Examining whether dental therapists constitute a disruptive innovation in US dentistry

Innovative state oral health initiatives: A qualitative analysis of Centers for Medicare & Medicaid Services demonstrations

BACKGROUND

US health care delivery and financing arrangements are changing rapidly as payers and providers seek greater efficiency, effectiveness, and safety. The Centers for Medicare & Medicaid Services uses grants and technical assistance to drive such development through innovative demonstration programs, including for oral health care. The authors reviewed these dental demonstrations to identify common themes and identify barriers to and facilitators of implementation.

METHODS

The authors compared 12 identified demonstrations across 6 domains: grant and technical assistance, stakeholders, inner care settings, outer contextual settings, interventions, and outcomes. They developed program summaries for each demonstration and interviewed key informants using a semistructured guide to review, correct, clarify, and expand on program summaries.

RESULTS

Common across all programs were engagement of nontraditional providers, care in nontraditional settings, payment as a critical externality for program adoption, interventions that integrate medical and oral health care, use of alternative payment models, and tracking process measures. Adoption facilitators included an engaged oral health champion and obtaining mission support and alignment among stakeholders. Common barriers included unanticipated organizational disruptions, poor information technology infrastructure, cultural resistance to nontraditional care models, and lack of providers in high-need areas.

CONCLUSIONS

Descriptive findings suggest that oral health care may evolve as a more accountable, integrated, and accessible health service with an expanded workforce; collaboration between providers and payers will remain key to creating innovative, sustainable models of oral health care.

PRACTICAL IMPLICATIONS

The Centers for Medicare & Medicaid Services' efforts to advance health equity, expand coverage, and improve health outcomes will continue to drive similar initiatives in oral health care.

Oral Health Survey in Burundi; Evaluation of the Caries Experience in Schoolchildren Using the DMFT Index

Background and objectives: There are no data on oral health in the population of Burundi. This study aimed to describe the oral health status of schoolchildren in Burundi using the dmft/DMFT index for the first time. Materials and methods: The study was designed as a cross-sectional population-based epidemiological survey. The survey was designed according to the WHO methodology for oral health surveys. Oral examinations were conducted in school rooms using a dental mirror, probe, and headlight. The following characteristics of primary dentition status were recorded: decayed (d/D), missing (m/M), and filled (f/F) teeth, and the dmft/DMFT (d + m + f t/D + M + F T) index was calculated for each subject. Quantitative and qualitative variables were represented by measures of position and variability. One-way ANOVA was used to assess differences between parametric variables. Logistic regression was performed for total caries experience and gender, age groups, living area, and geographical provinces. Results: A total of 1902 children were examined, 1007 (52.94%) six-year-olds and 895 (47.06%) in the older group. The dmft/DMFT and subgroups were statistically significantly different in terms of age groups, living areas, and geographical regions (dmft/DMFT d-subgroup and D-subgroup p < 0.01), but only for DMFT for sex. The ORs estimated by logistic regression by total caries experience showed a protective effect for 12 year old subjects and those living in southern provinces, an OR of 0.52 (95%CI 0.43-0.64) and an OR of 0.26 (95%CI 0.21-0.32), respectively. Conclusions: Dental caries in African countries, including Burundi, remains a major problem affecting the general health and wellbeing of the population. Tackling untreated caries requires a multifaceted approach, including strengthening oral health infrastructure, promoting oral health education, providing affordable dental services, and encouraging healthier eating habits.

