managing  than  precisely  treatment.  procedures  pointed out,are  and f e e d i n g of p a t i e n t s  during  about  Dental  have  be p r e p a r e d  nor the appointment  incontinent  particular  can  must  complications arise;  become a v e r s e  in  Patients  constraints the  be a d d r e s s e d .  and complicated  and the t o i l e t i n g  Inevitably may  should  The economic  as LTC p r a c t i t i o n e r s  consuming  office.  precisely  or  services.  time  dentists.  inconvenience,  They  in private  practice.  Financial specialized of  management  LTC d e n t a l work.  declined novice  i n recent  dentists  willingness practice, may  arrangements  years(lO),  into  dentists,  that  position  practices  are just  make  f o r novices(33).  78  a  this  of  i n the beginning  an LTC  practice,  nature  has  the security  Although  may  the  consuming  i s evident  who  as a p r i v a t e  and f e a s i b l e  o f new  This  LTC s e r v i c e .  fee or a salaried  account  and the time  and with  has d e t e r i o r a t e d .  to enter  into  The p r o f i t a b i l i t y  of the younger  more a t t r a c t i v e  take  of p a t i e n t s  n o t be a s p r o f i t a b l e  retainer  must  a  practice  guaranteed alternative  As t h e s t u d y  indicates, indicate special  those  continued care  professional a  period  viable for  who  have  interest  dentistry base  practised in this  through  so that  special  specialty  option.  This  community  w o r k . 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J o u r n a l of D e n t a l E d u c a t i o n 1964:28(2), pp.149-154.  33.  T e r r i l l , A . J . , a n d J . E l l i o t . The M o n t a n a A d v i s o r y J o u r n a l of the American D e n t a l A s s o c i a t i o n pp.402-406.  34.  The  35.  W a l k , R . I . and towards Society  36.  W i n g a r d , J . A . and C.L. Dorman. A t t i t u d e s t o w a r d s the e l d e r l y : c u l t u r a l v a r i a t i o n s and m e t h o d o l o g i c a l issues. Interdisciplinary Topics in Gerontology 1983:17, pp.157-169.  the  D.L., M.D. F e i g e n b a u m , F. F i t z g e r a l d and J . R o t h . Medical students'attitudes toward the geriatric p a t i e n t . J o u r n a l of the American G e r i a t r i c s S o c i e t y 1968:16(9), pp.976-983. a t t i t u d e s and knowledge about T h e s i s . U n i v e r s i t y of London.  Iowa S u r v e y o f O r a l H e a l t h 1980. Monograph. o f Iowa C o l l e g e o f D e n t i s t r y and t h e Iowa Association. R.B. Wolk. P r o f e s s i o n a l the a g e d . J o u r n a l of the 1971:19(7):pp.624-639.  83  worker's American  Program. 1979: 98,  University Dental  attitudes Geriatric  APPENDIX  84  T H E UNIVERSITY OF BRITISH C O L U M B I A . 2199 WE5BROOK MALL V A N C O U V E R , B.C., V6T  CANADA  1Z7  Dear I am i n v e s t i g a t i n g t h e a v a i l a b i l i t y o f d e n t a l s e r v i c e s t o t h e e l d e r l y r e s i d i n g i n l o n g t e r m c a r e f a c i l i t i e s ( h o s p i t a l s and n u r s i n g homes) i n G r e a t e r V a n c o u v e r . T h i s s t u d y , w h i c h i s p a r t o f my M a s t e r ' s t h e s i s , i s p a r t i a l l y f u n d e d by t h e B r i t i s h C o l u m b i a H e a l t h C a r e R e s e a r c h F o u n d a t i o n and i s c a r r i e d o u t i n c o l l a b o r a t i o n w i t h D r . M i c h a e l MacEntee o f t h e D e p a r t m e n t o f R e s t o r a t i v e D e n t i s t r y . Results w i l l be l i n k e d t o a