Dental referrals for patients with diabetes: survey of barriers and enablers for medical and health professionals

BACKGROUND

Oral health care improves diabetes management; however, medical and other health practitioners do not commonly refer their patients with diabetes for oral health care. This study aimed to understand barriers to and enablers of dental referrals for patients with diabetes.

METHODS

Quantitative data were collected from a cross-sectional survey of health care providers attending a virtual Grand Rounds on the relationship between oral health and diabetes. Attendees were invited to complete and share a Forms survey. Barriers to and enablers of dental referrals were compared for 18 health professionals working in inpatient/ward settings to 23 working in community/primary care settings using the chi-square test.

RESULTS

Across both work settings, only 12% of respondents often or always discussed the importance of oral health and only 8% often or always referred their patients with diabetes for dental care. Time barriers, awareness and knowledge of how/where to send dental referrals were significant barriers, while online referral pathways, more education and availability of brochures for the patient to take home were identified as key enablers for dental referrals.

CONCLUSIONS

Online referral pathways, targeted oral health education and resources for medical and health professionals caring for patients with diabetes may increase the number of patients being referred for dental care as part of their diabetes managements. © 2023 Australian Dental Association.

932 A QI PROJECT TO IMPROVE USE OF BOWEL CHARTS IN CLINICAL PRACTICE

Introduction

Bowel movements are vital to decision making, but are frequently overlooked in practice due to the fast-paced nature of medical ward rounds, impacting on patient care. This was felt to be exacerbated locally by the difficulties of finding the information in the nursing notes.

Aim To improve the documentation of bowel movements.

Method

We performed a closed loop audit examining how well patients’ bowel movements are documented in nursing and medical notes across 3 wards at a district general hospital. We collected snapshot data on whether a bowel chart was present, whether bowel movements were recorded regularly and whether doctors documented bowel movements during ward rounds. We then changed the colour of bowel chart paper from white to yellow, with identical contents. This data was prospectively collected again 5 weeks later for comparison.

Results

The sample size included 62 inpatients. Prior to the change in bowel chart, 79% of patients’ nursing folders had a bowel chart. Documentation of bowel movements in nursing and medical notes was 25% and 30% respectively. Following the introduction of yellow coloured bowel charts, 90% of patients’ nursing notes had a bowel chart present, with an increase in documentation in nursing and medical notes to 74% and 69% respectively.

Conclusion

(s) The importance of good bowel movements is essential to management decisions and discharge planning. Locally, this has been inhibited by the difficulties of locating white bowel charts in a folder of white paper, leading to incomplete documentation and poor recognition of problems in bowel movements. Changing the colour of the bowel charts made it easier to recognise the bowel chart, allowing nurses and doctors to use the bowel chart more efficiently, hopefully improving patient care. This change has been recognised as effective and has been rolled out trust wide.

Estimating the costs of intensity-modulated and 3-dimensional conformal radiotherapy in Ontario

BACKGROUND

Radiotherapy is a common treatment for many cancers, but up-to-date estimates of the costs of radiotherapy are lacking. In the present study, we estimated the unit costs of intensity-modulated radiotherapy (imrt) and 3-dimensional conformal radiotherapy (3D-crt) in Ontario.

METHODS

An activity-based costing model was developed to estimate the costs of imrt and 3D-crt in prostate cancer. It included the costs of equipment, staff, and supporting infrastructure. The framework was subsequently adapted to estimate the costs of radiotherapy in breast cancer and head-and-neck cancer. We also tested various scenarios by varying the program maturity and the use of volumetric modulated arc therapy (vmat) alongside imrt.

RESULTS

From the perspective of the health care system, treating prostate cancer with imrt and 3D-crt respectively cost $12,834 and $12,453 per patient. The cost of radiotherapy ranged from $5,270 to $14,155 and was sensitive to analytic perspective, radiation technique, and disease site. Cases of head-and-neck cancer were the most costly, being driven by treatment complexity and fractions per treatment. Although imrt was more costly than 3D-crt, its cost will likely decline over time as programs mature and vmat is incorporated.

CONCLUSIONS

Our costing model can be modified to estimate the costs of 3D-crt and imrt for various disease sites and settings. The results demonstrate the important role of capital costs in studies of radiotherapy cost from a health system perspective, which our model can accommodate. In addition, our study established the need for future analyses of imrt cost to consider how vmat affects time consumption.

