The collection of health statistics is an obligation of the Croatian Institute of Public Health and of public health institutes of the counties. The obligation of reporting and data collection in the domain of health care has been regulated by the Law on Health Care, the Official Statistics Act and the Regulations on the implementation of the Law on the Primary and Specialist Health Care Records (1-4). These Regulations also determine the forms that are to be used in the primary and specialist-consultative health care reporting, which have been amended according to the tenth revision of the International Classification of Diseases and Related Health Problems. The forms have been published as a supplement and the integral part of the Regulations (Figure 1) (3). All medical institutions and medical professionals in private practice (those that have and those that do not have contracts signed with the Croatian Health Insurance Fund) are obligated to complete prescribed dental medicine forms until prescribed time limits, as anticipated in the Programme of Statistical Surveys of the Republic of Croatia and the Annual Implementation Plan (by 31 January for the previous year) and submit them to public health institutes of the counties and to the Croatian Institute of Public Health. The data collected via reporting forms could give qualitative information regarding the use of dental health care, while the analysis of the same would contribute not only to the understanding and removal of obstacles of collecting and processing of the data but it would also affect further planning of activities aimed at improving oral health.
The purpose of this study was to analyse the data obtained from the Croatian Institute of Public Health for dental health care activities in the period between 2009 and 2013 in order to gain an insight into the data collected by counties and for the entire country.
Material and methods
The data were obtained from the 2009-2013 Croatian Health Care Statistics Yearbook, from annual reports submitted by contractual teams and institutions for dental medicine activities (5-9). Based on the analysis of the same we have interpreted the number of insured persons and of persons who received dental care, the number of dental care visits and general examinations, the proportion of general examinations performed during visits, established diagnoses and performed procedures. The statistical analysis of the resulting data was created in Microsoft Access 2.0. The results are presented in tables and graphs.
The dental health care has shown an increase in the number of insured persons (5%) and a decrease in the number of persons who actually received dental care services (10%), (Figure 2). On average 4.276.078 visits and 559.603 general examinations were registered with the trend of increase in the number of visits (14%) and examinations (13%). The greatest number of persons who received dental health care was in the City of Zagreb with the highest number of visits and a small number of general examinations per user (35%); while the Zadar County had the highest number of examinations in terms of the number of persons that received dental health care services (90%) and the proportion of examinations performed during visits (30%) (Table 1, Table 2). Dental caries (43%), in terms of oral pathology, had the highest incidence (Table 3). The results of the period from 2009 to 2013 show a decrease in the number of extracted teeth (22%) but an increase in the number of prosthetic procedures (6%) and oral cavity soft tissue treatments (7%), (Figure 3). However, a considerable number of reports of the five-year period were not submitted for the City of Zagreb and the Split-Dalmatia County.
Based on the collected data, of the respective period, a decrease was recorded in the number of insured persons-health care beneficiaries and an increase in the number of visits and examinations. Some of the factors that could have led to arbitrary decisions and arrangements by individuals with respect to their use of dental care services could be low family incomes, lack of information, loss of trust, anxiety, fear of the dental visit and the cost of services (10, 11), but, at the same time, the increase in the demand for dental services could be attributed to dental pain as the frequent reason for visits. Although the number of examinations increased, the proportion between the number of examinations and the number of users was low in the majority of counties, except the Zadar County and the Šibenik-Knin County. The Lika-Senj County with a small number of health care users had the lowest number of visits (19%), which could be justified by less available dental care facilities and a population structure. A study carried out among Europeans of the age of 50 years and over showed a tendency of increase in the number of preventive examinations and procedures, especially in Scandinavia and Western Europe, which was explained by different needs in the use and availability of dental health care (12). The lack of time and superficiality in their daily work should not be the reasons affecting examination procedures especially in counties with a large number of health care users and numerous contractual teams, as in the City of Zagreb. If we analysed the coverage of the total number of insured persons by general examinations we would see that it was very low, especially in the City of Zagreb (8%).
