Staying up-to-date …
for the next 35-40 years

Oral Health Care Delivery

October 13, 2004

Session 3. Part II

What is a profession?

A monopoly

How do we get this privilege?

What is a profession?

Expertise –

Code of ethics

What do we get in return?

Autonomy

Challenge of the profession/al

Challenge of maintaining expertise

Staying up-to-date in your field

Types of information directed at clinicians

1) Info that describes available treatments

without providing a basis for choosing among them

2) Info that describes biomedical/dental research results

without exploring their clinical implications

Types of information directed at clinicians

3) Info designed to deliver practice-relevant information

Effectiveness and outcomes research

Information concerning which practices lead to better outcomes

Effectiveness and outcomes research

Goal is to improve the quality of health care provided to patients

Especially health outcomes

How to reach the clinician and make this happen?

Effectiveness and outcomes research

Dissemination issues

Need to reach practitioners

Crucial role in determining whether goal is realized

Behavior change issues

effectiveness/outcomes research will not have an impact if…

It does not convince practitioners to comply

Dissemination of information

Process of communicating information

Sources

Biomedical/dental research

NIH panels

Professional associations

Dissemination of information

Transmitted through various media

Journals

Conferences

Word of mouth

Popular press

Dissemination of information

Reaches various audiences

Policymakers

Health care providers

Payers

Consumers

Does dissemination of information change behavior?

It is assumed

that when providers encounter new information

suggesting they should change the way they treat their patients

That they are willing to change

Does dissemination of information change behavior?

Quality of care likely to be achieved

Only if relevant research findings and guideline recommendations

appropriately incorporated into practice

How does profession influence behavior?
Modes of professional influence

1) Regulatory influence

(Threat of punishment/prospect of reward)

Present-day manifestations of regulatory (or direct) influence can be found in:

Third-party reimbursement policies

Threat of malpractice

Sanctions by peer review or other

authoritative bodies

Modes of professional influence

2) Normative influence

Impressions of what the profession expects you to do

What your colleagues expect you to do

What the “experts” expect you to do

What your patients expect you to do

What the professional leadership expects you to do

Modes of professional influence

3) Informational influence

Factual influence

Providing information that leads to belief that should change your practice

Informational influence

Informational influence – mode of influence that characterizes dissemination efforts

Randomized clinical trials

Consensus recommendations

Clinical practice guidelines

Continuing education courses

1) Randomized clinical trials

Results of randomized clinical trails reported by scientific investigators

Seek to document their methods and results for the scientific community

May have no specific intent to shape practitioner’s behavior

Systematic reviews in dentistry

Bader, JD, Shugars DA, Bonito AJ. A systematic review of the performance of methods for identifying carious lesions. Journal of Public Health Dentistry, 62: 201-213, 2002.

Bader, JD, Shugars DA, Bonito AJ. A systematic review of selected caries prevention and management methods. Community Dent Oral Epidemiol 29: 399-411, 2001.

Bader, JD, Shugars, DA, Bonito AJ. Systematic reviews of selected dental caries diagnostic and management methods, J Dent Ed 65: 960-968, 2001.

Use of the “systematic review” as alternative in dentistry

1) Identify questions to be answered

2) Define study inclusion/exclusion criteria

3) Conduct literature search

4) Abstract the articles

5) Evaluate the evidence

RCT’s – influence clinician’s behavior?

Fineberg reviewed many studies of effects of clinical evaluations on physicians’ behaviors

Despite difficulty in discerning long-term effects of RCTs

clear that physicians do not respond rapidly or in large numbers to newly published findings of RCTs

In many cases, little or no change in practice even after a considerable amount of time

2) NIH consensus conferences

One of the most visible activities aimed at disseminating information on state-of-the-art therapy

National Institutes of Health (NIH) Consensus Development Program

conducts evaluations of biomedical/dental technologies

produces and disseminates consensus statements

aimed at health care providers, the public, and the scientific community

NIH consensus conferences

http://consensus.nih.gov

Consensus statements prepared by a nonadvocate, non-Federal panel of experts based on:

1) presentations by investigators working in areas relevant to question

2) presentations made during 2-day public session

NIH consensus conferences

3) questions and statements from conference attendees during open discussion periods are part of the public session

4) closed deliberations by the panel during the remainder of the second day and morning of the third

NIH consensus conferences

5) statement is an independent report of the panel and not a policy statement of the NIH or the Federal Government

