Comportamiento del paciente de la clínica dental. Modelo basado en la percepción de la calidad del servicio y fidelización del paciente

Esta tesis doctoral propone un modelo de comportamiento del paciente de la clínica dental, basado en la percepción de la calidad del servicio (SERVQUAL), la fidelización del paciente, acciones de Marketing Relacional y aspectos socioeconómicos relevantes, de los pacientes de clínicas dentales. En particular, el estudio de campo se lleva a cabo en el ámbito geográfico de la Comunidad de Madrid, España, durante los años 2012 y 2013. La primera parte del proceso de elaboración del modelo está basada en la recolección de datos. Para ello, se realizaron cinco entrevistas a expertos dentistas y se aplicaron dos tipos encuestas diferentes: una para el universo formado por el conjunto de los pacientes de las clínicas dentales y la otra para el universo formado el conjunto de los dentistas de las clínicas dentales de la Comunidad de Madrid. Se obtuvo muestras de: 200 encuestas de pacientes y 220 encuestas de dentistas activos colegiados en el Ilustre Colegio Oficial de Odontólogos y Estomatólogos de la I Región Madrid. En la segunda parte de la elaboración del modelo, se realizó el análisis de los datos, la inducción y síntesis del modelo propuesto. Se utilizó la metodología de modelos gráficos probabilísticos, específicamente, una Red Bayesiana, donde se integraron variables (nodos) y sus dependencias estadísticas causales (arcos dirigidos), que representan el conocimiento obtenido de los datos recopilados en las encuestas y el conocimiento derivado de investigaciones precedentes en el área. Se obtuvo una Red Bayesiana compuesta por 6 nodos principales, de los cuales dos de ellos son nodos de observación directa: “Revisit Intention” y “SERVQUAL”, y los otros cuatro nodos restantes son submodelos (agrupaciones de variables), estos son respectivamente: “Attitudinal”, “Disease Information”, “Socioeconomical” y “Services”. Entre las conclusiones principales derivadas del uso del modelo, como herramientas de inferencia y los análisis de las entrevistas realizadas se obtiene que: (i) las variables del nodo “Attitudinal” (submodelo), son las más sensibles y significativas. Al realizarse imputaciones particulares en las variables que conforman el nodo “Attitudinal” (“RelationalMk”, “Satisfaction”, “Recommendation” y “Friendship”) se obtienen altas probabilidades a posteriori en la fidelidad del paciente de la clínica dental, medida por su intención de revisita. (ii) En el nodo “Disease Information” (submodelo) se destaca la relación de dependencia causal cuando se imputa la variable “Perception of disease” en “SERVQUAL”, demostrando que la percepción de la gravedad del paciente condiciona significativamente la percepción de la calidad del servicio del paciente. Como ejemplo destacado, si se realiza una imputación en la variable “Clinic_Type” se obtienen altas probabilidades a posteriori de las variables “SERVQUAL” y “Revisit Intention”, lo que evidencia, que el tipo de clínica dental influye significativamente en la percepción de la calidad del servicio y en la fidelidad del paciente (intención de revisita). (iii) En el nodo “Socioeconomical” (submodelo) la variable “Sex” resultó no ser significativa cuando se le imputaban diferentes valores, por el contrario, la variable “Age” e “Income” mostraban altas variabilidades en las probabilidades a posteriori cuando se imputaba alguna variable del submodelo “Services”, lo que evidencia, que estas variables condicionan la intención de contratar servicios (“Services”), sobretodo en las franjas de edad de 30 a 51 años en pacientes con ingresos entre 3000€ y 4000€. (iv) En el nodo “Services” (submodelo) los pacientes de las clínicas dentales mostraron altas probabilidades a priori para contratar servicios de fisiotrapia oral y gingival: “Dental Health Education” y “Parking”. (v) Las variables de fidelidad del paciente medidas desde su perspectiva comportamental que fueron utilizadas en el modelo: “Visit/year” “Time_clinic”, no aportaron información significativa. Tampoco, la variable de fidelidad del cliente (actitudinal): “Churn Efford”. (vi) De las entrevistas realizadas a expertos dentistas se obtiene que, los propietarios de la clínica tradicional tienen poca disposición a implementar nuevas estrategias comerciales, debido a la falta de formación en la gestión comercial y por falta de recursos y herramientas. Existe un rechazo generalizado hacia los nuevos modelos de negocios de clínicas dentales, especialmente en las franquicias y en lo que a políticas comerciales se refiere. Esto evidencia una carencia de gerencia empresarial en el sector. Como líneas futuras de investigación, se propone profundizar