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Goodwin M, Walsh T, Whittaker W, Emsley R, Kelly MP, Sutton M, Tickle M, Pretty IA. The CATFISH study: An evaluation of a water fluoridation program in Cumbria, UK. Community Dent Oral Epidemiol 2024. [PMID: 38757663 DOI: 10.1111/cdoe.12967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 01/12/2024] [Accepted: 04/12/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES The objective was to assess the effectiveness of a Water Fluoridation program on a contemporary population of children. METHODS The study used a longitudinal prospective cohort design. In Cumbria, England, two groups of children were recruited and observed over a period of 5-6 years. The Birth Cohort consisted of families recruited from two hospitals in Cumbria where children were conceived after water fluoridation was reintroduced. The systemic and topical effects of community water fluoridation were evaluated in the Birth Cohort. The Older Cohort were approximately 5 years old and recruited from primary schools in Cumbria, shortly after water fluoridation was reintroduced. The predominantly topical effects of fluoridated water were evaluated in the Older Cohort. The primary outcome was the proportion of children with clinical evidence of caries experience in their primary (Birth Cohort) or permanent teeth (Older Cohort). Unadjusted and adjusted regression models were used for analysis. RESULTS The final clinical examinations for the Birth Cohort involved 1444 participants (mean age 4.8 years), where 17.4% of children in the intervention group were found to have caries experience, compared to 21.4% in the control group. A beneficial effect of water fluoridation was observed adjusting for deprivation (a socioeconomic measure), sex, and age, (adjusted odds ratio 0.74 95% CI 0.55 to 0.98). The final Older Cohort clinical examinations involved 1192 participants (mean age 10.8 years) where 19.1% of children in the intervention group were found to have caries experience compared to 21.9% in the control group (adjusted odds ratio 0.80, 95% CI 0.58 to 1.09). For both the Birth Cohort and Older Cohort there was evidence of a beneficial effect on dmft/DMFT count (IRR 0.61, 95% CI 0.44, 0.86) and (IRR 0.69, 95% CI 0.52, 0.93) respectively. No conclusive proof was found to indicate that the effectiveness of water fluoridation differed across area deprivation quintiles. CONCLUSIONS In the contemporary context of lower caries levels and widespread use of fluoride toothpaste, the impact of water fluoridation on the prevalence of caries was smaller than previous studies have reported. It is important to consider the clinical importance of the absolute reduction in caries prevalence against the use of other dental caries preventive measures.
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Affiliation(s)
- Michaela Goodwin
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Tanya Walsh
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - William Whittaker
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Michael P Kelly
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Matt Sutton
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Martin Tickle
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Iain A Pretty
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Moore D, Nyakutsikwa B, Allen T, Lam E, Birch S, Tickle M, Pretty IA, Walsh T. Effect of fluoridated water on invasive NHS dental treatments for adults: the LOTUS retrospective cohort study and economic evaluation. Public Health Res (Southampt) 2024; 12:1-147. [PMID: 38785327 DOI: 10.3310/rfqa3841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Abstract
Background Most water fluoridation studies were conducted on children before the widespread introduction of fluoride toothpastes. There is a lack of evidence that can be applied to contemporary populations, particularly adolescents and adults. Objective To pragmatically assess the clinical and cost effectiveness of water fluoridation for preventing dental treatment and improving oral health in a contemporary population of adults, using a natural experiment design. Design Retrospective cohort study using routinely collected National Health Service dental claims (FP17) data. Setting National Health Service primary dental care: general dental practices, prisons, community dental services, domiciliary settings, urgent/out-of-hours and specialised referral-only services. Participants Dental patients aged 12 years and over living in England (n = 6,370,280). Intervention and comparison Individuals exposed to drinking water with a fluoride concentration ≥ 0.7 mg F/l between 2010 and 2020 were matched to non-exposed individuals on key characteristics using propensity scores. Outcome measures Primary: number of National Health Service invasive dental treatments (restorations/'fillings' and extractions) received per person between 2010 and 2020. Secondary: decayed, missing and filled teeth, missing teeth, inequalities, cost effectiveness and return on investment. Data sources National Health Service Business Services Authority dental claims data. Water quality monitoring data. Primary outcome Predicted mean number of invasive dental treatments was 3% lower in the optimally fluoridated group than in the sub/non-optimally fluoridated group (incidence rate ratio 0.969, 95% CI 0.967 to 0.971), a difference of -0.173 invasive dental treatments (95% CI -0.185 to -0.161). This magnitude of effect is smaller than what most stakeholders we engaged with (n = 50/54) considered meaningful. Secondary outcomes Mean decayed, missing and filled teeth were 2% lower in the optimally fluoridated group, with a difference of -0.212 decayed, missing and filled teeth (95% CI -0.229 to -0.194). There was no statistically significant difference in the mean number of missing teeth per person (0.006, 95% CI -0.008 to 0.021). There was no compelling evidence that water fluoridation reduced social inequalities in treatments received or missing teeth; however, decayed, missing and filled teeth data did not demonstrate a typical inequalities gradient. Optimal water fluoridation in England in 2010-20 was estimated to cost £10.30 per person (excluding original setup costs). Mean National Health Service treatment costs for fluoridated patients 2010-20 were 5.5% lower per person, by £22.26 (95% CI -£23.09 to -£21.43), and patients paid £7.64 less in National Health Service dental charges per person (2020 prices). Limitations Pragmatic, observational study with potential for non-differential errors of misclassification in fluoridation assignment and outcome measurement and residual and/or unmeasured confounding. Decayed, missing and filled teeth data have not been validated. Water fluoridation cost estimates are based on existing programmes between 2010 and 2020, and therefore do not include the potentially significant capital investment required for new programmes. Conclusions Receipt of optimal water fluoridation between 2010 and 2020 resulted in very small health effects, which may not be meaningful for individuals, and we could find no evidence of a reduction in social inequalities. Existing water fluoridation programmes in England produced a positive return on investment between 2010 and 2020 due to slightly lower National Health Service treatment costs. These relatively small savings should be evaluated against the projected costs and lifespan of any proposed capital investment in water fluoridation, including new programmes. Future work National Health Service dental data are a valuable resource for research. Further validation and measures to improve quality and completeness are warranted. Trial registrations This trial is registered as ISRCTN96479279, CAG: 20/CAG/0072, IRAS: 20/NE/0144. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR128533) and is published in full in Public Health Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Deborah Moore
- Division of Dentistry, The University of Manchester, Manchester, UK
| | | | - Thomas Allen
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Emily Lam
- Independent Patient and Public Engagement Representative
| | - Stephen Birch
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Martin Tickle
- Division of Dentistry, The University of Manchester, Manchester, UK
| | - Iain A Pretty
- Division of Dentistry, The University of Manchester, Manchester, UK
| | - Tanya Walsh
- Division of Dentistry, The University of Manchester, Manchester, UK
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Whittaker W, Goodwin M, Bashir S, Sutton M, Emsley R, Kelly MP, Tickle M, Walsh T, Pretty IA. Economic evaluation of a water fluoridation scheme in Cumbria, UK. Community Dent Oral Epidemiol 2024. [PMID: 38525802 DOI: 10.1111/cdoe.12958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 01/19/2024] [Accepted: 03/12/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVES The addition of fluoride to community drinking water supplies has been a long-standing public health intervention to improve dental health. However, the evidence of cost-effectiveness in the UK currently lacks a contemporary focus, being limited to a period with higher incidence of caries. A water fluoridation scheme in West Cumbria, United Kingdom, provided a unique opportunity to study the contemporary impact of water fluoridation. This study evaluates the cost-effectiveness of water fluoridation over a 5-6 years follow-up period in two distinct cohorts: children exposed to water fluoridation in utero and those exposed from the age of 5. METHODS Cost-effectiveness was summarized employing incremental cost-effectiveness ratios (ICER, cost per quality adjusted life year (QALY) gained). Costs included those from the National Health Service (NHS) and local authority perspective, encompassing capital and running costs of water fluoridation, as well as NHS dental activity. The measure of health benefit was the QALY, with utility determined using the Child Health Utility 9-Dimension questionnaire. To account for uncertainty, estimates of net cost and outcomes were bootstrapped (10 000 bootstraps) to generate cost-effectiveness acceptability curves and sensitivity analysis performed with alternative specifications. RESULTS There were 306 participants in the birth cohort (189 and 117 in the non-fluoridated and fluoridated groups, respectively) and 271 in the older school cohort (159 and 112, respectively). In both cohorts, there was evidence of small gains in QALYs for the fluoridated group compared to the non-fluoridated group and reductions in NHS dental service cost that exceeded the cost of fluoridation. For both cohorts and across all sensitivity analyses, there were high probabilities (>62%) of water fluoridation being cost-effective with a willingness to pay threshold of £20 000 per QALY. CONCLUSIONS This analysis provides current economic evidence that water fluoridation is likely to be cost-effective. The findings contribute valuable contemporary evidence in support of the economic viability of water fluoridation scheme.
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Affiliation(s)
- William Whittaker
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Michaela Goodwin
- Division of Dentistry, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Saima Bashir
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Matt Sutton
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Michael P Kelly
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Martin Tickle
- Division of Dentistry, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Tanya Walsh
- Division of Dentistry, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Iain A Pretty
- Division of Dentistry, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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Moore D, Nyakutsikwa B, Allen T, Lam E, Birch S, Tickle M, Pretty IA, Walsh T. How effective and cost-effective is water fluoridation for adults and adolescents? The LOTUS 10-year retrospective cohort study. Community Dent Oral Epidemiol 2024. [PMID: 38191778 DOI: 10.1111/cdoe.12930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/10/2023] [Accepted: 11/19/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To pragmatically assess the clinical and cost-effectiveness of water fluoridation for preventing dental treatment and improving oral health in a contemporary population of adults and adolescents, using a natural experiment design. METHODS A 10-year retrospective cohort study (2010-2020) using routinely collected NHS dental treatment claims data. Participants were patients aged 12 years and over, attending NHS primary dental care services in England (17.8 million patients). Using recorded residential locations, individuals exposed to drinking water with an optimal fluoride concentration (≥0.7 mg F/L) were matched to non-exposed individuals using propensity scores. Number of NHS invasive dental treatments, DMFT and missing teeth were compared between groups using negative binomial regression. Total NHS dental treatment costs and cost per invasive dental treatment avoided were calculated. RESULTS Matching resulted in an analytical sample of 6.4 million patients. Predicted mean number of invasive NHS dental treatments (restorations 'fillings'/extractions) was 3% lower in the optimally fluoridated group (5.4) than the non-optimally fluoridated group (5.6) (IRR 0.969, 95% CI 0.967, 0.971). Predicted mean DMFT was 2% lower in the optimally fluoridated group (IRR 0.984, 95% CI 0.983, 0.985). There was no difference in the predicted mean number of missing teeth per person (IRR 1.001, 95% CI 0.999, 1.003) and no compelling evidence that water fluoridation reduced social inequalities in dental health. Optimal water fluoridation in England 2010-2020 was estimated to cost £10.30 per person (excludes initial set-up costs). NHS dental treatment costs for optimally fluoridated patients 2010-2020 were 5.5% lower, by £22.26 per person (95% CI -£21.43, -£23.09). CONCLUSIONS Receipt of optimal water fluoridation 2010-2020 resulted in very small positive health effects which may not be meaningful for individuals. Existing fluoridation programmes in England produced a positive return on investment between 2010 and 2020 due to slightly lower NHS dental care utilization. This return should be evaluated against the projected costs and lifespan of any proposed capital investment in water fluoridation, including new programmes.
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Affiliation(s)
- Deborah Moore
- Faculty of Biology, Medicine and Health, Division of Dentistry, The University of Manchester, Manchester, UK
| | - Blessing Nyakutsikwa
- Faculty of Biology, Medicine and Health, Division of Dentistry, The University of Manchester, Manchester, UK
| | - Thomas Allen
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | | | - Stephen Birch
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Martin Tickle
- Faculty of Biology, Medicine and Health, Division of Dentistry, The University of Manchester, Manchester, UK
| | - Iain A Pretty
- Faculty of Biology, Medicine and Health, Division of Dentistry, The University of Manchester, Manchester, UK
| | - Tanya Walsh
- Faculty of Biology, Medicine and Health, Division of Dentistry, The University of Manchester, Manchester, UK
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Nyakutsikwa B, Allen T, Walsh T, Pretty I, Birch S, Tickle M, Moore D. Who are the 10%? Characteristics of the populations and communities receiving fluoridated water in England. Community Dent Health 2022; 39:247-253. [PMID: 35946922 DOI: 10.1922/cdh_00092nyakutsikwa07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES In England, around 10% of the population receive optimally fluoridated water. This coverage has evolved through a combination of historical local decision-making and natural geography, rather than being strategically targeted at the national level. It is important to understand if the current distribution is equitable according to indicators of oral health need and to identify any population-level differences in socio-demographic characteristics that could introduce bias to studies evaluating the effectiveness of water fluoridation. BASIC RESEARCH DESIGN Descriptive analysis comparing the census characteristics of populations that received optimally fluoridated (=/⟩ 0.7 mg F/L) and non-fluoridated water (⟨0.7 mg F/L) between 2009 and 2020. RESULTS Populations receiving fluoridated water between 2009-2020 were on average slightly younger, more urban, more deprived, with lower education levels, higher unemployment and lower car and home ownership than the populations who received non-fluoridated water. They are more ethnically diverse, with a higher proportion of Asian ethnicity and a lower proportion of White ethnicity, compared to the non-fluoridated population. DISCUSSION This descriptive analysis provides evidence that water fluoridation coverage within England is targeted reasonably equitably in relation to population-level indicators of need. It also confirms the need to consider the impact of underlying differences in age, deprivation, rurality, and ethnicity when evaluating the impact of water fluoridation on health outcomes in England.
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Affiliation(s)
- B Nyakutsikwa
- Division of Dentistry, The University of Manchester, UK
| | - T Allen
- Manchester Centre for Health Economics, Manchester, UK
| | - T Walsh
- Division of Dentistry, The University of Manchester, UK
| | - I Pretty
- Division of Dentistry, The University of Manchester, UK
| | - S Birch
- Manchester Centre for Health Economics, Manchester, UK
| | - M Tickle
- Division of Dentistry, The University of Manchester, UK
| | - D Moore
- Division of Dentistry, The University of Manchester, UK
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Goodwin M, Emsley R, Kelly MP, Sutton M, Tickle M, Walsh T, Whittaker W, Pretty IA. Evaluation of water fluoridation scheme in Cumbria: the CATFISH prospective longitudinal cohort study. Public Health Res 2022. [DOI: 10.3310/shmx1584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background
Water fluoridation was introduced in the UK against a background of high dental decay within the population. Levels of decay have dramatically reduced over the last 40 years following widespread use of fluoride toothpaste.
Objective
The aim of the CATFISH (Cumbrian Assessment of Teeth a Fluoride Intervention Study for Health) study was to address the question of whether or not the addition of fluoride to community drinking water, in a contemporary population, lead to a reduction in the number of children with caries and, if so, is this reduction cost-effective?
Design
A longitudinal prospective cohort design was used in two distinct recruited populations: (1) a birth cohort to assess systemic and topical effects of water fluoridation and (2) an older school cohort to assess the topical effects of drinking fluoridated water.
Setting
The study was conducted in Cumbria, UK. Broadly, the intervention group (i.e. individuals receiving fluoridated drinking water) were from the west of Cumbria and the control group were from the east of Cumbria.
Participants
Children who were lifetime residents of Cumbria were recruited. For the birth cohort, children were recruited at birth (2014–15), and followed until age 5 years. For the older school cohort, children were recruited at age 5 years (2013–14) and followed until the age of 11 years.
Intervention
The provision of a ‘reintroduced fluoridated water scheme’.
Main outcome measures
The primary outcome measure was the presence or absence of decay into dentine in the primary teeth (birth cohort) and permanent teeth (older school cohort). The cost per quality-adjusted life-year was also assessed.
