What is the evidence on the effectiveness of strategies to integrate oral health into primary care?

DATA SOURCES AND SEARCH STRATEGY

Seven databases (MEDLINE, CINAHL, Embase, Scopus, ProQuest, Cochrane and Google Scholar) were searched up to the third week in June 2022. Keyword search terms were based on four key concepts: oral health, primary health, strategies, and integration.

STUDY SELECTION

Peer-reviewed studies that evaluated any strategies to integrate oral health into primary care (e.g., guidelines, policies, workforce programmes) were included in the review. Eligibility was restricted to papers written in English language. Papers in non-primary care settings or which did not describe an evaluation were excluded. Two reviewers independently screened titles and abstracts and thereafter full texts. Disagreements were resolved by consulting a third reviewer.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by one reviewer; a second person verified accuracy. Covidence was used for data extraction. Two independent reviewers critically appraised the papers using the relevant tools (e.g. Critical Appraisal Skills Programme, Cochrane Collaboration, and STrengthening the Reporting of Observational studies in Epidemiology). PRISMA flow diagram was used to present the study selection process. Review findings were reported using a narrative synthesis approach. The Health System Building Blocks (HSBB) was used as a basis for structuring the results/discussion. Heterogeneity among the included studies was high and therefore no meta-analysis was conducted.

RESULTS

Forty-nine studies were included, of which two were RCTs. Most studies described oral healthcare delivered by non-dental primary care professionals within primary care services. Other settings included community, schools, and care homes. Outcomes of interest included: access to oral healthcare, knowledge/attitudes/perceptions, change in dental caries estimates. Almost all studies, except two studies which found no difference in the outcomes measured, favoured an integration strategy. Integration was achieved by enhancing competency (e.g. oral health promotion-trained educators), re-orientating responsibilities of health professionals at an organisation level and/or policy changes (e.g. expanded health insurance policy coverage to include oral health). Integration strategies enhanced access through improved referral pathways, documentation processes, operating efficiency, the number of health staff on hand, increased visits for oral health issues, higher fluoride varnish application rates for children, and more visits to dental health professionals.

CONCLUSIONS

In this review, promoting an integrated approach for oral health was associated with improvements across a range of outcomes. Integrating oral health into primary care is complex but holds promise for reducing the burden of dental diseases. Identifying the best practice models of service integration requires further research and evaluation.

A Scoping Review of the Oral Health Status, Oral Health Behaviours and Interventions to Improve the Oral Health of Children and Young People in Care and Care Leavers

BACKGROUND

Children and young people (CYP) in care experience poorer physical health and overall wellbeing in comparison to their peers. Despite this, relatively little is known about what their oral health needs and behaviours are. The aim of this scoping review was to provide a global perspective on the oral health status and behaviours of CYP in care and care leavers. It also aimed to synthesise interventions that have been trialled in this population to improve oral health.

METHODS

Five databases were searched, Ovid Embase, Ovid MEDLINE, CINAHL (EBSCOhost), SocINDEX (EBSCOhost) and Dentistry and Oral Sciences Source (EBSCOhost), alongside grey literature sources up to January 2023. Eligibility criteria were studies that (i) reported on children and adolescents aged 25 years or younger who are currently in formal/informal foster or residential care and care leavers, (ii) pertained to oral health profile, behaviours or oral health promotion interventions (iii) and were published in the English language. Thematic analysis was used to develop the domains for oral health behaviours and interventions.

RESULTS

Seventy-one papers were included. Most papers were published from very high or medium Human Development Index countries. CYP in care were found to experience high levels of decay, dental trauma, periodontal disease and poorer oral health-related quality of life. Oral health behaviours included limited oral health self-care behaviours and a lack of oral health-based knowledge. The trialled interventions involved oral health education, supervised brushing and treatment or preventative dental care.

