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The American Institutes for Research (AIR) and TRICARE—the Department of Defense's health plan for military personnel and their dependents—developed this survey independent of the CAHPS Consortium. However, the two organizations conducted the development process with the same emphasis on standardization and scientific rigor that characterize CAHPS products and surveys.

The Dental Plan Survey went through the following development process:

Literature review. After initial planning meetings, AIR conducted a comprehensive review of literature on the topic of patients' experiences with dental care. Based on this review, the team identified the following dimensions of dental care quality:

• An emotive or sensory dimension that includes patients' experiences of pain and anxiety, fear in anticipation of pain, and comfort during treatment.
• A dimension encompassing patients' communication and interaction with the dental care provider, including patient-doctor rapport and fostering of a collaborative relationship.
• A dimension regarding patients' perception of comfort, functionality, and aesthetics of dental work, especially with regard to prosthodontics.

Using these three dimensions, the team began work on developing specific domains for survey questions.

Meetings with stakeholders and beneficiaries. AIR and TRICARE held 12 meetings with dental care experts and stakeholders, plus 12 focus groups with beneficiaries and potential survey respondents to better understand their needs and interests. These meetings provided the team with valuable feedback on potential survey topics and domains, as well as strategies for achieving optimal response rates. This input resulted in an initial set of 139 survey items covering seven aspects of care and four domains.

Cognitive testing. After narrowing the instrument down to 61 questions, the survey developers submitted it to two rounds of cognitive testing with TRICARE Dental Plan enrollees. They revised the instrument according to findings from the interviews, resulting in a 50-item questionnaire that contained 3 eligibility items, 14 "Â鶹´«Ã½ You" items, and 33 substantive items (plus a retiree version that contained 3 fewer "Â鶹´«Ã½ You" items).

Field testing. In March 2005, AIR went into the field to test the draft instrument with a sample of over 6,000 TRICARE beneficiaries. AIR's analysis team conducted comprehensive psychometric analyses of the field test data and subsequent data collections. Based on these analyses, the team made revisions that were reflected in the survey submitted to the CAHPS Consortium.

Submission to CAHPS Consortium.  In late 2006, AIR submitted an application to the CAHPS Consortium requesting official adoption of the Dental Plan Survey as a CAHPS instrument. The CAHPS Project Officers and Principal Investigators reviewed the submission and voted to adopt the survey as an official CAHPS product in December 2006.

Additional testing of patient experience measures. During 2007 and 2008, TRICARE administered the CAHPS Dental Plan Survey to enrollees of TRICARE dental plans. AIR evaluated the measurement properties of modified items and composites to determine whether any of the changes compromised the reliability or validity of the composite or global scores. The measurement properties of the modified version were supported.