DISRUPTIVE INNOVATION IN HEALTHCARE: A REVIEW AND FUTURE RESEARCH AGENDAS

Disruptive innovation (DI) refers to a mode of low cost high ancillary performance innovation that starts at the lower end of the market and gradually moves up to eventually displace its incumbent counterparts. The concept of DI has become more and more popular in the healthcare sector. The paper studies how healthcare research has embraced the concept of DI in various areas within the healthcare sector. Areas of healthcare, where DI has been adopted as a management strategy, were identified in the last two decades, through initially shortlisting 157 papers and the final reviewed set of 117 papers. Through a multi-method approach comprising of co-word analysis, identification of themes, mapping of research work across these themes and geography, the study found that, although from a management perspective there are 13 major themes, the majority of the focus is on four major themes—healthcare delivery and services, healthcare administration, technology and equipment, and nursing and palliative care. Furthermore, the majority of the geography-specific research was conducted in developed countries, especially the USA. It was also observed that organisational strategies for successfully implementing DI in the healthcare sector are still in the nascent stage and the focus is mostly in the area of healthcare delivery and administration from the management perspective. Future research studies could aim at looking at the role that DI plays in the healthcare sector of the developing countries, as well as using DI in other areas of healthcare, rather than a few concentrated areas.

Dental therapists compared with general dental practitioners for undertaking check-ups in low-risk patients: pilot RCT with realist evaluation

Background

Many dental ‘check-ups’ in the NHS result in no further treatment. The patient is examined by a dentist and returned to the recall list for a further check-up, commonly in 6 or 12 months’ time. As the oral health of regular dental attenders continues to improve, it is likely that an increasing number of these patients will be low risk and will require only a simple check-up in the future, with no further treatment. This care could be delivered by dental therapists. In 2013, the body responsible for regulating the dental profession, the General Dental Council, ruled that dental therapists could see patients directly and undertake check-ups and routine dental treatments (e.g. fillings). Using dental therapists to undertake check-ups on low-risk patients could help free resources to meet the future challenges for NHS dentistry.

Objectives

The objectives were to determine the most appropriate design for a definitive study, the most appropriate primary outcome measure and recruitment and retention rates, and the non-inferiority margin. We also undertook a realist-informed process evaluation and rehearsed the health economic data collection tool and analysis.

Design

A pilot randomised controlled trial over a 15-month period, with a realist-informed process evaluation. In parallel, we rehearsed the health economic evaluation and explored patients’ preferences to inform a preference elicitation exercise for a definitive study.

Setting

The setting was NHS dental practices in North West England.

Participants

A total of 217 low-risk patients in eight high-street dental practices participated.

Interventions

The current practice of using dentists to provide NHS dental check-ups (treatment as usual; the control arm) was compared with using dental therapists to provide NHS dental check-ups (the intervention arm).

Main outcome measure

The main outcome measure was difference in the proportion of sites with bleeding on probing among low-risk patients. We also recorded the number of ‘cross-over’ referrals between dentists and dental therapists.

Results

No differences were found in the health status of patients over the 15 months of the pilot trial, suggesting that non-inferiority is the most appropriate design. However, bleeding on probing suffered from ‘floor effects’ among low-risk patients, and recruitment rates were moderately low (39.7%), which suggests that an experimental design might not be the most appropriate. The theory areas that emerged from the realist-informed process evaluation were contractual, regulatory, institutional logistics, patients’ experience and logistics. The economic evaluation was rehearsed and estimates of cost-effectiveness made; potential attributes and levels that can form the basis of preference elicitation work in a definitive study were determined.

Limitations

The pilot was conducted over a 15-month period only, and bleeding on probing appeared to have floor effects. The number of participating dental practices was a limitation and the recruitment rate was moderate.

Conclusions

Non-inferiority, floor effects and moderate recruitment rates suggest that a randomised controlled trial might not be the best evaluative design for a definitive study in this population. The process evaluation identified multiple barriers to the use of dental therapists in ‘high-street’ practices and added real value.

Future work

Quasi-experimental designs may offer more promise for a definitive study alongside further realist evaluation.

Trial registration

Current Controlled Trials ISRCTN70032696.

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. 9, No. 3. See the NIHR Journals Library website for further project information.