Screening for contaminant hotspots in the marine environment of Kuwait using ecotoxicological and chemical screening techniques

Kuwait is a country with low rainfall and highly concentrated industrial and domestic effluents entering its coastal waters. These can be both treated and untreated. In this study we sampled a series of coastal and open-sea sites and used a variety of analyses to identify those sites requiring the most attention. We used a high throughput GC-MS screen to look for over 1000 chemicals in the samples. Estrogen and androgen screens assessed the potential to disrupt endocrine activity. An oyster embryo development screen was used to assess biological effect potential. The chemical screen identified sites which had high numbers of identified industrial and domestic chemicals. The oyster screen showed that these sites had also caused high levels of developmental abnormalities with 100% of embryos affected at some sites. The yeast screen showed that estrogenic chemicals were present in outfalls at 2-3 ng/l E2 equivalent, and detectable even in some open water sites.

Impact of dental therapists on productivity and finances: III. FQHC-run, school-based dental care programs in Connecticut

In many developed countries, the primary role of dental therapists is to care for children in school clinics. This article describes Federally Qualified Health Center (FQHC)-run, school-based dental programs in Connecticut and explores the theoretical financial impact of substituting dental therapists for dentists in these programs. In schools, dental hygienists screen children and provide preventive services, using portable equipment and temporary space. Children needing dentist services are referred to FQHC clinics or to FQHC-employed dentists who provide care in schools. The primary findings of this study are that school-based programs have considerable potential to reduce access disparities and the estimated reduction in per patient costs approaches 50 percent versus providing care in FQHC dental clinics. In terms of substituting dental therapists for dentists, the estimated additional financial savings was found to be about 5 percent. Nationally, FQHC-operated, school-based dental programs have the potential to increase Medicaid/CHIP utilization from the current 40 percent to 60 percent for a relatively modest increase in total expenditures.

Impact of dental therapists on productivity and finances: II. Federally Qualified Health Centers

This article estimates the impact of dental therapists treating children on Federally Qualified Health Center (FQHC) dental clinic finances and productivity. The analysis is based on twelve months of patient visit and financial data from large FQHC dental clinics (multiple delivery sites) in Connecticut and Wisconsin. Assuming dental therapists provide restorative, extraction, and pulpal services and dental hygienists continue to deliver all hygiene services, the maximum reduction in costs is about 6 percent. The limited impact of dental therapists on FQHC dental clinic finances is because 1) dental therapists only account for 17 percent of children services and 2) dentists are responsible for only 25 percent of clinic expenses and cost reductions are related to the difference between dental therapist and dentist wage rates.

Impact of dental therapists on productivity and finances: I. Literature review

This study examined the financial impact of dental therapists on Federally Qualified Health Center dental clinics (treating children) and on private general dental practices (treating children and adults). This article, the first of four on this subject, reviews the dental therapy literature and the dental access problem for low-income children. Dental therapists now practice in many developed countries, tribal areas of Alaska, and Minnesota. These allied dental professionals vary in their training and required dentist supervision, but all provide routine restorative and other related services to children and adults. The limited literature on the impact of dental therapists suggests that they work mainly in school and community clinics and some private practices, are well accepted by patients, provide restorations that are comparable in quality to those of dentists, expand the supply of services, do not increase private practices' net revenues, and in school programs decrease the number of untreated decayed teeth. Of the approximately 33.8 million children enrolled in Medicaid and the Children's Health Insurance Program (CHIP), some 40 percent now receive at least one annual dental visit. To increase utilization for all children to 60 percent--the rate seen in children from upper-income families--another 6.7 million children need to receive care; dental therapists may help to accomplish that objective.

Cost-effectiveness of intensity-modulated radiotherapy in prostate cancer

AIMS

To compare the costs and effectiveness of intensity-modulated radiotherapy (IMRT) with three-dimensional conformal radiotherapy (3DCRT) for the radical treatment of localised prostate cancer at elevated doses (>70 Gy).

MATERIALS AND METHODS

A cost-effectiveness analysis model was developed using clinical effectiveness estimates from a systematic review. The base case analysis assumes equal biochemical survival for IMRT and 3DCRT, but lower frequency of gastrointestinal toxicity for IMRT. The costs of IMRT and 3DCRT were estimated through activity-based costing, incorporating input from radiation oncologists, physicists and treatment planners.

