Challenges with Collecting Smoking Status in Electronic Health Records.

Smoking is the leading cause of preventable death in the United States. Obtaining patients' smoking status is the first step in delivering smoking cessation counseling. In this study, we assessed the quality of smoking status captured in an electronic health record from a large academic medical center. We analyzed data from structured notes, finding that smoking status was documented in 98% of 64,451 hospital encounters in 2016. 32% hospital encounters had discrepant documentation, and 54.5% of patients had implausible changes (e.g., changes from "current smoker" to "never smoker"). Overall, only 2.9% of patients were documented as active smokers, but 36.4% were documented as "unknown" or had discrepancies in their smoking status. These results suggest that patients that smoke are not appropriately identified. Centralized documentation with clinically actionable smoking status categories and implementation of patient-facing tools that allow patients to directly record their information could improve data quality of smoking status.

Identifying Multilevel Barriers to Tobacco Intervention in Postdoctoral Dental Education.

The aims of this mixed-methods study were to assess tobacco treatment behaviors among residents and faculty in dental specialty postdoctoral programs and to explore factors in training and practice related to tobacco treatment education. Surveys and focus groups were conducted with a convenience sample of participants at three postdoctoral residency programs in New York City. Surveys assessed tobacco cessation training and behaviors. Focus groups explored barriers to implementing tobacco cessation treatment in educational settings. Data were collected between May and December 2013. Among the 160 faculty and residents identified as potentially eligible for the study, 60 were invited by program directors to participate, and 50 subsequently completed the survey and participated in a focus group (response rate of 31.3%). Survey results indicated high levels of asking patients about tobacco use and advising patients to quit. In contrast, specific tobacco cessation assistance and follow-up care occurred less frequently. There were statistically significant differences in tobacco cessation intervention across the specialties surveyed, but not between residents and faculty. Focus group comments were grouped into three broad areas: clinician factors, organizational support, and structural and contextual factors. Focus group results indicated that participants experienced significant organizational and structural barriers to learning about and providing tobacco treatment. Participants from each specialty indicated that multi-level barriers impeded their provision of evidence-based tobacco cessation interventions in postdoctoral educational settings. They suggested that didactic education should be reinforced by organizational- and systems-level changes to facilitate comprehensive tobacco education and effective cessation treatment in future dental practice.

Tobacco cessation via public dental clinics: results of a randomized trial.

OBJECTIVES: We sought to compare the effectiveness of a dental practitioner advice and brief counseling intervention to quit tobacco use versus usual care for patients in community health centers on tobacco cessation, reduction in tobacco use, number of quit attempts, and change in readiness to quit. METHODS: We randomized 14 federally funded community health center dental clinics that serve diverse racial/ethnic groups in 3 states (Mississippi, New York, and Oregon) to the intervention (brief advice and assistance, including nicotine replacement therapy) or usual care group. RESULTS: We enrolled 2549 smokers. Participants in the intervention group reported significantly higher abstinence rates at the 7.5-month follow-up, for both point prevalence (F(1,12) = 6.84; P < .05) and prolonged abstinence (F(1,12) = 14.62; P < .01) than did those in the usual care group. CONCLUSIONS: The results of our study suggest the viability and effectiveness of tobacco cessation services delivered to low-income smokers via their dental health care practitioner in community health centers. Tobacco cessation services delivered in public dental clinics have the potential to improve the health and well-being of millions of Americans.

Tobacco education in dentistry and dental hygiene.

INTRODUCTION AND AIMS: Dentists and dental hygienists are in a unique position to motivate and assist their patients to quit smoking and using smokeless tobacco, and there is ample evidence that they can be effective. Tobacco plays a major role in the development and treatment of many oral diseases, and the repeated nature of dental treatment provides multiple opportunities for information, advice and brief counselling. However, dentists and dental hygienists in practice report lack of training in effective tobacco cessation skills as a significant barrier to incorporating these behaviours into routine care. DESIGN AND METHODS: In this paper, we summarise the rationale for addressing tobacco use within dentistry and dental hygiene, review the extant policies regarding provision of tobacco-related education, and make recommendations for the content and format of tobacco dependence treatment training in undergraduate curricula and continuing education courses. RESULTS: Although worldwide dental education organisations have policies encouraging their members to provide tobacco cessation services to their patients, there are no national standards for tobacco cessation curriculum in US dental schools. In addition, tobacco cessation is not considered a clinical competency. DISCUSSION AND CONCLUSIONS: For dental professionals to systematically assist their patients to quit tobacco, changes must be made to the ways treatment of tobacco dependence is viewed within dentistry and taught at the undergraduate and post-graduate levels. Until that time, the dental profession will continue to fall short of the Clinical Practice Guidelines and the policies set out by its professional organisations.

An innovative, effective and cost effective survey method using a survey-check response format.