l a r g e r s u r v e y on t h e o r a l h e a l t h o f i n s t i t u t i o n a l i s e d e l d e r l y i n G r e a t e r Vancouver. I w o u l d be g r a t e f u l i f y o u c o u l d c o m p l e t e t h e f o l l o w i n g q u e s t i o n n a i r e which i n q u i r e s about y o u r e x p e r i e n c e w i t h the e l d e r l y and y o u r i n t e r e s t i n p r o v i d i n g d e n t a l s e r v i c e s t o t h e i n s t i t u t i o n a l i s e d elderly. T h i s s h o u l d t a k e no more t h a n 10 - 15 m i n u t e s o f y o u r t i m e . I would l i k e everyone to f i l l out the f i r s t s e c t i o n . Please f i l l o u t t h e s e c o n d s e c t i o n o n l y i f y o u have p r o v i d e d d e n t a l s e r v i c e s t o l o n g term c a r e f a c i l i t i e s . The q u e s t i o n n a i r e i s anonymous and s h o u l d be m a i l e d i n t h e r e t u r n stamped brown e n v e l o p e . I t i s a l s o important to mail i n the blue s h e e t s e p a r a t e l y i n t h e r e t u r n stamped w h i t e e n v e l o p e . A summary o f t h e f i n d i n g s w i l l be s u b m i t t e d f o r p u b l i c a t i o n to the B.C. C o l l e g e of Dental Surgeons' n e w s l e t t e r . Thank you f o r y o u r  help. Yours  RW/lg  sincerely,  R a c h e l Weiss Dept. o f R e s t o r a t i v e D e n t i s t r y  86  APPENDIX  87  SECTION 1 To be f i l l e d out by everyone What Is your age? How many years have you been practicing dentistry? How many of those years have been in specialty practice? What kind.of practice do you have? a) new private practice (less than 3 years), b) established private practice, c) retirement part-time private practice, d) part-time private practice ei f u l l - t i m e public salaried practice, f) part-time public salaried practice e) other, specify On the average, how many hours a week do you practice? a) less than 10, b) 11-25, c) 26-40, d) over 40 What type of practice do you have? a). General b) Prosthodontlc c) Endodontic d) Periodontic e) Orthodontic f) Pedodontlc g) Oral Surgery h)Hosp1tal 1) Other, specify What parts of the city or what suburb do you practice in? a) Burnaby b) West Vane, c) North Vane, d) Downtown Vane, e) Point Grey f) Kitsllano g) Kerrisdale h) Dunbar i) Marpole j ) Vane. South ki Oakridge DSouth Granville m) Mt. Pleasant n) Lower East Side o) Strathcona p) Vane. East q) Fraserview r) Fairview slopes s) Champlain Heights. Is your practice busy enough? a) yes, b) no Did you have training in geriatric dentistry at university? (Circle appropriate responses) a) formal university course (minimum 10 lectures) with c l i n i c a l experience b) formal university course (minimum 10 lectures) only c) c l i n i c a l Institutional experience only d) occasional lectures during undergraduate program e) post-graduate continuing education course f) no formal training  institutional  What percentage of your practice consists of patients aged 65 years or older? a) none, b) 5%, c) 6-10%, d) 11-25%, e) 25%+ Have you treated elderly patients at their home? a) no, b) yes, only in emergency, c) yes  88  12.  What s e r v i c e s have you most commonly provided to e l d e r l y p a t i e n t s 1n your p r a c t i c e ? C i r c l e a l l a p p l i c a b l e Items. Emergency: a) e x t r a c t i o n s , b) denture adjustments, c) endodontic or p e r i o d o n t i c emergencies, a) diagnosis of o r a l p a t h o s l s , e) b i o p s i e s , f ) other ( s p e c i f y )  Elective: a) examinations, b) o r a l hygiene a s s i s t a n c e / s c a l i n g , c) f i l l i n g s / c r o w n s d) d e n t u r e - f a b r i c a t i o n , e) denture r e l l n e s , f ) p e r i o d o n t a l therapy, g) endodontic therapy, h) other ( s p e c i f y )  13.  