RESULTS

The delivery of IMRT produced 0.023 more quality-adjusted life-years (QALY) than 3DCRT at an additional cost of $621 (QALY and costs discounted at 5% per year), yielding an incremental cost-effectiveness ratio of $26 768 per QALY gained. The treatment cost of IMRT was $1019 more than 3DCRT, but IMRT resulted in less frequent gastrointestinal toxicity, thus avoiding $402 in the treatment of toxicity. In the scenario that compared a higher dose of IMRT (75.6 Gy) to 3DCRT (68.4 Gy), IMRT improved disease control with equal toxicity incidence, and the IMRT strategy dominated (less costly and more effective). In the base case scenario (no survival difference), the cost-effectiveness of IMRT was most sensitive to the treatment cost difference between IMRT and 3DCRT.

CONCLUSION

For radical radiation treatment (>70 Gy) of prostate cancer, IMRT seems to be cost-effective when compared with an equivalent dose of 3DCRT.

Community pharmacists' experience of over-the-counter medicine misuse in Scotland

Over the last decade Britain has observed a trend towards the re-regulation of 'prescription only medicines' in favour of pharmacy status drugs. This move towards self-treatment to reduce pressures on general practitioner drug budgets and workloads has focused attention on the need for community pharmacists to extend their patient education and screening roles. In response to these changes, this study was conducted to explore: the type of over-the-counter (OTC) medicine being misused in Scotland; pharmacists' professional attitudes and management of OTC misuse; and the training and support needs of pharmacists. A postal questionnaire was designed. This was informed by an earlier stage of qualitative research and the available literature. It was then piloted and administered to all 110 pharmacies in the study area. A 79% response rate was achieved. The research found that OTC misuse, particularly of certain analgesics, sleeping prescriptions, products containing codeine or pseudoephedrine, caffeine, cough mixtures, and laxatives was common. The estimated mean number of patients suspected of misusing medicines in a typical week was 5.63. Pharmacies in urban areas were more likely than those in rural areas to report suspected misuse. The research identified a number of intervention strategies relating to: patient/pharmacist interaction; information provision; removal of products from the point of sale; sharing of information with other local pharmacists; and referral to other members of the primary care team. Pharmacists expressed a need for support in managing OTC misuse and in organising 'early warning systems' to share information locally.

The initial attitudes of patients toward longer maintenance hemodialysis

Longer hemodialysis (HD) as practiced in parts of Europe and Japan may improve both blood pressure control and patient survival. Nevertheless, in the USA, the trend has been to shorten dialysis time using larger dialyzers and increased blood flows. Many patients find the notion of shorter dialysis enticing. Most are unaware ofthe potential benefits of longer dialysis. We surveyed stable chronic HD patients in an urban area, the vast majority of whom received conventional 4-hour treatments, regarding their attitude toward extending their dialysis time to 5 hours. They were informed that longer dialysis has been associated with better blood pressure control and improved survival. One hundred and sixteen patients completed questionnaires during a single dialysis session. Forty-six (40%) agreed to extended dialysis while 70 (60%) did not. There was no difference between the groups with respect to the following variables: age, race, etiology of ESRD, time on dialysis, marital status, number of children at home, number residing in the household, education, or employment status. Male gender was associated with a positive response (p = 0.03). Various suggested and spontaneous reasons were given for a negative response.

CONCLUSION

With minimally detailed information, 4 in 10 patients were willing to extend their treatment time to 5 hours in the hope of improving morbidity and survival. No sociodemographic variable except gender was associated with a positive response.

Diabetic nephropathy

Diabetic nephropathy is the leading cause of end-stage renal disease in the United States and the largest contributor to the total cost of diabetic care. In addition to the development of diabetic nephropathy and end-stage renal failure, diabetic patients with evidence of albuminuria have a much higher risk of developing myocardial infarctions, cerebrovascular accidents, severe progressive retinopathy, and neuropathy. This article characterizes the clinical and pathologic features of diabetic nephropathy and reviews the major pathogenetic theories that underlie the development of this dreaded complication of diabetes. Widespread screening for this condition and aggressive treatment of diabetic nephropathy at early stages of disease are critical to diminish the risk of costly late complications.

