1 INTRODUCTION

Disability is defined as any limitation or restriction that involves bodily functions or structures.1 Over one billion people worldwide live with some intellectual, motor, physical, sensory or multiple disabilities,2 representing 15% of the population.1

Oral health inequalities are a significant issue among people with disabilities (PD). These individuals have more significant oral healthcare needs than the general population but less access to dental services and, consequently, more significant unmet dental treatment needs.3, 4 Also, healthcare disparities are observed. Patients with a disability who can access services receive less conservative dental treatments than the general population due to the accumulation of needs or behavioural diversities. Thus, both healthcare access and findings show inequalities.5

The Brazilian National Health Survey (2013) data showed that people with disabilities had a lower educational level and lower household income, worse health conditions and visited the dentist less than people without disabilities. Edentulism was more prevalent among disabled people.6 In Brazil, the National Health Policy for people with disabilities is supported by several laws and ensures PD’s rights in several sectors, including dental care.7

Care must be performed in a primary healthcare (PHC) environment, and, when this is not possible, the patient should be referred to a network of specialized Dental Specialties Centers (CEO)7 and hospitals, if dental support is required. This law7 defines the implementation and establishes that every CEO must perform dental care geared to this population. Adequate dental care must be provided by trained dentists, at an accessible dental clinic for PD and convenient location.8, 9 It is crucial to have recent and concrete data10 to provide adequate care and improve access to dental care for PD. However, in many countries, little is known about the use of oral health care among PD.11

The Brazilian Unified Health System (SUS), considering the doctrinal principles of universal access, comprehensiveness and equity of care, offers citizens of all ages free dental care for Brazilians through the National Oral Health Policy (NOHP). The Smiling Brazil policy aims to ensure the promotion, prevention and recovery of oral health for Brazilians in an oral healthcare network.12 The services are offered at family health units (FHU)/health units and mobile dental units (MDU) in primary care; in the CEO at the secondary care level; and in hospitals in tertiary care.13

The CEO are the primary health establishments of secondary oral health care in Brazil, considered an innovation of the NOHP. They compulsorily offer endodontics, periodontics, minor oral surgery, oral cancer detection and oral healthcare services for PD. They consist of primary care reference units, integrated into the loco-regional planning process, which use referral and counter-referral mechanisms, matrix support, and continuing health education to ensure comprehensive care.14 Currently, the mark exceeds 1,000 establishments implemented in all regions of the country. Therefore, the evaluation of the CEO must be considered a strategic action to the implementation of this policy.

The Program for Improving Access and Quality of Dental Specialty Centers (acronym in Portuguese, PMAQ/CEO) consisted of collecting information to analyse the conditions of access and quality of the CEO participating in the program.15 Oral health care for people with disabilities was one of the services evaluated by the PMAQ/CEO in the CEO.

The Brazilian Ministry of Health implemented the PMAQ/CEO with voluntary participation to evaluate public services. Performance evaluations were carried out during the program's external evaluation phase in 2014 and 2018. This study aims to identify changes in the provision of CEO per conditions of the supply of care to people with disabilities between the first and second cycles of the PMAQ/CEO and analyse the factors associated with any changes.

2 METHODS

This Brazilian nationwide ecological time series study adopted the CEO as analysis units. Only CEO that participated in the two PMAQ/CEO cycles were included in this study. CEO who did not have complete answers to the variables about the structure and work process were not included, totalling 827 CEO distributed in 777 Brazilian municipalities (13.9%). In 2014 (first cycle), Brazil had 988 CEO distributed in 780 municipalities (14%), and, in 2018 (second cycle), 1097 CEO in 901 municipalities (16.2%). We excluded CEO that were closed, under renovation, lost their accreditation, refused to participate in the external evaluation of the PMAQ/CEO.

The institutionalization of health assessment in Brazil has been established within the NOHP in the SUS. We highlight the operationalization of the two evaluation cycles of the PMAQ/CEO,15 organized in three phases and a cross-sectional axis of development.16

The theoretical bases used in the research go back to the Donabedian systemic structure-process-result model and can be considered a quality evaluation. Conceptually, quality will always be a social construction, produced and based on the subjects’ references—who attribute meaning to their experiences, favouring or excluding certain aspects per a preferential hierarchy. Thus, approaching the concept of quality in health will always be a huge challenge, considering the plurality of its dimensions (political, economic, social and technological) and the subjects involved in its construction (individuals, communities, groups, managers, users and professionals).17-19

The aspects of the structure involve the physical structure and the provision of material and human resources; the process involves the actions of governance, organization and planning of health services; and the results were measured by the effect of the CEO on user satisfaction. These establishments were evaluated from the perspective of managers, professionals and CEO users to know the quality of care and contribute to the decision-making process.15 This study explicitly adopted the structure and work process components. Structure (Module I of the questionnaire) and work process (Module II) features were retrieved from the external evaluation database of the first (2014) and second (2018) cycles of the PMAQ-CEO.15 The variables used in both cycles were as follows:

2.1 Structural features of the CEO

Number of dentists specifically attending the PD (0 or ≥1); corridors adapted for wheelchairs; adapted doors; wheelchairs available on site; access ramp with handrail; bathroom for users (adapted with a lower vase, accessories with sink, soap and paper dispenser at a lower level, support bars, doors opening outwards and an area that allows wheelchair manoeuvre); operating peripherals (sedation device with nitrous oxide and protective stabilization for people with disabilities).

