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de Lara JVI, Frazão P. Oral health guidelines in the primary care policies of five selected countries: An integrative review. HEALTH POLICY OPEN 2021. [DOI: 10.1016/j.hpopen.2021.100042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Harris R, Vernazza C, Laverty L, Lowers V, Burnside G, Brown S, Higham S, Ternent L. Presenting patients with information on their oral health risk: the PREFER three-arm RCT and ethnography. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
A new NHS dental practice contract is being tested using a traffic light (TL) system that categorises patients as being at red (high), amber (medium) or green (low) risk of poor oral health. This is intended to increase the emphasis on preventative dentistry, including giving advice on ways patients can improve their oral health. Quantitative Light-Induced Fluorescence (QLF™) cameras (Inspektor Research Systems BV, Amsterdam, the Netherlands) also potentially offer a vivid portrayal of information on patients’ oral health.
Methods
Systematic review – objective: to investigate how patients value and respond to different forms of information on health risks. Methods: electronic searches of nine databases, hand-searching of eight specialist journals and backwards and forwards citation-chasing followed by duplicate title, abstract- and paper-screening and data-extraction. Inclusion criteria limited studies to personalised information on risk given to patients as part of their health care. Randomised controlled trial (RCT) – setting: NHS dental practice. Objective: to investigate patients’ preferences for and response to different forms of information about risk given at check-ups. Design: a pragmatic, multicentred, three-arm, parallel-group, patient RCT. Participants: adults with a high/medium risk of poor oral health attending NHS dental practices. Interventions: (1) information given verbally supported by a card showing the patient’s TL risk category; (2) information given verbally supported by a QLF photograph of the patient’s mouth. The control was verbal information only (usual care). Main outcome measures: primary outcome – median valuation for the three forms of information measured by willingness to pay (WTP). Secondary outcomes included toothbrushing frequency and duration, dietary sugar intake, smoking status, self-rated oral health, a basic periodontal examination, Plaque Percentage Index and the number of tooth surfaces affected by caries (as measured by QLF). Qualitative study – an ethnography involving observations of 368 dental appointments and interviews with patients and dental teams.
Results
Systematic review – the review identified 12 papers (nine of which were RCTs). Eight studies involved the use of computerised risk assessments in primary care. Intervention effects were generally modest, even with respect to modifying risk perceptions rather than altering behaviour or clinical outcomes. RCT – the trial found that 51% of patients identified verbal information as their most preferred form, 35% identified QLF as most preferred and 14% identified TL information as most preferred. The median WTP for TL was about half that for verbal information alone. Although at 6 and 12 months patients reported taking less sugar in drinks, and at 12 months patients reported longer toothbrushing, there was no difference by information group. Qualitative study – there was very little explicit risk talk. Lifestyle discussions were often cursory to avoid causing shame or embarrassment to patients.
Limitations
Only 45% of patients were retained in the trial at 6 months and 31% were retained at 12 months. The trial was conducted in four dental practices, and five dental practices were involved in the qualitative work.
Conclusions
Patients prefer personal, detailed verbal advice on oral health at their check-up. A new NHS dental practice contract using TL categorisation might make this less likely.
Future work
Research on how to deliver, within time constraints, effective advice to patients on preventing poor oral health. More research on ‘risk work’ in wider clinical settings is also needed.