How would you d e c r l b e your work with the e l d e r l y ? Please c i r c l e appropriate items. a) I enjoy s o c i a l i z i n g w i t h 4 t r e a t i n g e l d e r l y p a t i e n t s . b) I don't see a d i s t i n c t i o n between e l d e r l y p a t i e n t s and p a t i e n t s In other age groups c ) E l d e r l y p a t i e n t s present d i f f i c u l t i e s due to such f a c t o r s as medical problems and c o n f u s i o n . d) E l d e r l y p a t i e n t s are often ungrateful or uncommunicative e) E l d e r l y o f t e n do not f o l l o w up preventive therapy f ) I t 1s d i f f i c u l t to improve t h e i r o r a l health s t a t u s due to l i m i t e d treatment options. g) T r e a t i n g the e l d e r l y Is time consuming and f i n a n c i a l l y unrewarding. h) Other, s p e c i f y  14.  Do you t h i n k the p o s i t i v e aspects of working w i t h e l d e r l y outweigh the a s p e c t s , or 1s 1t the other way around? a) p o s i t i v e aspects outweigh negative a s p e c t s , b ) negative aspects outweigh p o s i t i v e aspects c ) both p o s i t i v e and negative aspects are about the same d) uncertain  15.  Would you be I n t e r e s t e d In p r o v i d i n g on-going s e r v i c e s to r e s i d e n t s o f a long t e n s care f a c i l i t y ? a) no, b) u n c e r t a i n , c ) yes  16.  I f YES,  17.  How much time would you be prepared to take to t r a v e l to a f a c i l i t y ? a) none, b) 10-15 minutes, c ) h a l f an hour, d) more than h a l f an hour  about how many hours can you make a v a i l a b l e to long term care per month  89  negative  facilities?  18.  How Important are the f o l l o w i n g c o n s i d e r a t i o n s i n a r r i v i n g at y o u r d e c i s i o n r e g a r d i n g f u t u r e s e r v i c e s t o long terra care f a c i l i t i e s ? Very Imoortant  Moderately Imoortant  Minimally Imoortant  a) Loss o f p r i v a t e p r a c t i c e time  1  2  3  4  b) Loss o f l e i s u r e time  1  2  3  4  c) Distance  facillty(les)  1  2 -  3  4  d) F i n a n c i a l reimbursement 4 c a p t l a l expenses  1  2  3  4  e) A v a i l a b i l i t y - o f d e n t a l operatory A equipment at f a c i l i t y  1  2  3  4-  f) P r o f e s s i o n 4 personal s a t i s f a c t i o n In w o r k i n g with e l d e r l y patients  I  2  3  4  g) Experience 4 t r a i n i n g In t r e a t i n g d i s a b l e d and/or c h r o n i c a l l y 111 p a t i e n t s  1  2  3  4  19.  to  Would the c o s t o f purchasing p o r t a b l e equipment a f f e c t y o u r d e c i s i o n ? a) no, b) u n c e r t a i n , c) yes I f YES, would you c o n s i d e r u s i n g p o r t a b l e equipment purchased by the C o l l e g e Dental Surgeons, the f a c i l i t y or the government? a) no, b) u n c e r t a i n , c) yes  20.  of  Would the form o f reimbursement a f f e c t y o u r d e c i s i o n ? a) no, b) u n c e r t a i n , c) yes I f YES, how would you p r e f e r t o be paid? C i r c l e one o r more responses. a) fee per s e r v i c e , b) fee per time, c) s e s s i o n a l f e e , d) r e t a i n e r fee (on  21.  