Any assessment of the dental status, with or without a patient’s visit upon a specific request (4) is in general considered a systematic examination. The status of the teeth gives the exact number of decayed, filled and extracted teeth. On the basis of these data the DMFT (decayed, missed, filled teeth) index is then calculated. It is an important indicator of oral health that allows the monitoring of prevalence, incidence, distribution and frequency of dental caries and the planning of necessary enhanced and targeted preventive measures and rehabilitation actions for the patients (13, 14).
The new model of dental care contracts with the Croatian Health Insurance Fund (effective since 1 April 2013) should bring improvement to the quality and efficiency of services and, as a result, a better quality of the collected data (15). The list of diagnosed therapeutical procedures for dental medicine under the new model of contracts with the Croatian Health Insurance Fund is divided into ‘zero’ and ‘first’ level procedures. The ‘zero’ level procedures are the essential procedures applied to monitor daily dentist practice activities. The ‘first’ level procedures are part of and a sequence of activities derived from the ‘zero’ level, encompassing specific skills and knowledge of physicians applied in a holistic approach to patients both in diagnostic-therapeutic procedures and prevention efforts, which is of substantial relevance (16, 17). The additional option of earning income, i.e. the bonus part of the dental care practitioner’s income is paid based on the monitoring of efficiency and quality indicators. The quality indicator is derived from the performance of preventive examinations and it is measured via specific preference levels. This new way of additional income earning might be an incentive for a more systematic implementation of preventive examinations and procedures, and therefore better preventive care for patients with the decreased incidence of dental caries and gingival-periodontal diseases. It is interesting to note that in some members states of the European Union, health insurance companies obligate insured persons to carry out preventive examinations once a year or even every six months (18). Perhaps in this way health insurance users could be encouraged to be more regular in their examinations, because otherwise they could lose their dental health insurance rights.
The modification of the list of diagnostic-therapeutic procedures is the cause of the increased number of oral cavity soft tissue treatments. A large number of established caries-diagnoses show that caries remains a public health problem (19).
Insufficiently developed systems of monitoring and data collection, via reporting forms, at national level, relevant for reducing the incidence of dental caries and other oral diseases require further attention and action. Many European countries have reported a decline in the prevalence of caries owing to reliable, updated data important in the monitoring of the distribution of dental caries (20, 21) and along the same lines, in the organization and planning of dental health care and prevention programmes. One of the objectives of the European Union is to develop the methodology in the collection of comparable oral health data, oriented towards the improvement of such data (11). It would be desirable, certainly, to pay attention to the exact recording of diagnoses and procedures. A close cooperation with counties’ institutes of public health and direct communication in the field, would be necessary in this respect in order to obtain all the needed reports, indicate actual mistakes, establish recurring mistakes and identify other needs in order to improve the quality of the data. The computerization of the health care system or connection with the Central Health Information System of the Republic of Croatia would bring options for further and better use of the collected data, creating in turn further options for changes in reporting form contents, towards creating comparable databases associated with oral health.
The development of the health care information system should bring progress in data collection and processing activities, relevant to the assessment of oral health and dental health care. Better coverage, availability and exchange of data are factors that contribute to the improvement of the quality of data and their interpretation. Proper recording of diagnoses and procedures, general examinations, regular submission of reports to counties’ public health institutes and forms revisions could help in the further planning of dental health care. The assessment of individual regional area needs could boost oral health assessment efforts with respect to dental morbidity and actions taken to that effect. The objective of the activities would be to reduce, in the first place, the incidence of dental caries and periodontal diseases and the incidence of other diseases of the oral cavity (22). We need to continue to evaluate the activities of dental medicine shown in the collected statistical data, in order to eliminate and prevent possible errors and plan and implement necessary health care programmes, as well as to obtain and, as a result, improve oral health indicators.