Trial registration
Current Controlled Trials ISRCTN71242343.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 3. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rebecca Harris
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | | | - Louise Laverty
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Victoria Lowers
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Girvan Burnside
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Stephen Brown
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Susan Higham
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Laura Ternent
- Institute of Health and Social Care, Newcastle University, Newcastle upon Tyne, UK
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Robinson PG, Douglas GVA, Gibson BJ, Godson J, Vinall-Collier K, Pavitt S, Hulme C. Remuneration of primary dental care in England: a qualitative framework analysis of perspectives of a new service delivery model incorporating incentives for improved access, quality and health outcomes. BMJ Open 2019; 9:e031886. [PMID: 31585977 PMCID: PMC6797242 DOI: 10.1136/bmjopen-2019-031886] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE This study aimed to describe stakeholder perspectives of a new service delivery model in primary care dentistry incorporating incentives for access, quality and health outcomes. DESIGN Data were collected through observations, interviews and focus groups. SETTING This was conducted under six UK primary dental care practices, three working under the incentive-driven contract and three working under the traditional activity-based contract. PARTICIPANTS Observations were made of 30 dental appointments. Eighteen lay people, 15 dental team staff and a member of a commissioning team took part in the interviews and focus groups. RESULTS Using a qualitative framework analysis informed by Andersen's model of access, we found oral health assessments influenced patients' perceptions of need, which led to changes in preventive behaviour. Dentists responded to the contract, with greater emphasis on prevention, use of the disease risk ratings in treatment planning, adherence to the pathways and the utilisation of skill-mix. Participants identified increases in the capacity of practices to deliver more care as a result. These changes were seen to improve evaluated and perceived health and patient satisfaction. These outcomes fed back to shape people's predispositions to visit the dentist. CONCLUSION The incentive-driven contract was perceived to increase access to dental care, determine dentists' and patients' perceptions of need, their behaviours, health outcomes and patient satisfaction. Dentists face challenges in refocusing care, perceptions of preventive dentistry, deployment of skill mix and use of the risk assessments and care pathways. Dentists may need support in these areas and to recognise the differences between caring for individual patients and the patient-base of a practice.
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Affiliation(s)
- Peter G Robinson
- School of Oral and Dental Sciences, University of Bristol, Bristol, UK
| | | | - Barry J Gibson
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Jenny Godson
- School of Dentistry, University of Leeds, Leeds, UK
- Dental Public Health, Public Health England, Leeds, UK
| | | | - Sue Pavitt
- School of Dentistry, University of Leeds, Leeds, UK
| | - Claire Hulme
- Health Economics Group, University of Exeter, Exeter, UK
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Harris R, Vernazza C, Laverty L, Lowers V, Brown S, Burnside G, Ternent L, Higham S, Steele J. Presenting information on dental risk: PREFER study protocol for a randomised controlled trial involving patients receiving a dental check-up. Contemp Clin Trials Commun 2018; 11:1-9. [PMID: 30023454 PMCID: PMC6022252 DOI: 10.1016/j.conctc.2018.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 04/11/2018] [Accepted: 05/03/2018] [Indexed: 12/14/2022] Open
Abstract
Introduction A new dental contract being tested in England places patients into traffic light categories according to risk (Red = High risk). This reflects health policy which emphasises patients' shared responsibility for their health, and a growing expectation that clinicians discuss health risk in consultations. Alongside this, there are technological developments such as scans and photographs which have generated new, vivid imagery which may be used to communicate risk information to patients. However, there is little evidence as to whether the form in which risk information is given is important. Methods The PREFER study is a pragmatic, multi-centre, three-arm, patient-level randomised controlled trial, based in four NHS dental practices, from which 400 high/medium risk patients will be recruited. The study compares three ways of communicating risk information at dental check-ups: 1) verbal only (usual care); 2) a Traffic Light graphic with verbal explanation; 3) a Quantitative Light-Induced Fluorescence (QLF) photograph showing, for example, patches of red fluorescence where dental plaque has been present for two days or more (with a verbal explanation). The study assesses patient preferences using the economic preference-based valuation methodology Willingness-to-Pay (WTP). Any changes in oral self-care (for example in tooth-brushing), will be measured by self-report, and clinical outcome data collected by clinicians and extracted from QLF photographs. Predictors and moderators of any behaviour change will be explored using demographic characteristics and psychological variables from the Extended Parallel Process Model. A cost-benefit framework will explore the financial implications for NHS dentistry of the three risk presentation methods.