en algunas relaciones de dependencia (causales) como SERVQUALServices; SatisfactionServices; RelationalMKServices, Perception of diseaseSatisfaction, entre otras. Así como, otras variables de medición de la fidelidad comportamental que contribuyan a la mejora del modelo, como por ej. Gasto del paciente y rentabilidad de la visita. ABSTRACT This doctoral dissertation proposes a model of the behavior of the dental-clinic customer, based on the service-quality perception (SERVQUAL), loyalty, Relational Marketing and some relevant socio-economical characteristics, of the dental-clinic customers. In particular, the field study has been developed in the geographical region of Madrid, Spain during the years 2012 and 2013. The first stage of the preparation of the model consist in the data gathering process. For this purpose, five interviews where realized to expert dentists and also two different types of surveys: one for the universe defined by the set of dental-clinic patients and the second for the universe defined by the set of the dentists of the dental clinics of the Madrid Community. A sample of 200 surveys where collected for patients and a sample of 220 surveys where collected from active dentists belonging to the Ilustre Colegio Oficial de Odontólogos y Estomatólogos de la I Región Madrid. In the second stage of the model preparation, the processes of data-analysis, induction and synthesis of the final model where performed. The Graphic Probabilistic Models methodology was used to elaborate the final model, specifically, a Bayesian Network, where the variables (nodes) and their statistical and causal dependencies where integrated and modeled, representing thus, the obtained knowledge from the data obtained by the surveys and the scientific knowledge derived from previous research in the field. A Bayesian Net consisting on six principal nodes was obtained, of which two of them are directly observable: “Revisit Intention” y “SERVQUAL”, and the remaining four are submodels (a grouping of variables). These are: “Attitudinal”, “Disease Information”, “Socioeconomical” and “Services”. The main conclusions derived from the model, as an inference tool, and the analysis of the interviews are: (i) the variables inside the “Attitudinal” node are the most sensitive and significant. By making some particular imputations on the variables that conform the “Attitudinal” node (“RelationalMk”, “Satisfaction”, “Recommendation” y “Friendship”), high posterior probabilities (measured in revisit intention) are obtained for the loyalty of the dental-clinic patient. (ii) In the “Disease Information” node, the causal relation between the “Perception of disease” and “SERVQUAL” when “Perception of disease” is imputed is highlighted, showing that the perception of the severity of the patient’s disease conditions significantly the perception of service quality. As an example, by imputing some particular values to the “Clinic_Type” node high posterior probabilities are obtained for the “SERVQUAL” variables and for “Revisit Intention” showing that the clinic type influences significantly in the service quality perception and loyalty (revisit intention). (iii) In the “Socioeconomical” variable, the variable “Sex” showed to be non-significant, however, the “Age” variable and “Income” show high variability in its posterior probabilities when some variable from the “Services” node where imputed, showing thus, that these variables condition the intention to buy new services (“Services”), especially in the age range from 30 to 50 years in patients with incomes between 3000€ and 4000€. (iv) In the “Services” submodel the dental-clinic patients show high priors to buy services such as oral and gingival therapy, Dental Health Education and “Parking” service. (v) The obtained loyalty measures, from the behavioral perspective, “Visit/year” and “Time_clinic”, do not add significant information to the model. Neither the attitudinal loyalty component “Churn Efford”. (vi) From the interviews realized to the expert dentists it is observed that the owners of the traditional clinics have a low propensity to apply new commercial strategies due to a lack of resources and tools. In general, there exists an opposition to new business models in the sector, especially to the franchise dental model. All of this evidences a lack in business management in the sector. As future lines of research, a deep look into some statistical and causal relations is proposed, such as: SERVQUALServices; SatisfactionServices; RelationalMKServices, Perception of diseaseSatisfaction, as well as new measurement variables related to attitudinal loyalty that contribute to improve the model, for example, profit per patient and per visit.