call  I f you have not provided d e n t a l s e r v i c e s to l o n g term care f a c i l i t i e s why not? C i r c l e a p p r o p r i a t e answers. a) too busy i n p r i v a t e p r a c t i c e • b) inadequate t r a i n i n g and experience w i t h m e d i c a l l y compromised p a t i e n t s c) f i n a n c i a l l y c o s t l y and unrewarding d) b u r e a u c r a t i c b a r r i e r s would h i n d e r proper treatment of p a t i e n t s e ) l a c k o f a p p r o p r i a t e treatment f a c i l i t i e s a t I n s t i t u t i o n s f ) have not been asked by r e s i d e n t s or a d m i n i s t r a t o r s . • g) o t h e r ( s p e c i f y )  I f you have not seen p a t i e n t s i n a l o n g term care f a c t l l t y please stop here and r e t u r n the q u e s t i o n n a i r e . I f you have p r o v i d e d t h i s type of s e r v i c e , please, proceed to s e c t i o n I I . Thank you f o r y o u r h e l p . -• -  90  SECTION  II  To be f i l l e d out ONLY by d e n t i s t s who have p r a c t i c e d i n Long Term Care Facil ity(ies) If you have not p r a c t i c e d i n a Long Term Care F a c i l i t y , discard this section.  then you can  1.  What were the most common dental s e r v i c e s you nave provided to r e s i d e n t s of long t e r n care f a c i l i t i e s ? Eneroency Elective ly e x t r a c t i o n s I, oral examinations 2) denture adjustments 2) oral nygiene a s s i s t a n c e , 3 endodontic S p e r i o d o n t i c emergencies scaling 4) d i a g n o s i s of o r a l p a t n o s i s 2 ) fi11ings/c-cwns 5) b i o p s i e s 4) denture f a b r i c a t i o n 6) o t n e r ( s p e c i f y ) 5) denture r e i i n e s 6) p e r i o d o n t i c tnerapy 7) enaocontic tnerapy 8) other ( s p e c i f y )  2.  For p a t i e n t s under long term c a r e , do you charge more or l e s s than the fee guide recommended by the C O . 3 . S . C ? 1) I f o l l o w the guide 2) I cnarge more than the guide 3) I sometimes charge l e s s wnen i n d i v i d u a l c o n s i d e r a t i o n s i n v o l v e d 4) I always cnarge l e s s  3.  IF you charge more o r l e s s , by what percentage do your fees vary from the guide? 1)  4.  10S  2)  205  3)  20'.  4)  405  5) i n d i v i d u a l l y set fees  What have you l i k e d about working i n long term care f a c i l i t i e s ? C i r c l e the a p p r o p r i a t e responses. 1) found s o c i a l i z i n g witn e l d e r l y p a t i e n t s rewarding 2) p r o v i d e d o p p o r t u n i t y to increase the s i z e of my p r a c t i c e 3) broadened the scooe of my p r a c t i c e 4) p e r m i t t e d p a r t - t i m e p r a c t i c e 5) p u b l i c s e r v i c e o p p o r t u n i t y 6) met my p r o f e s s i o n a l r e s p o n s i b i l i t i e s to e l d e r l y 7) p r o v i d e d i n t e r a c t i o n with otner health care worxers 8) o t h e r ( s p e c i f y )  91  5.  6.  7.  What have you d i s l i k e d about working i n long term care f a c i l i t i e s ? C i r c l e the a p p r o p r i a t e r e s o o n s e s . 1) inaoeauate treatment f a c i l i t i e s 2) time consuming 3 ) f i n a n c i a l l y unrewarding 4) l i m i t e d treatment p o s s i b i l i t i e s 5) medical and o s y c n o l o g i c a l c o m o l i c a t i o n s of dental tnerapy 6) e l a e - l y d i f f i c u l t to work with ex. v e r o a l l y aousive 7) p e r s o n a l l y unrewarding 8) f a c i l i t i e s unpleasant, environments s m e l l , depressing atrospnere 9) a d m i n i s t r a t i o n e r e c t s D a r n e r s to p a t i e n t management ana long tern tnerapy 10) otner ( s p e c i f y )  have the p o s i t i v e aspects outweighed tne negative aspects of t r e a t i n g 1n long term c a r e f a c i l i t i e s , or i s i t tne ctne'- way around? 