1 INTRODUCTION

Dental Specialties Centers (CEO, in Portuguese), created in 2003, provide a secondary level of oral health assistance in the Brazilian health system, offering free public dental care to the population. The CEO are one of the measures of the National Oral Health Policy in Brazil, which aims to ensure comprehensive oral health care, acting as a reference for primary health care, constituting a vital factor for general health and for the population's quality of life.1

To be certified as an CEO and receive monthly funding from the Ministry of Health, the service must fulfil specific criteria, such as deliver care in five specialties [stomatology, surgery, endodontics, care for patients with special needs (PSN) and Periodontology] and provide a minimum number of dental offices proportional to its size (Type).2

The National Program for Improving Access to and Quality of Specialized Dental Care Centers (PMAQ-CEO, in Portuguese) was implemented to support an external assessment in loco of secondary oral care services. The program was designed to aid in the definition of quality parameters and certification in order to improve and expand oral healthcare actions nationwide.3

In the first phase of the PMAQ-CEO, in 2014, the waiting time for access to specialized care was identified as a dissatisfaction factor, and both regional and social inequalities were detected.3, 4 Although national oral health policies in several countries have not defined a standard waiting time for specialist consultations,5 organizing the waiting list by regulating access can allow for more equitable attention.

The management of waiting times in public health is one of the purposes of access regulation, which contributes to reducing inequality while strengthening equity in care delivery. Inequality in access to public oral health services has also been experienced in other countries, such as the United States6 or those with public healthcare systems, such as Canada, Spain and England.7-9 Nearly 50 years ago, Julian Hart developed the concept of the Inverse Care Law to demonstrate that health services are more accessible to individuals with higher socioeconomic conditions and vice-versa, perpetuating or even increasing health inequality.10 This paradigm remains true in several countries up to the present day.11

The regulation of access to healthcare embodies (i) the role of the State in guaranteeing the population's right to, or fair relations with, healthcare services12; and (ii) the public health administration, which should create opportunities, order, and qualify the access to, and delivery of, care; (iii) the regulation of access can also be related to the itinerary travelled by the user to attend health consultations.13 These authors conceptualized government regulation regimens (executed by policy —and decision-makers and operationalized by institutional rules and laws) into professional (executed by professionals who provide care via both institutional and independent mechanisms, through personal contacts) and lay regimes (when the user, relatives, friends and other users with the same needs employ cognitive, relational and economic resources to make government regulations more flexible and streamline their access to care). Collectively, these possibilities indicate that regulation is a field in permanent dispute, that is, a social production.

In Brazil, the regulation of access is often limited to organizing waiting lists and assistance flows.14 Given the negative consequences of waiting times on health outcomes,15 this study aimed to analyse the factors associated with the waiting time for access to specialized care at CEO in the Brazilian healthcare system by specialty (Stomatology, Surgery, Endodontics, Patients with Special Needs and Periodontology).

2 METHODS 2.1 Study design

This was an exploratory cross-sectional study. The secondary database from the second phase of the PMAQ-CEO’s External Assessment was used, which consisted of an in loco survey that analysed the conditions of access and quality of 1097 CEO distributed nationwide, regardless of their enrolment status in the program. Of these, 55 CEO were excluded from the assessment because they were undergoing renovation, were disabled, or because their managers declined participation in the external assessment. Therefore, the present census-based study considered the 1042 CEO available and accredited by Brazil's Ministry of Health in 2018.

The data used in our study corresponded to interviews with CEO managers and dentists.3 Data from the second phase of the PMAQ-CEO were provided by the Ministry of Health (http://aps.saude.gov.br/ape/pmaq/ciclo2ceo/).

2.2 Study variables

The dependent variable considered in the study model was the estimated waiting time that the patient expected to be seen in each specialty in the CEO. The waiting time consisted of the time elapsed between the confirmation of the appointment until the appointment date. It was calculated for each dental specialty and dichotomized by the median, as follows: minor oral surgery (≤20 or >20 days); endodontics (≤30 or >30 days); PSN care (≤7 or >7 days); periodontology (≤15 or >15 days); and stomatology (≤5 or >5 days). We chose to dichotomize the dependent variables, considering that there is no way to guarantee the accuracy of the managers’ answers regarding the exact waiting time for each specialty. In addition to facilitating understanding and, as there is no cut-off point established in the literature, we used the median.