Intrastriatal injection of an adenoviral vector expressing glial-cell-line-derived neurotrophic factor prevents dopaminergic neuron degeneration and behavioral impairment in a rat model of Parkinson disease

Glial-cell-line-derived neurotrophic factor (GDNF) is a potent neurotrophic factor for adult nigral dopamine neurons in vivo. GDNF has both protective and restorative effects on the nigro-striatal dopaminergic (DA) system in animal models of Parkinson disease. Appropriate administration of this factor is essential for the success of its clinical application. Since it cannot cross the blood–brain barrier, a gene transfer method may be appropriate for delivery of the trophic factor to DA cells. We have constructed a recombinant adenovirus (Ad) encoding GDNF and injected it into rat striatum to make use of its ability to infect neurons and to be retrogradely transported by DA neurons. Ad-GDNF was found to drive production of large amounts of GDNF, as quantified by ELISA. The GDNF produced after gene transfer was biologically active: it increased the survival and differentiation of DA neurons in vitro. To test the efficacy of the Ad-mediated GDNF gene transfer in vivo, we used a progressive lesion model of Parkinson disease. Rats received injections unilaterally into their striatum first of Ad and then 6 days later of 6-hydroxydopamine. We found that mesencephalic nigral dopamine neurons of animals treated with the Ad-GDNF were protected, whereas those of animals treated with the Ad-β-galactosidase were not. This protection was associated with a difference in motor function: amphetamine-induced turning was much lower in animals that received the Ad-GDNF than in the animals that received Ad-β-galactosidase. This finding may have implications for the development of a treatment for Parkinson disease based on the use of neurotrophic factors.

Rapid down-regulation of mammalian Period genes during behavioral resetting of the circadian clock

The pervasive role of circadian clocks in regulating physiology and behavior is widely recognized. Their adaptive value is their ability to be entrained by environmental cues such that the internal circadian phase is a reliable predictor of solar time. In mammals, both light and nonphotic behavioral cues can entrain the principal oscillator of the hypothalamic suprachiasmatic nuclei (SCN). However, although light can advance or delay the clock during circadian night, behavioral events trigger phase advances during the subjective day, when the clock is insensitive to light. The recent identification of Period (Per) genes in mammals, homologues of dperiod, which encodes a core element of the circadian clockwork in Drosophila, now provides the opportunity to explain circadian timing and entrainment at a molecular level. In mice, expression of mPer1 and mPer2 in the SCN is rhythmic and acutely up-regulated by light. Moreover, the temporal relations between mRNA and protein cycles are consistent with a clock based on a transcriptional/translational feedback loop. Here we describe circadian oscillations of Per1 and Per2 in the SCN of the Syrian hamster, showing that PER1 protein and mRNA cycles again behave in a manner consistent with a negative-feedback oscillator. Furthermore, we demonstrate that nonphotic resetting has the opposite effect to light: acutely down-regulating these genes. Their sensitivity to nonphotic resetting cues supports their proposed role as core elements of the circadian oscillator. Moreover, this study provides an explanation at the molecular level for the contrasting but convergent effects of photic and nonphotic cues on the clock.

Orphanin FQ acts as an anxiolytic to attenuate behavioral responses to stress

Orphanin FQ (OFQ, Nociceptin) is a recently discovered 17-amino acid neuropeptide that is structurally related to the opioid peptides but does not bind opioid receptors. OFQ has been proposed to act as an anti-opioid peptide, but its widespread sites of action in the brain suggest that it may have more general functions. Here we show that OFQ plays an important role in higher brain functions because it can act as an anxiolytic to attenuate the behavioral inhibition of animals acutely exposed to stressful/anxiogenic environmental conditions. OFQ anxiolytic-like effects were consistent across several behavioral paradigms generating different types of anxiety states in animals (light-dark preference, elevated plus-maze, exploratory behavior of an unfamiliar environment, pharmacological anxiogenesis, operant conflict) and were observed at low nonsedating doses (0.1–3 nmol, intracerebroventricular). Like conventional anxiolytics, OFQ interfered with regular sensorimotor function at high doses (>3 nmol). Our results show that an important role of OFQ is to act as an endogenous regulator of acute anxiety responses. OFQ, probably in concert with other major neuropeptides, exerts a modulatory role on the central integration of stressful stimuli and, thereby, may modulate anxiety states generated by acute stress.

Elucidation of a PTS–Carbohydrate Chemotactic Signal Pathway in Escherichia coli Using a Time-resolved Behavioral Assay

