key: cord-0976055-hmnuu2gf authors: Liu, Deborah Zhuoen; Gallo, Gabriella; Babikow, Erika; Wiesen, Christopher; Jackson, Tate Harris; Mitchell, Kelly; Jacox, Laura Anne title: Impacts of the COVID-19 Pandemic on Dentists’ Workforce Confidence and Workflow date: 2021-12-13 journal: J Am Dent Assoc DOI: 10.1016/j.adaj.2021.11.011 sha: b49e37e1a1b0783f524976bb8183721156d1f451 doc_id: 976055 cord_uid: hmnuu2gf Background The COVID-19 pandemic has impacted the U.S. economy and workforce, with marked effects on small businesses. Studies have evaluated workers’ views of financial confidence and advancement, but there has been limited focus on the dental industry. Methods To extend investigations to dentistry, published scales and pretested questions were used to determine workforce confidence and workflow changes among dentists. Data were evaluated using descriptive and bivariate statistics. In the wake of the pandemic, surveys were distributed to the American Dental Association (ADA) and American Association of Orthodontics (AAO) membership (N=656). Results Dentists’ top concern is increased cost of providing treatment (57.4% [Confidence Interval (CI): 53.5, 61.3]), associated with widely adopted workflow changes including reduced patient volumes (66.0% [CI: 62.4, 69.6]) and increased safety protocols and equipment (health screening, 75.5% [CI: 72.2, 78.8]), KN/N95 masks, 76.7% [CI: 73.5, 80.0]). However, the majority of respondents do not expect their personal or practice finances to be negatively affected after the pandemic, as only 18.5% ([CI: 15.4, 21.7]) predict their practice’s gross revenue to decrease. Conclusions Dentists are optimistic in the wake of vaccinations and lifting restrictions. Most expect their finances and practice performance to remain the same or grow in the short-term and expect long-term improvements post-pandemic. Practical Implications Results suggest that despite shutdowns and workflow changes, dentists have financially rebounded and anticipate future growth. The COVID-19 pandemic has changed perceptions of financial security and career trajectories among the U.S. workforce. 1 Frontline healthcare workers face concerns about workplace exposures, higher volumes of acutely ill patients, and potential economic insecurity. [2] [3] [4] A study exploring nurses' experiences of stress early in the pandemic found 51% of responses related to work-place problems, including failure of leadership to meet safety and training needs, and 22% citing fear of the unknown, including financial hardship. 5 Small businesses, notably medical and dental practices, experienced dramatic economic and workflow disruptions. 6, 7 Surveyed physicians reported decreased patient visits, which directly correlated to reduced revenue and often led to staffing reductions. 8 Primary care practices are estimated to have lost $67,000 in gross revenue per full-time equivalent physician throughout 2020. 9 Dentists, in particular, faced heightened risk of infection with their proximity to the oral cavity. 10 Following recommendations from the American Dental Association (ADA) and Center for Disease Control (CDC), dentists closed their offices to all but emergency appointments in March-May of 2020. 11 Collections for the majority of dentists were down over 95% during this shutdown. 12 As practices reopened, many were forced to make changes to their workflow, adding new safety procedures, products and personal protective equipment, and altering patient scheduling and staffing to meet safety recommendations. 13 Although these changes are widely recognized, the pandemic's immediate and long-term impacts on dentists' financial security are poorly understood. Dentists' concerns in treating patients and their emotional and financial wellbeing were explored early in the pandemic but not during the vaccination and recovery period. 14, 15 More recent studies evaluated the pandemic's impacts on dental patient volumes and on the broader healthcare sector, without polling dentists' workforce confidence. 16, 17 LinkedIn's TM Workforce Confidence Index (WCI) poll suggests healthcare workers' confidence has increased over the past year, to levels above the general workforce nationally. 17, 18 With limited responses from dentists, it is difficult to ascertain where dental professionals fall in these statistics. The ADA Health Policy Institute has conducted biweekly surveys of dental practices since March 2020. March 2021's report shows roughly half of practices reporting lower patient volume with some staff still receiving unemployment benefits. 16, 19 Collections have been increasing steadily, but are not fully recovered to pre-pandemic levels. 