Results
In the birth cohort (n = 1444), 17.4% of children in the intervention group had decay into dentine, compared with 21.4% of children in the control group. The evidence, after adjusting for deprivation, age and sex, with an adjusted odds ratio of 0.74 (95% confidence interval 0.56 to 0.98), suggested that water fluoridation was likely to have a modest beneficial effect. There was insufficient evidence of difference in the presence of decay in children in the older school cohort (n = 1192), with 19.1% of children in the intervention group having decay into dentine, compared with 21.9% of children in the control group (adjusted odds ratio 0.80, 95% confidence interval 0.58 to 1.09). The intervention was found to be likely to be cost-effective for both the birth cohort and the older school cohort at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year. There was no significant difference in the performance of water fluoridation on caries experience across deprivation quintiles.
Conclusions
The prevalence of caries and the impact of water fluoridation was much smaller than previous studies have reported. The intervention was effective in the birth cohort group; however, the importance of the modest absolute reduction in caries (into dentine) needs to be considered against the use of other dental caries preventative measures. Longer-term follow-up will be required to fully understand the balance of benefits and potential risks (e.g. fluorosis) of water fluoridation in contemporary low-caries populations.
Limitations
The low response rates to the questionnaires reduced their value for generalisations. The observed numbers of children with decay and the postulated differences between the groups were far smaller than anticipated and, consequently, the power of the study was affected (i.e. increasing the uncertainty indicated in the confidence intervals).
Study registration
This study is registered as Integrated Research Application System 131824 and 149278.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Michaela Goodwin
- Division of Dentistry, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Michael P Kelly
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Matt Sutton
- Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - Martin Tickle
- Division of Dentistry, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Tanya Walsh
- Division of Dentistry, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - William Whittaker
- Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - Iain A Pretty
- Division of Dentistry, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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Moore D, Allen T, Boyers D, McKenzie K, Thompson W, Nyakutsikwa B, Pretty I, Tickle M. Unlocking the potential of NHS primary care dental datasets. Br Dent J 2022; 232:241-250. [PMID: 35217745 DOI: 10.1038/s41415-022-3987-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/25/2021] [Indexed: 11/09/2022]
Abstract
Introduction Maximising the use of routinely collected health data for research is a key part of the UK Government's Industrial Strategy. Rich data are generated by NHS primary care dental services, but the extent of their use in research is unknown.Aims To profile the utility of the post-2006 NHS dental datasets for research, map how they have been used to date and develop recommendations to maximise their utility.Methods The content of and access to the four UK NHS dental datasets was collated using publicly available information and a free-text questionnaire, completed by the relevant data controllers. A scoping review was carried out to identify and map literature that has utilised NHS dental activity data.Results The contents of the UK NHS dental activity datasets are described, alongside how they may be accessed for research. Strengths and weaknesses of these datasets for research are highlighted. The scoping review identified 33 studies which had utilised NHS dental activity data since 2006. We classified 15 as public health practice, 11 as service evaluation and 7 as research.Conclusion In comparision to other NHS activity datasets, it appears that the UK dental datasets have been underutilised for research. We make 11 recommendations on how their utility for research may be increased.
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Affiliation(s)
- Deborah Moore
- Research Associate, Dental Public Health, The University of Manchester, Division of Dentistry, Dental Health Unit, Lloyd Street North, Manchester Science Park, M15 6SE, UK.
| | - Thomas Allen
- Research Fellow, Health Economics, Danish Centre for Health Economics, University of Southern Denmark, Denmark; The University of Manchester, Manchester Centre for Health Economics, Room 4.305 Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Dwayne Boyers
- Research Fellow, Health Economics Research Unit, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Kate McKenzie
- Research Assistant, Dental Public Health, The University of Manchester, Division of Dentistry, Dental Health Unit, Lloyd Street North, Manchester Science Park, M15 6SE, UK
| | - Wendy Thompson
- NIHR Clinical Lecturer, The University of Manchester, Division of Dentistry, Coupland 3, M13 9PL, UK
| | - Blessing Nyakutsikwa
- Research Associate, Dental Public Health, The University of Manchester, Division of Dentistry, Dental Health Unit, Lloyd Street North, Manchester Science Park, M15 6SE, UK
| | - Iain Pretty
- Professor of Public Health Dentistry, The University of Manchester, Division of Dentistry, Dental Health Unit, Lloyd Street North, Manchester Science Park, M15 6SE, UK
| | - Martin Tickle
- Professor of Dental Public Health and Primary Care, The University of Manchester, Division of Dentistry, Coupland 3, M13 9PL, UK
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O’Malley L, Macey R, Allen T, Brocklehurst P, Thomson F, Rigby J, Lalloo R, Tomblin Murphy G, Birch S, Tickle M. Workforce Planning Models for Oral Health Care: A Scoping Review. JDR Clin Trans Res 2022; 7:16-24. [PMID: 33323035 PMCID: PMC8674798 DOI: 10.1177/2380084420979585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND For health care services to address the health care needs of populations and respond to changes in needs over time, workforces must be planned. This requires quantitative models to estimate future workforce requirements that take account of population size, oral health needs, evidence-based approaches to addressing needs, and methods of service provision that maximize productivity. The aim of this scoping review was to assess whether and how these 4 elements contribute to existing models of oral health workforce planning. METHODS A scoping review was conducted. MEDLINE, Embase, HMIC, and EconLit were searched, all via OVID. Additionally, gray literature databases were searched and key bodies and policy makers contacted. Workforce planning models were included if they projected workforce numbers and were specific to oral health. No limits were placed on country. A single reviewer completed initial screening of abstracts; 2 independent reviewers completed secondary screening and data extraction. A narrative synthesis was conducted. RESULTS A total of 4,009 records were screened, resulting in 42 included articles detailing 47 models. The workforce planning models varied significantly in their use of data on oral health needs, evidence-based services, and provider productivity, with most models relying on observed levels of service utilization and demand. CONCLUSIONS This review has identified quantitative workforce planning models that aim to estimate future workforce requirements. Approaches to planning the oral health workforce are not always based on deriving workforce requirements from population oral health needs. In many cases, requirements are not linked to population needs, while in models where needs are included, they are constrained by the existence and availability of the required data. It is critical that information systems be developed to effectively capture data necessary to plan future oral health care workforces in ways that relate directly to the needs of the populations being served. KNOWLEDGE TRANSFER STATEMENT Policy makers can use the results of this study when making decisions about the planning of oral health care workforces and about the data to routinely collect within health services. Collection of suitable data will allow for the continual improvement of workforce planning, leading to a responsive health service and likely future cost savings.
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Affiliation(s)
- L. O’Malley
- Division of Dentistry, School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - R. Macey
- Division of Dentistry, School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - T. Allen
- Centre for Health Economics, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - P. Brocklehurst
- NWORTH Clinical Trials Unit, University of Bangor, Bangor, UK
| | - F. Thomson
- Division of Dentistry, School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - J. Rigby
- WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada
- Research, Innovation and Discovery, Nova Scotia Health Authority, Halifax, Canada
| | - R. Lalloo
- School of Dentistry, The University of Queensland, Brisbane, Australia
| | - G. Tomblin Murphy
- WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada
- Research, Innovation and Discovery, Nova Scotia Health Authority, Halifax, Canada
| | - S. Birch
- Centre for the Business and Economics of Health, Faculty of Business Economics and Law, The University of Queensland, Brisbane, Australia
| | - M. Tickle
- Division of Dentistry, School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
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Hill H, Birch S, Tickle M, Petty I, Goldthorpe J. An eReferral Management & Triage System for minor Oral surgery referrals from primary care dentists: a cost-effectiveness evaluation. BMC Health Serv Res 2021; 21:781. [PMID: 34364370 PMCID: PMC8349481 DOI: 10.1186/s12913-021-06775-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 07/21/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Oral surgery referrals from NHS dental practices are rising, increasing the pressures on available hospital resources. We assess if an electronic referral system with consultant or peer (general dental practitioner) led triage of patient referrals from general dental practices can effectively divert patients requiring minor oral surgery into specialist led primary care settings at a reduced cost whilst providing care of the same or enhanced quality. One year of no triage (all referrals treated in secondary care) was followed by one-year of consultant led triage, which in turn was followed by year of peer-led triage. METHOD A health economic evaluation of all patient referrals from 27 UK dental practices for oral surgery procedures. The follow-up is over a three-year period at hospital dental services in two general hospitals, one dental hospital, and a single specialist oral surgeon based in two primary care practices. The evaluation is a comparison of mean outcomes in the hospitals and in specialist primary care dental services between the study periods (i.e. periods with and without the triage system). The main outcomes of interest are mean NHS cost saving per referral (costs to the NHS and costs to broader society), proportion of diverted referrals, case-mix of referrals and patient reports of the quality of dentistry services received at their referral destination. RESULTS The proportion of referrals diverted to specialist primary care was similar during both periods (45% under consultant-led triage and 43% under GDP-led triage). Statistically significant savings per referral diverted were found (£116.11 under consultant-led triage, £90.25 under GDP-led triage). There were no statistically significant changes in the case-mix of referrals. Cost savings varied according to the coding (and hence tariff) of referred cases by the provider hospitals. Patients reported similarly high levels of satisfaction scores for treatment in specialist primary care and secondary care settings. CONCLUSIONS Implementation of electronic referral management in primary care, when combined with triage, led to appropriate diversions to specialist primary care. Although cost savings were realised by referral diversion these savings are dependent on the particular tariff allocation (coding) practices of provider hospitals.
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Affiliation(s)
- Harry Hill
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Stephen Birch
- Health Services Research & Primary Care, University of Manchester, Manchester, UK.,Centre for Business and Economics of Health, University of Queensland, St Lucia, Australia
| | - Martin Tickle
- School of Dentistry, University of Manchester, Manchester, UK
| | - Iain Petty
- School of Dentistry, University of Manchester, Manchester, UK
| | - Joanna Goldthorpe
- Division of Psychology & Mental Health, University of Manchester, Manchester, UK
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Moore D, Allen T, Birch S, Tickle M, Walsh T, Pretty IA. How effective and cost-effective is water fluoridation for adults? Protocol for a 10-year retrospective cohort study. BDJ Open 2021; 7:3. [PMID: 33479223 PMCID: PMC7820470 DOI: 10.1038/s41405-021-00062-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Tooth decay can cause pain, sleepless nights and loss of productive workdays. Fluoridation of drinking water was identified in the 1940s as a cost-effective method of prevention. In the mid-1970s, fluoride toothpastes became widely available. Since then, in high-income countries the prevalence of tooth decay in children has reduced whilst natural tooth retention in older age groups has increased. Most water fluoridation research was carried out before these dramatic changes in fluoride availability and oral health. Furthermore, there is a paucity of evidence in adults. The aim of this study is to assess the clinical and cost-effectiveness of water fluoridation in preventing invasive dental treatment in adults and adolescents aged over 12. METHODS/DESIGN Retrospective cohort study using 10 years of routinely available dental treatment data. Individuals exposed to water fluoridation will be identified by sampled water fluoride concentration linked to place of residence. Outcomes will be based on the number of invasive dental treatments received per participant (fillings, extractions, root canal treatments). A generalised linear model with clustering by local authority area will be used for analysis. The model will include area level propensity scores and individual-level covariates. The economic evaluation will focus on (1) cost-effectiveness as assessed by the water fluoridation mean cost per invasive treatment avoided and (2) a return on investment from the public sector perspective, capturing the change in cost of dental service utilisation resulting from investment in water fluoridation. DISCUSSIONS There is a well-recognised need for contemporary evidence regarding the effectiveness and cost-effectiveness of water fluoridation, particularly for adults. The absence of such evidence for all age groups may lead to an underestimation of the potential benefits of a population-wide, rather than targeted, fluoride delivery programme. This study will utilise a pragmatic design to address the information needs of policy makers in a timely manner.
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Affiliation(s)
- Deborah Moore
- grid.5379.80000000121662407Dental Public Health, Division of Dentistry, Dental Health Unit, The University of Manchester, Lloyd Street North Manchester Science Park, Manchester, M15 6SE UK
| | - Thomas Allen
- Director, Centre for the Business and Economics of Health, University of Queensland, St Lucia, Queensland, 4072 UK
| | - Stephen Birch
- Director, Centre for the Business and Economics of Health, University of Queensland, St Lucia, Queensland, 4072 UK ,grid.5379.80000000121662407Health Economics, Manchester Centre for Health Economics, The University of Manchester, Jean McFarlane Building Oxford Road, Manchester, M13 9PL UK
| | - Martin Tickle
- grid.5379.80000000121662407Dental Public Health & Primary Care, Division of Dentistry, The University of Manchester, Coupland 3, Manchester, M13 9PL UK
| | - Tanya Walsh
- grid.5379.80000000121662407Healthcare Evaluation, Division of Dentistry, The University of Manchester, Coupland 3, Manchester, M139PL UK
| | - Iain A. Pretty
- grid.5379.80000000121662407Public Health Dentistry, Division of Dentistry, Dental Health Unit, The University of Manchester, Lloyd Street North Manchester Science Park, Manchester, M15 6SE UK
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11
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Birch S, Ahern S, Brocklehurst P, Chikte U, Gallagher J, Listl S, Lalloo R, O'Malley L, Rigby J, Tickle M, Tomblin Murphy G, Woods N. Planning the oral health workforce: Time for innovation. Community Dent Oral Epidemiol 2020; 49:17-22. [PMID: 33325124 PMCID: PMC7839544 DOI: 10.1111/cdoe.12604] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/01/2020] [Accepted: 11/09/2020] [Indexed: 12/19/2022]
Abstract
The levels and types of oral health problems occurring in populations change over time, while advances in technology change the way oral health problems are addressed and the ways care is delivered. These rapid changes have major implications for the size and mix of the oral health workforce, yet the methods used to plan the oral health workforce have remained rigid and isolated from planning of oral healthcare services and healthcare expenditures. In this paper, we argue that the innovation culture that has driven major developments in content and delivery of oral health care must also be applied to planning the oral health workforce if we are to develop ‘fit for purpose’ healthcare systems that meet the needs of populations in the 21st century. An innovative framework for workforce planning is presented focussed on responding to changes in population needs, service developments for meeting those needs and optimal models of care delivery.
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Affiliation(s)
- Stephen Birch
- Centre for the Business and Economics of Health, University of Queensland, Brisbane, Queensland, Australia.,Centre for Health Economics, University of Manchester, Manchester, UK
| | - Susan Ahern
- Oral Health Services Research Centre, Cork University Dental School & Hospital, University College Cork, Cork, Ireland
| | | | - Usuf Chikte
- Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Jennifer Gallagher
- Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK
| | - Stefan Listl
- Department of Dentistry - Quality and Safety of Oral Healthcare, Radboud University, Nijmegen, The Netherlands
| | - Ratilal Lalloo
- School of Dentistry, University of Queensland, Brisbane, Queensland, Australia
| | - Lucy O'Malley
- School of Dentistry, University of Manchester, Manchester, UK
| | - Janet Rigby
- WHO/PAHO Collaborating Centre on Health Workforce Planning & Research, Dalhousie University, Halifax, NS, Canada
| | - Martin Tickle
- School of Dentistry, University of Manchester, Manchester, UK
| | - Gail Tomblin Murphy
- WHO/PAHO Collaborating Centre on Health Workforce Planning & Research, Dalhousie University, Halifax, NS, Canada
| | - Noel Woods
- Centre for Policy Studies, Cork University Business School, University College Cork, Cork, Ireland
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Goodwin M, Whittaker W, Walsh T, Emsley R, Sutton M, Tickle M, Kelly M, Pretty I. Recruitment and Consent in an observational study. Community Dent Health 2020; 37:287-292. [PMID: 33026721 DOI: 10.1922/cdh_000682020goodwin06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The study sought to explore the consent rate and associated potential bias across a cohort in a large longitudinal population based study. RESEARCH DESIGN Data were taken from a study designed to examine the effects of the reintroduction of community water fluoridation on children's oral health over a five-year period. Children were recruited from a fluoridated and non-fluoridated area in Cumbria, referred to as Group 1 and Group 2. RESULTS Data were available for 3138 individuals. The consent rate was 12.91 percentage points lower in Group 2 than Group 1 (95% CI -16.27 to -9.56, p⟨0.001). The population in Group 2 was more deprived (higher Index of Multiple Deprivation (IMD)) than Group 1 before consent was taken. Consent was not associated with deprivation in either group. CONCLUSION The cohort appeared to be unaffected by IMD-related non-consent. However there was a difference in consent rate between the two groups. With the population in Group 1 being more deprived than Group 2, it will be important to incorporate these differences into the analysis at the end of this longitudinal study.
