By Linda G. Levin, D.D.S., Ph.D.
Whether you are having your car serviced, completing an online purchase or using your bank app on your phone, it has become routine to be asked at the end of your encounter to fill out a survey. Surveys allow organizations to gather massive amounts of information, which they can then use to better meet the expectations of their clientele. Though we used to rely on mail or phone surveys, online surveys now are the norm as they collect data faster and with less cost while still maintaining good data quality and reliability. In fact, results from election polls show that online surveys are more accurate than older forms of polling.1 The AAE has followed suit by distributing the AAE Member Needs Surveys electronically. But questions still remain - how can we improve the accuracy of our data and how can we apply that data to serve members more effectively?
When you research the science of surveys, it immediately becomes apparent that acquiring a valid representation of opinion from a selected population is a complex process. Perhaps the most significant question is whom are we surveying. Vince Matthews states, "a population is a well-defined collection of all the items to be surveyed."2 If it is likely that a proposed survey will have a chance of querying everyone in a particular population of interest, this is called a probability survey. (If you survey everyone in a population, that is a census.) In contrast, if you select only a representative subset of a population to survey, that is called a nonprobability survey. The advantages of the latter are that it can be easier to perform, less expensive and require less follow-up, but the disadvantages are that it is less precise and less dependable. All types of surveys have their advantages and limitations. The AAE membership satisfaction surveys qualify as probability surveys - every member is given the opportunity to respond. While the precision of the survey has the potential to be high, there are other factors that influence its validity (and that of any survey).
Nonresponse is a factor that introduces imperfection into the sampling of a population. While the initial design of a survey may include every member of the cohort, the data are only as representative as the respondents. Jan Wretman describes "real life probability sampling" as a process by which the original sample is designed and a final sample is the result of what happens to that original cohort when disturbances such as nonresponse are incorporated but not considered disqualifying.3 So when we send a survey to every AAE member and only a percentage of our ranks respond, we have a "real life probability sampling" of the AAE membership. Statistics from our 2016 survey indicated a response rate of 17% (1,175 members). This represents a 3% decrease from the 2015 survey, but still provides a 95% confidence level. Could our data be more accurate or representative? Of course, but only if more members respond.
Sampling has its challenges. Despite the fact that we all are endodontic specialists, the AAE is no longer a homogeneous group. Our membership is diverse with varying needs and expectations. The AAE Board of Directors has recognized this, and accordingly, our recent Member Needs Surveys have focused on areas that the 2013 survey found are important to members but registered lower satisfaction ratings. They include advocacy, outreach and marketing and practice management resources.
So what do our surveys tell us? Overall, the 2016 Member Needs Survey indicated that 69% of our members are satisfied with AAE products and services, and 59% see membership in the AAE as a good value. Seventy-three percent of our members are extremely likely to renew their memberships. The bad news is that our members are less satisfied with the AAE's outreach and advocacy. We need to work harder to understand the advocacy our members seek from the AAE - political advocacy, or advocacy within dentistry and among dental professionals and our patients. Though I suspect it is the latter, it is imperative that we understand our data and our members' expectations before designing any initiative to meet those needs.
Our surveys also tell us about your practice and educational topics of interest. Over one half of practicing members estimate their 2015 endodontic practice income at $1,000 or more. For the majority, patient volume is increasing. The practice setting is changing with fewer members in solo private practice and a concomitant increase in the numbers engaged in group endodontic practices. You are most interested in topics pertaining to clinical endodontic techniques, clinical/medical guidelines and case studies. Interest in practice management topics and product evaluations were relatively lower. This data informs our continuing education offerings so they are tailored to your needs. The Board, the Annual Session Planning Committee and the Continuing Education Committee use these survey results as a road map. Can we do it better if our response rate is better than 17%? Yes, and that's where we need your help. When you see the next survey in your email inbox, please take a few minutes to thoughtfully fill it out.