16 These ADA data speak to practices' financial state without including dentists' attitudes and confidence levels regarding job security, future success, and personal financial stability. J o u r n a l P r e -p r o o f Shifts in workforce confidence and workflow are key drivers behind economic recovery and are important to evaluate as a barometer of dentists' financial future. 17 To enhance knowledge of dentists' financial confidence and workflow changes, we developed and distributed a national survey to the ADA and American Association of Orthodontics (AAO) membership. We hypothesized that significant workflow changes have occurred for more than half of dentists and that outlooks are increasingly optimistic, as mass vaccination progresses and restrictions are loosened. As one of the first surveys to explore these topics on a national level, our results provide insight into dentists' professional and financial perspectives in the shadow of the COVID-19 pandemic. We developed a cross-sectional survey to assess dentists' workforce confidence. It included validated questions adapted from LinkedIn's TM WCI and our pretested questions. 10 With LinkedIn's TM permission, their questions were adapted for dental audiences (Appendix). Additional questions on practice workflow were written and revised with a survey expert at the University of North Carolina (UNC) Odum Institute for Research in Social Science, prior to pretesting. The survey was pre-tested 20 times, by 2 general dental faculty who retired from private practice, 4 dental students, 8 orthodontic faculty and 6 residents. Revisions occurred iteratively until a final draft was approved by the survey expert and team. The final survey consisted of 35 questions including 8 validated WCI questions, 4 pre-tested questions on workflow changes, and 11 demographics questions (Appendix). The survey was distributed to 9,000 ADA and (Table S1 ). This research and its digital consent forms were approved by UNC's Institutional Review Board (IRB #16-2743); all respondents consented to participate. Data were evaluated using descriptive and bivariate statistics. Due to common trends and few significant differences (Tables S2-4 ), the responses of general dentists (n=544) and specialists (n=112) across age groups were pooled for most analyses, totaling N=656 responses. Statistical analyses were conducted using SAS 9 Software (SAS Institute, Cary, NC, USA). Cross tabulation was used to examine the associations among categorical variables. Hypotheses of no association were tested using Pearson's chi square test. P values less than 0.05 were considered significant. Graphs were made using Prism 9 Software (GraphPad Software Inc., La Jolla, CA, USA), and figures were created using Adobe Suite (Adobe Inc., San Jose, CA, USA). Participants (N=656) were practicing general dentists (n=544, from the ADA email list) or specialists (n=112, from the ADA and AAO email lists) in the USA. Because the AAO membership was emailed, specialist data includes a high proportion of orthodontists (54.1%), in addition to other dental specialists from the ADA (Table 1) . Self-reported demographic data include age, gender, race, ethnicity, ownership status, state, geographic region, practice model, primary practice location and specialty, when applicable ( Table 1) . Respondents were asked to choose their top three concerns regarding operating in a changed business environment due to the pandemic. A majority (57.4% [Confidence Interval inability to come to work (28.2% [24.8, 30.9] ). Responses were consistent across age groups (Table S2) . To understand how clinical dentistry has changed during the pandemic, respondents were asked to report changes in 1) personal protective equipment (PPE), 2) safety products, Fig 2C) . To explore short-term impacts of the pandemic, respondents were asked to make predictions about their financial situation in the next six months (Fig 3A) . Dentists were asked if they believed their total earned income (salary, dividends, etc.), personal savings, contributions to investments, and personal spending would decrease, stay the same, or increase over this time span (Appendix, Q4 Fig 3A) . There were no significant differences when accounting for ownership status (solo owner, partner or non-owner employee), location (large, medium or small city, suburb, or rural setting), and region ( Fig 3A) . To understand practicing dentists' long-term outlooks, respondents were asked to assume it is the year 2022 and the COVID-19 pandemic is over. Respondents were then asked to compare this scenario to their