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Affiliation(s)
- M Goodwin
- University of Manchester, School of Dentistry, UK
| | - W Whittaker
- University of Manchester, Population Health, Health Services Research & Primary Care, UK
| | - T Walsh
- University of Manchester, School of Dentistry, UK
| | - R Emsley
- King's College London, Psychiatry, Psychology & Neuroscience, UK
| | - M Sutton
- University of Manchester, Population Health, Health Services Research & Primary Care, UK
| | - M Tickle
- University of Manchester, School of Dentistry, UK
| | - M Kelly
- University of Cambridge, Public Health, UK
| | - I Pretty
- University of Manchester, School of Dentistry, UK
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13
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Toedtling V, Devlin H, O'Malley L, Tickle M. A systematic review of second molar distal surface caries incidence in the context of third molar absence and emergence. Br Dent J 2020; 228:261-266. [PMID: 32112019 DOI: 10.1038/s41415-020-1255-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Objective The aim of this systematic review was to gain a greater insight into the incidence rates of distal surface caries (DSC) on second permanent molars.Data sources A literature search using the Cochrane Library, Lilacs, Embase and Medline via Ovid retrieved English and non-English language articles from inception to June 2016. The electronic searches were supplemented with reference searching and citation tracking. Reviewers independently and in duplicate performed data extraction and completed structured quality assessments using a validated risk of bias tool for observational studies and categorised the summary scores.Data selection The search yielded 81 records and, after application of inclusion and exclusion criteria, two incidence studies were included in this systematic review.Data extraction The DSC incidence was reported in one study as relative risk (RR = 2.53; 95% CI, 1.55 to 4.14) adjacent to erupted, (RR = 0.83; 95% CI, 0.11 to 6.04) soft tissue impacted and (RR = 1.44; 95% CI, 0.55 to 3.72) bony impacted third molars in comparison to when the third molar was absent with a 25-year follow-up. The second study reported a DSC incidence of 100 surface-years (1% of all sites) with an 18-month follow-up period.Conclusions Both cohort studies indicated that DSC incidence was higher when third molars were erupted in the intermediate term, but greater over the long term for an ageing male population. However, further high-quality research is required to improve the accuracy of these findings.
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Affiliation(s)
- Verena Toedtling
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, Oral and Maxillofacial Surgery, The University of Manchester, Manchester, UK.
| | - Hugh Devlin
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, Restorative Dentistry, The University of Manchester, Manchester, UK
| | - Lucy O'Malley
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, Evidence-Based Health Care, The University of Manchester, Manchester, UK
| | - Martin Tickle
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, Population Health, The University of Manchester, Manchester, UK
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14
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Goodwin M, Walsh T, Whittaker W, Emsley R, Sutton M, Tickle M, Kelly MP, Pretty IA. Increasing questionnaire response: evidence from a nested RCT within a longitudinal birth cohort study. BMC Med Res Methodol 2020; 20:163. [PMID: 32571269 PMCID: PMC7309972 DOI: 10.1186/s12874-020-01034-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 05/27/2020] [Indexed: 11/23/2022] Open
Abstract
Background High response rates are essential when questionnaires are used within research, as representativeness can affect the validity of studies and the ability to generalise the findings to a wider population. The study aimed to measure the response rate to questionnaires from a large longitudinal epidemiological study and sought to determine if any changes made throughout data collection had a positive impact on the response to questionnaires and addressed any imbalance in response rates by participants’ levels of deprivation. Methods Data were taken from a prospective, comparative study, designed to examine the effects of the reintroduction of water fluoridation on children’s oral health over a five-year period. Response rates were analysed for the first year of data collection. During this year changes were made to the questionnaire layout and cover letter to attempt to increase response rates. Additionally a nested randomised control trial compared the effect on response rates of three different reminders to complete questionnaires. Results Data were available for 1824 individuals. Sending the complete questionnaire again to non-responders resulted in the highest level of response (25%). A telephone call to participants was the only method that appeared to address the imbalance in deprivation, with a mean difference in deprivation score of 2.65 (95% CI -15.50 to 10.20) between the responders and non-responders. Conclusions Initially, low response rates were recorded within this large, longitudinal study giving rise to concerns about non-response bias. Resending the entire questionnaire again was the most effective way of reminding participants to complete the questionnaire. As this is a less labour intensive method than for example, calling participants, more time can then be spent targeting groups who are underrepresented. In order to address these biases, data can be weighted in order to draw conclusions about the population.
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Affiliation(s)
- Michaela Goodwin
- The Dental Health Unit, Division of Dentistry, Williams House, University of Manchester, Manchester Science Park, Manchester, M15 6SE, UK.
| | - Tanya Walsh
- The Dental Health Unit, Division of Dentistry, Williams House, University of Manchester, Manchester Science Park, Manchester, M15 6SE, UK
| | - William Whittaker
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crispigny Park, London, SE5 8AF, UK
| | - Matt Sutton
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Martin Tickle
- The Dental Health Unit, Division of Dentistry, Williams House, University of Manchester, Manchester Science Park, Manchester, M15 6SE, UK
| | - Michael P Kelly
- Primary Care Unit, Institute of Public Health, University of Cambridge, Cambridge, CB2 0SR, UK
| | - Iain A Pretty
- The Dental Health Unit, Division of Dentistry, Williams House, University of Manchester, Manchester Science Park, Manchester, M15 6SE, UK
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Hill H, Howarth E, Walsh T, Tickle M, Birch S, Brocklehurst P. The impact of changing provider remuneration on clinical activity and quality of care: Evaluation of a pilot NHS contract in Northern Ireland. Community Dent Oral Epidemiol 2020; 48:395-401. [DOI: 10.1111/cdoe.12544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/02/2020] [Accepted: 05/03/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Harry Hill
- School of Health and Related Research University of Sheffield Sheffield UK
| | | | - Tanya Walsh
- School of Dentistry University of Manchester Manchester UK
| | - Martin Tickle
- School of Dentistry University of Manchester Manchester UK
| | - Stephen Birch
- Health Services Research & Primary Care University of Manchester Manchester UK
- Centre for Business and Economics of Health University of Queensland Australia
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16
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Byrne M, O’Malley L, Glenny AM, Campbell S, Tickle M. A RAND/UCLA appropriateness method study to identify the dimensions of quality in primary dental care and quality measurement indicators. Br Dent J 2020; 228:83-88. [DOI: 10.1038/s41415-020-1200-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Brocklehurst P, Tickle M, Birch S, McDonald R, Walsh T, Goodwin TL, Hill H, Howarth E, Donaldson M, O’Carolan D, Fitzpatrick S, McCrory G, Slee C. Impact of changing provider remuneration on NHS general dental practitioner services in Northern Ireland: a mixed-methods study. Health Serv Deliv Res 2020. [DOI: 10.3310/hsdr08060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background
Policy-makers wanted to reform the NHS dental contract in Northern Ireland to contain costs, secure access and incentivise prevention and quality. A pilot project was undertaken to remunerate general dental practitioners using a capitation-based payment system rather than the existing fee-for-service system.
Objective
To investigate the impact of this change in remuneration.
Design
Mixed-methods design using a difference-in-difference evaluation of clinical activity levels, a questionnaire of patient-rated outcomes and qualitative assessment of general dental practitioners’ and patients’ views.
Setting
NHS dental practices in Northern Ireland.
Participants
General dental practitioners and patients in 11 intervention practices and 18 control practices.
Interventions
Change from fee for service to a capitation-based system for 1 year and then reversion back to fee for service.
Main outcome measures
Access to care, activity levels, service mix and financial impact, and patient-rated outcomes of care.
Results
The difference-in-difference analyses showed significant and rapid changes in the patterns of care provided by general dental practitioners to patients (compared with the control practices) when they moved from a fee-for-service system to a capitation-based remuneration system. The number of registered patients in the intervention practices compared with the control practices showed a small but statistically significant increase during the capitation period (p < 0.01), but this difference was small. There were statistically significant reductions in the volume of activity across all treatments in the intervention practices during the capitation period, compared with the control practices. This produced a concomitant reduction in patient charge revenue of £2403 per practice per month (p < 0.05). All outcome measures rapidly returned to baseline levels following reversion from the capitation-based system back to a fee-for-service system. The analysis of the questionnaires suggests that patients did not appear to notice very much change. Qualitative interviews showed variation in general dental practitioners’ behaviour in response to the intervention and how they managed the tension between professional ethics and maximising the profits of their business. Behaviours were also heavily influenced by local context. Practice principals preferred the capitation model as it freed up time and provided opportunities for private work, whereas capitation payments were seen by some principals as a ‘retainer fee’ for continuing to provide NHS care. Non-equity-owning associates perceived the capitation model as a financial risk.
Limitations
The active NHS pilot period was only 1 year, which may have limited the scope for meaningful change. The number of sites was restricted by the financial budget for the NHS pilot.
Conclusions
General dental practitioners respond rapidly and consistently to changes in remuneration, but differences were found in the extent of this change by practice and provider type. A move from a fee-for-service system to a capitation-based system had little impact on access but produced large reductions in clinical activity and patient charge income. Patients noticed little difference in the service that they received.
Future work
With changing population need and increasing financial pressure on the NHS, research is required on how to most efficiently meet the expectations of patients within an affordable cost envelope. Work is also needed to identify and evaluate interventions that can complement changes in remuneration to meet policy goals.
Trial registration
Current Controlled Trials ISRCTN29840057.
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. 6. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Martin Tickle
- School of Dentistry, University of Manchester, Manchester, UK
| | - Stephen Birch
- Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Ruth McDonald
- Manchester Business School, University of Manchester, Manchester, UK
| | - Tanya Walsh
- School of Dentistry, University of Manchester, Manchester, UK
| | | | - Harry Hill
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Tickle M, Ricketts DJN, Duncan A, O’Malley L, Donaldson PM, Clarkson JE, Black M, Boyers D, Donaldson M, Floate R, Forrest MM, Fraser A, Glenny AM, Goulao B, McDonald A, Ramsay CR, Ross C, Walsh T, Worthington HV, Young L, Bonetti DL, Gouick J, Mitchell FE, Macpherson LE, Lin YL, Pretty IA, Birch S. Protocol for a Randomised controlled trial to Evaluate the effectiveness and cost benefit of prescribing high dose FLuoride toothpaste in preventing and treating dEntal Caries in high-risk older adulTs (reflect trial). BMC Oral Health 2019; 19:88. [PMID: 31126270 PMCID: PMC6534863 DOI: 10.1186/s12903-019-0749-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dental caries in the expanding elderly, predominantly-dentate population is an emerging public health concern. Elderly individuals with heavily restored dentitions represent a clinical challenge and significant financial burden for healthcare systems, especially when their physical and cognitive abilities are in decline. Prescription of higher concentration fluoride toothpaste to prevent caries in older populations is expanding in the UK, significantly increasing costs for the National Health Services (NHS) but the effectiveness and cost benefit of this intervention are uncertain. The Reflect trial will evaluate the effectiveness and cost benefit of General Dental Practitioner (GDP) prescribing of 5000 ppm fluoride toothpaste and usual care compared to usual care alone in individuals 50 years and over with high-risk of caries. METHODS/DESIGN A pragmatic, open-label, randomised controlled trial involving adults aged 50 years and above attending NHS dental practices identified by their dentist as having high risk of dental caries. Participants will be randomised to prescription of 5000 ppm fluoride toothpaste (frequency, amount and duration decided by GDP) and usual care only. 1200 participants will be recruited from approximately 60 dental practices in England, Scotland and Northern Ireland and followed up for 3 years. The primary outcome will be the proportion of participants receiving any dental treatment due to caries. Secondary outcomes will include coronal and root caries increments measured by independent, blinded examiners, patient reported quality of life measures, and economic outcomes; NHS and patient perspective costs, willingness to pay, net benefit (analysed over the trial follow-up period and modelled lifetime horizon). A parallel qualitative study will investigate GDPs' practises of and beliefs about prescribing the toothpaste and patients' beliefs and experiences of the toothpaste and perceived impacts on their oral health-related behaviours. DISCUSSION The Reflect trial will provide valuable information to patients, policy makers and clinicians on the costs and benefits of an expensive, but evidence-deficient caries prevention intervention delivered to older adults in general dental practice. TRIAL REGISTRATION ISRCTN: 2017-002402-13 registered 02/06/2017, first participant recruited 03/05/2018. Ethics Reference No: 17/NE/0329/233335. Funding Body: Health Technology Assessment funding stream of National Institute for Health Research. Funder number: HTA project 16/23/01. Trial Sponsor: Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL. The Trial was prospectively registered.
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Affiliation(s)
- M. Tickle
- Division of Dentistry, University of Manchester, Coupland 3 Building, Oxford Road,M13 9PL, Manchester, UK
| | | | - A. Duncan
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, Scotland, UK
| | - L. O’Malley
- Division of Dentistry, University of Manchester, Coupland 3 Building, Oxford Road,M13 9PL, Manchester, UK
| | - P. M. Donaldson
- School of Dentistry, University of Dundee, Dundee, Scotland, UK
| | - J. E. Clarkson
- Division of Dentistry, University of Manchester, Coupland 3 Building, Oxford Road,M13 9PL, Manchester, UK
- School of Dentistry, University of Dundee, Dundee, Scotland, UK
| | - M. Black
- School of Dentistry, University of Dundee, Dundee, Scotland, UK
| | - D. Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - M. Donaldson
- Division of Dentistry, University of Manchester, Coupland 3 Building, Oxford Road,M13 9PL, Manchester, UK
- Northern Ireland Health & Social Care Board, Belfast, Northern Ireland
| | - R. Floate
- School of Dentistry, University of Dundee, Dundee, Scotland, UK
| | - M. M. Forrest
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, Scotland, UK
| | - A. Fraser
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, Scotland, UK
| | - A. M. Glenny
- Division of Dentistry, University of Manchester, Coupland 3 Building, Oxford Road,M13 9PL, Manchester, UK
| | - B. Goulao
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, Scotland, UK
| | - A. McDonald
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, Scotland, UK
| | - C. R. Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - C. Ross
- School of Dentistry, University of Dundee, Dundee, Scotland, UK
| | - T. Walsh
- Division of Dentistry, University of Manchester, Coupland 3 Building, Oxford Road,M13 9PL, Manchester, UK
| | - H. V. Worthington
- Division of Dentistry, University of Manchester, Coupland 3 Building, Oxford Road,M13 9PL, Manchester, UK
| | - L. Young
- NHS Education for Scotland, Edinburgh, Scotland, UK
| | - D. L. Bonetti
- School of Dentistry, University of Dundee, Dundee, Scotland, UK
| | - J. Gouick
- School of Dentistry, University of Dundee, Dundee, Scotland, UK
| | - F. E. Mitchell
- School of Dentistry, University of Dundee, Dundee, Scotland, UK
| | | | - Y. L. Lin
- Division of Dentistry, University of Manchester, Coupland 3 Building, Oxford Road,M13 9PL, Manchester, UK
| | - I. A. Pretty
- Division of Dentistry, University of Manchester, Coupland 3 Building, Oxford Road,M13 9PL, Manchester, UK
| | - S. Birch
- Division of Dentistry, University of Manchester, Coupland 3 Building, Oxford Road,M13 9PL, Manchester, UK
- Centre for the Business and Economics of Health, University of Queensland, Brisbane, Australia
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Toedtling V, Devlin H, Tickle M, O'Malley L. Prevalence of distal surface caries in the second molar among referrals for assessment of third molars: a systematic review and meta-analysis. Br J Oral Maxillofac Surg 2019; 57:505-514. [PMID: 31128951 DOI: 10.1016/j.bjoms.2019.04.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
Abstract
We conducted a systematic review of epidemiological studies to assess the prevalence of distal surface caries (DSC) in second molars adjacent to third molars. We searched the Cochrane Library, Lilacs, Embase, and Medline through Ovid® (Wolters Kluwer) to retrieve English and non-English papers from inception to June 2016, and supplemented this with a search of the references and by tracking citations. Three reviewers contributed: one reviewed all the papers, and the other two divided the rest between them. They extracted data, completed structured quality assessments with a validated risk of bias tool for observational studies, and categorised the summary scores. The search yielded 81 records and 11 studies were analysed. The considerable methodological diversity meant that five were not eligible for inclusion in the quantitative synthesis. A meta-analysis of six studies on the prevalence of DSC and a subgroup analysis of three on various third-molar angulations were indicated. The overall pooled prevalence estimate calculated with a random-effects model was 23% (95% CI 2% to 44%) among patients. Prevalence subtotals were 20% (95% CI 5% to 36%) for prospective, and 15% (95% CI 5% to 36%) for retrospective studies among teeth. A subgroup analysis of three studies with 1296 patients (1666 molars) yielded a prevalence of DSC of 36% (95% CI 5% to 67%) for mesial impactions and 22% (95% CI 1% to 42%) for horizontal impactions. DSC was present in 3% of distally-inclined impactions, (95% CI 1% to 5%) and in 7% (95% CI 1% to 13%) of vertical third molars. The studies varied. The risk of bias was low in one and moderate in two. European studies suggested that DSC may be present in about one in four referrals for the assessment of third molars, and that the risk is considerably higher in those with convergent third molar impactions.