Chemotaxis of Escherichia coli toward phosphotransferase systems (PTSs)–carbohydrates requires phosphoenolpyruvate-dependent PTSs as well as the chemotaxis response regulator CheY and its kinase, CheA. Responses initiated by flash photorelease of a PTS substrates d-glucose and its nonmetabolizable analog methyl α-d-glucopyranoside were measured with 33-ms time resolution using computer-assisted motion analysis. This, together with chemotactic mutants, has allowed us to map out and characterize the PTS chemotactic signal pathway. The responses were absent in mutants lacking the general PTS enzymes EI or HPr, elevated in PTS transport mutants, retarded in mutants lacking CheZ, a catalyst of CheY autodephosphorylation, and severely reduced in mutants with impaired methyl-accepting chemotaxis protein (MCP) signaling activity. Response kinetics were comparable to those triggered by MCP attractant ligands over most of the response range, the most rapid being 11.7 ± 3.1 s−1. The response threshold was <10 nM for glucose. Responses to methyl α-d-glucopyranoside had a higher threshold, commensurate with a lower PTS affinity, but were otherwise kinetically indistinguishable. These facts provide evidence for a single pathway in which the PTS chemotactic signal is relayed rapidly to MCP–CheW–CheA signaling complexes that effect subsequent amplification and slower CheY dephosphorylation. The high sensitivity indicates that this signal is generated by transport-induced dephosphorylation of the PTS rather than phosphoenolpyruvate consumption.

Behavioral alterations associated with apoptosis and down-regulation of presenilin 1 in the brains of p53-deficient mice

Presenilin 1 (PS1) expression is repressed by the p53 tumor suppressor. As shown herein, wild-type PS1 is an effective antiapoptotic molecule capable of significantly inhibiting p53-dependent and p53-independent cell death. We analyzed, at the functional and molecular levels, the brains of p53 knockout mice. Surprisingly, we found that lack of p53 expression induces apoptotic brain lesions, accompanied by learning deficiency and behavioral alterations. p53-deficient mice show an unexpected overexpression of p21waf1 with subsequent down-regulation of PS1 in their brains. This process is progressive and age-dependent. These data indicate that the p53 pathway, besides affecting tumor suppression, may play a major role in regulating neurobehavioral function and cell survival in the brain.

Ts1Cje, a partial trisomy 16 mouse model for Down syndrome, exhibits learning and behavioral abnormalities

A mouse model for Down syndrome, Ts1Cje, has been developed. This model has made possible a step in the genetic dissection of the learning, behavioral, and neurological abnormalities associated with segmental trisomy for the region of mouse chromosome 16 homologous with the so-called “Down syndrome region” of human chromosome segment 21q22. Tests of learning in the Morris water maze and assessment of spontaneous locomotor activity reveal distinct learning and behavioral abnormalities, some of which are indicative of hippocampal dysfunction. The triplicated region in Ts1Cje, from Sod1 to Mx1, is smaller than that in Ts65Dn, another segmental trisomy 16 mouse, and the learning deficits in Ts1Cje are less severe than those in Ts65Dn. In addition, degeneration of basal forebrain cholinergic neurons, which was observed in Ts65Dn, was absent in Ts1Cje.

The role of the D2 dopamine receptor (D2R) in A2A adenosine receptor (A2AR)-mediated behavioral and cellular responses as revealed by A2A and D2 receptor knockout mice

The A2AR is largely coexpressed with D2Rs and enkephalin mRNA in the striatum where it modulates dopaminergic activity. Activation of the A2AR antagonizes D2R-mediated behavioral and neurochemical effects in the basal ganglia through a mechanism that may involve direct A2AR–D2R interaction. However, whether the D2R is required for the A2AR to exert its neural function is an open question. In this study, we examined the role of D2Rs in A2AR-induced behavioral and cellular responses, by using genetic knockout (KO) models (mice deficient in A2ARs or D2Rs or both). Behavioral analysis shows that the A2AR agonist 2–4-(2-carboxyethyl)phenethylamino-5′-N-ethylcarboxamidoadenosine reduced spontaneous as well as amphetamine-induced locomotion in both D2 KO and wild-type mice. Conversely, the nonselective adenosine antagonist caffeine and the A2AR antagonist 8-(3-chlorostyryl)caffeine produced motor stimulation in mice lacking the D2R, although the stimulation was significantly attentuated. At the cellular level, A2AR inactivation counteracted the increase in enkephalin expression in striatopallidal neurons caused by D2R deficiency. Consistent with the D2 KO phenotype, A2AR inactivation partially reversed both acute D2R antagonist (haloperidol)-induced catalepsy and chronic haloperidol-induced enkephalin mRNA expression. Together, these results demonstrate that A2ARs elicit behavioral and cellular responses despite either the genetic deficiency or pharmacological blockade of D2Rs. Thus, A2AR-mediated neural functions are partially independent of D2Rs. Moreover, endogenous adenosine acting at striatal A2ARs may be most accurately viewed as a facilitative modulator of striatal neuronal activity rather than simply as an inhibitory modulator of D2R neurotransmission.