A Markov model assessing the impact on primary care practice revenues and patient's health when using mid-level providers, lesson learned from the United Kingdom

OBJECTIVE

To evaluate the cost-effectiveness of using mid-level providers for dental "check-up" examinations and the treatment of caries in different NHS settings in the United Kingdom. Mid-level providers are a broad category that describes non-dentist members of dental teams. This study focused on the potential use of Dental Hygiene Therapists undertaking dental "check-up" examinations and simple restorative treatment, instead of dentists.

METHODS

A Markov model was used to construct the natural history of caries development in adults that visit a dental practice every six months over a five-year period. Three cost perspectives are taken: those borne to dental healthcare providers in England and Wales, Northern Ireland and Scotland. These represent three separate forms of retrospective payment system that are currently in use in the United Kingdom. The cost outcome was the average amount of retained practice earnings required to provide healthcare per patient visit. The health outcome was the average length of time in a cavity-free state and the cost-effectiveness outcome was incremental cost for six months in a cavity-free state.

RESULTS

No statistical difference was found between dentists and mid-level providers in the length of time in a cavity-free state but the use of the latter saved money in all three NHS health system jurisdictions. This ranged from £7.85 (England and Wales) to £9.16 (Northern Ireland) per patient visit ($10.20 to $11.90, respectively) meaning the incremental cost for six month in a cavity-free state ranged from £261.67 ($339.93) in England and Wales to £305.33 ($369.68) in Northern Ireland. Further, changes in baseline assumptions and parameter values did not change mid-level providers being the dominant service intervention.

CONCLUSION

In a time of limited funds for dental services, these results suggest that resources in public funded systems could be saved using mid-level providers in dental practices, without any health risk to patients or capital investment.

The technical efficiency of oral healthcare provision: Evaluating role substitution in National Health Service dental practices in England

OBJECTIVES

In many countries increasing use is being made of dental care professionals (DCPs) to provide aspects of clinical activity previously undertaken by dentists. This study evaluates the differences in practice efficiency associated with the utilisation of DCPs in the provision of General Dental Services in the National Health Service (NHS) in England.

METHODS

One hundred twenty-one NHS practices completed a questionnaire and shared practice information held at the NHS Business Services Authority. Practice efficiency was estimated using data envelopment analysis with the robustness of the findings checked using Stochastic Frontier Model estimation.

RESULTS

Dental practices operated at an estimated mean level of technical efficiency of 64%. Variations among practices in the use of DCPs were not associated with variations in practice efficiency after controlling for other staffing levels, patient population characteristics and practice variables.

CONCLUSIONS

The current NHS dental contract limits the potential for efficiency improvements by setting annual practice activity targets that produce little incentive for role substitution. Whilst DCPs may by practising efficiently, this is not reflected in practice-level efficiency, possibly because of dentists using the time released for other non-NHS activity.

Determining the optimal model for role substitution in NHS dental services in the UK: a mixed-methods study

Background

Maximising health gain for a given level and mix of resources is an ethical imperative for health-service planners. Approximately half of all patients who attend a regular NHS dental check-up do not require any further treatment, whereas many in the population do not regularly attend. Thus, the most expensive resource (the dentist) is seeing healthy patients at a time when many of those with disease do not access care. Role substitution in NHS dentistry, where other members of the dental team undertake the clinical tasks previously provided by dentists, has the potential to increase efficiency and the capacity to care and lower costs. However, no studies have empirically investigated the efficiency of NHS dental provision that makes use of role substitution.

Research questions

This programme of research sought to address three research questions: (1) what is the efficiency of NHS dental teams that make use of role substitution?; (2) what are the barriers to, and facilitators of, role substitution in NHS dental practices?; and (3) how do incentives in the remuneration systems influence the organisation of these inputs and production of outputs in the NHS?

Design

Data envelopment analysis was used to develop a productive efficiency frontier for participating NHS practices, which were then compared on a relative basis, after controlling for patient and practice characteristics. External validity was tested using stochastic frontier modelling, while semistructured interviews explored the views of participating dental teams and their patients to role substitution.