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Affiliation(s)
- V Toedtling
- Faculty of Biology, Medicine and Health, Division of Dentistry, University of Manchester, Coupland Building 3, Coupland Road, Manchester, M13 9PL, UK.
| | - H Devlin
- Faculty of Biology, Medicine and Health, Division of Dentistry, University of Manchester, Coupland Building 3, Coupland Road, Manchester, M13 9PL, UK
| | - M Tickle
- Dental Public Health and Primary Care, University of Manchester, Coupland Building 3, Coupland Road, Manchester, M13 9PL, UK
| | - L O'Malley
- Faculty of Biology, Medicine and Health, Division of Dentistry, University of Manchester, Coupland Building 3, Coupland Road, Manchester, M13 9PL, UK
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20
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Byrne MJ, Tickle M, Glenny AM, Campbell S, Goodwin T, O'Malley L. A systematic review of quality measures used in primary care dentistry. Int Dent J 2018; 69:252-264. [PMID: 30430563 DOI: 10.1111/idj.12453] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION 'Quality' in primary care dentistry is poorly defined. There are significant international efforts focussed on developing quality measures within dentistry. The aim of this research was to identify measures used to assess quality in primary care dentistry and categorise them according to which dimensions of quality they attempt to measure. METHODS Quality measures were identified from the peer-reviewed and grey literature. Peer-reviewed papers describing the development and validation of measures were identified using a structured literature search. Measures from the grey literature were identified using structured searches and direct contact with dental providers and institutions. Quality measures were categorised according to domains of structure, process and outcome and by disaggregated dimensions of quality. RESULTS From 22 studies, 11 validated measure sets (comprising nine patient satisfaction surveys and two practice assessment instruments) were identified from the peer-reviewed literature. From the grey literature, 24 measure sets, comprising 357 individual measures, were identified. Of these, 96 addressed structure, 174 addressed process and 87 addressed outcome. Only three of these 24 measure sets demonstrated evidence of validity testing. The identified measures failed to address dimensions of quality, such as efficiency and equity. CONCLUSIONS There has been a proliferation in the development of dental quality measures in recent years. However, this development has not been guided by a clear understanding of the meaning of quality. Few existing measures have undergone rigorous validity or reliability testing. A consensus is needed to establish a definition of quality in dentistry. Identification of the important dimension of quality in dentistry will allow for the production of a core quality measurement set.
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Affiliation(s)
- Matthew J Byrne
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Martin Tickle
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Anne-Marie Glenny
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Stephen Campbell
- NIHR Patient Safety Translational Research Centre, Division of Population Health, HSR & Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Tom Goodwin
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Lucy O'Malley
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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21
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Macey R, Tickle M, MacKay L, McGrady M, Pretty IA. A comparison of dental fluorosis in adult populations with and without lifetime exposure to water fluoridation. Community Dent Oral Epidemiol 2018; 46:608-614. [PMID: 30178518 DOI: 10.1111/cdoe.12411] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES There is a lack of evidence on the proportion and severity of fluorosis in adult populations exposed and not exposed to fluoridated water over their lifetimes. The aim of this study was to compare the proportion and severity of fluorosis in adults with lifetime exposure to water fluoridation with a nonexposed sample. A secondary aim was to report the gradient of fluorosis severity by age. METHODS A cross-sectional study recruited a sample with lifetime exposure to water fluoridation and a matched, nonexposed group. 580 participants, aged 18-52 years (mean 34.3, SD 9.4) and 64% female, were recruited in general dental practices located in fluoridated (Birmingham and County Durham) and nonfluoridated areas (Manchester). Three digital images were taken of their incisors and an experienced examiner who was blind to exposure status viewed the images remotely and allocated fluorosis scores using the Thylstrup and Fejerskov (TF) scale. RESULTS At TF ≥ 1 (any fluorosis), a significantly higher proportion of participants from the fluoridated area had fluorosis (F 39% NF 21.3%, P < 0.001), at the threshold TF ≥ 3 ("aesthetic concern"), the difference was no longer statistically significant (F 4.1%, NF 2.2%, P = 0.25). There was a gradient by age, whereby fluorosis was highest in the youngest and lowest in the oldest age group. CONCLUSIONS Although fluorosis is more common in adults with lifetime exposure to water fluoridation than those with no exposure, the aesthetic impact of fluorosis seems to diminish with age.
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Affiliation(s)
- Richard Macey
- Division of Dentistry, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Martin Tickle
- Division of Dentistry, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Laura MacKay
- Division of Dentistry, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Michael McGrady
- Division of Dentistry, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Iain A Pretty
- Division of Dentistry, School of Medical Sciences, The University of Manchester, Manchester, UK
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Goldthorpe J, Sanders C, Macey R, Gough L, Rogers J, Tickle M, Pretty I. Exploring implementation of an electronic referral management system and enhanced primary care service for oral surgery: perspectives of patients, providers and practitioners. BMC Health Serv Res 2018; 18:646. [PMID: 30126391 PMCID: PMC6102936 DOI: 10.1186/s12913-018-3424-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/26/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A specialist primary care oral surgery service combined with an electronic referral management and triage system was developed in response to concerns raised around overburdened secondary care services in the UK. Whilst the system has the potential to manage conflicting demand for oral surgery services against an objective need, the new pathway represents a number of challenges to existing working practices and could compromise the sustainability of existing hospital services. The aim of this research was to carry out a qualitative exploration of implementation of a new intervention to gain insight into how these challenges have manifested and been addressed. METHODS Views were sought from stakeholders (dentists, hospital staff, commissioners and patients) at various time points over 3 years during and after implementation using semi-structured interviews. Normalization Process Theory informed a qualitative thematic analysis which was carried out using data from interview transcripts to identify important emerging issues. RESULTS Themes emerging from the data were; amenability to change and assimilation into practice (primary care dentists), compliance and governance, changing perceptions of impact (secondary care staff and commissioners) understanding change in service provision and priorities for treatment (patients). The new pathway impacted stakeholders at different stages of implementation. CONCLUSION Electronic referral management with a primary care advanced service for oral surgery was successfully implemented in a specific area of the UK. The service model evaluated has the potential to be expanded across a wider geographical footprint and to support demand management in other specialist services.
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Affiliation(s)
- Joanna Goldthorpe
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, University of Manchester, Coupland 1 Building, Manchester, M13 9PL UK
| | - Caroline Sanders
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Williamson Building, Manchester, M13 9PL UK
| | - Richard Macey
- Division of Dentistry, University of Manchester, J R Moore Building, Manchester, M13 9PL UK
| | - Lesley Gough
- Public Health England, Cheshire and Merseyside PHE Centre 5th Floor, Rail House Lord Nelson Street, Liverpool, L1 1JF UK
| | - Jean Rogers
- NHS England North, Regatta Place, Brunswick Business Park, Summers Road, Liverpool, L3 4BL UK
| | - Martin Tickle
- Division of Dentistry, University of Manchester, J R Moore Building, Manchester, M13 9PL UK
| | - Iain Pretty
- Colgate Palmolive/ University of Manchester Dental Health Unit, Williams House, Manchester Science Park, Manchester, M15 6SE UK
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Goldthorpe J, Sanders C, Gough L, Rogers J, Bridgman C, Tickle M, Pretty I. Implementing and evaluating a primary care service for oral surgery: a case study. BMC Health Serv Res 2018; 18:636. [PMID: 30107796 PMCID: PMC6092788 DOI: 10.1186/s12913-018-3420-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/25/2018] [Indexed: 11/10/2022] Open
Abstract
Background A primary care oral surgery service was commissioned alongside an electronic referral management system in England, in response to rising demand for Oral Surgery services in secondary care. It is important to ensure that standards of quality and safety are similar to those in existing secondary care services, and that the new service is acceptable to stakeholders. The aim of this study is therefore to conduct an in depth case study to explore safety, quality, acceptability and implementation of the new service. Methods This case study draws on multiple sources of evidence to report on the commissioning process, implementation, treatment outcomes and acceptability to patients relating to a new oral surgery service in a primary care setting. A combination of audit data and interviews were analysed. Results Most referrals to the new service consisted of tooth extractions of appropriate complexity for the service. There were issues with lack of awareness of the new service in a primary care setting within referring primary care practices and patients at the start of implementation, however over time the service became a fully integrated part of the service landscape. Complications reported following surgery were low. Conclusion Patients liked the convenience of the new service in terms of shorter waiting time and geographical location and their patient reported experience measures and outcomes were similar to those reported in secondary care. Providing appropriate clinical governance was in place, oral surgery could safely be provided in a primary care setting for patients without complex medical needs. Attention needs to be paid to communication with general dental practices around changes to the service pathway during the early implementation period to ensure all patients can receive care in the most appropriate setting.
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Affiliation(s)
- Joanna Goldthorpe
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, University of Manchester, Coupland 1 Building, Manchester, M13 9PL, UK.
| | - Caroline Sanders
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Williamson Building, Manchester, M13 9PL, UK
| | - Lesley Gough
- Public Health England, Cheshire and Merseyside PHE Centre 5th Floor, Rail House, Lord Nelson Street, Liverpool, L1 1JF, UK
| | - Jean Rogers
- NHS England North, Regatta Place, Brunswick Business Park, Summers Road, Liverpool, L3 4BL, UK
| | - Colette Bridgman
- Primary Care Division, Directorate of Primary Care and Innovation, Health and Social Services Group, Welsh Government, Cardiff, UK
| | - Martin Tickle
- Division of Dentistry, University of Manchester, J R Moore Building, Manchester, M13 9PL, UK
| | - Iain Pretty
- Colgate Palmolive - University of Manchester Dental Health Unit, Williams House, Manchester Science Park, M15 6SE, UK
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Tickle M, O'Neill C, Donaldson M, Birch S, Noble S, Killough S, Murphy L, Greer M, Brodison J, Verghis R, Worthington HV. A randomised controlled trial to measure the effects and costs of a dental caries prevention regime for young children attending primary care dental services: the Northern Ireland Caries Prevention In Practice (NIC-PIP) trial. Health Technol Assess 2018; 20:1-96. [PMID: 27685609 DOI: 10.3310/hta20710] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Dental caries is the most common disease of childhood. The NHS guidelines promote preventative care in dental practices, particularly for young children. However, the cost-effectiveness of this policy has not been established. OBJECTIVE To measure the effects and costs of a composite fluoride intervention designed to prevent caries in young children attending dental services. DESIGN The study was a two-arm, parallel-group, randomised controlled trial, with an allocation ratio of 1 : 1. Randomisation was by clinical trials unit, using randomised permuted blocks. Children/families were not blinded; however, outcome assessment was blinded to group assessment. SETTING The study took place in 22 NHS dental practices in Northern Ireland, UK. PARTICIPANTS The study participants were children aged 2-3 years, who were caries free at baseline. INTERVENTIONS The intervention was composite in nature, comprising a varnish containing 22,600 parts per million (p.p.m.) fluoride, a toothbrush and a 50-ml tube of toothpaste containing 1450 p.p.m. fluoride; plus standardised, evidence-based prevention advice provided at 6-monthly intervals over 3 years. The control group received the prevention advice alone. MAIN OUTCOME MEASURES The primary outcome measure was conversion from caries-free to caries-active states. Secondary outcome measures were the number of decayed, missing or filled tooth surfaces in primary dentition (dmfs) in caries-active children, the number of episodes of pain, the number of extracted teeth and the costs of care. Adverse reactions (ARs) were recorded. RESULTS A total of 1248 children (624 randomised to each group) were recruited and 1096 (549 in the intervention group and 547 in the control group) were included in the final analyses. A total of 87% of the intervention children and 85% of control children attended every 6-month visit (p = 0.77). In total, 187 (34%) children in the intervention group converted to caries active, compared with 213 (39%) in the control group [odds ratio (OR) 0.81, 95% confidence interval (CI) 0.64 to 1.04; p = 0.11]. The mean number of tooth surfaces affected by caries was 7.2 in the intervention group, compared with 9.6 in the control group (p = 0.007). There was no significant difference in the number of episodes of pain between groups (p = 0.81). However, 164 out of the total of 400 (41%) children who converted to caries active reported toothache, compared with 62 out of 696 (9%) caries-free children (OR 7.1 95% CI 5.1 to 9.9; p < 0.001). There was no statistically significant difference in the number of teeth extracted in caries-active children (p = 0.95). Ten children in the intervention group had ARs of a minor nature. The average direct dental care cost was £155.74 for the intervention group and £48.21 for the control group over 3 years (p < 0.05). The mean cost per carious surface avoided over the 3 years was estimated at £251.00. LIMITATIONS The usual limitations of a trial such as generalisability and understanding the underlying reasons for the outcomes apply. There is no mean willingness-to-pay threshold available to enable assessment of value for money. CONCLUSIONS A statistically significant effect could not be demonstrated for the primary outcome. Once caries develop, pain is likely. There was a statistically significant difference in dmfs in caries-active children in favour of the intervention. Although adequately powered, the effect size of the intervention was small and of questionable clinical and economic benefit. FUTURE WORK Future work should assess the caries prevention effects of interventions to reduce sugar consumption at the population and individual levels. Interventions designed to arrest the disease once it is established need to be developed and tested in practice. TRIAL REGISTRATION Current Controlled Trials ISRCTN36180119 and EudraCT 2009-010725-39. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 71. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin Tickle
- School of Dentistry, University of Manchester, Manchester, UK
| | - Ciaran O'Neill
- J.E. Cairnes School of Business and Economics, National University of Ireland, Galway, Ireland
| | | | - Stephen Birch
- Centre for Health Economics, University of Manchester, Manchester, UK
| | | | - Seamus Killough
- General Dental Practitioner, Ballycastle, UK.,British Dental Association Northern Ireland, Belfast, UK
| | - Lynn Murphy
- Northern Ireland Clinical Trials Unit, Belfast Health & Social Care Trust, Belfast, UK
| | - Margaret Greer
- Northern Ireland Clinical Trials Unit, Belfast Health & Social Care Trust, Belfast, UK
| | | | - Rejina Verghis
- Northern Ireland Clinical Trials Unit, Belfast Health & Social Care Trust, Belfast, UK
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25
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Goldthorpe J, Walsh T, Tickle M, Birch S, Hill H, Sanders C, Coulthard P, Pretty IA. An evaluation of a referral management and triage system for oral surgery referrals from primary care dentists: a mixed-methods study. Health Serv Deliv Res 2018. [DOI: 10.3310/hsdr06080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundOral surgery referrals from dentists are rising and putting increased pressure on finite hospital resources. It has been suggested that primary care specialist services can provide care for selected patients at reduced costs and similar levels of quality and patient satisfaction.Research questionsCan an electronic referral system with consultant- or peer-led triage effectively divert patients requiring oral surgery into primary care specialist settings safely, and at a reduced cost, without destabilising existing services?DesignA mixed-methods, interrupted time study (ITS) with adjunct diagnostic test accuracy assessment and health economic evaluation.SettingThe ITS was conducted in a geographically defined health economy with appropriate hospital services and no pre-existing referral management or primary care oral surgery service. Hospital services included a district general, a foundation trust and a dental hospital.ParticipantsPatients, carers, general and specialist dentists, consultants (both surgical and Dental Public Health), hospital managers, commissioners and dental educators contributed to the qualitative component of the work. Referrals from primary care dental practices for oral surgery procedures over a 3-year period were utilised for the quantitative and health economic evaluation.InterventionsA consultant- then practitioner-led triage system for oral surgery referrals embedded within an electronic referral system for oral surgery with an adjunct primary care service.Main outcome measuresDiagnostic test accuracy metrics for sensitivity and specificity were calculated. Total referrals, numbers of referrals sent to primary care and the cost per referral are reported for the main intervention. Qualitative findings in relation to patient experience and whole-system impact are described.ResultsIn the diagnostic test accuracy study, remote triage was found to be highly specific (mean 88.4, confidence intervals 82.6 and 92.8) but with lower values for sensitivity. The implementation of the referral system and primary care service was uneventful. During consultant triage in the active phases of the study, 45% of referrals were diverted to primary care, and when general practitioner triage was used this dropped to 43%. Only 4% of referrals were sent from specialist primary care to hospital, suggesting highly efficient triage of referrals. A significant per-referral saving of £108.23 [standard error (SE) £11.59] was seen with consultant triage, and £84.13 (SE £11.56) with practitioner triage. Cost savings varied according the differing methods of applying the national tariff. Patients reported similar levels of satisfaction for both settings, and speed of treatment was their over-riding concern.ConclusionsImplementation of electronic referral management in primary care can lead, when combined with triage, to diversions of appropriate cases to primary care. Cost savings can be realised but are dependent on tariff application by hospitals, with a risk of overestimating where hospitals are using day case tariffs extensively.Study limitationsThe geographical footprint of the study was relatively small and, hence, the impact on services was minimal and could not be fully assessed across all three hospitals.Future workThe findings suggest that the intervention should be tested in other localities and disciplines, especially those, such as dermatology, that present the opportunity to use imaging to triage.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Joanna Goldthorpe
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Tanya Walsh
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Martin Tickle
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Stephen Birch
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Harry Hill
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Caroline Sanders
- Division of Population Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Paul Coulthard
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Iain A Pretty
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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26
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O'Malley L, Worthington HV, Donaldson M, O'Neil C, Birch S, Noble S, Killough S, Murphy L, Greer M, Brodison J, Verghis R, Tickle M. Oral health behaviours of parents and young children in a practice-based caries prevention trial in Northern Ireland. Community Dent Oral Epidemiol 2017; 46:251-257. [PMID: 29271079 DOI: 10.1111/cdoe.12357] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 11/14/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The NICPIP trial evaluated the costs and effects of a caries prevention intervention delivered to 2- to 3-year-old children attending dental practices in Northern Ireland. This supplementary study explored the oral health behaviours of children and their parents to help understand the reasons for the trial's findings. METHODS A mixed methods study that included a questionnaire completed by all parents (n = 1058) at the time they brought their child for the NICPIP final clinical assessment. The questionnaire collected data on frequency of toothbrushing and sugar consumption. Questionnaire data were analysed by trial group and caries status. Parents of trial participants (n = 42) were invited to take part in telephone interviews. Parents were purposively sampled according to trial group and whether or not their child developed caries. The interviews explored how and why oral health behaviours happened. Interview data were audio-recorded, transcribed verbatim and analysed thematically. RESULTS The questionnaire data indicated that toothbrushing and between-meal sugar snacking were common in the majority of children. The children of parents who automatically reminded their child to brush their teeth were more likely to remain caries-free (Odds Ratio 1.24; 95% CI 1.08, 1.41; P = .002). Frequency of sweet drink consumption was associated with the child developing caries (Odds Ratio 0.88; 95% CI 0.79, 0.98; P = .021). The interview data showed that parents had positive attitudes towards brushing both in terms of perceived importance and expected outcomes. Attitudes towards sugar snacking were more complex, with parents reporting difficulties in controlling this behaviour. Sugar was described as being something that was "ever present" in children's lives. CONCLUSIONS Toothbrushing was widely adopted from a young age, but between-meal sugar consumption was highly prevalent. The results suggest that effective family-level and population-level interventions are needed to reduce sugar consumption if substantial improvements in caries prevention are to be achieved.