Maximizing the response rate to surveys involves thoughtful choices about survey design, sampling and collection methods. This paper describes an innovative survey method, to provide immediate reinforcement for responding and to minimize the response cost. This method involves using a questionnaire printed as checks on security (anti-fraud) paper with questions and responses separated using a perforated tear off section. Once a participant completes the survey, the response area is detached from the questions, thus protecting the confidentiality of the subject, and the check is returned via the banking system. This report describes the survey-check methodology, the survey flow process, and the results from four research studies which have used this method. These studies include (1) a technology accessibility survey of parents with children enrolled in a low-income preschool program; (2) a parent report of their child's behavior used as screening criteria for inclusion in a computer-mediated parent education project; (3) a follow-up questionnaire as part of a longitudinal study of child behavior, covering home and classroom interventions, and service utilization, and; (4) a survey of dentists in support of efforts to recruit them to participate in a randomized control trial of tobacco cessation in dental offices. The results of using this method show great improvement in response rates over traditionally administered surveys for three of the four reported studies. Results are discussed in terms of future applications of this method, limitations, and potential cost savings.

An examination of periodontal treatment and per member per month (PMPM) medical costs in an insured population.

BACKGROUND: Chronic medical conditions have been associated with periodontal disease. This study examined if periodontal treatment can contribute to changes in overall risk and medical expenditures for three chronic conditions [Diabetes Mellitus (DM), Coronary Artery Disease (CAD), and Cerebrovascular Disease (CVD)]. METHODS: 116,306 enrollees participating in a preferred provider organization (PPO) insurance plan with continuous dental and medical coverage between January 1, 2001 and December 30, 2002, exhibiting one of three chronic conditions (DM, CAD, or CVD) were examined. This study was a population-based retrospective cohort study. Aggregate costs for medical services were used as a proxy for overall disease burden. The cost for medical care was measured in Per Member Per Month (PMPM) dollars by aggregating all medical expenditures by diagnoses that corresponded to the International Classification of Diseases, 9th Edition, (ICD-9) codebook. To control for differences in the overall disease burden of each group, a previously calculated retrospective risk score utilizing Symmetry Health Data Systems, Inc. Episode Risk Groups (ERGs) were utilized for DM, CAD or CVD diagnosis groups within distinct dental services groups including; periodontal treatment (periodontitis or gingivitis), dental maintenance services (DMS), other dental services, or to a no dental services group. The differences between group means were tested for statistical significance using log-transformed values of the individual total paid amounts. RESULTS: The DM, CAD and CVD condition groups who received periodontitis treatment incurred significantly higher PMPM medical costs than enrollees who received gingivitis treatment, DMS, other dental services, or no dental services (p < .001). DM, CAD, and CVD condition groups who received periodontitis treatment had significantly lower retrospective risk scores (ERGs) than enrollees who received gingivitis treatment, DMS, other dental services, or no dental services (p < .001). CONCLUSION: This two-year retrospective examination of a large insurance company database revealed a possible association between periodontal treatment and PMPM medical costs. The findings suggest that periodontitis treatment (a proxy for the presence of periodontitis) has an impact on the PMPM medical costs for the three chronic conditions (DM, CAD, and CVD). Additional studies are indicated to examine if this relationship is maintained after adjusting for confounding factors such as smoking and SES.

Tobacco use by adolescents: the role of the oral health professional in evidence-based cessation programs.

The use of tobacco products, especially cigarette smoking, represents the leading cause of preventable illness and death in the developed world. In the United States, major gains have been made to reduce smoking among adults. Similar gains, however, have not been realized with adolescents. In recent years, substantial interest has been directed to tobacco cessation studies with adolescents. The previously limited interest in adolescent cessation programs was attributable in large part to the mistaken assumptions that: (1) adolescent tobacco users were not dependent on nicotine and could stop at any time; (2) adolescents did not want to quit; and (3) adult tobacco cessation programs would be effective with adolescents. The need for programs to increase adolescent cessation attempts is underscored by the Healthy People 2010 goal that calls for an increase in tobacco use cessation attempts by adolescent smokers to 84%. Dental providers need to take steps to prevent tobacco use by adolescent patients. For those who are already addicted, they need to provide cessation counseling services or referral for appropriate treatment. The purpose of this paper was to provide dental clinicians with information on: (1) tobacco and health; (2) the epidemiology of adolescent tobacco use; and (3) tobacco cessation programs for parents and adolescents that can be implemented in the dental office setting.

On the primary care frontlines: the role of the general practitioner in smoking-cessation activities and diabetes management.