situation in 2019, before the start of the pandemic, with regard to their practice's gross revenue (collections), take-home income (net practice income), patient clinic hours, and the number of new jobs available for dentists (Appendix, Q5A, Q5B). Results (Table S4) . Respondents are also hopeful regarding the dental job market, with 78.6% believing the number of new jobs for dentists will either remain the same or increase (Fig 3B, Table 5 ). When data were segregated by practice location, ownership status and region, sentiments were consistent across groups (Table 5 and data not shown). The dental profession experienced an unprecedented national shutdown with the emerging COVID-19 pandemic, as appointments were restricted to emergency care. 11 Early in the pandemic, dentists worldwide believed they would be profoundly impacted; on a Likert scale where 1 indicated little financial impact and 5 represented significant impact, surveyed dentists averaged a striking 4.8. 14 A separate June-July 2020 survey of endodontists and general dentists found >90% reported the pandemic had a negative financial impact, with a quarter indicating loss of over half their business. 21 In subsequent months, offices reopened with significant changes and evolved toward a new normal. It could be expected that this disruption would negatively impact dentists, materially and psychologically, yet our study conducted February-April 2021 portrays a more optimistic picture. 22 To explore dentists' financial confidence, workflow changes, and future perspectives, a national survey was distributed to practicing dentists in early 2021. Data show that after reopening, a large majority of dentists report substantial workflow changes (98.8%), added safety products (98.9%) and PPE (96.6%) (Fig 2A, C, Table 3 ). Considering the added costs associated with these changes, it is not surprising that higher operating expenses are a concern among respondents ( Fig 1, Table 2 ). ADA data from December 2020 indicate about a third of dentists were paying at least three times more for all types of PPE. 23 Despite added costs, dentists' outlooks on their financial futures are optimistic; most expect their personal finances and practice performance to remain the same or grow in the near future ( Fig 3A, Table 4 ). In the long term, most expect further fiscal improvements post-pandemic and do not believe their personal or practice finances will be negatively affected (Fig 3B, Table 5 ). Results suggest despite the shutdown and ensuing workflow changes, many dentists are rebounding financially and anticipate future growth. Healthcare surveys from earlier in the pandemic have more dire outlooks than those distributed later, like ours. In April-May of 2020, results gathered from the general healthcare sector reported one in three individuals' financial security was impacted by the COVID-19 pandemic. 24, 25 Reduced income was reported most among physicians, physician assistants, and nurse practitioners in a survey of hospital workers. 24, 25 As the pandemic progressed, dentists embraced workflow changes and patients resumed dental care. 26 Infection control protocols proved effective at preventing transmission in dental settings, and COVID-19 cases among US-practicing dentists have remained notably low. 27 Analysis of practice management data finds dental utilization has fully rebounded to pre-pandemic levels among privately insured patients. 28 These later studies, indicating adaptation to new safety procedures and rebounding dental demand, are consistent with our optimistic findings. The present survey was distributed from February-April 2021 and found 65.3% of participants anticipate their income staying the same or increasing over the next 6 months. These findings are consistent with the healthcare field, as evaluated by LinkedIn TM through their biweekly survey starting in April 2020. The LinkedIn TM survey is distributed to approximately 5,000 U.S. workers across many industries. It assesses employees' sense of job security, financial confidence, and prospects of career advancement to calculate an aggregated Workforce Confidence Index (WCI). 17 Data from March 2021 shows a significant increase in healthcare workers' WCI as compared to April 2020, and healthcare's WCI was well above the US overall WCI. 18 Similarly, a majority of our dental respondents anticipate their personal finances and career advancement will either remain the same or increase between now and the summer of 2022 (Fig 3A,B, Table 4 ,5). The events of 2020 were not as catastrophic for dental practices as expected. In June 2020, the ADA predicted annual dental practice revenue would decrease by 38%; the actual decrease in revenue in 2020 was only 6%. 