2.2 CEO work process features

Dentists’ weekly workload with exclusive care for patients with disabilities (sum of the weekly workload: 0–8; 9–20; >20 weekly hours); training of dental surgeons working for this profile (only undergraduate, refresher/improvement and postgraduate); support from other professionals to assist in solving complex cases (yes or no); access to the CEO (walk-in, mixed or referred demand); pre-defined quotas for referring PD to the CEO (yes or no); CEO receives users with detailed term/information (yes or no); agreed clinical protocols guiding the referral of PHC patients to the CEO (yes or no); defined and agreed referral related to care in the hospital environment for general anaesthesia or sedation at the hospital level (yes, no, did not respond, no hospital agreement); how the offer of vacancies for the hospital environment is organized (no hospital agreement, quota system, unlimited number, others); restrained demand for hospital care for PDs; estimated waiting time for service at the CEO (yes, no, did not respond); guarantee of full treatment for PD in CEO (yes or no).

2.3 Patient profile (yes or no)

With involuntary movements; autistic; with behavioural disorders; visual, hearing, speech or physical impairment; pregnant women or babies without any limitations; people with diabetes, cardiac patients and older adults; HIV-positive.

The latent transition analysis (LTA) was performed to identify classes of CEO with similar features and model the transition between classes over time. This analysis considers that CEO can change their latent class over time. The number of classes was selected from the adjustment criteria based on models with 2–5 classes related to the features of the CEO’s offer to people with disabilities.

The adjustment criteria were the statistical test of likelihood ratio, p-value, degree of freedom (df), Akaike information criterion (AIC), Bayesian information criterion (BIC) and entropy. Low AIC and BIC values, entropy with values close to 1, and RMSEA test p-value > .0513 indicate better model fits. The model with four classes and five variables was selected:

The first latent class called ‘Better’ has CEO with better conditions to assist PD: high proportions of dentists working specifically with PD, interface with PHC (protocols and quotas), hospital referral, and all CEO guarantee treatment for the patient. The second latent class (medium better) does not have dentists working specifically with PD, but a high proportion of the other features. The third latent class (medium worse) has high proportions of CEO with dentists working specifically with PD, but a low proportion of the other features. The last class (worse) has the worst conditions for attending PD, with low proportions of all features.

When considering that CEO can change the latent class over time, LTA uses the term ‘latent state (LS)’. Therefore, the parameters used in the LTA were probabilities of CEO having features that belong to each LS; the proportion of CEO in each LS at each moment; transition probabilities between LS over each time.20

Choropleth maps of Brazil were made, highlighting the municipalities with CEO in each of the LT standards of the CEO’s services (improved, better, maintained better, medium, maintained worse and worsened). The proportion of CEO in the municipality with each of the transitions was classified on a 5-level scale (0%, >0% and ≤25%, >25% and ≤50%, >50% and ≤75%, and >75%). Excel 2013, Stata 14.0, MPlus 8.4 and ArcGIS PRO 2.5 programs were employed.

A multinomial logistic regression analysis was performed to identify factors associated with the dependent variable: changes in the provision of dental services (improved, remained or worsened). The independent variables comprise sociodemographic aspects, the provision of health services, and specialized dental services in the municipal context. These variables were estimated as the difference between 2014 and 2018 (first and second cycles): estimated oral health teams population coverage, family health teams population coverage, Municipal Human Development Index (M-HDI), population size, CEO types (I—three dental chairs; II—four to six dental chairs; and III—more than seven dental chairs) and CEO’s Global Achievement of Goals (CGM), categorized as did not meet any goals; met one goal; met two goals; met three goals; met four or more goals. Data are available from official databases and governmental websites. Odds ratio (OR) and 95% confidence intervals (95% CI) were calculated (alpha = 5%).

The Research Ethics Committee of the Federal University of Pernambuco (UFPE) approved this project on 30 January 2018 under process CAAE 23458213.0.0000.5208.