The following independent variables were considered: the size of the CEO (type I—3 dental offices; II—4 to 6 dental offices; and III—7 or more dental offices); the presence of a manager at the CEO (yes, exclusive; yes, not exclusive; no manager); the manager's work experience (<1 year, 1–2 years, 3–4 years, 5–9 years, >9 years); the manager's complementary training (yes, in collective health/public health, or no); the frequency of contact between the CEO and the primary care facility — PCF (always or sometimes/never); the mechanisms for appointment scheduling at CEO (only via the PCF, only via the user or via the PCF/user); referral-based access to CEO (yes or no); the percentage of absenteeism (≤19% or >19%); actions to reduce absenteeism (get in contact in advance/overbook or none); the existence of pre-defined allotments for the referral of users to specialized care, by specialty (yes or no); and proof of agreed clinical protocols that guide the referral of users via the PCF to CEO, by specialty (yes or no).

2.3 Data analysis

Due to the lack of empirical and theoretical evidence regarding the waiting time for the studied dental specialties, we chose to carry out an exploratory data analysis.

The frequency distribution of variables was entered into a table according to the waiting time of each specialty. Then, a binary logistic regression model was obtained to determine the likelihood of users having a shorter waiting time for assistance at CEO, by specialty. The independent variables were inserted into the model and submitted to adjustment using the backward stepwise procedure (Wald). Variables with p > .20 were removed from the adjusted model and those with p < .05 were considered statistically significant. Odds Ratio (OR) measures and 95% confidence intervals (CI) were obtained for the study variables. Data were tabulated and analysed in the Statistical Package for Social Sciences program (IBM-SPSS, v.24, IBM, Chicago, IL).

This study followed the ethical principles of the National Health Council's Resolution No. 416/2012 and was previously approved by the Research Ethics Committee of the Center for Health Sciences at the Federal University of Pernambuco, under protocol CAAE 23458213.0.0000.5208.

3 RESULTS

Among the 1042 CEO, 418 (40.1%) were type I, 488 (46.8%) were type II, and 136 (13.1%) were type III. The specialties with the highest and lowest median waiting time were endodontics (30 days) and stomatology (5 days), respectively. Most CEO had a manager (n = 994), and in 38.7% (n = 403) of the cases, the manager worked exclusively in this position. The data further showed that 60% of the CEO’s managers (n = 625) had a work experience of <2 years (Table 1).