29 The top 10% of dental practices performed better in 2020 than 2019 in terms of revenue, average patient value, and patient growth. 29 There has also been remarkable growth in the stock market, buoying personal investment returns. 30 This suggests multiple factors may underlie dentists' positive outlook on their financial future and the resilience of the dental profession. This survey's findings may also be partially explained by timing. Distribution occurred when the vaccine rollout was gaining traction and most dentists had been offered the vaccine. Most (86.0%) of our survey respondents reported receiving the vaccine, and of those 14.0% who had not been vaccinated, 61.9% reported being offered the vaccine ( Table 1 ). During that same period, the stock market showed strong performance and restrictions were beginning to J o u r n a l P r e -p r o o f lift as businesses began returning to more normal practices. 31 Understandably, respondents were more optimistic about their financial future at the time of survey distribution than immediately post-shutdown. Interestingly, our data suggest changes brought on by the pandemic are expected to linger. Although 57.2% of respondents predict higher gross practice revenue in 2022, only 46.6% expect higher net income (Fig 3B, Table 5 ). This suggests about 10% of respondents anticipate increased operating expenses to persist even after the pandemic has subsided. This study was limited by sample size (N=656). However, data are consistent among subgroups when broken down by age, gender, ownership status and practice location, indicating trends are broadly applicable across groups. Responses include dentists from all regions and age groups suggesting our sample is representative of the 201,117 dentists in the US. 16 Our sample had overrepresentation of particular groups, with more responses from males (69.4%), older respondents (67.4% over 50 years old) and solo owners (76.7%) relative to partners (10.9%) and associates (4.6%) ( Table 1 ). There were also more participants from large cities and suburbs than small towns and rural populations (Table 1) . Regionally, our representation is approximately proportional to the population demographics of practicing dentists provided by the ADA though certain regions are slightly overrepresented such as the Mid-Atlantic (Table 1) . 32 The survey was distributed by email, favoring doctors who were digitally capable with email addresses registered with the ADA and AAO. Our population consisted of 84% generalists and 16% specialists; this is roughly consistent with the percentage of specialists nationwide (21.2%) ( Table 1) . 32 However, orthodontists were disproportionately represented among specialists' data, as the AAO Partners in Research Program disseminated the survey, and digital distribution of our online survey was unavailable through many specialty organizations. As a result, non-orthodontic specialists are underrepresented, with overrepresentation of the orthodontic perspective and business model. This is a weakness of our data, though few differences were found between specialists and general dentists and between orthodontists and other dental specialists (Tables S3-4) . Nonetheless, we are unable to draw robust conclusions for all specialists and acknowledge that specialist data is skewed towards orthodontists. An additional limitation is the overall response rate of 6.37%, which may be due to our email lists' lack of pre-screening for participants' desire to participate in research. However, our response rate and total number of respondents are fairly consistent with similar surveys. [33] [34] [35] This is the first investigation of changes in dentists' workforce confidence and workflow in response to the COVID-19 pandemic. Our results provide insight into the repercussions of the J o u r n a l P r e -p r o o f pandemic on the dental field and indicate broad optimism among dentists for their short and long-term professional prospects. These findings are valuable for understanding the economic recovery and future of dental healthcare. • A majority (57.9%) of respondents report increased costs of providing dental treatment in their top three concerns regarding operating in a changed business environment due to the pandemic. • A majority of survey respondents report increasing utilization of PPE, safety products, and safety-oriented workflow changes. Those most frequently adopted include KN/N95 masks (73.3%), thermometers (84.6%), and health screening questionnaires (76.1%). • A majority