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

BACKGROUND: US health care delivery and financing arrangements are changing rapidly as payers and providers seek greater efficiency, effectiveness, and safety. The Centers for Medicare & Medicaid Services uses grants and technical assistance to drive such development through innovative demonstration programs, including for oral health care. The authors reviewed these dental demonstrations to identify common themes and identify barriers to and facilitators of implementation. METHODS: The authors compared 12 identified demonstrations across 6 domains: grant and technical assistance, stakeholders, inner care settings, outer contextual settings, interventions, and outcomes. They developed program summaries for each demonstration and interviewed key informants using a semistructured guide to review, correct, clarify, and expand on program summaries. RESULTS: Common across all programs were engagement of nontraditional providers, care in nontraditional settings, payment as a critical externality for program adoption, interventions that integrate medical and oral health care, use of alternative payment models, and tracking process measures. Adoption facilitators included an engaged oral health champion and obtaining mission support and alignment among stakeholders. Common barriers included unanticipated organizational disruptions, poor information technology infrastructure, cultural resistance to nontraditional care models, and lack of providers in high-need areas. CONCLUSIONS: Descriptive findings suggest that oral health care may evolve as a more accountable, integrated, and accessible health service with an expanded workforce; collaboration between providers and payers will remain key to creating innovative, sustainable models of oral health care. PRACTICAL IMPLICATIONS: The Centers for Medicare & Medicaid Services' efforts to advance health equity, expand coverage, and improve health outcomes will continue to drive similar initiatives in oral health care.

Community Engagement to Advance Equitable Cardio-Oncology Care: A Call to Action: JACC: CardioOncology How To.

•Situating engagement within the experience and priorities of survivors will enhance translational research and health equity.•The TRUST framework provides a guide to expand opportunities for community engagement in cardio-oncology for multiple constituents and across the care continuum.•Training community members as cardio-oncology champions may promote stakeholder representation.•Community connectors can support bidirectional engagement and support for survivors as they transition from active treatment.

Change in parental knowledge and beliefs about early childhood dental caries following a pragmatic community-based trial.

OBJECTIVES: To evaluate parent knowledge and belief changes following the MySmileBuddy (MSB) early childhood caries (ECC) intervention. METHODS: Pre- and post-intervention surveys were completed by 669 parents of children with visually-evident ECC from among 977 participants in a 6-12-month pragmatic community-based caries management trial administered by community health workers (CHWs). Six domains of knowledge about caries and motivating and facilitating determinants were assessed via 26 survey items. Principal components analysis and reliability testing reduced dataset dimensionality. Parent and CHW characteristics were analyzed as potential moderators. Paired T-tests measured pre-to-post-intervention changes. Generalized estimating equations accounted for within-participant correlation with significance set at p < 0.05. RESULTS: Twenty items consolidated into five factors (saliva, hygiene, diet, seriousness/susceptibility, and outcome expectations). Six additional items were evaluated individually. Positive post-intervention changes (p < 0.0001) were observed across all factors and all but one individual item (tooth decay is very common). Greatest knowledge increases related to caries as a bacterial disease in two measures, the saliva factor and a single caries belief item tooth decay is an infectious disease (0.59 unit increase, 95% CI [0.55, 0.64] and 0.46 unit increase, 95% CI [0.4, 0.51], respectively), and in the value of fluoridated water over bottled (0.46 unit increase, 95% CI [0.39-0.53]). Most parents improved knowledge of ECC salivary (72%) and dietary risks (57%), and preventative hygiene behaviors (59%). CONCLUSIONS: MSB enhanced knowledge and beliefs about caries and confirmed hypothesized mediators of behavior change among parents of high-risk children. Engaging peer-like CHW interventionists may have moderated intervention effects, warranting further exploration.

A scoping review of the economic impact of family oral health: Implications for public health, research, and policy.

OBJECTIVES: To summarize evidence on the impact of oral health on individual and family economic outcomes, describe trends in the literature, and identify areas for additional research to inform public health research and practice. METHODS: Searches were conducted within PubMed, CINAHL, EconLit, Cochrane Library, PsycInfo, and Web of Science databases. Article review, selection, abstraction, and reporting processes were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. RESULTS: Of 2758 unduplicated records identified, 52 met inclusion criteria. Study outcomes included indicators of employment/employability (n = 9), earnings/earnings potential (n = 26), parent missed work and family financial impacts of child oral health (n = 19), and financial loss (n = 3). Dental caries-related variables were the most common predictors of poorer economic outcomes. Other oral health problems, such as poorer dental functioning or poorer self-reported oral health status, also were associated with adverse economic outcomes. Significant associations with employment were found among studies that assessed interventions designed to improve oral health. Only one study estimated the impact of oral health on earnings. One-third of studies conducted multivariable analyses, and 14% incorporated race and ethnicity variables. CONCLUSIONS: Although existing evidence suggests associations between oral health problems and poorer economic outcomes, there is a substantial need for more rigorous research to better understand the extent of economic impact of oral health problems and which populations are most affected. Additional high-quality research is needed to inform which interventions are most likely to improve oral health, reduce adverse economic impacts, and promote health and economic equity.