TABLE 1. Absolute and relative frequency distribution of the independent variables according to the waiting time for specialized care (stomatology, surgery, endodontics, care for patients with special needs, periodontology) at CEO. Variables Total of CEO Waiting time Stomatology Surgery Endodontics PSN Periodontology >5 days ≤5 days >20 days ≤20 days >30 days ≤30 days >7 days ≤7 days > 15 days ≤15 days N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) Size of the CEO (Type) I 418 (40.1) 155 (47.8) 169 (52.2) 148 (36.3) 260 (63.7) 159 (39.5) 244 (60.5) 136 (35.1) 251 (64.9) 118 (30) 275 (70) II 488 (46.8) 202 (49.5) 206 (50.5) 243 (52.9) 216 (47.1) 230 (50.9) 222 (49.1) 209 (46.1) 244 (53.9) 166 (36.9) 284 (63.1) III 136 (13.1) 47 (41.2) 67 (58.8) 69 (57) 52 (43) 64 (52.5) 58 (47.5) 58 (48.3) 62 (51.7) 47 (39.2) 73 (60.8) Presence of a manager at the CEO Yes, exclusive. 403 (38.7) 142 (43.4) 185 (56.6) 192 (51.6) 180 (48.4) 185 (50.3) 183 (49.7) 169 (46.8) 192 (53.2) 136 (37.5) 227 (62.5) Yes, not exclusive. 591 (56.7) 247 (50.3) 244 (49.7) 246 (42.9) 327 (57.1) 243 (42.9) 323 (57.1) 221 (39.7) 336 (60.3) 182 (32.7) 375 (67.3) No manager. 48 (4.6) 15 (53.6) 13 (46.4) 22 (51.2) 21 (48.8) 25 (58.1) 18 (41.9) 13 (31) 29 (69) 13 (30.2) 30 (69.8) The manager's work experience <1 year 245 (23.5) 99 (49.7) 100 (50.3) 105 (44.7) 130 (55.3) 112 (48.9) 117 (51.1) 93 (40.6) 136 (59.4) 85 (38.1) 138 (61.9) 1–2 years 380 (36.5) 162 (51.6) 152 (48.4) 154 (41.8) 214 (58.2) 138 (37.8) 227 (62.2) 148 (41) 213 (59) 105 (29) 257 (71) 3–4 years 107 (10.3) 40 (47.1) 45 (52.9) 50 (51.5) 47 (48.5) 45 (46.4) 52 (53.6) 45 (47.9) 49 (52.1) 38 (38.8) 60 (61.2) 5–9 years 166 (15.9) 59 (40.1) 88 (59.9) 85 (54.8) 70 (45.2) 86 (56.2) 67 (43.8) 63 (42) 87 (58) 59 (38.6) 94 (61.4) More than 9 years 49 (4.7) 16 (38.1) 26 (61.9) 24 (52.2) 22 (47.8) 28 (60.9) 18 (39.1) 22 (51.2) 21 (48.8) 14 (33.3) 28 (66.7) The manager's complementary training Yes, in Public Health 402 (38.6) 149 (42.3) 203 (57.7) 195 (51.9) 181 (48.1) 187 (50) 187 (50) 161 (43) 213 (57) 146 (39) 228 (61) No 592 (56.8) 240 (51.5) 226 (48.5) 243 (42.7) 326 (57.3) 241 (43) 319 (57) 229 (42.1) 315 (57.9) 172 (31.5) 374 (68.5) Frequency of contact between CEO and PCF Always 432 (41.5) 159 (44.3) 200 (55.7) 167 (40) 251 (60) 170 (41) 245 (59) 138 (33.9) 269 (66.1) 115 (28.4) 290 (71.6) Sometimes/never 665 (63.8) 245 (50.3) 242 (49.7) 293 (51.4) 277 (48.6) 283 (50.4) 279 (49.6) 265 (47.9) 288 (52.1) 216 (38.7) 342 (61.3) Mechanisms for appointment scheduling at CEO Only via the PCF 215 (20.6) 78 (42.6) 105 (57.4) 127 (67.6) 61 (32.4) 123 (66.5) 62 (33.5) 83 (43.5) 108 (56.5) 93 (50.3) 92 (49.7) Only via the user 566 (54.3) 228 (51) 219 (49) 212 (38.8) 334 (61.2) 215 (39.8) 325 (60.2) 215 (40.8) 312 (59.2) 154 (28.9) 378 (71.1) Via the PCF/user 316 (30.3) 98 (45.4) 118 (54.6) 121 (47.6) 133 (52.4) 115 (45.6) 137 (54.4) 105 (43.4) 137 (56.6) 84 (34.1) 162 (65.9) Referral-based access to CEO Yes 637 (61.1) 243 (46.2) 283 (53.8) 312 (52.4) 283 (47.6) 304 (51.5) 286 (48.5) 241 (41.4) 341 (58.6) 226 (38.6) 359 (61.4) No 405 (38.9) 161 (50.3) 159 (49.7) 148 (37.7) 245 (62.3) 149 (38.5) 238 (61.5) 162 (42.9) 216 (57.1) 105 (27.8) 273 (72.2) Percentage of absenteeism ≤19% 392 (37.6) 147 (44.7) 182 (55.3) 167 (44.1) 212 (55.9) 163 (43) 216 (57) 145 (38.7) 230 (61.3) 128 (34.3) 245 (65.7) >19% 380 (36.5) 149 (45.7) 177 (54.3) 208 (59.1) 144 (40. 