CONCLUSIONS

This scoping review reveals that CYP in care experience poorer oral health in comparison to their peers. They are also less likely to carry out oral health self-care behaviours. This review highlights a scarcity of interventions to improve the oral health of this population and a paucity of evidence surrounding the oral health needs of care leavers.

Access to Dental Care for Children and Young People in Care and Care Leavers: A Global Scoping Review

AIMS

This scoping review aimed to explore three research questions: 1. What is the dental care access for children and young people (CYP) in care and care leavers? 2. What factors influence CYP in care and care leavers' access to dental care? 3. What pathways have been developed to improve access to oral health care for CYP in care and care leavers?

METHODS

Five databases (Ovid MEDLINE, Ovid Embase, CINAHL, SocINDEX and Dentistry and Oral Sciences Source) and grey literature sources were systematically searched. Articles relating to CYP in care or care leavers aged 0-25 years old, published up to January 2023 were included. Abstracts, posters and publications not in the English language were excluded. The data relating to dental care access were analysed using thematic analysis.

RESULTS

The search identified 942 articles, of which 247 were excluded as duplicates. A review of the titles and abstracts yielded 149 studies. Thirty-eight were eligible for inclusion in the review: thirty-three peer-reviewed articles, one PhD thesis and four grey literature sources. All papers were published from very high or medium Human Development Index countries. The studies indicate that despite having higher treatment needs, CYP in care and care leavers experience greater difficulty in accessing dental services than those not care-experienced. Organisational, psycho-social and logistical factors influence their access to dental care. Their experience of dental care may be impacted by adverse childhood events. Pathways to dental care have been developed, but little is known of their impact on access. There are very few studies that include care leavers. The voices of care-experienced CYP are missing from dental access research.

CONCLUSIONS

care-experienced CYP are disadvantaged in their access to dental care, and there are significant barriers to their treatment needs being met.

Dental Surgical Activity in Hospitals during COVID-19: A Nationwide Observational Cohort Study

INTRODUCTION

The number of surgical extractions performed in hospitals in England remains unclear. This study reports the volume of surgical extractions conducted in hospitals and change in activity during the COVID-19 pandemic.

METHODS

We conducted a nationwide observational cohort study using Hospital Episode Statistics (HES) in England for patients undergoing surgical removal of a tooth (defined using OPSC-4 code F09) between April 1, 2015, and December 31, 2020. Procedures were stratified by age, gender, and urgency (elective or nonelective), reported using descriptive statistics, number, and percentage. We conducted post hoc modeling to predict surgical activity to December 2023. In addition, we contrasted this with aggregate national data on simple dental extraction procedures and drainage of dental abscesses in hospital as well as dental activity in general practice.

RESULTS

We identified a total of 569,938 episodes for the surgical removal of a tooth (females 57%). Of these, 493,056/569,938 (87%) were for adults and 76,882/569,938 (13%) children ≤18 years. Surgical extractions were most frequent in adult females. Elective cases accounted for 96% (n = 548,805/569,938) of procedures. The median number of procedures carried out per quarter was 27,256, dropping to 12,003 during the COVID-19 pandemic, representing a 56% reduction in activity. This amounted to around 61,058 cancelled procedures. Modeling predicts that this activity has not returned to prepandemic levels.

CONCLUSIONS

The number of surgical extractions taking place in hospitals during the pandemic fell by 56%. The true impact of this reduction is unknown, but delayed treatment increases the risk of complications, including life-threatening infections.

KNOWLEDGE TRANSFER STATEMENT

The result of this study provides an evidence-based overview of the trends relating to surgical extractions of teeth in England taking place in hospitals. This information can be used to inform service and workforce planning to meet the needs of patients requiring surgical extractions. The data also provide an insight into the oral health needs of the population in England.

Knowledge Based Planning Evolution: Multi-Criteria Optimization of Prostates. Is There Always a Better Model?