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Affiliation(s)
- Rebecca Harris
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, Merseyside, UK
| | - Christopher Vernazza
- School of Dental Sciences, Newcastle University, Newcastle-upon-Tyne, Tyne and Wear, UK
| | - Louise Laverty
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, Merseyside, UK
| | - Victoria Lowers
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, Merseyside, UK
| | - Stephen Brown
- Department of Psychological Sciences, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, Merseyside, UK
| | - Girvan Burnside
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, Merseyside, UK
| | - Laura Ternent
- Institute of Health and Society, Newcastle University, Newcastle-upon-Tyne, Tyne and Wear, UK
| | - Susan Higham
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, Merseyside, UK
| | - Jimmy Steele
- School of Dental Sciences, Newcastle University, Newcastle-upon-Tyne, Tyne and Wear, UK
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Barreiro-Pérez M, Tundidor-Sanz E, Martín-García A, Díaz-Peláez E, Íscar-Galán A, Merchán-Gómez S, Gallego-Delgado M, Jiménez-Candil J, Cruz-González I, Sánchez PL. Primera resonancia magnética gestionada por cardiología en la red sanitaria pública española: experiencia y dificultades de un modelo innovador. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2017.11.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Barreiro-Pérez M, Tundidor-Sanz E, Martín-García A, Díaz-Peláez E, Íscar-Galán A, Merchán-Gómez S, Gallego-Delgado M, Jiménez-Candil J, Cruz-González I, Sánchez PL. First Magnetic Resonance Managed by a Cardiology Department in the Spanish Public Healthcare System. Experience and Difficulties of an Innovative Model. ACTA ACUST UNITED AC 2018; 71:365-372. [PMID: 29598851 DOI: 10.1016/j.rec.2018.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/24/2017] [Indexed: 01/03/2023]
Abstract
Magnetic resonance (MR) is considered the gold standard in the assessment of myocardial morphology, function, perfusion, and viability. However, its main limitation is its scarce availability. In 2014, we installed the first MR scanner exclusively managed by a cardiology department within the publicly-funded Spanish healthcare system with the aim of improving patient-care, training and research in the department. In the time interval analyzed, July 2014 to May 2017, 3422 cardiac MR scans were performed (32minutes used per study; 96% with good quality; 75% with contrast media administration). The most prevalent clinical indications were cardiomyopathy (29%) and ischemic heart disease (12%). Twenty-five percent of studies were conducted in the context of research protocols. Follow-up studies predominated among outpatients, while pretherapeutic assessment was more common in hospitalized patients. The presumptive diagnosis was changed by cardiac MR scanning in up to 20% of patients investigated for ischemic heart disease. The installation and operative management of an MR scanner in our cardiology department has allowed us to integrate this technique into daily clinical practice, modify our clinical protocols, optimize access to this technology among cardiac patients, improve training, and conduct clinical research.
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Affiliation(s)
- Manuel Barreiro-Pérez
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Elena Tundidor-Sanz
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Ana Martín-García
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Elena Díaz-Peláez
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Alberto Íscar-Galán
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Soraya Merchán-Gómez
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - María Gallego-Delgado
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Javier Jiménez-Candil
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Ignacio Cruz-González
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Pedro L Sánchez
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain.
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Hulme C, Robinson PG, Saloniki EC, Vinall-Collier K, Baxter PD, Douglas G, Gibson B, Godson JH, Meads D, Pavitt SH. Shaping dental contract reform: a clinical and cost-effective analysis of incentive-driven commissioning for improved oral health in primary dental care. BMJ Open 2016; 6:e013549. [PMID: 27609858 PMCID: PMC5020665 DOI: 10.1136/bmjopen-2016-013549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the clinical and cost-effectiveness of a new blended dental contract incentivising improved oral health compared with a traditional dental contract based on units of dental activity (UDAs). DESIGN Non-randomised controlled study. SETTING Six UK primary care dental practices, three working under a new blended dental contract; three matched practices under a traditional contract. PARTICIPANTS 550 new adult patients. INTERVENTIONS A new blended/incentive-driven primary care dentistry contract and service delivery model versus the traditional contract based on UDAs. MAIN OUTCOME MEASURES Primary outcome was as follows: percentage of sites with gingival bleeding on probing. Secondary outcomes were as follows: extracted and filled teeth (%), caries (International Caries Detection and Assessment System (ICDAS)), oral health-related quality of life (Oral Health Impact Profile-14 (OHIP-14)). Incremental cost-effective ratios used OHIP-14 and quality adjusted life years (QALYs) derived from the EQ-5D-3L. RESULTS At 24 months, 291/550 (53%) patients returned for final assessment; those lost to follow-up attended 6.46 appointments on average (SD 4.80). The primary outcome favoured patients in the blended contract group. Extractions and fillings were more frequent in this group. Blended contracts were financially attractive for the dental provider but carried a higher cost for the service commissioner. Differences in generic health-related quality of life were negligible. Positive changes over time in oral health-related quality of life in both groups were statistically significant. CONCLUSIONS This is the first UK study to assess the clinical and cost-effectiveness of a blended contract in primary care dentistry. Although the primary outcome favoured the blended contract, the results are limited because 47% patients did not attend at 24 months. This is consistent with 39% of adults not being regular attenders and 27% only visiting their dentist when they have a problem. Promotion of appropriate attendance, especially among those with high need, necessitates being factored into recruitment strategies of future studies.