Setting

NHS ‘high-street’ general dental practices.

Participants

121 practices across the north of England.

Interventions

No active interventions were undertaken.

Main outcome measures

Relative efficiency of participating NHS practices, alongside a detailed narrative of their views about role substitution dentistry. Social acceptability for patients.

Results

The utilisation of non-dentist roles in NHS practices was relatively low, the most common role type being the dental hygienist. Increasing the number of non-dentist team members reduced efficiency. However, it was not possible to determine the relative efficiency of individual team members, as the NHS contracts only with dentists. Financial incentives in the NHS dental contract and the views of practice principals (i.e. senior staff members) were equally important. Bespoke payment and referral systems were required to make role substitution economically viable. Many non-dentist team members were not being used to their full scope of practice and constraints on their ability to prescribe reduced efficiency further. Many non-dentist team members experienced a precarious existence, commonly being employed at multiple practices. Patients had a low level of awareness of the different non-dentist roles in a dental team. Many exhibited an inherent trust in the professional ‘system’, but prior experience of role substitution was important for social acceptability.

Conclusions

Better alignment between the financial incentives within the NHS dental contract and the use of role substitution is required, although professional acceptability remains critical.

Study limitations

Output data collected did not reflect the quality of care provided by the dental team and the input data were self-reported.

Future work

Further work is required to improve the evidence base for the use of role substitution in NHS dentistry, exploring the effects and costs of provision.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Role of telemedicine and mid-level dental providers in expanding dental-care access: potential application in rural Australia

Despite great progress in oral health over the past three decades, the rates of caries remain high in Australia, particularly among underserved populations. The reasons for poor oral health amongst underserved populations are multiple, but rests with socio-economic determinants of health. The present review considers international workforce models that have been created to enhance the recruitment and retention of dental providers in rural areas. Several strategies have been developed to address care access problems in rural areas, including the use of telemedicine and mid-level dental providers (MLDPs). Despite ongoing opposition from dentistry organisations, the Alaska and Minnesota workforce models have proven that developing and deploying dental therapists from rural communities has the potential to address the unmet needs of underserved populations. It is more efficient and cost-effective for MLDPs to perform triage and treat simple cases and for dentists to treat complicated cases. The use of MLDPs is intended to increase the capacity of the dental workforce in areas that are too isolated to entice dentists. Telemedicine has emerged as one solution to address limited access to health care, particularly in locations where there is a lack of providers. Telemedicine not only provides access to care, but also offers support, consultations and access to continuing education for practicing dental providers in rural areas. This strategy has the potential to free up resources to increase care access and reduce oral health disparities, thereby contributing to closing the rural-urban oral health gap.

Skill-mix in preventive dental practice--will it help address need in the future?

BACKGROUND

Population health needs are changing. The levels of dental caries and periodontal disease across the population as a whole is falling. The proportion of adults with a functional dentition in many developed countries has increased substantially and edentulous rates have dropped to some of their lowest levels. Despite this, a pronounced social gradient still exists, many adults do not attend dental services regularly and disease in young children remains intransigent amongst the poorest. New challenges are emerging too as the growing number of older people, above sixty-five years of age, retain their teeth.

METHODS

Ensuring "the right number of people with the right skills are in the right place at the right time to provide the right services to the right people" is critical for future dental service provision, both to meet the new challenges ahead and to ensure future services are cost-effective, efficient and reduce health-inequalities. Greater use of "skill-mix" models could have a substantial role in the future, as dentistry moves from a "cure" to a "care" culture.

DISCUSSION

The provision of dental services in many countries currently adopts a "one-size-fits-all", where the dentist is the main care-giver and the emphasis is on intervention. As needs change in the future, the whole of the dental team should be utilised to deliver primary, secondary and tertiary prevention in an integrated model. Growing evidence suggests that other members of the dental team are effective in providing care, but introducing this paradigm shift is not without its challenges. The provision of incentives within funding systems and social acceptability are amongst the key determinants in producing a service that is responsive to need, improves access and delivers equity.