PURPOSE/OBJECTIVE(S)

The current paradigm of radiotherapy Knowledge Based Planning (KBP) utilizes dose volume relationships on previously treated plans and may be insensitive to clinician plan preferences. To improve KBP models, incorporation of plan quality metrics and optimization weightings can be achieved using Clinical Scoring Metrics (CSM) and Multi-Criteria Optimization (MCO) respectively. A combination of KBP, MCO and CSM may result in higher quality plan output with potential to improve all prospective clinical plans. This study assesses the benefit of MCO, using CSM, and its application in the evolution of the KBP model.

MATERIALS/METHODS

A retrospective Dose Volume Histogram (DVH) parameter review was undertaken for 40 intact prostate radiotherapy cases. Following analysis, these cases were used to develop the CSM system to reflect clinician preferences and departmental protocol. Hypofractionated plans containing simultaneous integrated boost (SIB) and urethral sparing were originally planned using a clinically approved KBP model (Model A). Model A was then refined using MCO, improving the 40 individual model plans to form Model B. A further 20 prostate patients, who were excluded from KBP development, were planned using both models to compare plan quality using the CSM system.

RESULTS

Using a single optimization, Model A resulted in a median plan score of 134.1 (92.4-151.5), compared to the median Model B score of 145.1 (114.5-175.1) out of a possible score of 200 points. A Wilcoxon rank sum test was conducted and found the model score difference was significant (p = 0.014). Organ At Risk (OAR) doses, including Rectum V30 Gy, were found to significantly (p = 0.019) decrease, with Model A resulting in a median of 22.1 Gy (9.3-39.0), compared to the Model B median of 16.3 Gy (6.8-35.7). PTV coverage metric V57 Gy, resulted in no significant differences (p = 0.47) with a median score of 98.4% (97.2% - 99.9%) and 98.4% (96.9% - 99.2%) for model A and B, respectively.

CONCLUSION

The application of MCO was used to influence and produce higher quality KBP models, as supported by a CSM system. OAR doses were found to significantly decrease, with no effect on target coverage. As a result, existing plan objectives were tightened through the utilization of KBP models, even with a single optimization resulting in higher scoring plans. The future development of this work may increase the efficiency of planning operations and allow the clinician to accurately anticipate planning goals for not only prostate, but all disease sites.

The use of continuous electronic prescribing data to infer trends in antimicrobial consumption and estimate the impact of stewardship interventions in hospitalized children

Background

Understanding antimicrobial consumption is essential to mitigate the development of antimicrobial resistance, yet robust data in children are sparse and methodologically limited. Electronic prescribing systems provide an important opportunity to analyse and report antimicrobial consumption in detail.

Objectives

We investigated the value of electronic prescribing data from a tertiary children’s hospital to report temporal trends in antimicrobial consumption in hospitalized children and compare commonly used metrics of antimicrobial consumption.

Methods

Daily measures of antimicrobial consumption [days of therapy (DOT) and DDDs] were derived from the electronic prescribing system between 2010 and 2018. Autoregressive moving-average models were used to infer trends and the estimates were compared with simulated point prevalence surveys (PPSs).

Results

More than 1.3 million antimicrobial administrations were analysed. There was significant daily and seasonal variation in overall consumption, which reduced annually by 1.77% (95% CI 0.50% to 3.02%). Relative consumption of meropenem decreased by 6.6% annually (95% CI −3.5% to 15.8%) following the expansion of the hospital antimicrobial stewardship programme. DOT and DDDs exhibited similar trends for most antimicrobials, though inconsistencies were observed where changes to dosage guidelines altered consumption calculation by DDDs, but not DOT. PPS simulations resulted in estimates of change over time, which converged on the model estimates, but with much less precision.

Conclusions

Electronic prescribing systems offer significant opportunities to better understand and report antimicrobial consumption in children. This approach to modelling administration data overcomes the limitations of using interval data and dispensary data. It provides substantially more detailed inferences on prescribing patterns and the potential impact of stewardship interventions.

ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes: protocol for the ELECTRIC randomised trial

BACKGROUND

Urinary incontinence (UI) is highly prevalent in nursing and residential care homes (CHs) and profoundly impacts on residents' dignity and quality of life. CHs predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous posterior tibial nerve stimulation (TPTNS) is a non-invasive, safe and low-cost intervention with demonstrated effectiveness for reducing UI in adults. However, the effectiveness of TPTNS to treat UI in older adults living in CHs is not known. The ELECTRIC trial aims to establish if a programme of TPTNS is a clinically effective treatment for UI in CH residents and investigate the associated costs and consequences.

METHODS

This is a pragmatic, multicentre, placebo-controlled, randomised parallel-group trial comparing the effectiveness of TPTNS (target n = 250) with sham stimulation (target n = 250) in reducing volume of UI in CH residents. CH residents (men and women) with self- or staff-reported UI of more than once per week are eligible to take part, including those with cognitive impairment. Outcomes will be measured at 6, 12 and 18 weeks post randomisation using the following measures: 24-h Pad Weight Tests, post void residual urine (bladder scans), Patient Perception of Bladder Condition, Minnesota Toileting Skills Questionnaire and Dementia Quality of Life. Economic evaluation based on a bespoke Resource Use Questionnaire will assess the costs of providing a programme of TPTNS. A concurrent process evaluation will investigate fidelity to the intervention and influencing factors, and qualitative interviews will explore the experiences of TPTNS from the perspective of CH residents, family members, CH staff and managers.

DISCUSSION

TPTNS is a non-invasive intervention that has demonstrated effectiveness in reducing UI in adults. The ELECTRIC trial will involve CH staff delivering TPTNS to residents and establish whether TPTNS is more effective than sham stimulation for reducing the volume of UI in CH residents. Should TPTNS be shown to be an effective and acceptable treatment for UI in older adults in CHs, it will provide a safe, low-cost and dignified alternative to the current standard approach of containment and medication.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03248362. Registered on 14 August 2017. ISRCTN, ISRCTN98415244. Registered on 25 April 2018. https://www.isrctn.com/.

9 Using what people value to develop new interventions in palliative care: a multilevel level review approach

Introduction

Complex interventions are common in palliative care (PC) but are difficult to evaluate. Complementary therapies (CT) are one type of widely-used complex intervention for which there is inconclusive evidence. No systematic review has been conducted in PC of trials or of qualitative studies of patients’ views of CTs. There are novel approaches with established exemplars of using both types of reviews to help develop more clinically appropriate interventions. These approaches are in their infancy in PC research and have much to offer the specialism.

Aims

Using our on-going review on CT we present as an exemplar in PC an approach to draw together the findings of trials and qualitative studies in a data table (matrix) to contrast what patients value and want with how the intervention is tested.

Methods

We sought trials on the effectiveness of CT and qualitative studies on patients’ perspectives about these therapies. Our primary outcomes for trials included anxiety. Eight databases were searched in 2017. Citations and full-text papers were reviewed to identify relevant studies. Meta-analyses pooled trial data where appropriate and a thematic synthesis is being undertaken to understand patient experience. These findings will be combined in a matrix to explore similarities and differences.

Results

19 trials and five qualitative studies were included. Data analysis and development of the matrix which includes intervention content and patients’ needs is currently underway. We will present the final matrix framework.

Conclusions

Our approach demonstrates a potential way in PC to enhance development of practice appropriate complex interventions.

Pharmacokinetic modelling and validation of the half-life extension needed to reduce the burden of infusions compared with standard factor VIII

INTRODUCTION

Currently, no universally accepted definition of extended half-life (EHL) recombinant FVIII (rFVIII) exists. Identifying the minimum half-life extension ratio required for a reduction in dosing frequency compared with standard rFVIII could enable a more practical approach to decisions around prophylaxis with EHL rFVIII.

AIM

To identify the half-life extension ratio required to decrease rFVIII dosing frequency by at least 1 day while maintaining the proportion of patients with plasma rFVIII levels above 1 IU/dL and without increasing the total weekly dose.