6) statement reflects the panel’s assessment of knowledge at the time written

Provides a “snapshot in time” of the state of knowledge

When reading the statement, keep in mind that new knowledge is inevitably accumulating through research

NIH Consensus Conferences pertaining to dentistry

Dental implants: benefit and risk – June 1978

Removal of third molars – Nov 1979

Dental sealants in the prevention of tooth decay – Dec 1983

Dental implants – June 1988

Oral complications of cancer therapies: diagnosis, prevention, and treatment – April 1989

Diagnosis and management of dental caries throughout life – March 2001

NIH consensus conferences

Study evaluating the NIH Consensus Development program – Rand Corporation – David Kanouse

Used medical record review (behavior) to examine changes in hospital-based procedures that were subject of conference

Physician’s self-reported preferred practices were strongly related to what actually did

Although program’s dissemination effort was moderately successful at reaching the appropriate target audience

the conferences mostly failed to stimulate changes in physicians’ practices.

Clinical practice guidelines (CPG)

Systematically developed statements

to assist practitioner and patient decisions

about appropriate health care for specific clinical circumstances”

Their successful implementation should improve quality of care

by decreasing inappropriate variation

and expediting the application of effective advances to everyday practice

Clinical practice guidelines (CPG)

Despite wide dissemination

guidelines have had limited effect on changing clinician behavior

Little is known about the process and factors

responsible for how clinicians change their practice standards

when they become aware of a guideline

Barriers to CPG adherence

Adherence to guidelines may be hindered by a variety of barriers

A theoretical approach can help explain these barriers

possibly help target interventions to specific barriers

Barriers to CPG adherence

Cabana et al., Why don’t physicians follow clinical practice guidelines, JAMA 282 (15), October 20, 1999, 1458-1465.

Barrier defined as “any factor that limits or restricts complete physician adherence to a guideline”

Focus on those that could be changed

As a result did not consider age, sex, ethnic background, or specialty of the clinician

Knowledge-related barriers

Lack of awareness

The inability to correctly acknowledge a guideline’s existence

Lack of familiarity

Included the inability to correctly answer questions about a guidelines content as well as self-reported lack of familiarity

Attitudinal barriers

Lack of agreement

Differences in interpretation of the evidence

Belief that benefits not worth patient risk, discomfort, or cost

Applicability to the practice population

Guidelines oversimplified or “cookbook”

Guidelines reduce autonomy

Authors’ lack of credibility , bias

Attitudinal barriers

Lack of self-efficacy

Belief that s/he cannot perform guideline recommendation

Lack of outcome expectancy

Belief that performance of guideline recs will not lead to desired outcome

Attitudinal barriers

Lack of motivation/

Inertia of previous practice

Habit

routine

External barriers

Patient factors

Inability to reconcile patient preference with guideline recs

Guidelines

Guideline characteristics

Difficult to use

Not convenient

Cumbersome

Confusing

Presence of contradictory guidelines

External barriers

Environment

Lack of time

Lack of resources – insufficient staff or consultant support

Lack of reimbursement

Perceived increase in malpractice liability


	Expertise –
	Code of ethics

	What do we get in return?
	Autonomy


	Challenge of maintaining expertise

	Staying up-to-date in your field


	1) Info that describes available treatments
		without providing a basis for choosing among them
	2) Info that describes biomedical/dental research results
		without exploring their clinical implications


	3) Info designed to deliver practice-relevant information
			Effectiveness and outcomes research
			Information concerning which practices lead to better outcomes


	Goal is to improve the quality of health care provided to patients
		Especially health outcomes

	How to reach the clinician and make this happen?


	Dissemination issues
		Need to reach practitioners
		Crucial role in determining whether goal is realized
	Behavior change issues
		effectiveness/outcomes research will not have an impact if…
		It does not convince practitioners to comply


	Process of communicating information
	Sources
		Biomedical/dental research
		NIH panels
		Professional associations


	Transmitted through various media
	Journals
	Conferences
	Word of mouth
	Popular press


	Reaches various audiences
	Policymakers
	Health care providers
	Payers
	Consumers


	It is assumed
	that when providers encounter new information
	suggesting they should change the way they treat their patients

	That they are willing to change


	Quality of care likely to be achieved
		Only if relevant research findings and guideline recommendations
		appropriately incorporated into practice