Implementation of a Cancer Education Program in Rural Counties with the Lowest HPV Vaccination Rates and Health Rankings.

Background: Human papillomavirus (HPV) is the most common sexually transmitted infection (STI). To address STIs, one rural county public school district developed a series of Family Life Programs to educate pre-teens about pertinent health information. The Schooling Cancer Program (SCP) was developed in partnership with the local Cancer Research and Resource Center to raise awareness about cancer risk factors including HPV-related cancers and HPV prevention methods. Methods: We collected a post-evaluation survey from students who attended a SCP session at one of the targeted middle schools. The SCP educated students about topics focusing on healthy lifestyles. The survey asked students' knowledge on the SCP topics, HPV knowledge, tobacco usage, and factors that reduced cancer development. Results: 87% agreed that tobacco products are associated with cancer, and 81% did not agree that E-cigarettes are scientifically proven to be safer than cigarettes. Although we do not have pre-evaluation data about these students' HPV knowledge, our evaluation survey shows that 80% of students correctly identified HPV as the most common STI, and 84% of students correctly identified the factors that decrease their risk of developing cancer. Conclusion: Through this initiative, students learned essential health concepts and HPV-related risk factors.

Quantifying denitrification in a field-scale bioremediation experiment.

Nitrate (NO3-) in mine waste rock derived from undetonated NH4NO3 can contaminate receiving waters. An in-situ bioremediation experiment was conducted at a coal mining operation in Elk Valley, British Columbia, Canada to remediate NO3- from large volumes of mine water. Over the test period (201 d), 5000 to 7500 m3 d-1 of NO3--rich (mean concentration 22 mg N L-1) mine water was injected into saturated waste rock along with methanol, nutrients, and a conservative tracer (Br-). Complete denitrification (<0.5 mg N L-1) was recorded in monitoring wells located 38 m from the injection wells after 114 to 141 d of operation. Plots of δ15N- and δ18O-NO3- versus NO3--N concentrations for monitoring wells yielded isotopic enrichment factors (ε) for δ15N- and δ18O-NO3- of -25.7 and -13.2 ‰ for high C/C0 NO3- concentrations (>10.5 mg N L-1) and -5.5 and -3.6 ‰ for lower C/C0 values. The fraction of NO3- denitrified (Dp) calculated using bi-linear ε values for δ15N- and δ18O reproduced the Dp determined independently using a conservative tracer indicating that stable isotope tracers of the NO3- reducing processes in bioremediation are invaluable to determine Dp. Based on the success of this ongoing bioremediation experiment, the technology is being applied at other sites.

The inverse square law: A basic principle in brachytherapy.

The purpose of this article is to remind the importance of the inverse square law in radiotherapy and especially in brachytherapy. Indeed, beyond the impact in radiation therapy with high energy beam, there is the use of radionuclides and low energy photons with short FSD where it is still more important. Comparisons between Iridium Brachytherapy and low energy X-rays brachytherapy show equivalent dose distributions in the first few centimeters. If the inverse square law is not the only element influencing the dose distributions calculations, it must not be forgotten. And it is playing a major role in brachytherapy with short FSD (<6cm).

Small-area socioeconomic status and children's oral health in a safety-net care delivery setting.

OBJECTIVES: To better understand the impact of small-area socioeconomic status (SES) on caries experience and sealant presence among children receiving services through a comprehensive community-based safety-net oral health program. METHODS: Census-tract level household data from the American Community Survey was utilized to construct an index that reflects the small-area socioeconomic environments in which children receive oral health services. This area SES index was entered into a logistic model with sociodemographic participant data collected by the community-based oral health program to consider its association with outcomes (caries and sealant experience) at first program visit, among children older and younger than 5 years. RESULTS: Among poor children older than 5 years of age, higher census-tract level SES was associated with lesser caries experience and greater sealant experience at presentation for care to a community-based oral health program. Each standard deviation increase in census-tract level SES index was associated with reduced odds of any caries experience (aOR = 0.92; 95 percent CI 0.85, 0.99; P = 0.021) and increased odds of sealants (aOR = 1.20; 95 percent CI 1.05, 1.37; P = 0.009). Among children 5 years and under, only grade was associated with both outcomes. CONCLUSIONS: Within an inner city area of poverty, the greater a census tract's socioeconomic risks to health, the greater the odds that children over age five experience caries and the lesser their odds of having dental sealants. While associations between SES and oral health outcomes across the full spectrum of SES have been recognized, this study suggests that within lower SES areas, SES-associated gradients exist in children's oral health.