METHODS

A previously published population pharmacokinetic model for standard rFVIII was used to estimate the percentage of patients with factor VIII (FVIII) levels always >1 IU/dL using various benchmark regimens. Using modelling, dosing frequency was reduced while rFVIII half-life was extended until the percentage of patients with FVIII >1 IU/dL equalled that of the benchmark regimen.

RESULTS

Benchmark 3×/wk dosing totalling 100 IU/kg/wk of rFVIII resulted in 56.6% of patients with FVIII levels always >1 IU/dL. With 2×/wk dosing, totalling 80 or 90 IU/kg/wk, half-life extensions required to maintain 56.6% of patients at FVIII levels >1 IU/dL were 1.30 and 1.26, respectively. A half-life extension ratio of 1.33 was required to change dosing from every 48 hours to every 72 hours (both at 105 IU/kg/wk) while maintaining 92.8% of patients with FVIII >1 IU/dL.

CONCLUSION

Based on this investigation, EHL rFVIII products should have a minimum half-life extension ratio of 1.3 to provide a reduction in dosing frequency from 3× to 2×/wk compared with standard rFVIII products while maintaining the same minimum FVIII trough level.

A Randomised Controlled Trial to Compare a Nurse Practitioner to Medical Staff in the Preparation of Patients for Diagnostic Cardiac Catheterisation: The Study of Nursing Intervention in Practice (SNIP)

BACKGROUND

A number of initiatives have employed nurses in roles traditionally associated with the medical profession but few have been evaluated in prospective randomised studies. This paper reports the results of a randomised controlled trial to assess the performance of a nurse practitioner (NP), trained to prepare patients for diagnostic cardiac catheterisation.

METHODS

Eligible and consenting patients were randomised to preparation by either the NP or junior medical staff (JMS). The safety outcome measure was the rate of in-hospital major adverse clinical events including death, myocardial infarction and emergency bypass coronary surgery. Other outcome measures included rate of minor adverse events, cardiologist assessment of case preparation and presentation, patient satisfaction and duration of pre-admission clinic.

RESULTS

From April 1997 to May 1998 a series of 355 patients scheduled for elective, day-case, diagnostic cardiac catheterisation were screened. Of these, 345 patients were eligible for the study. A total of 339 patients consented to participate and were randomised. Major adverse clinical events occurred in 0/175 (0%) patients in the NP group and 2/161 (1.2%) patients in the JMS group. (Risk difference = -1.2%, upper boundary of the 95% confidence interval = +2.0%) The cardiologist's evaluation that the patient's preparation was acceptable was high in both groups: NP group 98.3% vs. JMS group 98.8%: P = 1.0). Patient satisfaction, assessed by questionnaire, was greater in the NP group (P = 0.04). The median duration of the pre-admission clinic visit was lower in the NP group 165 min vs. 185 min in the JMS group, P = 0.01).

CONCLUSIONS

The preparation of patients for diagnostic cardiac catheterisation can be safely performed by an appropriately trained NP. This approach may be associated with improved patient satisfaction and reduced clinic duration times.

From Paper to Practice: The Views of Occupational Therapists on the Impact of the National Service Framework for Older People on Practice

Philp (2003) outlined the fundamental role that occupational therapists could have in implementing the National Service Framework (NSF) for Older People and reforming services for older people (Department of Health 2001). A research project was undertaken, which aimed to investigate the views of occupational therapists about the implementation of the policy in order to identify the key areas and issues that have had an impact on practice. The research design was qualitative and took the form of focus groups.

The focus group data were analysed using a long-table analysis method (Krueger and Casey 2000), which identified five key themes: a raised profile of older people's services, a changing delivery of services, a revisiting of occupational therapy core skills, assessment and resource allocation. The emerging themes suggested that the NSF for Older People has had an impact on the practice of the occupational therapists involved in the focus groups.