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Affiliation(s)
- Lucy O'Malley
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Helen V Worthington
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Ciaran O'Neil
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Stephen Birch
- Centre for Health Economics, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | | | | | - Lynn Murphy
- Northern Ireland Clinical Trials Unit, Belfast Health & Social Care Trust, Belfast, UK
| | - Margaret Greer
- hVIVO, Queen Mary BioEnterprises Innovation Centre, London, UK
| | - Julie Brodison
- Northern Ireland Clinical Trials Unit, Belfast Health & Social Care Trust, Belfast, UK
| | - Rejina Verghis
- Northern Ireland Clinical Trials Unit, Belfast Health & Social Care Trust, Belfast, UK
| | - Martin Tickle
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Hall-Scullin EP, Whitehead H, Rushton H, Milsom K, Tickle M. A longitudinal study of the relationship between dental caries and obesity in late childhood and adolescence. J Public Health Dent 2017; 78:100-108. [DOI: 10.1111/jphd.12244] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 07/24/2017] [Indexed: 11/27/2022]
Affiliation(s)
| | - Hilary Whitehead
- Community Dental Service; Salford Royal NHS Foundation Trust; Salford UK
| | - Helen Rushton
- Health eResearch Centre; University of Manchester; Manchester UK
| | - Keith Milsom
- Division of Dentistry, School of Medical Sciences; University of Manchester; Chester UK
| | - Martin Tickle
- Division of Dentistry, School of Medical Sciences; University of Manchester; Manchester UK
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Price J, Whittaker W, Birch S, Brocklehurst P, Tickle M. Socioeconomic disparities in orthodontic treatment outcomes and expenditure on orthodontics in England's state-funded National Health Service: a retrospective observational study. BMC Oral Health 2017; 17:123. [PMID: 28927396 PMCID: PMC5605975 DOI: 10.1186/s12903-017-0414-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 09/07/2017] [Indexed: 12/02/2022] Open
Abstract
Background This study aimed to assess whether there are potential areas for efficiency improvements in the National Health Service (NHS) orthodontic service in North West England and to assess the socioeconomic status (SES)-related equity of the outcomes achieved by the NHS. Methods The study involved a retrospective analysis of 2008–2012 administrative data, and the study population comprised patients aged ≥10 who started NHS primary care orthodontic treatment in North West England in 2008. The proportions of treatments that were discontinued early and ended with residual need (based on post-treatment Index of Orthodontic Treatment Need [IOTN] scores that met or exceeded the NHS eligibility threshold of 3.6) and the associated NHS expenditure were calculated. In addition, the associations with SES were investigated using linear probability models. Results We found that 7.6% of treatments resulted in discontinuation (which was associated with an NHS annual expenditure of £2.3 m), and a further 19.4% (£5.9 m) had a missing outcome record. Furthermore, 5.2% of treatments resulted in residual need (£1.6 m), and a further 38.3% (£11.6 m) had missing IOTN data (due to either a missing outcome record or an incomplete IOTN outcome field in the record), which led to an annual NHS expenditure of £13.2 m (44% of the total expenditure) on treatments that are a potential source of inefficiency. Compared to the patients in the highest SES group, those in the lower SES groups were more likely both to discontinue treatment and to have residual need on treatment completion. Conclusions Substantial inefficiencies were evident in the NHS orthodontic service, with 7.6% of treatments ending in discontinuation (£2.3 m) and 5.2% ending with residual need (£1.6 m). Over a third of cases had unreported IOTN outcome scores, which highlights the need to improve the outcome monitoring systems. In addition, the SES gradients indicate inequity in the orthodontic outcomes, with children from disadvantaged communities having poorer outcomes compared to their more affluent peers. Electronic supplementary material The online version of this article (10.1186/s12903-017-0414-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Juliet Price
- Division of Dentistry, School of Medical Sciences, University of Manchester, Manchester, UK
| | - William Whittaker
- Manchester Centre for Health Economics, School of Health Sciences, University of Manchester, Manchester, UK.
| | - Stephen Birch
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Paul Brocklehurst
- Institute of Medical and Social Care Research, Bangor University, Bangor, UK
| | - Martin Tickle
- Division of Dentistry, School of Medical Sciences, University of Manchester, Manchester, UK
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Hill H, Birch S, Tickle M, McDonald R, Brocklehurst P. Productive efficiency and its determinants in the Community Dental Service in the north-west of England. Community Dent Health 2017; 34:102-106. [PMID: 28573841 DOI: 10.1922/cdh_4028hill05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 11/03/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To assess the efficiency of service provision in the Community Dental Services and its determinants in the North-West of England. SETTING AND SAMPLE 40 Community Dental Services sites operating across the North-West of England. BASIC RESEARCH DESIGN A data envelopment analysis was undertaken of inputs (number of surgeries, hours worked by dental officers, therapists, hygienists and others) and outputs (treatments delivered, number of courses of treatment and patients seen) of the Community Dental Services to produce relative efficiency ratings by health authority. These were further analyzed in order to identify which inputs (determined within the Community Dental Services) or external factors outside the control of the Community Dental Services are associated with efficiency. MAIN OUTCOME MEASURE Relative efficiency rankings in Community Dental Services production of dental healthcare. RESULTS Using the quantity of treatments delivered as the measure of output, on average the Community Dental Services in England is operating at a relative efficiency of 85% (95% confidence interval 77%- 99%) compared to the best performing services. Average efficiency is lower when courses of treatment and unique patients seen are used as output measures, 82% and 68% respectively. Neither the input mix nor the patient case mix explained variations in the efficiency across Community Dental Services. CONCLUSIONS Although large variations in performance exist across Community Dental Services, the data available was not able to explain these variations. A useful next step would be to undertake detailed case studies of several best and under-performing services to explore the factors that influence relative performance levels.
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Affiliation(s)
- H Hill
- School of Dentistry, University of Manchester, Manchester, M13 9PL
| | - S Birch
- Manchester Centre for Health Economics, University of Manchester, M13 9PL, UK.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, ON L8S 4K1,Canada
| | - M Tickle
- School of Dentistry, University of Manchester, Manchester, M13 9PL
| | - R McDonald
- Manchester Business School, University of Manchester, M13 9PL, UK
| | - P Brocklehurst
- NWORTH Clinical Trials Unit, Bangor University, Bangor, Gwynedd, LL57 2PZ, UK
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O’Neill C, Worthington H, Donaldson M, Birch S, Noble S, Killough S, Murphy L, Greer M, Brodison J, Verghis R, Tickle M. Cost-Effectiveness of Caries Prevention in Practice: A Randomized Controlled Trial. J Dent Res 2017; 96:875-880. [DOI: 10.1177/0022034517708968] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 2-arm parallel-group randomized controlled trial measured the cost-effectiveness of caries prevention in caries-free children aged 2 to 3 y attending general practice. The setting was 22 dental practices in Northern Ireland. Participants were centrally randomized into intervention (22,600 ppm fluoride varnish, toothbrush, a 50-mL tube of 1,450 ppm fluoride toothpaste, and standardized prevention advice) and control (advice only), both provided at 6-monthly intervals during a 3-y follow-up. The primary outcome measure was conversion from caries-free to caries-active states assessed by calibrated and blinded examiners; secondary outcome measures included decayed, missing, or filled teeth surfaces (dmfs); pain; and extraction. Cumulative costs were related to each of the trial’s outcomes in a series of incremental cost effectiveness ratios (ICERs). Sensitivity analyses examined the impact of using dentist’s time as measured by observation rather than that reported by the dentist. The costs of applying topical fluoride were also estimated assuming the work was undertaken by dental nurses or hygienists rather than dentists. A total of 1,248 children (624 randomized to each group) were recruited, and 1,096 (549 in the intervention group and 547 in the control group) were included in the final analyses. The mean difference in direct health care costs between groups was £107.53 (£155.74 intervention, £48.21 control, P < 0.05) per child. When all health care costs were compared, the intervention group’s mean cost was £212.56 more than the control group (£987.53 intervention, £774.97 control, P < 0.05). Statistically significant differences in outcomes were only detected with respect to carious surfaces. The mean cost per carious surface avoided was estimated at £251 (95% confidence interval, £454.39–£79.52). Sensitivity analyses did not materially affect the study’s findings. This trial raises concerns about the cost-effectiveness of a fluoride-based intervention delivered at the practice level in the context of a state-funded dental service (EudraCT No: 2009-010725-39; ISRCTN: ISRCTN36180119).
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Affiliation(s)
- C. O’Neill
- Centre for Public Health, Queen’s University Belfast, Belfast, UK
| | - H.V. Worthington
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - M. Donaldson
- Health & Social Care Board of Northern Ireland, Belfast, UK
| | - S. Birch
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Centre for Health Economics and Policy Analysis, McMaster University, Ontario, Canada
| | - S. Noble
- Northern Health & Social Care Trust, Antrim, UK
| | | | - L. Murphy
- Northern Ireland Clinical Trials Unit, Belfast Health & Social Care Trust, Belfast, UK
| | - M. Greer
- hVIVO, Queen Mary BioEnterprises Innovation Centre, London, UK
| | - J. Brodison
- Northern Ireland Clinical Trials Unit, Belfast Health & Social Care Trust, Belfast, UK
| | - R. Verghis
- Northern Ireland Clinical Trials Unit, Belfast Health & Social Care Trust, Belfast, UK
| | - M. Tickle
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Tickle M, O'Neill C, Donaldson M, Birch S, Noble S, Killough S, Murphy L, Greer M, Brodison J, Verghis R, Worthington HV. A Randomized Controlled Trial of Caries Prevention in Dental Practice. J Dent Res 2017; 96:741-746. [PMID: 28375708 DOI: 10.1177/0022034517702330] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We conducted a parallel group randomized controlled trial of children initially aged 2 to 3 y who were caries free, to prevent the children becoming caries active over the subsequent 36 mo. The setting was 22 dental practices in Northern Ireland, and children were randomly assigned by a clinical trials unit (CTU) (using computer-generated random numbers, with allocation concealed from the dental practice until each child was recruited) to the intervention (22,600-ppm fluoride varnish, toothbrush, 50-mL tube of 1,450 ppm fluoride toothpaste, and standardized, evidence-based prevention advice) or advice-only control at 6-monthly intervals. The primary outcome measure was conversion from caries-free to caries-active states. Secondary outcome measures were number of decayed, missing, or filled teeth (dmfs) in caries-active children, number of episodes of pain, and number of extracted teeth. Adverse reactions were recorded. Calibrated external examiners, blinded to the child's study group, assessed the status of the children at baseline and after 3 y. In total, 1,248 children (624 randomized to each group) were recruited, and 1,096 (549 intervention, 547 control) were included in the final analyses. Eighty-seven percent of intervention and 86% of control children attended every 6-mo visit ( P = 0.77). A total of 187 (34%) in the intervention group converted to caries active compared to 213 (39%) in the control group (odds ratio, 0.81; 95% confidence interval, 0.64-1.04; P = 0.11). Mean dmfs of those with caries in the intervention group was 7.2 compared to 9.6 in the control group ( P = 0.007). There was no significant difference in the number of episodes of pain between groups ( P = 0.81) or in the number of teeth extracted in caries-active children ( P = 0.95). Ten children in the intervention group had adverse reactions of a minor nature. This well-conducted trial failed to demonstrate that the intervention kept children caries free, but there was evidence that once children get caries, it slowed down its progression (EudraCT No: 2009-010725-39; ISRCTN: ISRCTN36180119).