3 FINDINGS

Eight hundred and twenty-seven CEO were included in the study. An increase was observed in almost all items regarding the PD care structure in the second cycle, as follows: the number of dentists who treated PD (1.8%), the weekly workload (3.1%), adapted corridors (9.7%), wheelchair-adapted doors (4.9%), adapted restrooms (19.6%), wheelchairs (15.7%) and access ramps (38.7%). However, the amount of sedation (0.6%) and restraint devices for patients in working conditions (7.5%) decreased (Table 1).

TABLE 1. Characteristics of the structure and work process of the CEO that offer assistance to people with disabilities Characteristics

Cycle 1

N (%)

Cycle 2

N (%)

p-Value Structure Number of dentists that specifically attending the PD <.001 0 79 (9.5) 64 (7.7) ≥1 748 (90.4) 763 (92.3) Corridors adapted for wheelchairs <.001 Yes 638 (77.1) 718 (86.8) No 189 (22.9) 109 (13.2) Adapted doors .001 Yes 645 (80.0) 702 (84.9) No 182 (22.0) 125 (15.1) Wheelchairs available on site <.001 Yes 501 (60.6) 631 (76.3) No 326 (39.4) 196 (23.7) Access ramp with handrail <.001 Yes 395 (47.8) 715 (86.5) No 432 (52.2) 112 (13.5) Adapted bathroom for users <.001 Yes 388 (46.9) 550 (66.5) No 439 (53.1) 277 (33.5) Number of sedation devices <.001 0 794 (96.0) 789 (95.4) ≥1 33 (4.0) 38 (4.6) Number of protective stabilization for PD <.001 0 591 (71.5) 529 (64.0) ≥1 236 (28.5) 298 (37.0) Work Process Weekly workload of all dentists working with PD (weekly hours) <.001 0 – 8 118 (14.3) 92 (11.1) 9 – 20 357 (43.2) 362 (43.8) ≥21 352 (42.6) 373 (45.1) Training of dentists who work with PD .136 Graduation only 277 (33.5) 349 (42.2) Update / improvement 225 (27.2) 164 (19.8) Postgraduate 325 (39.3) 314 (37.0) CEO receives support from other professionals to assist in solving complex cases .665 Yes 532 (64.3) 643 (77.7) No 295 (35.7) 184 (22.3) Access to the CEO occurs through demand .286 Spontaneous 12 (1.4) 7 (0.9) Mixed 334 (40.4) 495 (59.8) Referenced 481 (58.2) 325 (39.3) Pre-defined quotas for referring PDs to the CEO .388 Yes 147 (17.8) 144 (17.4) No 680 (82.2) 683 (82.6) CEO receives users with detailed term/information .211 Yes 620 (75.0) 805 (97.3) No 207 (25.0) 22 (2.7) Agreed clinical protocols guiding the referral of PHC patients to the CEO .609 Yes 555 (67.1) 677 (81.9) No 272 (32.9) 150 (18.1) Defined and agreed referral related to care in the hospital environment for general anaesthesia or sedation at the hospital level .771 Yes 492 (59.5) 624 (75.5) No 335 (40.5) 203 (24.5) How the offer of vacancies for the hospital environment is organized .070 Quota system 107 (13.0) 120 (14.5) Unlimited number 321 (38.8) 433 (52.4) Others 64 (7.7) 72 (8.7) No hospital agreement 335 (40.5) 202 (24.4) Agreed referral related to care in the hospital environment for general anaesthesia or sedation at the hospital level .771 Yes 99 (12.0) 136 (16.4) No 359 (43.4) 470 (56.8) Did not respond 34 (4.1) 19 (2.3) No hospital agreement 335 (40.5) 202 (24.4) Guarantee of full treatment for PDs .834 Yes 682 (82.5) 796 (96.3) No 145 (17.5) 31 (3.7) Note PMAQ-CEO. Brazil, 2014 and 2018.

In the work process, we observed an increase in the number of dentists who have only graduated (8.7%) attending PDs, the support of other professionals to assist in the resolution of complex cases (13.4%), access to the CEO through mixed demands (19.5%), receiving patients with detailed information (22.4%), agreed clinical protocols for referring PHC patients to the CEO (14.7%), agreed referrals for general anaesthesia and sedation in a hospital environment (12.2%), hospital environment vacancies (13.5%), CEO’s guarantee of patient care (13.7%) and restrained demand for care at the hospital level (13.4%). However, a slight decrease was noted in the PD access to the CEO through pre-defined quotas (0. 4%) and referenced demand (18.9%) (Table 1).

The profile of these patients also changed, with an increase in the attendance to patients with involuntary movements (1.3%), autistics (9.1%) and behavioural disorders (0.6%), while those with visual, hearing, speech or physical impairments (6.6%), pregnant women or babies without any limitation (9.8%), people with diabetes, cardiac patients, older adults (8.5%) and HIV-positive patients (6.4%) decreased (Data not available in the table).

