De-implementing opioid prescribing in a dental group practice: Lessons learned

Clinical Decision Support to Reduce Opioid Prescriptions for Dental Extractions using SMART on FHIR: Implementation Report

BACKGROUND

Clinical decision support (CDS) has the potential to improve clinical decision-making consistent with evidence-based care. CDS can be designed to save health care providers time and help them provide safe and personalized analgesic prescribing.

OBJECTIVE

The aim of this report is to describe the development of a CDS system designed to provide dentists with personalized pain management recommendations to reduce opioid prescribing following extractions. The use of CDS is also examined.

METHODS

This study was conducted in HealthPartners, which uses an electronic health record (EHR) system that integrates both medical and dental information upon which the CDS application was developed based on SMART (Substitutable Medical Applications and Reusable Technologies) on FHIR (Fast Healthcare Interoperability Resources). The various tools used to bring relevant medical conditions, medications, patient history, and other relevant data into the CDS interface are described. The CDS application runs a drug interaction algorithm developed by our organization and provides patient-specific recommendations. The CDS included access to the state Prescription Monitoring Program database.

IMPLEMENTATION (RESULTS)

The pain management CDS was implemented as part of a study examining opioid prescribing among patients undergoing dental extraction procedures from February 17, 2020, to May 14, 2021. Provider-level use of CDS at extraction encounters ranged from 0% to 87.4% with 12.1% of providers opening the CDS for no encounters, 39.4% opening the CDS for 1%-20% of encounters, 36.4% opening it for 21%-50% of encounters, and 12.1% opening it for 51%-87% of encounters.

CONCLUSIONS

The pain management CDS is an EHR-embedded, provider-facing tool to help dentists make personalized pain management recommendations following dental extractions. The SMART on FHIR-based pain management CDS adapted well to the point-of-care dental setting and led to the design of a scalable CDS tool that is EHR vendor agnostic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03584789; https://clinicaltrials.gov/study/NCT03584789.

Dissemination and implementation research for oral and craniofacial health: Background, a review of literature and future directions

Oral conditions are highly prevalent globally and have profound consequence on individuals and communities. Clinical (e.g. dental treatments, behavioural counselling) and non-clinical (e.g. community-based programming, water fluoridation, oral health policy) evidence-based interventions have been identified, recommended and applied at the clinic, community and policy levels. Still, the burden of oral conditions persists, with inequitable distribution across populations. A major driver of this lack of progress is poor translation of research findings, which results in an evidence-to-practice gap. Dissemination and implementation science (DIS) has emerged to address this gap. A relatively new field, application of DIS represents an important avenue for achieving good dental, oral and craniofacial health for all. The goal of this introductory article is to provide a brief background on DIS relevant to researchers in dentistry and oral health. The problem of knowledge translation, basic concepts and terminology in DIS, and approaches to doing dissemination and implementation research-including implementation strategies, key outcomes, and implementation theories, models and frameworks-are discussed. Additionally, the article reviews literature applying DIS to dentistry and oral health. Results of published studies and their implications for the field are presented. Drawing on the literature review and contemporary thinking in DIS, current gaps, opportunities and future directions are discussed. Resources for understanding and applying DIS are provided throughout. This article serves as a primer on DIS for dental and oral health researchers of all types working across a range of contexts; it also serves as a call to action for increased application of DIS to address the burden of oral conditions globally.

Perspectives on the future of dissemination and implementation research in oral and craniofacial sciences

Dissemination and implementation science is a field of research that promotes the adoption and maintenance of evidence-based interventions in healthcare delivery and community settings and seeks to understand the processes by which such adoption and maintenance occur. While dissemination and implementation science is an established field in health services research, it is relatively new and making inroads in dental, oral and craniofacial research. This article summarizes the proceedings from a scientific panel on 'Dissemination and Implementation Science for Oral and Craniofacial Health' that was held during the international Behavioral and Social Oral Health Sciences Summit. The panelists were four experts on dissemination and implementation science in dental and non-dental academic settings in the United States and Scotland, with affiliations ranging from schools of dentistry and public health to the National Institutes of Health and a healthcare system with integrated dental services. The panel discussion addressed how dissemination and implementation science can be used to further oral health research. The narrative report presented here aims to describe the panelists' reflections and insights on their current initiatives in dissemination and implementation research to inform future research endeavors within the oral and craniofacial sciences. Specifically, this article focuses on six discussion topics: (1) how organizational determinants can serve as facilitators or barriers to the implementation of evidence-based dental practice; (2) how dentistry can 'de-implement' practices that are not effective; (3) how implementation science can support the delivery of evidence-based dental practice using adaptation; (4) how to get started in implementation science; (5) how the broader environment can support large-scale implementation efforts; and (6) how oral and craniofacial science is well suited for advancing dissemination and implementation research.

Behavioural and cognitive-behavioural theories in oral health research: Current state and future directions

OBJECTIVES

Behavioural and cognitive-behavioural theories, models and frameworks have been incorporated for decades in behavioural and social oral health sciences, oral health care, and education of dentists, hygienists, and other oral healthcare professionals.

METHODS

While a myriad of these conceptualizations have been incorporated in this work, there are six of them that have had the greatest impact in the oral health arena: (a) Health Belief Model; (b) Theory of Reasoned Action, Theory of Planned Behavior and Integrated Behavioral Model, which are considered in unison; (c) Social Learning Theory and Social Cognitive Theory which are considered together; (d) Transtheoretical Model/Stages of Change Model; (e) Salutogenesis Model/Theory and Sense of Coherence Framework; and the (f) Behavior Change Wheel, Capability-Opportunity-Motivation-Behavior Model and Theoretical Domains Framework, which are categorized together.

RESULTS

An analysis of nomenclature (i.e. theories, models, frameworks and conceptualizations) is provided in the context of a description of each of these theories and models, with discussion about their aspects that particularly relate to oral health. Additionally, a quantitative, longitudinal view is provided of the frequency of use of these theories and models in the oral health arena. Given the benefits of theory-based intervention development, dissemination and implementation, it is important to consider these theories and models in a collective context.

CONCLUSIONS

At a basic level, these theories and models help in identifying and acting on mechanisms, both of behaviour itself and behaviour change. Future directions are discussed in terms of need for theory evolution and development.