Behavioral inferences from the Skhul/Qafzeh early modern human hand remains

Two groups of humans are found in the Near East ≈100,000 years ago, the late archaic Neanderthals and the early modern Skhul/Qafzeh humans. Observations that Neanderthals were more heavily muscled, had stronger upper-limb bones, and possessed unusual shapes and orientations of some upper-limb joint complexes relative to the Skhul/Qafzeh hominids, have led some researchers to conclude that significant between-group upper-limb-related behavioral differences must have been present, despite the association of the two groups with similar Middle Paleolithic archeological complexes. A three-dimensional morphometric analysis of the hand remains of the Skhul/Qafzeh hominids, Neanderthals, early and late Upper Paleolithic humans, and Holocene humans supports the dichotomy. The Skhul/Qafzeh carpometacarpal remains do not have any unique morphologies relative to the other fossil samples remains examined. However, in the functionally significant metacarpal 1 and 3 bases they resemble Upper Paleolithic humans, not Neanderthals. Furthermore, the Skhul/Qafzeh sample differs significantly from the Neanderthals in many other aspects of hand functional anatomy. Given the correlations between changes in tool technologies and functional adaptations seen in the hands of Upper Paleolithic humans, it is concluded that the Skhul/Qafzeh hand remains were adapted to Upper Paleolithic-like manipulative repertoires. These results support the inference of significant behavioral differences between Neanderthals and the Skhul/Qafzeh hominids and indicate that a significant shift in human manipulative behaviors was associated with the earliest stages of the emergence of modern humans.

Behavioral economics: Reunifying psychology and economics

“Behavioral economics” improves the realism of the psychological assumptions underlying economic theory, promising to reunify psychology and economics in the process. Reunification should lead to better predictions about economic behavior and better policy prescriptions.

The neural development and organization of letter recognition: Evidence from functional neuroimaging, computational modeling, and behavioral studies

Although much of the brain’s functional organization is genetically predetermined, it appears that some noninnate functions can come to depend on dedicated and segregated neural tissue. In this paper, we describe a series of experiments that have investigated the neural development and organization of one such noninnate function: letter recognition. Functional neuroimaging demonstrates that letter and digit recognition depend on different neural substrates in some literate adults. How could the processing of two stimulus categories that are distinguished solely by cultural conventions become segregated in the brain? One possibility is that correlation-based learning in the brain leads to a spatial organization in cortex that reflects the temporal and spatial clustering of letters with letters in the environment. Simulations confirm that environmental co-occurrence does indeed lead to spatial localization in a neural network that uses correlation-based learning. Furthermore, behavioral studies confirm one critical prediction of this co-occurrence hypothesis, namely, that subjects exposed to a visual environment in which letters and digits occur together rather than separately (postal workers who process letters and digits together in Canadian postal codes) do indeed show less behavioral evidence for segregated letter and digit processing.

Chemical communication in scarab beetles: reciprocal behavioral agonist-antagonist activities of chiral pheromones.

A novel mechanism of reciprocal behavioral agonist-antagonist activities of enantiomeric pheromones plays a pivotal role in overcoming the signal-to-noise problem derived from the use of a single-constituent pheromone system in scarab beetles. Female Anomala osakana produce (S, Z)-5-(+)-(1-decenyl)oxacyclopentan-2-one, which is highly attractive to males; the response is completely inhibited even by 5% of its antipode. These two enantiomers have reverse roles in the Popillia japonica sex pheromone system. Chiral GC-electroantennographic detector experiments suggest that A. osakana and P. japonica have both R and S receptors that are responsible for behavioral agonist and antagonist responses.

Common endocrine and genetic mechanisms of behavioral development in male and worker honey bees and the evolution of division of labor.

Temporal polyethism is a highly derived form of behavioral development displayed by social insects. Hormonal and genetic mechanisms regulating temporal polyethism in worker honey bees have been identified, but the evolution of these mechanisms is not well understood. We performed three experiments with male honey bees (drones) to investigate how mechanisms regulating temporal polyethism may have evolved because, relative to workers, drones display an intriguing combination of similarities and differences in behavioral development. We report that behavioral development in drones is regulated by mechanisms common to workers. In experiment 1, drones treated with the juvenile hormone (JH) analog methoprene started flying at significantly younger ages than did control drones, as is the case for workers. In experiment 2, there was an age-related increase in JH associated with the onset of drone flight, as in workers. In experiment 3, drones derived from workers with fast rates of behavioral development themselves started flying at younger ages than drones derived from workers with slower rates of behavioral development. These results suggest that endocrine and genetic mechanisms associated with temporal polyethism did not evolve strictly within the context of worker social behavior.