	1) Regulatory influence
	(Threat of punishment/prospect of reward)
	Present-day manifestations of regulatory (or direct) influence can be found in:
	Third-party reimbursement policies
	Threat of malpractice
	Sanctions by peer review or other
	authoritative bodies


	2) Normative influence
	Impressions of what the profession expects you to do
	What your colleagues expect you to do
	What the “experts” expect you to do
	What your patients expect you to do
	What the professional leadership expects you to do


	3) Informational influence
	Factual influence
		Providing information that leads to belief that should change your practice


	Informational influence – mode of influence that characterizes dissemination efforts
	Randomized clinical trials
	Consensus recommendations
	Clinical practice guidelines
	Continuing education courses


	Results of randomized clinical trails reported by scientific investigators
		Seek to document their methods and results for the scientific community
		May have no specific intent to shape practitioner’s behavior


	Bader, JD, Shugars DA, Bonito AJ. A systematic review of the performance of methods for identifying carious lesions. Journal of Public Health Dentistry, 62: 201-213, 2002.
	Bader, JD, Shugars DA, Bonito AJ. A systematic review of selected caries prevention and management methods. Community Dent Oral Epidemiol 29: 399-411, 2001.
	Bader, JD, Shugars, DA, Bonito AJ. Systematic reviews of selected dental caries diagnostic and management methods, J Dent Ed 65: 960-968, 2001.


	1) Identify questions to be answered
	2) Define study inclusion/exclusion criteria
	3) Conduct literature search
	4) Abstract the articles
	5) Evaluate the evidence


	Fineberg reviewed many studies of effects of clinical evaluations on physicians’ behaviors
	Despite difficulty in discerning long-term effects of RCTs
		clear that physicians do not respond rapidly or in large numbers to newly published findings of RCTs
	In many cases, little or no change in practice even after a considerable amount of time


	One of the most visible activities aimed at disseminating information on state-of-the-art therapy
	National Institutes of Health (NIH) Consensus Development Program
		conducts evaluations of biomedical/dental technologies
		produces and disseminates consensus statements
		aimed at health care providers, the public, and the scientific community


	http://consensus.nih.gov
	Consensus statements prepared by a nonadvocate, non-Federal panel of experts based on:
	1) presentations by investigators working in areas relevant to question
	2) presentations made during 2-day public session


	3) questions and statements from conference attendees during open discussion periods are part of the public session
	4) closed deliberations by the panel during the remainder of the second day and morning of the third


	5) statement is an independent report of the panel and not a policy statement of the NIH or the Federal Government
	6) statement reflects the panel’s assessment of knowledge at the time written
		Provides a “snapshot in time” of the state of knowledge
		When reading the statement, keep in mind that new knowledge is inevitably accumulating through research


	Dental implants: benefit and risk – June 1978
	Removal of third molars – Nov 1979
	Dental sealants in the prevention of tooth decay – Dec 1983
	Dental implants – June 1988
	Oral complications of cancer therapies: diagnosis, prevention, and treatment – April 1989
	Diagnosis and management of dental caries throughout life – March 2001


	Study evaluating the NIH Consensus Development program – Rand Corporation – David Kanouse
	Used medical record review (behavior) to examine changes in hospital-based procedures that were subject of conference
	Physician’s self-reported preferred practices were strongly related to what actually did
	Although program’s dissemination effort was moderately successful at reaching the appropriate target audience
	the conferences mostly failed to stimulate changes in physicians’ practices.


	Systematically developed statements
		to assist practitioner and patient decisions
		about appropriate health care for specific clinical circumstances”
	Their successful implementation should improve quality of care
		by decreasing inappropriate variation
		and expediting the application of effective advances to everyday practice


	Despite wide dissemination
		guidelines have had limited effect on changing clinician behavior
	Little is known about the process and factors
		responsible for how clinicians change their practice standards
		when they become aware of a guideline


	Adherence to guidelines may be hindered by a variety of barriers
		A theoretical approach can help explain these barriers
		possibly help target interventions to specific barriers


	Cabana et al., Why don’t physicians follow clinical practice guidelines, JAMA 282 (15), October 20, 1999, 1458-1465.
	Barrier defined as “any factor that limits or restricts complete physician adherence to a guideline”
	Focus on those that could be changed
	As a result did not consider age, sex, ethnic background, or specialty of the clinician


	Lack of awareness
		The inability to correctly acknowledge a guideline’s existence
	Lack of familiarity
		Included the inability to correctly answer questions about a guidelines content as well as self-reported lack of familiarity