9) 201 (57.8) 147 (42.2) 161 (46.7) 184 (53.3) 131 (38) 214 (62) Actions to reduce absenteeism Get in contact in advance/overbook 549 (52.7) 207 (43.3) 271 (56.7) 262 (50.3) 259 (49.7) 252 (48.6) 267 (51.4) 200 (38.7) 317 (61.3) 175 (34.1) 338 (65.9) None 223 (21.4) 89 (50.3) 88 (49.7) 113 (53.8) 97 (46.2) 112 (53.8) 96 (46.2) 106 (52.2) 97 (47.8) 84 (41) 121 (59) Allotments for surgery Yes 205 (19.7) 69 (43.1) 91 (56.9) 92 (48.4) 98 (51.6) 89 (47.8) 97 (52.2) 80 (43.5) 104 (56.5) 76 (41.5) 107 (58.5) No 823 (79.0) 331 (48.9) 346 (51.1) 366 (46.3) 425 (53.7) 359 (46) 421 (54) 319 (41.6) 447 (58.4) 252 (32.7) 518 (67.3) Allotments for endodontics Yes 230 (22.1) 80 (42.8) 107 (57.2) 100 (47.2) 112 (52.8) 95 (45.2) 115 (54.8) 87 (42.2) 119 (57.8) 80 (38.6) 127 (61.4) No 795 (76.3) 319 (49.2) 329 (50.8) 357 (46.9) 405 (53.1) 357 (46.9) 405 (53.1) 313 (42.2) 428 (57.8) 248 (33.3) 497 (66.7) Allotments for PSN Yes 174 (16.7) 63 (47) 71 (53) 72 (45.6) 86 (54.4) 71 (45.8) 84 (54.2) 74 (47.1) 83 (52.9) 63 (41.2) 90 (58.8) No 821 (78.8) 334 (49) 348 (51) 370 (47) 417 (53) 369 (47.3) 411 (52.7) 328 (41.8) 456 (58.2) 252 (32.6) 520 (67.4) Allotments for Periodontology Yes 189 (18.1) 65 (43.6) 84 (56.4) 85 (49.1) 88 (50.9) 81 (47.9) 88 (52.1) 73 (43.7) 94 (56.3) 72 (42.6) 97 (57.4) No 823 (79.0) 333 (48.8) 349 (51.2) 365 (46.3) 424 (53.7) 362 (46.2) 421 (53.8) 322 (41.8) 449 (58.2) 259 (33) 526 (67) Allotments for stomatology Yes 108 (10.4) 56 (55.4) 45 (44.6) 49 (48.5) 52 (51.5) 48 (48.5) 51 (51.5) 41 (41.4) 58 (58.6) 45 (45.5) 54 (54.5) No 745 (71.5) 343 (49.8) 346 (50.2) 354 (49.8) 357 (50.2) 344 (48.9) 359 (51.1) 300 (42.7) 402 (57.3) 248 (35.4) 453 (64.6) Proof of protocols for surgery Yes 792 (76.0) 308 (45.6) 367 (54.4) 380 (50.5) 373 (49.5) 367 (49.1) 381 (50.9) 316 (42.4) 430 (57.6) 273 (37) 465 (63) No 95 (9.1) 39 (54.2) 33 (45.8) 29 (31.2) 64 (68.8) 34 (37) 58 (63) 32 (36) 57 (64) 23 (25.8) 66 (74.2) Proof of protocols for endodontics Yes 799 (76.7) 311 (45.8) 368 (54.2) 385 (50.5) 377 (49.5) 373 (49.3) 384 (50.7) 322 (42.8) 431 (57.2) 276 (37) 469 (63) No 94 (9.0) 40 (56.3) 31 (43.7) 26 (28.9) 64 (71.1) 32 (35.2) 59 (64.8) 30 (35.3) 55 (64.7) 23 (26.1) 65 (73.9) Proof of protocols for PSN Yes 771 (74.0) 305 (46.6) 350 (53.4) 374 (51) 360 (49) 356 (48.8) 373 (51.2) 320 (43.8) 411 (56.2) 270 (37.6) 449 (62.4) No 78 (7.5) 34 (55.7) 27 (44.3) 24 (31.2) 53 (68.8) 31 (40.3) 46 (59.7) 31 (40.8) 45 (59.2) 19 (25.7) 55 (74.3) Proof of protocols for periodontology Yes 791 (75.9) 313 (46.4) 362 (53.6) 381 (50.6) 372 (49.4) 366 (48.9) 382 (51.1) 319 (42.8) 426 (57.2) 277 (37.4) 463 (62.6) No 86 (8.3) 37 (56.1) 29 (43.9) 23 (27.4) 61 (72.6) 32 (38.1) 52 (61.9) 29 (36.3) 51 (63.8) 22 (26.8) 60 (73.2) Proof of protocols for stomatology Yes 652 (62.6)