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Affiliation(s)
- C Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - P G Robinson
- School of Oral and Dental Sciences, University of Bristol, Bristol, UK
| | - E C Saloniki
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - P D Baxter
- Division of Epidemiology & Biostatistics, Leeds Institute of Cardiovascular & Metabolic Medicine, University of Leeds, Leeds, UK
| | - G Douglas
- School of Dentistry, University of Leeds, Leeds, UK
| | - B Gibson
- Unit of Dental Public Health, School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - J H Godson
- School of Dentistry, University of Leeds, Leeds, UK
| | - D Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - S H Pavitt
- Director of the Dental Translational and Clinical Research Unit, School of Dentistry, University of Leeds, Leeds, UK
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Holmes RD, Steele JG, Donaldson C, Exley C. Learning from contract change in primary care dentistry: A qualitative study of stakeholders in the north of England. Health Policy 2015; 119:1218-25. [PMID: 25765782 PMCID: PMC4561527 DOI: 10.1016/j.healthpol.2015.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/16/2015] [Accepted: 02/17/2015] [Indexed: 12/01/2022]
Abstract
Commissioners’ ability to reallocate resources between contracts is constrained. Patients are unclear about the costs of dental treatment and the NHS charge bands. Dentists dislike the target-based approach involving units of dental activity. Disease prevention is not adequately rewarded under the current dental contract. The quality of dental care provided by dentists should be measured and rewarded.
The aim of this research was to explore and synthesise learning from stakeholders (NHS dentists, commissioners and patients) approximately five years on from the introduction of a new NHS dental contract in England. The case study involved a purposive sample of stakeholders associated with a former NHS Primary Care Trust (PCT) in the north of England. Semi-structured interviews were conducted with 8 commissioners of NHS dental services and 5 NHS general dental practitioners. Three focus group meetings were held with 14 NHS dental patients. All focus groups and interviews were audio recorded and transcribed verbatim. The data were analysed using a framework approach. Four themes were identified: ‘commissioners’ views of managing local NHS dental services’; ‘the risks of commissioning for patient access’; ‘costs, contract currency and commissioning constraints’; and ‘local decision-making and future priorities’. Commissioners reported that much of their time was spent managing existing contracts rather than commissioning services. Patients were unclear about the NHS dental charge bands and dentists strongly criticised the contract's target-driven approach which was centred upon them generating ‘units of dental activity’. NHS commissioners remained relatively constrained in their abilities to reallocate dental resources amongst contracts. The national focus upon practitioners achieving their units of dental activity appeared to outweigh interest in the quality of dental care provided.
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Affiliation(s)
- Richard D Holmes
- Centre for Oral Health Research, School of Dental Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4BW, UK.
| | - Jimmy G Steele
- Centre for Oral Health Research, School of Dental Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4BW, UK.
| | - Cam Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Level 3-Buchanan House, 58 Port Dundas Road, Glasgow G4 0BA, UK.
| | - Catherine Exley
- Institute of Health & Society, Newcastle University, The Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne NE2 4AX, UK.
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