1) p o s i t i v e aspects outweign negative aspects 2) negative aspects cutwiegn p o s i t i v e aspects 3) p o s i t i v e and negative aspects aDout tne same 4) u n c e r t a i n  'why d i d you o r i g i n a l l y decide to provide dental facilities? C i r c l e one or more tnan one. 1) o p p o r t u n i t y to i n c r e a s e s i z e of p r a c t i c e ' 2! s o c i a l c o n t a c t s witn e l o e r l y are rewarding 3) wanted to p e f o r m a p u s l i c s e r v i c e i ) part of p r o f e s s i o n a l r e s p o n s i a i l i t i e s 5) p a r t - t i m e p r a c t i c e o p p o r t u n i t y 6/ part of a se">i-reti rement p r a c t i c e 7) otner i s p e c i f y )  elderly  s e r v i c e s to long term care  r  8.  For tnose who no longer work i n f a c i l i t i e s , wr,y did you stop? C i r c l e one or more tnan one. 1) no demand 2) a d m i n i s t r a t i v e d i f f i c u l t i e s i n p a t i e n t management and working environment 2) f i n a n c i a l l y unrewarding 4) l o s s of l e i s u r e time 5) i n c r e a s i n g conrnitments to p r i v a t e o f f i c e p r a c t i c e 6) p r o f e s s i o n a l l y ano p e r s o n a l l y u n s a t i s f i e d witn work 7) o t h e r , ( s p e c i f y )  92  B)  Tne f o l l o w i n g Q u e s t i o n s h a v e been c o n s t r u c t e d f c r more d e t a i l s of y o u r d e n t i l 1n l o n g t e r m f a c i l i t i e s . The q u e s t i o n s a r e r e p e a t e d 3 t i m e s i n o r d e r f o r y o u i n c l u d e up t o t n r e e f a c i l i t i e s i n w h i c h y o u h a v e p r a c t i c e d Facility 1.  practice to  fl  Name o f f a c i l i t y o t y p e i f y o u cannot r e m e T O t r name: ~ a) r e n a o i 1 i t a t i o n c e n t r e b) p r i v a t e h o s p i t a l c) extended care p u b l i c d) n o n - p r o f i t n u r s i n g nome e ) p r i v a t e n u r s i n g home r  2.  O v e r now l o n g  a p e r i o d of  time d i d you p r a c t i c e  2.  A p p r o x i m a t e l y how o f t e n d i d y o u work t n e r e ? a : wnen c a l l e d f o r e m e r g e n c y b) once a week e) o n c e a 1/2 y e a r f) once a y e a r g) o o n ' t  at t h i s  ncspital  facility?  c) bi-monthly rememoer  d) once a 1/4  year  4.  A p p r o x i m a t e l y how mucn t i m e d i d y o u s p e n d p e r s e s s i o n , i . e . l e n g t h c f v i s i t ? a) 1/2 h o u r b) 1 h o u r c) f u l l M y i) 2 o- more days e; one wee* f; t r o ouch v a r i a t i o n t o g i v e an a v e r a g e h) d o n ' t rememper  5.  Ho» f a r was t h e a) 5-10 m i n u t e s  6.  7.  d) > i / 2  nour  wnat t r e a t m e n t a r r a n g e m e n t s d i d t n e f a c i l i t y n a v e ? C i r c l e a l l a) d e n t a l o o e r a t o r y b) e x a m i n i n g room c ) p o r t a D l e e a u i p m e n t e) d o n ' t rememoer f ) none  e)  oon't  d) h i g h  remencer  intensity  w n a t t y p e o f r e i m p j r s e m e n t was made? P l e a s e c i r c l e more tnar, one r e s p o n s e f o r c o m p i l a t i o n s , e . g . fee per item 4 s e s s i o n a l fee a) f e e p e r i t e m b) f e e p e r t i m e c) s e s s i o n a l fee d) r e t a i n e r f e e ( o n c a l l availability) e) o t h e r f ) o o n ' t rememoer g) no r e i m b u r s e m e n t  Facility 1.  f a c i l i t y f r o r your o f f i c e ? 0) 10-15 m i n u t e s c ! 