BACKGROUND: Advances in understanding the relationship between oral disease and systemic conditions need to be translated into clinical practice. Relevant here is assessing dentists' active involvement in in-office smoking-cessation activities and management of the patient with type 1 or type 2 diabetes. METHODS: The authors mailed a survey to a net sample of 132 active general practitioners (GPs) in the northeastern United States during fall 2002. They drew a random sample of GPs listed in the designated states from the 2001 American Dental Association directory. They received 105 responses, for a response rate of 80 percent. RESULTS: With regard to smoking-cessation activities and management of diabetic patients, a majority of GPs reported having a lack of knowledge, viewed such activities as peripheral to their role and disagreed that colleagues and/or patients expected them to perform such activities. More GPs performed both activities on an assessing/advising basis than on an active management basis. CONCLUSION: Results suggest that approaches to changing dentists' behavior should aim not only at increasing knowledge but at overcoming attitudes and orientations associated with actively managing patients who smoke and patients who have diabetes. PRACTICE IMPLICATIONS: The profession's growing evidence base supports an increased primary and preventive care role for dentists. This role affords them opportunities to expand the bounds of dental practice, improve therapeutic outcomes and promote patients' overall health.

Tobacco attitudes, practices, and behaviors: a survey of dentists participating in managed care.

Tobacco cessation knowledge, attitudes, and behaviors of dentists participating in a large national managed care dental plan were assessed using a mailed survey. The survey was administered to dentists recruited to participate in an evaluation of a CD-ROM and supportive electronic detailing to promote increased tobacco cessation activities. General dentists who met specific technological criteria, had an active E-mail account, and at least 200 adult patients were eligible to participate in this study. A total of 184 dentists, located in 29 states, agreed to participate. The survey instrument included questions that addressed (a) Ask, Advise, Assess, Assist, and Arrange behaviors, (b) self-efficacy including knowledge, confidence, and success regarding tobacco cessation, (c) success of various tobacco cessation strategies, (d) barriers to tobacco cessation, and (e) demographics including year of graduation, gender, and race/ethnicity. Self-reported baseline tobacco intervention-related behaviors were low, with 28% of dentists reporting that they asked their patients about tobacco or recorded tobacco use in their patients' charts at least 41% of the time. For Advise behavior, approximately half of the dentists advised tobacco-using patients to quit at least 41% of the time. Although self-reported lack of knowledge was high, 71% of respondents indicated that their lack of knowledge was either not a barrier or a slight barrier to incorporating tobacco cessation into their practices. The survey revealed that dentists do not routinely incorporate tobacco cessation into their practices. Newer information-transfer technologies may serve as vehicles for increased smoking cessation activities by dentists.

Models for delivering school-based dental care.

School-based health centers (SBHCs) often are located in high-need schools and communities. Dental service is frequently an addition to existing comprehensive services, functioning in a variety of models, configurations, and locations. SBHCs are indicated when parents have limited financial resources or inadequate health insurance, limiting options for primary care and preventive services, or within low-access areas such as dental health professional shortage areas. Poor health and concomitantly poor oral health can lead to attendance problems. Oral health services in school-based setting are often the only access to services a child may have. Children who attend schools with SBHCs have immediate access to services that are coordinated with the student'sfamily and school personnel or administrators. Comprehensive services can be collaborative, with support or administration provided by more than 1 organization. For example, the Children's Aid Society (CAS), Columbia University School of Dental and Oral Surgery (CUSDOS), and Columbia University Mailman School of Public Health developed, implemented, and currently operate SBHCs in 2 communities in the northern Manhattan section of New York City (Central Harlem and Washington-Heights/Inwood). The clinics operate in or are affiliated with public schools in New York City. All CAS and Columbia University sites include dental components, using a variety of delivery models. Determining which dental delivery system to use for a particular community or population is a complex decision. The models, reasons for selection, and sustainability of each system are described.

The use of 'academic detailing' to promote tobacco-use cessation counseling in dental offices.

BACKGROUND: The authors conducted this study to ascertain the feasibility of face-to-face educational outreach visits, also called "academic detailing," as a methodology to promote dentists' adoption and incorporation of tobacco-use cessation counseling activities into their practices. METHODS: The authors obtained a sampling frame of one dental health maintenance organization's, or DHMO's, enrolled dentists who practiced in one of four Northeastern states and who had more than 300 DHMO patients. Of 507 eligible dentists, 88 agreed to participate, and the authors randomly assigned them to either intervention (an academic detailing program) or control (practice as usual) conditions. Changes in practice behaviors over time were obtained by questionnaires. The authors used descriptive statistics to analyze data using a statistics software package. RESULTS: Only 9 percent of dentists who agreed to participate had received any training in decreasing patients' tobacco use. The authors associated the dentists' staff members' considerable resistance to the detailing program with issues such as having to deal with additional paperwork and uncooperative patients, the perception that only a few patients use tobacco and that counseling does not work. Many dentists also expressed concern about their lack of tobacco-use cessation knowledge. Overall, dentists' resistance to detailing decreased with follow-up detailing visits. CONCLUSIONS: It is feasible to increase and incorporate tobacco-use cessation counseling in dental offices. However, significant barriers must be surmounted first if this goal is to be achieved by use of academic detailing. CLINICAL IMPLICATIONS: Using academic detailing, dentists can be effective agents in increasing the longevity, decreasing the morbidity and improving the oral health status of their patients through the promotion of smoking cessation.