Innovations in dental care delivery for the older adult

Access to and reducing disparities in oral health for older adults is a complex problem that requires innovative strategies. In addition to offering dental services in alternative settings, such as senior centers, places that are familiar to older adults, and where physical limitations can be better accommodated, alternatives to the traditional provider should be considered. Many states are changing laws and practice acts to allow dental hygienists to provide preventive services without the supervision of a dentist. Also, collaborations between dental and non-dental professionals can be a successful strategy for increasing access to oral health care for this high-risk population.

Integrating a primary oral health care approach in the dental curriculum: a Tanzanian experience

This paper is based on a conference presentation made during the inauguration of the Faculty of Dentistry, Kuwait University, as a World Health Organization Collaborating Centre for Primary Oral Health Care (POHC) on November 27-28, 2012. The aim of this paper is to review how the POHC approach has been integrated into the dental curriculum, sharing the Tanzanian experience as a case presentation from a developing country. The burden of oral diseases worldwide is high, and the current oral health workforce is inadequate to meet the challenges. Curative oral health care is very costly and not accessible to the poor and minorities. To tackle the problem, the POHC approach rooted in primary health care that emphasizes equity, community involvement, prevention, appropriate technology and a multi-sectorial approach was developed and has been operating for more than 3 decades now. Execution of a comprehensive POHC requires a trained oral health workforce mix with essential competencies. For this case study, a literature search was done using the search engines subscribed to by the library of Muhimbili University of Health and Allied Sciences, including PubMed, Cochrane, ScienceDirect and Scopus, Wiley-Blackwell Interscience, Sage and the Health InterNetwork Access to Research Initiative (HINARI) that gives access to Scirus and Google Scholar. Challenges are discussed with an emphasis more on addressing the common risk factors and determinants of oral health. Integration of the POHC approach in the dental curriculum for training a competent workforce is crucial in attaining better oral health. Resources are still a major challenge, and the impact of the POHC approach in the curriculum is yet to be evaluated.

Determining the optimal model for role-substitution in NHS dental services in the United Kingdom

Background

Role-substitution describes a model of dental care where Dental Care Professionals (DCPs) provide some of the clinical activity previously undertaken by General Dental Practitioners. This has the potential to increase technical efficiency, the capacity to care and reduce costs. Technical efficiency is defined as the production of the maximum amount of output from a given amount of input so that the service operates at the production frontier i.e. optimal level of productivity. Academic research into technical efficiency is becoming increasingly utilised in health care, although no studies have investigated the efficiency of NHS dentistry or role-substitution in high-street dental practices. The aim of this study is to examine the barriers and enablers that exist for role-substitution in general dental practices in the NHS and to determine the most technically efficient model for role-substitution.

Methods/design

A screening questionnaire will be sent to DCPs to determine the type and location of role-substitutive models employed in NHS dental practices in the United Kingdom (UK). Semi-structured interviews will then be conducted with practice owners, DCPs and patients at selected sites identified by the questionnaire. Detail will be recorded about the organisational structure of the dental team, the number of NHS hours worked and the clinical activity undertaken. The interviews will continue until saturation and will record the views and attitudes of the members of the dental team. Final numbers of interviews will be determined by saturation.

The second work-stream will examine the technical efficiency of the selected practices using Data Envelopment Analysis and Stochastic Frontier Modeling. The former is a non-parametric technique and is considered to be a highly flexible approach for applied health applications. The latter is parametric and is based on frontier regression models that estimate a conventional cost function.

Discussion

Maximising health for a given level and mix of resources is an ethical imperative for health service planners. This study will determine the technical efficiency of role-substitution and so address one of the key recommendations of the Independent Review of NHS dentistry in England.