of dentists anticipate the same or greater savings (65.4%), total earned income (70.4%), investment contributions (68.1%) and personal spending (54.5%) in the short term. • Dentists are optimistic about their careers post-pandemic in 2022, anticipating the same or greater monthly collections (81.5%) and net practice income (78.3%). • These results suggest broad optimism for dental healthcare as the COVID-19 pandemic draws to a close. to "decrease" (red), "stay the same" (orange), or "increase" (blue) over the next 6 months. ( Table 4 , Question stem in Appendix Q4) [B] Percent of respondents expecting aspects of their finances and career to "decrease" (red), "stay the same" (orange), or "increase" (blue), J o u r n a l P r e -p r o o f assuming it is the year 2022 and the pandemic is over. (Table 5 , Question stem in Appendix Q5A, Q5B) Management and/or long-term impact of new HR regulation (e.g. unemployment claims) 11 .5% (75) [9.1, 14.2] Lack of employee confidence in their ability to keep themselves and their families safe if they go to work 9.3% (61) [7.2, 11.8] Increased personal responsibilities for you (e.g. childcare, caring for elderly or sick family members) 7.0% (46) [5.2, 9.3] J o u r n a l P r e -p r o o f World Health Organization (WHO). Coronavirus. World Health Organization Protecting the front line: a cross-sectional survey analysis of the occupational factors contributing to healthcare workers' infection and psychological distress during the COVID-19 pandemic in the USA Factors Contributing to Healthcare Professional Burnout During the COVID-19 Pandemic: A Rapid Turnaround Global Survey. medRxiv Mental Health Needs of Health Care Workers Providing Frontline Nurse Reports of Stressful Situations during the COVID-19 Pandemic: Qualitative Analysis of Survey Responses COVID-19's Crushing Effects on Medical Practices, Some of Which Might Not Survive How Will Dentistry Respond to the Coronavirus Disease COVID-19's Financial Impact on Primary Care Clinicians and Practices Primary Care Practice Finances In The United States Amid The COVID-19 Pandemic. Health Aff (Millwood) The Workers Who Face the Greatest Coronavirus Risk ADA Urges Dentists to Heed April 30 Interim Postponement Recommendation, Maintain Focus on Urgent and Emergency Dental Care Only Second week of HPI polling shows dentists' response to COVID-19 COVID-19): Emerging and Future Challenges for Dental and Oral Medicine Dentists' knowledge, attitudes, and professional behavior toward the COVID-19 pandemic: A multisite survey of dentists' perspectives 16. Health Policy Institute. COVID-19 Econimic Impact of Dental Practices; Week of March 15 Core Results Workforce Confidence Index: Introducing a biweekly pulse on the mood of workers Everyone to the front lines! How a crisis is jolting health care hiring 2020 trends in dental office visits during the COVID-19 pandemic Response by Endodontists to the SARS-CoV-2 COVID−19) Pandemic: An International Survey Fear and Practice Modifications among Dentists to Combat Novel Coronavirus Disease (COVID-19) Outbreak HPI poll: Dentists see 'substantial' increase in PPE prices Pandemic on US Healthcare Workers: Results from the HERO Registry The Hidden Cost of COVID-19 Impact on Healthcare Heroes' Finances American Dental Professionals Prepared and Ready During Unprecedented Challenges Changes in Dental Utilization Patterns due to COVID-19 among Insured Patients in the US The Pandemic's Economic Impact on Dental Practices in the Stock Market Outlook 2021: Bull Market, But Buckle Up Centers for Disease Control and Prevention. When You've Been Fully Vaccinated: How to Protect Yourself and Others Trends in the Use of Digital Study Models and Other Technologies Among Practicing Orthodontists Patients', parents', and orthodontists' perceptions of the need for and costs of additional procedures to reduce treatment time Willingness and ability of oral health care workers to work during the COVID-19 pandemic P-values calculated by Pearson's chi-squared test. 31.7% (187) jobs available in an average month of 2022 the We greatly appreciate the help and collaboration of LinkedIn's TM Senior Editor George Anders and all those who worked to produce LinkedIn's TM Workforce Confidence Index. We would like to thank the UNC Department of Orthodontics, now the Orthodontics Group within the Division of Craniofacial and Surgical Care, for hosting this study. We would also like to thank Teresa Edwards and Chris Wiesen, at the UNC Odum Institute for Research in Social Science, for their important guidance in preparing, testing, and revising our survey along with survey data analysis.