The AAE is not just surveying our members. In 2013, your Board of Directors appointed a special committee to direct environmental scanning for our specialty. While still ongoing, we have derived important data regarding trends in health care in general and how they relate to Endodontics in particular. One of my favorite sayings comes from hockey great Wayne Gretzky - "I skate to where the puck is going to be, not where it has been." If we are going to anticipate where our energies and focus need to be concentrated, we must know where the larger world of healthcare delivery is headed. The 2015-2016 Environmental Scan focused on specific questions, namely:
- How will the dental insurance industry influence dentistry/endodontics over the next decade?
- How can the AAE position to help shape these decisions (i.e., "outcomes-based" reimbursements), rather than simply react to them?
- How can the AAE assist in the struggle of young members with excessive student loan/personal debt and changing practice models?
- What will be the role of electronic and online information in endodontic practice and how can the AAE guide the information-seeking patient to factual information regarding endodontic treatment?
The results of our scanning have been informative. From these results, we can predict that the insurance industry will use its size as leverage to decrease reimbursements; that this leverage is increasing due to mergers/consolidation; and that the cottage industry of small endodontic practices will have a harder time countering pressure from third parties. Endodontic practices will need to focus on managing overhead and administrative costs to maintain profitability. New practice models may emerge such as loosely affiliated practices that share overhead costs and make purchases as a group. We know that large multispecialty practices are already growing as are the larger single-specialty group practices.
Patient discontent with their dental insurance plans continues to grow due to limitations imposed by low reimbursements and a stagnation in coverage amounts. This discontent represents a growing catalyst for change. Patients expect dental insurance to perform like medical insurance and then are dismayed to find that this is not the case. The typical dental plan gives patients a fixed amount per year to spend on dental insurance, and once that amount is maxed out, everything is self-pay. The amount has increased very little in more than 20 years and is typically around $1,000-1,500. According to the Centers for Medicare and Medicaid Services, 40% of all dental expenditures nationally are "out of pocket" compared to 11% of medical expenditures. As consensus grows that oral health is critical to systemic health, it is likely that consumers will push for more comprehensive dental coverage.
The AAE is maintaining an active dialogue with dental insurers and partnering with the ADA to decipher codes and provide resources to navigate the insurance environment. However, our influence depends on our ability to obtain better outcomes measures. In the next 3-5 years, it is likely that the Dental Quality Alliance will require general dentists and pediatric dentists to report on outcomes measures to state Medicaid programs and possibly dental insurers. We do not know if this requirement eventually will extend to other specialties. If and when it includes endodontics, we must be ready with our outcomes data.
With regard to student debt, we know it has an impact on many of our members, and especially on their initial career choices. Our new Career Resources section of the AAE website provides information to assist members who are beginning their endodontic careers. We are working to increase awareness for these resources and develop more initiatives for residents and early-career endodontists.
Lastly, as mentioned in last month's President's Message, increasing numbers of our patients are using online media to educate themselves about endodontic procedures and to research providers. Our environmental scan confirms this trend and we anticipate that it will continue. We have responded with patient-focused website content and search engine optimization to enhance our online search rankings. We are strengthening our social media presence to educate our patients as well as provide resources for our members to share on their own social media channels.
So while surveys serve an important purpose, they are only as effective as the questions they ask and the answers they evoke. The principal goal of your Board of Directors is to serve you, but we cannot do it in a vacuum. We need your feedback to tailor the AAE's offerings to your needs and those of our patients. In addition to responding to the Member Needs Survey and other AAE surveys, you can contact your district directors at any time with concerns or messages for the Board of Directors. We want to hear from you! The Board, the leadership and staff will listen.
- Chang L, Krosnick JA. National surveys via RDD telephone interviewing versus the internet. Public Opin Q. 2009;73(4):641-78.
- Matthews V. Probability or nonprobability: a survey is a survey - or is it? National Agriculture Statistics Services.
- Wretman J. Reflections on Probability vs. Nonprobability Sampling. Official Statistics - Methodology and Applications in Honour of Daniel Thorburn; 29-35.