Different models with two, three, four or five classes were tested. The four-class model was selected because it had the better fit properties (less likelihood ratio chi-square, p-value > .05, entropy closer to 1 and high values of AIC/BIC) and conceptual cohesion, representing the structure's features and the work process with guarantee of treatment, interface of the CEO with the PHC and interface with tertiary care (Table 2).

TABLE 2. Model fit information used when selecting the LTA model Number of latent classes Likelihood ratio Chi-squarea Degrees of Freedom p-Valueb AICc BICd Entropye Structure, care network (PHCf and THCg) and treatment guarantee 2 533.610 1007 >.999 7195.253 7256.584 0.582 3 444.097 999 >.999 7105.671 7214.180 0.791 4 378.437 986 >.999 7075.223 7240.346 0.818 5 349.440 972 >.999 7072.082 7303.254 0.687

Table 3 presents the model with four classes concerning the provision of care to PD in the CEO. LS1 has all (100%) CEO assuring treatment for the patient, high proportions of dentists working specifically with PD (98.7%), interface with PHC (through protocols, 87.5%; quotas, 19.2%) and tertiary care (hospital referral, 77.7%).

TABLE 3. Four-class model about providing care to people with disabilities in the CEO Steps for transitioning latent classes Latent status

Class 1

Better

Class 2

Medium better

Class 3

Medium worse

Class 4

Worse

Probability of item response (class/status latent) Dentists that specifically attending the people with disability Yes 98.7 0.0 93.5 18.3 No 1.3 100.0 6.5 81.7 Pre-defined quotas for referring PDs to the CEOa Yes 19.2 31.4 13.0 4.3 No 80.8 68.6 87.0 95.7 Agreed clinical protocols guiding the referral of PHCb patients to the people with disability Yes 87.5 100.0 41.5 9.8 No 12.5 0.0 58.5 90.2 Defined and agreed referral related to care in the hospital environment for general anaesthesia or sedation at the hospital level Yes 77.7 82.4 39.3 35.0 No 22.3 17.6 60.7 65.0 Guarantee of full treatment for people with disability Yes 100.0 84.3 62.5 56.4 No 0.0 15.7 37.5 43.6 Proportion of Latent Status Time 1 (Cycle 1 of PMAQ-CEOa, 2014) 50.1 4.7 43.5 1.7 Time 2 (Cycle 2 of PMAQ-CEOa, 2018) 90.8 1.4 1.6 6.2 Transition probabilities (Rows for time 1, Columns for Time 2) Better 94.0 0.3 2.1 3.6 Medium better 48.2 4.0 0.0 47.8 Medium worse 95.1 1.7 1.3 1.9 Worse 0.0 21.6 0.0 78.4 Note PMAQ-CEO. Brazil, 2014 and 2018.

LS2 have all CEO articulated with the PHC network (clinical protocols, 100%; quotas, 31.4%), but none have dentists working specifically with PD (0%); they have a high proportion of CEO articulated with tertiary care (82.4%) and a guaranteed treatment (84.3%).

LS3 have high proportions of CEO with dentists working specifically with PDs (93.5%) and with just over half of the CEO guaranteeing treatment (62.5%), but a low proportion of CEO articulated with PHC (protocols, 41.5%; quotas, 13%) and tertiary care (39.3%).

LS4 has low proportions of CEO with dentists working specifically with PDs (18.3%), articulated with PHC network (protocols 9.8%, quotas 4.3%), and tertiary care (35%), and a high proportion of CEO who guarantee treatment (43.6%).

Over cycles 1 and 2, the proportion of CEO in LS 1 (better) increased by 40.7% (50.1%–90.8%), LS 2 (medium better) slightly decreased by 3.3% (4.7%–1.4%), LS 3 (medium worse) decreased by 41.9% (43.5%–1.6%) and LS 4 (worse) slightly increased by 4.5% (1.7%–6.2%) (Table 3; Figure 1).

Choropleth maps with the proportion of municipalities with latent status in the CEO that offer assistance to people with disabilities. Brazil, 2014, 2018 [Colour figure can be viewed at wileyonlinelibrary.com]

There was a high probability of ‘maintained’ on LS1 (94% better) and LS4 (78.4% worse), and a low probability of ‘maintained’ on LS2 (4% medium better) and LS3 (1.3% medium worse) (Table 3).

Figure 1 shows the spatial distribution of the percentage of CEO in Brazilian municipalities. Almost all states improved or maintained better between the first and second cycles. There were hardly any CEOs who maintained a medium level and few CEOs had worsened.

Considering the outcome CEO that improved, maintained or worsened, and the exposures as the difference between 2018 (cycle 2) and 2014 (cycle 1), two variables were associated with the outcome: population size and achieving goals (Table 4).

TABLE 4. Analysis of factors associated with changes in the provision of dental services Variables difference between cycle 2 and cycle 1 Changes in the provision of dental servi