1/2 h o u r  12  Mame o f F a c i l i t y o r t y p e 1 f y o u c a n n c : r e m e r o e name: a ) r e n a b i 11 t a t i on c e n t r e b) p r i v a t e h o s p i t a l c) extended care p u b l i c d) n o n - p r o f i t n u r s i n g nome e j p r i v a t e n u r s i n g home r  a p e r i o d of  time d i d you p r a c t i c e a t t h i s  hospital  2.  O v e r how l o n g  3.  A p p r o x i m a t e l y how o f t e n d i d y o u work t h e r e ? a) wnen c a l l e d f o r e m e r g e n c y b) once a week c) bi-monthly d) o n c e a month e ) o n c e a 1/4 y e a r f ) o n c e a 1/2 y e a r g) o n c e a y e a r h) o o n ' t rememoer  4.  A p p r o x i m a t e l y how much t i m e d i d y o u s p e n d p e r s e s s i o n . I . e . l e n g t h o f v i s i t ? a) 1/2 h o u r b) 1 h o u r c ) 1/2 day d) f u l l day e ) 2 o r more days f ) one week g) t o o much v a r i a t i o n t o g i v e an a v e r a g e h) o o n ' t rememper  93  facility?  5.  6.  7.  How far was the f a c i l i t y from your office? a) 5-10 minutes b) 10-15 minutes c) 1/2 nour  e) don't rememoer  What treatment arrangements did the f a c i l i t y have? Circle a l l a) dental ODeratory b) examining room c) portaole equipment d) hign light e) don't rememoer f) none  intensity  What tyoe of reimbursement was made? Please c i r c l e more than one response for combinations, e.g. fee per item & sessional fee a) fee per item D ) fee per time c) sessional fee d) retainer fee ( on c a l l availability) e) other f) don't rememoer g; no reimoursement  Facility  1.  d) > 1/2 hour  «  Name of f a c i l i t y or type If you cannot rememoer narce: a) renabllitation centre b) private hospital c) extended care public hospital d) non-profit nursing nome e) private nursing home  2.  Over how long a period of time did you practice at this f a c i l i t y ?  3.  Aoproximately how often did you work there? a) wnen called for emergency b) once a week c) bi-monthly d) once a month e) once a 1/4 year f) once a 1/2 year g) once a year h) don't rememper  4.  Approximately how much time did you spend per session, i . e . length of v i s i t ? a) 1/2 nour b) 1 nour c) 1/2 day d) full day e) 2 or more days f) one week g) too mucn variation to give an average h) aon't rememoer  5.  How far was the f a c i l i t y from your office? a) 5-10 minutes b) 10-15 minutes c) 1/2 hour  6.  7.  d) > 1/2 hour  e) don't remember  What treatment arrangements did the f a c i l i t y have? Circle a l l . a) dental operatory b) examining room c) portable equipment d) high l i g h t e) aon't rememoer f) none  intensity  What type of reimbursement was made? Please c i r c l e more than one response for combinations, e.g. fee per Item 4 sessional fee. a) fee per item b) fee per time c) sessional fee d) retainer fee (on call availability) e) other f) don't rememoer g) no reimbursement  94  APPENDIX  95  Table  C:1:Interest  by P e r c e p t i ons  o f Work wi t h  the E1der1y  Interest  No(%)  Var i a b i e s Descriptions Enjoy  socializing  w/elderly  No d i s t i n c t i o n s Limited  treatment  options  (u)Summary o f p o s i t i v e a n d n e g a t i v e  Chi-square  Deg.  Freedom  46(25)  82(45)  182(100)  12.46  .01  2  37(30)  36(29)  125(100)  5.84  .05  2  44(41 )  21(25)  25(34)  90(100)  8 . 30  .02  2  43(26)  72(44)  aspects:(Q14) 49(30) 15(62)  Total  Total(%)  52(41)  Negative Uncertain  Yes(%)  54(30)  P o s i t i v e outweigh negative outweigh p o s i t i v e  B o t h t h e same  Uncertain^/.)  