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Affiliation(s)
- M Tickle
- 1 Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - C O'Neill
- 2 Centre for Public Health, Queens' University Belfast, Belfast, Northern Ireland
| | - M Donaldson
- 3 Health & Social Care Board of Northern Ireland, Belfast, Northern Ireland
| | - S Birch
- 4 School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,5 Centre for Health Economics and Policy Analysis, McMaster University, Canada
| | - S Noble
- 6 Northern Health & Social Care Trust, Northern Ireland, Antrim, Northern Ireland
| | - S Killough
- 7 British Dental Association, Belfast, Northern Ireland
| | - L Murphy
- 8 Northern Ireland Clinical Trials Unit, Belfast Health & Social Care Trust, Belfast, Northern Ireland
| | - M Greer
- 9 hVIVO, Queen Mary BioEnterprises Innovation Centre, London, UK
| | - J Brodison
- 10 DJ Maguire and Associates, Portadown, Northern Ireland
| | - R Verghis
- 8 Northern Ireland Clinical Trials Unit, Belfast Health & Social Care Trust, Belfast, Northern Ireland
| | - H V Worthington
- 1 Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Hill H, Birch S, Tickle M, McDonald R, Donaldson M, O'Carolan D, Brocklehurst P. Does capitation affect the delivery of oral healthcare and access to services? Evidence from a pilot contact in Northern Ireland. BMC Health Serv Res 2017; 17:175. [PMID: 28264677 PMCID: PMC5339966 DOI: 10.1186/s12913-017-2117-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 02/24/2017] [Indexed: 11/22/2022] Open
Abstract
Background In May 2009, the Northern Ireland government introduced General Dental Services (GDS) contracts based on capitation in dental practices newly set up by a corporate dental provider to promote access to dental care in populations that had previously struggled to secure service provision. Dental service provision forms an important component of general health services for the population, but the implications of health system financing on care delivered and the financial cost of services has received relatively little attention in the research literature. The aim of this study is to evaluate the policy effect capitation payment in recently started corporate practices had on the delivery of primary oral healthcare in Northern Ireland and access to services. Methods We analysed the policy initiative in Northern Ireland as a natural experiment to find the impact on healthcare delivery of the newly set up corporate practices that use a prospective capitation system to remunerate primary care dentists. Data was collected from GDS claim forms submitted to the Business Services Organisation (BSO) between April 2011 and October 2014. Health and Social Care Board (HSCB) practices operating within a capitation system were matched to a control group, who were remunerated using a retrospective fee-for-service system. Results No evidence of patient selection was found in the HSCB practices set up by a corporate provider and operated under capitation. However, patients were less likely to visit the dentist and received less treatment when they did attend, compared to those belonging to the control group (P < 0.05). The extent of preventive activity offered and the patient payment charge revenue did not differ between the two practice groups. Conclusion Although remunerating NHS primary care dentists in newly set up corporate practices using a prospective capitation system managed costs within healthcare, there is evidence that this policy may have reduced access to care of registered patients. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2117-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Harry Hill
- School of Dentistry, University of Manchester, Manchester, M13 9PL, UK. .,Manchester Centre for Health Economics, University of Manchester, Manchester, M13 9PL, UK. .,Centre for Health Economics, Institute of Population Health Faculty of Medical and Human Sciences, University of Manchester, Room 4.311, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK.
| | - Stephen Birch
- Manchester Centre for Health Economics, University of Manchester, Manchester, M13 9PL, UK.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Martin Tickle
- School of Dentistry, University of Manchester, Manchester, M13 9PL, UK
| | - Ruth McDonald
- Manchester Business School, University of Manchester, Manchester, M13 9PL, UK
| | | | | | - Paul Brocklehurst
- NWORTH Clinical Trials Unit, Bangor University, Bangor, Gwynedd, LL57 2PZ, UK
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Abstract
The World Health Organization (WHO) stated that globally, dental caries is the most important oral condition. To develop effective prevention strategies requires an understanding of how this condition develops and progresses over time, but there are few longitudinal studies of caries onset and progression in children. The aim of the study was to establish the pattern of caries development from childhood into adolescence and to explore the role of potential risk factors (age, sex, ethnicity, and social deprivation). Of particular interest was the disease trajectory of dentinal caries in the permanent teeth in groups defined by the presence or absence of dentinal caries in the primary teeth. Intraoral examinations to assess oral health were performed at 4 time points by trained and calibrated dentist examiners using a standardized, national diagnostic protocol. Clinical data were available from 6,651 children. Mean caries prevalence (% D3MFT > 0) was 16.7% at the first clinical examination (ages 7-9 y), increasing to 31.0%, 42.2%, and 45.7% at subsequent examinations. A population-averaged model (generalized estimating equations) was used to model the longitudinal data. Estimated mean values indicated a rising D3MFT count as pupils aged (consistent with new teeth emerging), which was significantly higher (4.49 times; 95% confidence interval, 3.90-5.16) in those pupils with caries in their primary dentition than in those without. This study is one of the few large longitudinal studies to report the development of dental caries from childhood into adolescence. Children who developed caries in their primary dentition had a very different caries trajectory in their permanent dentition compared to their caries-free contemporaries. In light of these results, caries-free and caries-active children should be considered as 2 separate populations, suggesting different prevention strategies are required to address their different risk profiles.
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Affiliation(s)
- E Hall-Scullin
- 1 Public Health Department, NHS Ayrshire & Arran, Afton House, UK
| | - H Whitehead
- 2 Community Dental Service, Salford Royal NHS Foundation Trust, Pendleton Gateway, Salford, UK
| | - K Milsom
- 3 Division of Dentistry, JR Moore Building, University of Manchester, Manchester, UK
| | - M Tickle
- 3 Division of Dentistry, JR Moore Building, University of Manchester, Manchester, UK
| | - T-L Su
- 3 Division of Dentistry, JR Moore Building, University of Manchester, Manchester, UK
| | - T Walsh
- 3 Division of Dentistry, JR Moore Building, University of Manchester, Manchester, UK
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Hill H, Birch S, Tickle M, McDonald R, Brocklehurst P. The technical efficiency of oral healthcare provision: Evaluating role substitution in National Health Service dental practices in England. Community Dent Oral Epidemiol 2017; 45:310-316. [PMID: 28239951 DOI: 10.1111/cdoe.12292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 01/18/2017] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Harry Hill
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK.,Division of Dentistry, University of Manchester, Manchester, UK
| | - Stephen Birch
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Martin Tickle
- Division of Dentistry, University of Manchester, Manchester, UK
| | - Ruth McDonald
- Manchester Business School, University of Manchester, Manchester, UK
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Jawad S, Barclay C, Whittaker W, Tickle M, Walsh T. A pilot randomised controlled trial evaluating mini and conventional implant retained dentures on the function and quality of life of patients with an edentulous mandible. BMC Oral Health 2017; 17:53. [PMID: 28202072 PMCID: PMC5310054 DOI: 10.1186/s12903-017-0333-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 01/06/2017] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Total tooth loss (edentulism) can be a debilitating condition, impacting on ability to chew, speak and interact with others. The most common treatment is with complete removable dentures, which may be successful, but in the lower jaw, bone resorption that worsens over time makes denture-wearing difficult. Two dental implants in the mandible to retain the lower denture has been advocated as the gold standard of treatment, but has not been universally provided due largely to financial constraints and also patient fear. Mini implants (MI) are cheaper and less invasive than conventional implants (CI), but may not have equivalent longevity. Therefore, it is unknown whether they represent a cost-effective treatment modality over time. The aim of this pilot randomised controlled trial was to assess the feasibility of carrying out a trial on this cohort of patients, and to inform the study design of a large multicentre trial. METHODS Forty-six patients were randomly allocated to receive either two mini implants or two conventional implants in the mandible to retain their lower dentures. Quality of life (QoL) questionnaires, pain and anxiety scores, and an objective "gummy jelly" chewing test were carried out at multiple timepoints, along with detailed health economics information. Implants were placed one-stage, and an early loading protocol was utilised. Patients were reviewed 8 weeks post-placement, and finally at 6 months. Implant failure, recruitment and retention rates were recorded and analysed. RESULTS The pilot study demonstrated that it is possible to recruit, randomise and retain edentulous (mainly elderly) patients for an implant trial. We recruited to target and retention rates were acceptable. The large number of questionnaires was onerous for participants to complete, but the distribution of scores and feedback from participants helped inform the choice of primary and secondary outcomes in a full trial. The chewing test was time-consuming and inconsistent. Implant failure rate was low (1/46). The data on indirect costs gathered at every visit was viewed as repetitive and unnecessary, as there was little or no change between visits. CONCLUSIONS The pilot study has shown that acceptable recruitment and retention rates are achievable in this population of patients for this intervention. The results provide valuable information for selection of outcome variables and sample size calculations for future trials. TRIAL REGISTRATION (ISRCTN): 87342238 Trial registration date: 05/07/2013.
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Affiliation(s)
- Sarra Jawad
- Department of Restorative Dentistry, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester, M15 6FH, UK.
| | - Craig Barclay
- Department of Restorative Dentistry, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester, M15 6FH, UK
| | - William Whittaker
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Martin Tickle
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Tanya Walsh
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Brocklehurst P, Birch S, McDonald R, Hill H, O’Malley L, Macey R, Tickle M. Determining the optimal model for role substitution in NHS dental services in the UK: a mixed-methods study. Health Serv Deliv Res 2016. [DOI: 10.3310/hsdr04220] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundMaximising 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 questionsThis 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?DesignData 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.SettingNHS ‘high-street’ general dental practices.Participants121 practices across the north of England.InterventionsNo active interventions were undertaken.Main outcome measuresRelative efficiency of participating NHS practices, alongside a detailed narrative of their views about role substitution dentistry. Social acceptability for patients.ResultsThe 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.ConclusionsBetter alignment between the financial incentives within the NHS dental contract and the use of role substitution is required, although professional acceptability remains critical.Study limitationsOutput data collected did not reflect the quality of care provided by the dental team and the input data were self-reported.Future workFurther work is required to improve the evidence base for the use of role substitution in NHS dentistry, exploring the effects and costs of provision.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | - Stephen Birch
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Ruth McDonald
- Manchester Business School, University of Manchester, Manchester, UK
| | - Harry Hill
- School of Dentistry, University of Manchester, Manchester, UK
| | - Lucy O’Malley
- School of Dentistry, University of Manchester, Manchester, UK
| | - Richard Macey
- School of Dentistry, University of Manchester, Manchester, UK
| | - Martin Tickle
- School of Dentistry, University of Manchester, Manchester, UK
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Goodwin M, Emsley R, Kelly M, Rooney E, Sutton M, Tickle M, Wagstaff R, Walsh T, Whittaker W, Pretty IA. The CATFISH study protocol: an evaluation of a water fluoridation scheme. BMC Oral Health 2016; 16:8. [PMID: 26831505 PMCID: PMC4736087 DOI: 10.1186/s12903-016-0169-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 01/25/2016] [Indexed: 11/16/2022] Open
Abstract
Background Tooth decay is the commonest disease of childhood. We have known for over 90 years that fluoride can prevent tooth decay; it is present in nearly all toothpastes and can be provided in mouthwashes, gels and varnishes. The oldest method of applying fluoride is via the water supply at a concentration of 1 part per million. The two most important reviews of water fluoridation in the United Kingdom (the York Review and MRC Report on water fluoridation and health) concluded that whilst there was evidence to suggest water fluoridation provided a benefit in caries reduction, there was a need to improve the evidence base in several areas. Methods/Design This study will use a natural experiment to assess the incidence of caries in two geographical areas, one in which the water supply is returned to being fluoridated following a discontinuation of fluoridation and one that continues to have a non-fluoridated water supply. The oral health of two discrete study populations will be evaluated - those born 9 months after the water fluoridation was introduced, and those who were in their 1st year of school after the introduction of fluoridated water. Both populations will be followed prospectively for 5 years using a census approach in the exposed group along with matched numbers recruitment in a non-exposed control. Parents of the younger cohort will complete questionnaires every 6 months with child clinical examination at ages 3 and 5, whilst the older cohort will have clinical examinations only, at approximately 5, 7 and 11 years old. Discussion This project provides a unique opportunity to conduct a high quality evaluation of the reintroduction of a water fluoridation scheme, which satisfies the inclusion criteria stipulated by the York systematic review and can address the design issues identified in the MRC report. The research will make a major contribution to the understanding of the costs and effects of water fluoridation in the UK in the 21st Century. Its findings will help inform UK policy on this important public health intervention and may have a significant impact on public health policy in other developed countries. There is currently true equipoise in relation to the effectiveness of water fluoridation in contemporary populations and while the biological plausibility is well established, there is a need to examine impact on the changing epidemiological status of dental decay.
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Affiliation(s)
- Michaela Goodwin
- The Dental Health Unit, School of Dentistry, The University of Manchester, Williams House, Manchester Science Park, Manchester, M15 6SE, UK.
| | - Richard Emsley
- Centre for Biostatistics, Institute of Population Health, The University of Manchester, Manchester Academic Health Science Centre, 1.304 Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK.
| | - Michael Kelly
- Institute of Public Health, University of Cambridge, Forvie Site, Cambridge, CB2 OSR, UK.
| | - Eric Rooney
- Dental Observatory, NHS Central Lancashire, Preston Business Centre, Watling Street Road, Fulwood, PR2 8DY, UK.
| | - Matthew Sutton
- Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK.
| | - Martin Tickle
- , Coupland 3 Building, Oxford Road, Manchester, M15 6FH, UK.
| | - Rebecca Wagstaff
- Public Health England, North West, 1st Floor, York House, Ackhurst Business Park, Foxhole Road, Chorley, PR7 1NY, UK.
| | - Tanya Walsh
- , Coupland 3 Building, Oxford Road, Manchester, M15 6FH, UK.
| | | | - Iain A Pretty
- The Dental Health Unit, School of Dentistry, The University of Manchester, Williams House, Manchester Science Park, Manchester, M15 6SE, UK.
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Bailey E, Tickle M, Campbell S, O'Malley L. Systematic review of patient safety interventions in dentistry. BMC Oral Health 2015; 15:152. [PMID: 26613736 PMCID: PMC4662809 DOI: 10.1186/s12903-015-0136-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 11/11/2015] [Indexed: 11/11/2022] Open
Abstract
Background The concept of patient safety in dentistry is in its infancy, with little knowledge about the effectiveness of tools or interventions developed to improve patient safety or to minimise the occurrence of adverse events. Methods The aim of this qualitative systematic review was to search the academic and grey literature to identify and assess tools or interventions used in dental care settings to maintain or improve patient safety. All study designs were included from all dental care settings. Outcome measures were: patient safety, harm prevention, risk minimization, patient satisfaction and patient acceptability, professional acceptability, efficacy, cost-effectiveness and efficiency. Quality assessments were performed on the included studies based on CASP tools. Further analysis was undertaken to discover whether any of the tools had been trialled or verified by the authors, or by subsequent authors. Results Following abstract screening, and initial qualitative synthesis, nine studies were found to meet the inclusion criteria with 31 being excluded following initial analysis. Tools identified included: checklists (4 studies), reporting systems (3), the use of electronic notes (1) and trigger tools (1). Grey literature searching did not identify any further appropriate studies. In terms of study design, there were observational studies including audit cycles (5 studies), epidemiological studies (3) and prospective cluster randomised clinical trials (1). The quality of the studies varied and none of their outcomes were verified by other researchers. The tools identified have the potential to be used for measuring and improving patient safety in dentistry, with two surgical safety checklists demonstrating a reduction in erroneous dental extractions to nil following their introduction. Reporting systems provide epidemiological data, however, it is not known whether they lead to any improvement in patient safety. The one study on trigger tools demonstrates a 50 % positive predictive value for safety incidents. It is not clear as to what impact the introduction of electronic guidelines has on patient safety outcomes. Conclusions This systematic review finds that the only interventions in dentistry that reduce or minimise adverse events are surgical safety checklists. We believe this to be the first systematic review in this field; it demonstrates the need for further research into patient safety in dentistry across several domains: epidemiological, conceptual understanding and patient and practitioner involvement. Electronic supplementary material The online version of this article (doi:10.1186/s12903-015-0136-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Edmund Bailey
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health - Centre for Primary Care, University of Manchester, 7th Floor: Williamson Building, Manchester, M13 9PL, UK.
| | - Martin Tickle
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health - Centre for Primary Care, University of Manchester, 7th Floor: Williamson Building, Manchester, M13 9PL, UK.
| | - Stephen Campbell
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health - Centre for Primary Care, University of Manchester, 7th Floor: Williamson Building, Manchester, M13 9PL, UK.
| | - Lucy O'Malley
- School of Dentistry, University of Manchester, J R Moore Building, Oxford Road, Manchester, M13 9PL, UK.