Pharmacokinetics and safety of single intravenous infusions of the adenosine agonist, AMP 579, in patients with end-stage renal insufficiency

The pharmacokinetics of an adenosine agonist (AMP 579) were characterized in patients with end-stage renal disease compared to sex- and age-matched healthy volunteers. All study participants were administered single AMP 579 doses of 50 micrograms/kg as a 6-hour, constant-rate intravenous infusion. Serial blood samples were obtained for measurement of plasma AMP 579 concentration, and predose samples were collected for determination of AMP 579 plasma protein binding. The safety of AMP 579 administration in renally impaired patients also was evaluated. AMP 579 was rapidly cleared from the systemic circulation in all subjects as plasma concentrations were below the limit of detection by 2 to 4 hours after terminating the infusion. Noncompartmental analysis yielded mean values for the plasma AMP 579 concentration at the end of the 6-hour infusion (C6 h) of 9.6 and 10.5 ng/mL and for systemic clearances (Cl) of 0.91 and 0.72 L/h/kg in renally impaired patients and healthy volunteers, respectively. Mean volumes of distribution (Vss) in the renally impaired and healthy volunteers were 0.92 and 0.84 L/kg, and terminal elimination half-life values (t1/2) were 1.61 and 1.33 hours, respectively. The extent to which AMP 579 is bound to plasma protein was not altered in renally impaired patients since the free fractions were 4.0% and 3.4% for renally impaired and healthy volunteers, respectively. It was concluded that the pharmacokinetic parameters of AMP 579 were similar in both groups. The 6-hour AMP 579 infusion was generally well tolerated by both renal patients and healthy volunteers. There were no serious adverse events, and there were only two mild adverse events in 1 renally impaired patient judged possibly related to the study drug that quickly resolved. There were no clinically significant changes in laboratory values or clinical evaluations during the study. There was a slight increase in heart rate during the infusion of similar magnitude for both the renal patients and healthy volunteers. These data suggest that AMP 579 may be administered to renally impaired patients with minimal cardiovascular effects and adverse events. These results in end-stage renal patients (worst-case scenario) indicate that dose adjustment in patients with renal insufficiency of any degree is not indicated in future studies of AMP 579.

Efficacy of theophylline in "irreversible" airflow obstruction

We studied ventilatory, hemodynamic, and subjective responses to different plasma theophylline concentrations in 10 patients with "irreversible" airflow obstruction. Subjects received theophylline at doses that produced low (9.0 to 12.5 micrograms/mL) and high (17 to 22 micrograms/mL) peak plasma concentrations; subjects also received placebo. A significant (P less than 0.05) dose-related difference in pulmonary function was observed between each treatment. The mean maximal increase in forced expiratory volume at 1 second over placebo was 21.3% for high-dose theophylline and 6.0% for low dose. Both treatments were well tolerated with respect to hemodynamic changes and other adverse effects. Despite improved findings in pulmonary function tests patients were unable to distinguish either treatment from placebo in terms of improvement in breathlessness.

Acute respiratory failure following severe arsenic poisoning

A 47-year-old man had an episode of severe respiratory failure after acute intoxication with arsenic. Features of the initial clinical presentation included nausea, vomiting, and diarrhea, acute psychosis, diffuse skin rash, and marked pancytopenia. A peripheral neuropathy then developed which resulted in severe weakness of all muscles of the limbs, the shoulder and pelvis girdles, and the trunk. The neuropathy continued to progress despite treatment with dimercaprol (BAL in oil). Five weeks after the initial exposure, the patient was no longer able to maintain adquate ventilation and required mechanical ventilatory support. Improvement in the patient's neuromuscular status permitted successful weaning from the ventilator after one month of mechanical ventilation. Long-term follow-up revealed no further respiratory difficulty and slow improvement in the strength of the peripheral muscles.

Mechanisms of airway smooth muscle response to isoproterenol and theophylline

Airway smooth muscle preparations from various sites and species exhibit a range of sensitivities to the same beta-adrenergic agonist. This variability has been attributed to beta-receptor function but the exact mechanism determining the response has not been identified. After first inducing contraction with acetylcholine, we measured isoproterenol and theophylline relaxation responses in five separate airway smooth muscle preparations in vitro. The order of sensitivity was identical for both drugs: guinea pig trachea greater than dog lung strip greater than dog bronchiole greater than rat trachea greater than dog trachea. Because of evidence that both drugs act by increasing adenosine 3',5'-cyclic monophosphate (cAMP) concentrations, we utilized a kinetic model of cAMP metabolism to investigate the possibility that the identical order of sensitivity to both drugs could be explained by a common mechanism. Relaxation responses to both drugs are in accord with known kinetic data. Small differences in the velocity constants of enzymes affecting cAMP metabolism or differences in the relaxation response to the same concentrations of cAMP can fully explain the variable muscle responses to both drugs.

Alcohol-induced taste aversion in golden hamsters

Multiple injections of alcohol were effective in producing substantial aversions to saccharin-flavored water in golden hamsters. A dose of 1.76 g of alcohol per kg produced a long-lasting aversion, whereas aversion produced by injections of 1.17 g per kg extinguished rapidly.