o f work:(Q13)  42(41) 12(45) 118(37)  3(13)  6(25)  27(27)  33(32)  9(33) 82(26)  6(22) 117(37)  96  164(100) 24(100) 102(100) 27(100) 317(100)  14.81  .02  T a b l e C : 2 : I n t e r e s t by S e l e c t e d P r a c t i c e C h a r a c t e r i s t i c s No(%)  Var i a b l e s Percentage e l d e r l y  Relevant t o E1der1y  Interest UncertainC/.)  Yes(%)  Total(%)  Chi-square  Deg.  P  0 l e s s than 5 6-10 1 1-25 25+ Total  10(84)  K8)  1(8)  53(38) 29(35)  51 ( 3 7 ) 32(38)  138(100) 83(100)  19(30) 9(33)  34(25) 22(27) 21(33) 6(22)  120(37)  84(26)  24(37) 12(45) 120(37)  64(100) 27(100) 324(100)  90(44) 29(24) 119(37)  54(26) 31(26) 85(26)  61(30) 60(50) 121(37)  12(100)  14.12  .08  16.39  .01  Home v i s i t s : ( Q 1 1 ) Do n o t make home Make home v i s i t s Total  Freedom  i n p r a c t i c e ::(Q10)  visits  97  205(100) 120(100) 325(100)  8  Tab! e C: 3 : I n t e r e s t by Ger i a t r i c T r a i n i ng o f Dent i s t s Interest Variables Training:(Q9) Informal undergraduate lectures Clinical institutional training No f o r m a l t r a i n i n g  No( % ) 28(27) 7(17) 76(49)  U n c e r t a i n ( % ) Yes( % 29(28) 11(27) 37(24)  48(45) 23(56) 42(27)  98  )  T o t a l (%) 105(100) 41(100) • 155(100)  Chi-square 7.51 9.54 20.69  p .02 .01 .01  Deg.  Freedom 2 2 2  Table  C : 4 : I n t e r e s t by Age and Y e a r s  of Pract i ce  Interest Variables Age o f d e n t i s t : ( Q 1 ) l e s s t h a n 35 36-45 46-55 56 p l u s Total  Years  No(%) 26(22) 45(44) 22(45) 27(49) 120(37)  Uncertain(%)  Yes(%)  32(27) 29(28) 13(27) 12(22) 86(26)  62(51 ) 29(28) 14(28) 16(29) 121 ( 3 7 )  Total(%) 120(100) 103(100) 49(100) 55(100) 327(100)  of Practice:(Q2) 14(23)  16(26)  31(51)  61(100)  6-15 16-25  41 ( 3 2 ) 35(49)  53(41) 16(22)  129(100) 72(100)  26-35 36 +  19(43) 11(52)  35(27) 21(29) 10(23)  15(34) 6(29)  44(100) 21(100)  Total  120(37)  121(37)  327(100)  l e s s than  5  4( 19) 86(26)  99  Deg. Freedom  Chi -square  23.54  .01  Table  C:5:Interest  by S t a t u s o f P r a c t i c e a n d B u s y n e s s  Interest Variables Status of News ( l e s s  No(%)  Part-time  Yes(%)  Total(%)  Chi-square  Deg.  practice:(Q4) than  5 yrs.)  Ful1-time(established, Total  Uncertain(%)  salaried)  11(23)  8( 17)  29(60)  48(100)  97(39)  72(29)  78(32)  247(100)  11(36)  6( 19)  14(45)  31(100)  119(37)  86(26)  121(37)  326(100)  167(100)  15.57  .01  7.26  .02  Busyness: Busy Not  busy  Total  71(43)  44(26)  52(31)  45(30)  38(26)  67(44)  150(100)  116(36)  82(26)  119(38)  317(100)  100  Freedom  T a b l e C:6 : I n t e r e s t by Cons i d e r a t i o n s f o r LTC S e r v i c e Interest Variables C o n s i d e r a t i o n s of importance:(Q18) Loss of p r i v a t e p r a c t i c e time Loss of l e i s u r e time Persona 1/professional s a t i s f a c t i o n Cost o f p o r t a b l e equipment(Q19)  UncertainC/,)  No(%) 78(36) 64(40) 63(26) 56(27)  67(31 ) 50(31) 71(29) 64(31 )  Yes(%)  71 ( 3 3 ) 48(29) 108(45) 90(42)  Total(%) 216(100) 162(100) 242(100) 210(100)  Chi-square 15.51 14.98 19.08 15.82  T a b l e C : 7 : I n t e r e s t by R e a s o n s f o r Not P r o v i d i ng  p .01 .01 .01 .01  Services  Reasons:(Q21) Too b u s y i n p r i v a t e p r a c t i c e I n a d e q u a t e t r a i n i n g and e x p e r i e n c e  41(49) 34(53)  28(33) 20(31)  15(18) 10(16)  84(100) 64(100)  17.84 16.42  F i n a n c i a l l y c o s t l y and u n r e w a r d i n g Have n o t b e e n a s k e d  26(62) 38(25)  9(21) 53(35)  7(17) 60(40)  42(100) 151(100)  14.16 18.53  101  .01 .01 .01 .01  Deg.  Freedom 2 2 2 4  

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