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Tickle M, O' Malley L, Brocklehurst P, Glenny AM, Walsh T, Campbell S. A national survey of the public's views on quality in dental care. Br Dent J 2015; 219:E1. [PMID: 26271885 DOI: 10.1038/sj.bdj.2015.595] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND There is a lack of evidence and poor understanding of quality measurement and improvement in dentistry. The aim of this study was to undertake a nationally representative survey of the public in England to explore their views on the meaning of quality in dentistry. METHODS A cross sectional survey of the adult population (18 years and over) of England was undertaken. A sample size of 500 was set to provide a precision to plus or minus 5% after allowing for item non-response. A quota sampling approach was used, with predetermined quotas set for sex, age, working status and tenure to ensure the sample was nationally representative. Question selection and design were informed by the literature and a series of interviews with the public. Simple content analysis was used to identify themes in the responses to open questions. Dental service use, gender, age, ethnicity and social class were recorded. Frequency distributions were computed and outputs were cross-tabulated with various population sub-group categories. RESULTS Five hundred and thirteen people were interviewed. Approximately 20% of patients reported that their care was suboptimal; a third thought it was poor value for money and 20% did not trust their dentist. Good interpersonal communication, politeness and being put at ease were the most important factors that elicited positive responses. Negative factors were cost of care and waiting times. In making an assessment of quality, access (40% of all responses), technical quality of care (35%), professionalism (30%), hygiene/cleanliness (30%), staff attitude (27%), pain-free treatment (23%), value for money (22%), and staff putting patients at ease (21%) all emerged as important factors. CONCLUSIONS Quality in dentistry is multi-dimensional in nature, and includes different elements and emphases to other areas of healthcare. The results will inform the development of a measure of quality in dentistry.
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Affiliation(s)
- M Tickle
- Institute of Population Health, University of Manchester
| | - L O' Malley
- School of Dentistry, University of Manchester
| | - P Brocklehurst
- 1] School of Dentistry, University of Manchester [2] NWORTH Trials Unit, Bangor University, Holyhead Road, Gwynedd, LL57 2PZ
| | - A-M Glenny
- School of Dentistry, University of Manchester
| | - T Walsh
- School of Dentistry, University of Manchester
| | - S Campbell
- Institute of Population Health, University of Manchester, Oxford Road, Manchester, M13 9PL
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Peters S, Goldthorpe J, McElroy C, King E, Javidi H, Tickle M, Aggarwal VR. Managing chronic orofacial pain: A qualitative study of patients', doctors', and dentists' experiences. Br J Health Psychol 2015; 20:777-91. [DOI: 10.1111/bjhp.12141] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 03/25/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Sarah Peters
- Manchester Centre for Health Psychology; School of Psychological Sciences; University of Manchester; UK
| | | | | | - Elizabeth King
- Manchester Centre for Health Psychology; School of Psychological Sciences; University of Manchester; UK
| | - Hanieh Javidi
- School of Clinical Dentistry; University of Sheffield; UK
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Macey R, Glenny A, Walsh T, Tickle M, Worthington H, Ashley J, Brocklehurst P. The efficacy of screening for common dental diseases by hygiene-therapists: a diagnostic test accuracy study. J Dent Res 2015; 94:70S-78S. [PMID: 25604256 PMCID: PMC4541095 DOI: 10.1177/0022034514567335] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Regularly attending adult patients are increasingly asymptomatic and not in need of treatment when attending for their routine dental examinations. As oral health improves further, using the general dental practitioner to undertake the "checkup" on regular "low-risk" patients represents a substantial and potentially unnecessary cost for state-funded systems. Given recent regulatory changes in the United Kingdom, it is now theoretically possible to delegate a range of tasks to hygiene-therapists. This has the potential to release the general dental practitioner's time and increase the capacity to care. The aim of this study is to compare the diagnostic test accuracy of hygiene-therapists when screening for dental caries and periodontal disease in regularly attending asymptomatic adults who attend for their checkup. A visual screen by hygiene-therapists acted as the index test, and the general dental practitioner acted as the reference standard. Consenting asymptomatic adult patients, who were regularly attending patients at 10 practices across the Northwest of England, entered the study. Both sets of clinicians made an assessment of dental caries and periodontal disease. The primary outcomes measured were the sensitivity and specificity values for dental caries and periodontal disease. In total, 1899 patients were screened. The summary point for sensitivity of dental care professionals when screening for caries and periodontal disease was 0.81 (95% CI, 0.74 to 0.87) and 0.89 (0.86 to 0.92), respectively. The summary point for specificity of dental care professionals when screening for caries and periodontal disease was 0.87 (0.78 to 0.92) and 0.75 (0.66 to 0.82), respectively. The results suggest that hygiene-therapists could be used to screen for dental caries and periodontal disease. This has important ramifications for service design in public-funded health systems.
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Affiliation(s)
- R Macey
- School of Dentistry, University of Manchester, Oxford Road, Manchester, UK
| | - A Glenny
- School of Dentistry, University of Manchester, Oxford Road, Manchester, UK
| | - T Walsh
- School of Dentistry, University of Manchester, Oxford Road, Manchester, UK
| | - M Tickle
- School of Dentistry, University of Manchester, Oxford Road, Manchester, UK
| | - H Worthington
- School of Dentistry, University of Manchester, Oxford Road, Manchester, UK
| | - J Ashley
- General Dental Practitioner, Woodlands Dental Practice, Wirral, UK
| | - P Brocklehurst
- School of Dentistry, University of Manchester, Oxford Road, Manchester, UK
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Abstract
BACKGROUND Poor or inequitable access to oral health care is commonly reported in high-, middle- and low-income countries. Although the severity of these problems varies, a lack of supply of dentists and their uneven distribution are important factors. Delegating care to dental auxiliaries could ease this problem, extend services to where they are unavailable and liberate time for dentists to do more complex work. Before such an approach can be advocated, it is important to know the relative effectiveness of dental auxiliaries and dentists. OBJECTIVES To assess the effectiveness, costs and cost effectiveness of dental auxiliaries in providing care traditionally provided by dentists. SEARCH METHODS We searched the following electronic databases from their inception dates up to November 2013: the Cochrane Effective Practice and Organisation of Care (EPOC) Group's Specialised Register; Cochrane Oral Health Group's Specialised Register; the Cochrane Central Register of Controlled Trials (Issue 11, 2013); MEDLINE; EMBASE; CINAHL; Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effectiveness; five other databases and two trial registries. We also undertook a grey literature search and searched the reference list of included studies and contacted authors of relevant papers. SELECTION CRITERIA We included randomised controlled trials (RCTs), non-randomised controlled clinical trials (NRCTs), interrupted time series (ITSs) and controlled before and after studies (CBAs) evaluating the effectiveness of dental auxiliaries compared with dentists in undertaking clinical tasks traditionally performed by a dentist. DATA COLLECTION AND ANALYSIS Three review authors independently applied eligibility criteria, extracted data and assessed the risk of bias of each included study and two review authors assessed the quality of the evidence from the included studies, according to The Cochrane Collaboration's procedures. Since meta-analysis was not possible, we gave a narrative description of the results. MAIN RESULTS We identified five studies (one cluster RCT, three RCTs and one NRCT), evaluating the effectiveness of dental auxiliaries compared with dentists in providing dental care traditionally provided by dentists, eligible for inclusion in this review. The included studies, which involved 13 dental auxiliaries, six dentists, and more than 1156 participants, evaluated two clinical tasks/techniques: placement of preventive resin fissure sealants and the atraumatic restorative technique (ART). Two studies were conducted in the US, and one each in Canada, Gambia and Singapore.Of the four studies evaluating effectiveness in placing preventive resin fissure sealants, three found no evidence of a difference in retention rates of those placed by dental auxiliaries and dentists over a range of follow-up periods (six to 24 months). One study found that fissure sealants placed by a dental auxiliary had lower retention rates than one placed by a dentist after 48 months (9.0% with auxiliary versus 29.1% with dentist). The same study reported that the net reduction after 48 months in the number teeth exhibiting caries (dental decay) was lower for teeth treated by the dental auxiliary than the dentist (3 with auxiliary versus 60 with dentist, P value < 0.001).One study showed no evidence of a difference in dental decay after treatment with fissure sealants between groups. The one study comparing the effectiveness of dental auxiliaries and dentists in performing ART reported no difference in survival rates of the restorations (fillings) after 12 months.All studies were at high risk of bias and the overall quality of the evidence was very low, as assessed using the GRADE approach. In addition, four of the included studies were more than 20 years old; the materials used and the techniques assessed were out of date. We found no eligible studies comparing the effectiveness of dental auxiliaries and dentists in the diagnosis of oral diseases and conditions, in delivering oral health education and other aspects of health promotion, or studies assessing participants' perspectives including the acceptability of care received. None of the included studies reported adverse effects. In addition, we found no studies comparing the costs and cost-effectiveness of dental auxiliaries and dentists, their impact on access and equity of access to care that met the pre-specified inclusion criteria. AUTHORS' CONCLUSIONS We only identified five studies for inclusion in this review, all of which were at high risk of bias and four were published more than 20 years ago, highlighting the paucity of high-quality evaluations of the relative effectiveness, cost-effectiveness and safety of dental auxiliaries compared with dentists in performing clinical tasks. No firm conclusions could be drawn from the present review about the relative effectiveness of dental auxiliaries and dentists.
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Affiliation(s)
- Tom A Dyer
- University of SheffieldSchool of Clinical DentistryClaremont CrescentSheffieldUKS10 2TA
| | - Paul Brocklehurst
- School of Dentistry, The University of ManchesterCoupland III BuildingOxford RoadManchesterUKM13 9PL
| | - Anne‐Marie Glenny
- School of Dentistry, The University of ManchesterCochrane Oral Health GroupCoupland III Building, Oxford RoadManchesterUKM13 9PL
| | - Linda Davies
- School of Community Based Medicine, University of ManchesterHealth Sciences Research Group: Health EconomicsManchesterUK
| | - Martin Tickle
- School of Dentistry, The University of ManchesterCoupland III BuildingOxford RoadManchesterUKM13 9PL
| | - Ansy Issac
- Smile Bright Dental Care, MaduraiGeneral Dentistry, Preventive DentistryIndian Bank Colony, New Natham RoadMaduraiTamil NaduIndia625014
| | - Peter G Robinson
- School of Clinical Dentistry, University of SheffieldClaremont CrescentSheffieldUKS10 2TA
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Brocklehurst P, Mertz B, Jerković-Ćosić K, Littlewood A, Tickle M. Direct access to midlevel dental providers: an evidence synthesis. J Public Health Dent 2014; 74:326-35. [DOI: 10.1111/jphd.12062] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 05/02/2014] [Indexed: 11/29/2022]
Affiliation(s)
| | - Beth Mertz
- Preventive and Restorative Dental Sciences; School of Dentistry; University of California; San Francisco CA USA
| | - Katarina Jerković-Ćosić
- Research Centre for Innovation in Health Care; Hogeschool Utrecht University of Applied Science; Utrecht The Netherlands
| | - Anne Littlewood
- Cochrane Oral Health Group; School of Dentistry; The University of Manchester; Manchester UK
| | - Martin Tickle
- School of Dentistry; The University of Manchester; Manchester UK
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Sharif MO, Catleugh M, Merry A, Tickle M, Dunne SM, Brunton P, Aggarwal VR, Chong LY. Replacement versus repair of defective restorations in adults: resin composite. Cochrane Database Syst Rev 2014; 2014:CD005971. [PMID: 24510679 PMCID: PMC7388846 DOI: 10.1002/14651858.cd005971.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Composite filling materials have been increasingly used for the restoration of posterior teeth in recent years as a tooth-coloured alternative to amalgam. As with any filling material composites have a finite life-span. Traditionally, replacement was the ideal approach to treat defective composite restorations, however, repairing composites offers an alternative more conservative approach to the tooth structure where restorations are partly still serviceable. Repairing the restoration has the potential of taking less time and may sometimes be performed without the use of local anaesthesia hence it may be less distressing for a patient when compared with replacement. OBJECTIVES To evaluate the effects of replacing (with resin composite) versus repair (with resin composite) in the management of defective resin composite dental restorations in permanent molar and premolar teeth. SEARCH METHODS For the identification of studies relevant to this review we searched the Cochrane Oral Health Group's Trials Register (to 24 July 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 6); MEDLINE via OVID (1946 to 24 July 2013); EMBASE via OVID (1980 to 24 July 2013); BIOSIS via Web of Knowledge (1969 to 24 July 2013); Web of Science (1945 to 24 July 2013); and OpenGrey (to 24 July 2013). Researchers, experts and organisations known to be involved in this field were contacted in order to trace unpublished or ongoing studies. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA Trials were selected if they met the following criteria: randomised controlled trial (including split-mouth studies), involving replacement and repair of resin composite restorations in adults with a defective molar restoration in a permanent molar or premolar teeth. DATA COLLECTION AND ANALYSIS Two review authors independently assessed titles and abstracts for each article identified by the searches in order to decide whether the article was likely to be relevant. Full papers were obtained for relevant articles and both review authors studied these. The Cochrane Collaboration statistical guidelines were to be followed for data synthesis. MAIN RESULTS The search strategy retrieved 298 potentially eligible studies, after de-duplication. After examination of the titles and abstracts, full texts of potentially relevant studies were retrieved but none of the retrieved studies met the inclusion criteria of the review. AUTHORS' CONCLUSIONS There are no published randomised controlled trials relevant to this review question. There is therefore a need for methodologically sound randomised controlled trials that are reported according to the Consolidated Standards of Reporting Trials (CONSORT) statement (www.consort-statement.org/). Further research also needs to explore qualitatively the views of patients on repairing versus replacement and investigate themes around pain, anxiety and distress, time and costs.
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Affiliation(s)
- Mohammad O Sharif
- School of Dentistry, The University of ManchesterCoupland III Building, Oxford RoadManchesterUKM13 9PL
| | - Melanie Catleugh
- Public Health England ‐ Cumbria and LancashireRoom 251, Preston Business CentreWatling Street RoadFulwoodUKPR2 8DY
| | - Alison Merry
- NHS HerefordshirePublic Health DepartmentRuckhall LaneBelmontHerefordUKHR2 9RP
| | - Martin Tickle
- School of Dentistry, The University of ManchesterCoupland III Building, Oxford RoadManchesterUKM13 9PL
| | - Stephen M Dunne
- Kings College London Dental InstitutePrimary Dental CareDenmark Hill CampusCaldecot RoadLondonUKSE5 9RW
| | - Paul Brunton
- Leeds Dental InstituteFixed & Removable ProsthodonticsClarendon WayLeedsUKLS2 9LU
| | - Vishal R Aggarwal
- School of Dentistry, The University of ManchesterCoupland III Building, Oxford RoadManchesterUKM13 9PL
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Abstract
BACKGROUND Amalgam is a common filling material for posterior teeth, as with any restoration amalgams have a finite life-span. Traditionally replacement was the ideal approach to treat defective amalgam restorations, however, repair offers an alternative more conservative approach where restorations are only partially defective. Repairing a restoration has the potential of taking less time and may sometimes be performed without the use of local anaesthesia hence it may be less distressing for a patient when compared with replacement. Repair of amalgam restorations is often more conservative of the tooth structure than replacement. OBJECTIVES To evaluate the effects of replacing (with amalgam) versus repair (with amalgam) in the management of defective amalgam dental restorations in permanent molar and premolar teeth. SEARCH METHODS For the identification of studies relevant to this review we searched the Cochrane Oral Health Group's Trials Register (to 5 August 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 7); MEDLINE via OVID (1946 to 5 August 2013); EMBASE via OVID (1980 to 5 August 2013); BIOSIS via Web of Knowledge (1969 to 5 August 2013); Web of Science (1945 to 5 August 2013) and OpenGrey (to 5 August 2013). Researchers, experts and organisations known to be involved in this field were contacted in order to trace unpublished or ongoing studies. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA Trials were selected if they met the following criteria: randomised controlled trial (including split-mouth studies), involving replacement and repair of amalgam restorations in adults with a defective restoration in a molar or premolar tooth/teeth. DATA COLLECTION AND ANALYSIS Two review authors independently assessed titles and abstracts for each article identified by the searches in order to decide whether the article was likely to be relevant. Full papers were obtained for relevant articles and both review authors studied these. The Cochrane Collaboration statistical guidelines were to be followed for data synthesis. MAIN RESULTS The search strategy retrieved 201 potentially eligible studies after de-duplication. After examination of the titles and abstracts, full texts of the relevant studies were retrieved but none of these met the inclusion criteria of the review. AUTHORS' CONCLUSIONS There are no published randomised controlled trials relevant to this review question. There is therefore a need for methodologically sound randomised controlled trials that are reported according to the Consolidated Standards of Reporting Trials (CONSORT) statement (www.consort-statement.org/). Further research also needs to explore qualitatively the views of patients on repairing versus replacement and investigate themes around pain, distress and anxiety, time and costs.
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Affiliation(s)
- Mohammad O Sharif
- School of Dentistry, The University of ManchesterCoupland III Building, Oxford RoadManchesterUKM13 9PL
| | - Alison Merry
- NHS HerefordshirePublic Health DepartmentRuckhall LaneBelmontHerefordUKHR2 9RP
| | - Melanie Catleugh
- Public Health England ‐ Cumbria and LancashireRoom 251, Preston Business CentreWatling Street RoadFulwoodUKPR2 8DY
| | - Martin Tickle
- School of Dentistry, The University of ManchesterCoupland III Building, Oxford RoadManchesterUKM13 9PL
| | - Paul Brunton
- Leeds Dental InstituteFixed & Removable ProsthodonticsClarendon WayLeedsUKLS2 9LU
| | - Stephen M Dunne
- Kings College London Dental InstitutePrimary Dental CareDenmark Hill CampusCaldecot RoadLondonUKSE5 9RW
| | - Vishal R Aggarwal
- School of Dentistry, The University of ManchesterCoupland III Building, Oxford RoadManchesterUKM13 9PL
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Northcott A, Brocklehurst P, Jerković-Ćosić K, Reinders JJ, McDermott I, Tickle M. Direct access: lessons learnt from the Netherlands. Br Dent J 2013; 215:607-610. [DOI: 10.1038/sj.bdj.2013.1193] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2013] [Indexed: 11/09/2022]
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Brocklehurst P, Price J, Glenny A, Tickle M, Birch S, Mertz E, Grytten J. The effect of different methods of remuneration on the behaviour of primary care dentists. Cochrane Database Syst Rev 2013; 2013:CD009853. [PMID: 24194456 PMCID: PMC6544809 DOI: 10.1002/14651858.cd009853.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Methods of remuneration have been linked with the professional behaviour of primary care physicians. In dentistry, this can be exacerbated as clinicians operate their practices as businesses and take the full financial risk of the provision of services. The main methods for remunerating primary care dentists include fee-for-service, fixed salary and capitation payments. The aim of this review was to determine the impact that these remuneration mechanisms have upon primary care dentists' behaviour. OBJECTIVES To evaluate the effects of different methods of remuneration on the level and mix of activities provided by primary care dentists and the impact this has on patient outcomes. SEARCH METHODS We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 7, 2013); MEDLINE (Ovid) (1947 to 11 June 2013); EMBASE (Ovid) (1947 to 11 June 2013); EconLit (1969 to 11 June 2013); the NHS Economic Evaluation Database (EED) (11 June 2013); and the Health Economic Evaluations Database (HEED) (11 June 2013). We conducted cited reference searches for the included studies in ISI Web of Knowledge; searched grey literature sources; handsearched selected journals; and contacted authors of relevant studies. SELECTION CRITERIA Primary care dentists were defined as clinicians that deliver routine or mainstream dental care in a primary care environment. We included randomised controlled trials (RCTs), non-randomised controlled clinical trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies. The methods of remuneration that we considered were: fee-for-service, fixed salary and capitation payments. Primary outcome measures were: measures of clinical activity; volume of clinical activity undertaken; time taken and clinical session length, or both; clinician type utilised; measures of health service utilisation; access and attendance as a proportion of the population; re-attendance rates; recall frequency; levels of oral health inequalities; non-attendance rates; healthcare costs; measures of patient outcomes; disease reduction; health maintenance; and patient satisfaction. We also considered measures of practice profitability/income and any reported unintended effects of the included methods of remuneration. DATA COLLECTION AND ANALYSIS Three of the review authors (PRB, JP, AMG) independently reviewed titles and abstracts and resolved disagreements by discussion. The same three review authors undertook data extraction and assessed the quality of the evidence from all the studies that met the selection criteria, according to Cochrane Collaboration procedures. MAIN RESULTS Two cluster-RCTs, with data from 503 dental practices, representing 821 dentists and 4771 patients, met the selection criteria. We judged the risk of bias to be high for both studies and the overall quality of the evidence was low/very low for all outcomes, as assessed using the GRADE approach.One study used a factorial design to investigate the impact of fee-for-service and an educational intervention on the placement of fissure sealants in permanent molar teeth. The authors reported a statistically significant increase in clinical activity in the arm that was incentivised with a fee-for-service payment. However, the study was conducted in the four most deprived areas of Scotland, so the applicability of the findings to other settings may be limited. The study did not report data on measures of health service utilisation or measures of patient outcomes.The second study used a parallel group design undertaken over a three-year period to compare the impact of capitation payments with fee-for-service payments on primary care dentists' clinical activity. The study reported on measures of clinical activity (mean percentage of children receiving active preventive advice, health service utilisation (mean number of visits), patient outcomes (mean number of filled teeth, mean percentage of children having one or more teeth extracted and the mean number of decayed teeth) and healthcare costs (mean expenditure). Teeth were restored at a later stage in the disease process in the capitation system and the clinicians tended to see their patients less frequently and tended to carry out fewer fillings and extractions, but also tended to give more preventive advice.There was insufficient information regarding the cost-effectiveness of the different remuneration methods. AUTHORS' CONCLUSIONS Financial incentives within remuneration systems may produce changes to clinical activity undertaken by primary care dentists. However, the number of included studies is limited and the quality of the evidence from the two included studies was low/very low for all outcomes. Further experimental research in this area is highly recommended given the potential impact of financial incentives on clinical activity, and particular attention should be paid to the impact this has on patient outcomes.
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Affiliation(s)
- Paul Brocklehurst
- School of Dentistry, The University of ManchesterCoupland III BuildingOxford RoadManchesterUKM13 9PL
| | - Juliet Price
- The University of ManchesterSchool of DentistryManchesterUK
| | - Anne‐Marie Glenny
- School of Dentistry, The University of ManchesterCochrane Oral Health GroupCoupland III Building, Oxford RoadManchesterUKM13 9PL
| | - Martin Tickle
- School of Dentistry, The University of ManchesterCoupland III BuildingOxford RoadManchesterUKM13 9PL
| | - Stephen Birch
- Faculty of Health Sciences, McMaster UniversityCentre for Health Economics and Policy Analysis, Department of Clinical Epidemiology and Biostatistics1280 Main Street WestHamiltonCanadaL8S 4K1
| | - Elizabeth Mertz
- San Francisco School of Dentistry, University of CaliforniaPreventative and Restorative Dental Sciences, Suite 4103333 California StreetSan FranciscoUSACA 94118
| | - Jostein Grytten
- University of OsloDepartment of Community DentistryBox 1052BlindernOsloNorway0316
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Clarkson JE, Ramsay CR, Averley P, Bonetti D, Boyers D, Campbell L, Chadwick GR, Duncan A, Elders A, Gouick J, Hall AF, Heasman L, Heasman PA, Hodge PJ, Jones C, Laird M, Lamont TJ, Lovelock LA, Madden I, McCombes W, McCracken GI, McDonald AM, McPherson G, Macpherson LE, Mitchell FE, Norrie JDT, Pitts NB, van der Pol M, Ricketts DNJ, Ross MK, Steele JG, Swan M, Tickle M, Watt PD, Worthington HV, Young L. IQuaD dental trial; improving the quality of dentistry: a multicentre randomised controlled trial comparing oral hygiene advice and periodontal instrumentation for the prevention and management of periodontal disease in dentate adults attending dental primary care. BMC Oral Health 2013; 13:58. [PMID: 24160246 PMCID: PMC4015981 DOI: 10.1186/1472-6831-13-58] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 07/22/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Periodontal disease is the most common oral disease affecting adults, and although it is largely preventable it remains the major cause of poor oral health worldwide. Accumulation of microbial dental plaque is the primary aetiological factor for both periodontal disease and caries. Effective self-care (tooth brushing and interdental aids) for plaque control and removal of risk factors such as calculus, which can only be removed by periodontal instrumentation (PI), are considered necessary to prevent and treat periodontal disease thereby maintaining periodontal health. Despite evidence of an association between sustained, good oral hygiene and a low incidence of periodontal disease and caries in adults there is a lack of strong and reliable evidence to inform clinicians of the relative effectiveness (if any) of different types of Oral Hygiene Advice (OHA). The evidence to inform clinicians of the effectiveness and optimal frequency of PI is also mixed. There is therefore an urgent need to assess the relative effectiveness of OHA and PI in a robust, sufficiently powered randomised controlled trial (RCT) in primary dental care. METHODS/DESIGN This is a 5 year multi-centre, randomised, open trial with blinded outcome evaluation based in dental primary care in Scotland and the North East of England. Practitioners will recruit 1860 adult patients, with periodontal health, gingivitis or moderate periodontitis (Basic Periodontal Examination Score 0-3). Dental practices will be cluster randomised to provide routine OHA or Personalised OHA. To test the effects of PI each individual patient participant will be randomised to one of three groups: no PI, 6 monthly PI (current practice), or 12 monthly PI.Baseline measures and outcome data (during a three year follow-up) will be assessed through clinical examination, patient questionnaires and NHS databases.The primary outcome measures at 3 year follow up are gingival inflammation/bleeding on probing at the gingival margin; oral hygiene self-efficacy and net benefits. DISCUSSION IQuaD will provide evidence for the most clinically-effective and cost-effective approach to managing periodontal disease in dentate adults in Primary Care. This will support general dental practitioners and patients in treatment decision making. TRIAL REGISTRATION Protocol ID: ISRCTN56465715.
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Affiliation(s)
- Jan E Clarkson
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee DD1 4HN, UK
- NHS Education for Scotland, Edinburgh, UK
| | - Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Debbie Bonetti
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee DD1 4HN, UK
| | - Dwayne Boyers
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Louise Campbell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Anne Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Andrew Elders
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jill Gouick
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee DD1 4HN, UK
| | - Andrew F Hall
- Dundee Dental School, University of Dundee, Dundee, UK
| | | | | | - Penny J Hodge
- School of Medicine, University of Glasgow Dental School, Glasgow, UK
| | - Clare Jones
- School of Dentistry, University of Manchester, Manchester, UK
| | - Marilyn Laird
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee DD1 4HN, UK
| | - Thomas J Lamont
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee DD1 4HN, UK
| | - Laura A Lovelock
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee DD1 4HN, UK
| | | | | | | | | | - Gladys McPherson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Lorna E Macpherson
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee DD1 4HN, UK
| | - Fiona E Mitchell
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee DD1 4HN, UK
| | - John DT Norrie
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | | | | | | | | | - Moira Swan
- Newcastle University, Newcastle Upon Tyne, UK
| | - Martin Tickle
- School of Dentistry, University of Manchester, Manchester, UK
| | - Pauline D Watt
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee DD1 4HN, UK
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Jones C, Macfarlane TV, Milsom KM, Ratcliffe P, Wyllie A, Tickle M. Patient perceptions regarding benefits of single visit scale and polish: a randomised controlled trial. BMC Oral Health 2013; 13:50. [PMID: 24090395 PMCID: PMC3851473 DOI: 10.1186/1472-6831-13-50] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 09/26/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Single visit scale and polish is frequently carried out in dental practices however there is little evidence to support (or refute) its clinical effectiveness. The purpose of this research was to compare patient-reported outcomes between groups receiving a scale and polish at 6-, 12-, and 24-month intervals. Outcomes recorded included participants' subjective assessment of their oral cleanliness; the perceived importance of scale and polish for oral health and aesthetics; and frequency at which this treatment is required. METHODS A practice-based randomised control trial was undertaken, with a 24-month follow-up period. Participants were healthy adults with no significant periodontal disease (BPE codes <3) randomly allocated to three groups to receive scale and polish at 6-, 12-, or 24-month intervals. Patient-reported outcomes were recorded at baseline and follow-up. Oral cleanliness was reported using a 5-point scale and recorded by examiners blinded to trial group allocation. A self-completed questionnaire enabled participants to report perceived importance of scale and polish (5-point scale), and required frequency of treatment (6-point scale). The main hypothesis was that participants receiving 6-monthly scale and polish would report higher levels of oral cleanliness compared to participants receiving scale and polish at 12- and 24-month intervals. RESULTS 369 participants were randomised: 125 to the 6-month group; 122 to the 12-month group; and 122 to the 24-month group. Complete data set analysis was carried out to include 107 (6-month group), 100 (12-month group) and 100 (24-month group) participants. Multiple imputation analyses were conducted where follow-up data was missing. The difference in the proportions of participants reporting a 'high' level of oral cleanliness at follow-up was significant (Chi-squared P = 0.003): 52.3% (6-month group), 47.0% (12-month group) and 30.0% (24-month group). Scale and polish was thought to be important by the majority in each group for keeping mouths clean and gums healthy, whitening teeth, and preventing bad breath and tooth decay; there were no statistically significant differences between groups at follow-up. Most participants at follow-up thought that the frequency of scale and polish should be "every 6 months" or more frequently: 77.9% (6-month group), 64.6% (12-month group), 71.7% (24-month group); differences between groups were not statistically significant (Chi squared P = 0.126). The results suggest that participants in the 24-month trial group were more likely to choose a scale and polish interval of "once a year" or less frequently (OR 2.89; 95% CI 1.36, 6.13). CONCLUSIONS The majority of healthy adults regarded 6-monthly single-visit scale and polish as being beneficial for their oral health. Receiving the treatment at different frequencies did not alter this belief; and those with the longest interval between scale and polish provision perceived that their mouth was less clean. In the absence of a strong evidence base to support (or refute) the effectiveness of single-visit scale and polish, the beliefs and preferences of patients regarding scale and polish may be influential drivers for maintaining provision of this treatment.
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Affiliation(s)
- Clare Jones
- School of Dentistry, The University of Manchester, Coupland 3 Building, Oxford Road, Manchester M13 9PL, UK
| | - Tatiana V Macfarlane
- Division of Applied Medicine, School of Medicine and Dentistry, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Keith M Milsom
- School of Dentistry, The University of Manchester, Coupland 3 Building, Oxford Road, Manchester M13 9PL, UK
- Cheshire & Merseyside Centre, Public Health England, Chester, UK
| | - Philip Ratcliffe
- Woodlands Dental Practice, 493 Old Chester Rd, Dacre Hill, Birkenhead CH42 4NG, UK
| | - Annette Wyllie
- Martins Lane Dental Practice, 1-3 Martins Lane, Wallasey WIRRAL CH44 1BA, UK
| | - Martin Tickle
- School of Dentistry, The University of Manchester, Coupland 3 Building, Oxford Road, Manchester M13 9PL, UK
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