Children's dental service use reflects their parents' dental service experience and insurance.

BACKGROUND: Decisions about children's oral health care are made by parents. Parents' dental insurance, dental service use, and perceived affordability all influence their children's oral health care. METHODS: Using data from the 2016 National Health Interview Survey, the authors constructed a database of 4,396 nationally representative US children and their linked household adults. The authors assessed the relationship between children's and parents' use of dental services, private and public dental insurance, and deferral of oral health care owing to cost. To adjust for factors that may influence outcomes independently, the authors performed multivariate analyses to consider child, parent, and household characteristics. RESULTS: Children have 2 times the risk of lacking a dental visit in a year if the parent has none, 7 times the risk of reportedly lacking dental coverage if the parent has none, and nearly 10 times the risk of having care deferred owing to cost if the parent finds oral health care unaffordable. Affordability risk factors for children include older age and minority race, whereas protective factors include public insurance, parents with higher educational attainment, and female-led households. Increased oral health care use by children was associated with states that provide more extensive adult Medicaid dental benefits. CONCLUSIONS: Greater parental dental service use, dental coverage, and ability to afford care benefit their children's use of oral health care. PRACTICE IMPLICATIONS: Policies by employers and government that expand quality private and public coverage for adults hold strong promise to improve oral health care for both parents and their children.

Fundamental social causes of inequalities in colorectal cancer mortality: A study of behavioral and medical mechanisms.

BACKGROUND: Fundamental cause theory posits that social conditions strongly influence the risk of health risks. This study identifies risk mechanisms that social conditions associated with socioeconomic status (SES) and race/ethnicity shape in the production of colorectal cancer (CRC) mortality. METHODS: Two large datasets in the United States examining behavioral and medical preventive factors (N = 4.63-million people) were merged with population-level mortality data observing 761,100 CRC deaths among 3.31-billion person-years of observation to examine trends in CRC mortality from 1999-2012. Analyses examined the changing role of medical preventions and health behaviors in catalyzing SES and racial/ethnic inequalities in CRC mortality. RESULTS: Lower SES as well as Black, Hispanic, Asian/Pacific Islander, and Native American race/ethnicity were associated with decreased access to age-appropriate screening and/or increased prevalence of behavioral risk factors. Analyses further revealed that SES and racial/ethnic inequalities were partially determined by differences in engagement in two preventive factors: use of colonoscopy, and participation in physical activity. DISCUSSION: Social inequalities were not completely determined by behavioral risk factors. Nevertheless, a more equitable distribution of preventive medicines has the potential to reduce both the risk of, and social inequalities in, CRC mortality.

Midface Growth in Patients With Unilateral Cleft Lip and Palate Treated With a Nasoalveolar Molding Protocol.

This retrospective cohort study aimed to determine the impact of a nasoalveolar molding (NAM) protocol on midface growth in school-aged children with non-syndromic unilateral cleft lip and palate (UCLP). Data from 56 consecutively treated, NAM-prepared, Caucasian patients with non-syndromic UCLP from a single US cleft palate center were compared to pooled center data based on 56 patients with non-syndromic UCLP treated at 2 Eurocleft centers that did not use presurgical infant orthopedics (non-PSIO). Lateral cephalograms were obtained and 28 landmarks were identified. Published cephalometric measurements from Eurocleft centers were used for comparison. Seven cephalometric measurements (SNA, SNB, ANB, A'N'B', G'-Sn'-Pg', Sn-CT-LS, ANS-Me/N-Me%), available or derivable for both centers, were analyzed. Means and standard deviations for the 7 measurements were calculated for the NAM center. Student's t-tests were used to compare group means for 6 of the measures and a test of proportion was used for ANS-Me/N-Me%. No significant differences were found between the NAM protocol-prepared group and the Eurocleft non-PSIO centers on any of the 7 analyzed cephalometric relationships after accounting for false discovery rate. The NAM treatment protocol does not appear to impact skeletal or soft tissue facial growth in school-aged children with non-syndromic UCLP.

A survey of US early childhood caries programs: findings and recommendations.

OBJECTIVES: To identify and characterize US early childhood caries (ECC) programs. METHODS: A 39 question online survey was fielded to 245 ECC programs identified from the literature and peer programs. The 101 respondents (41 percent response rate) reported their program's geographic reach, type, areas of focus, target populations, approaches, affiliations, providers, goals, costs, and funding. RESULTS: Half of the programs affiliate with formal early childhood social service or nutrition programs. Almost all characterize their work as risk reduction, disease suppression, or arrest. In descending order, programs describe their approaches as educating parents, addressing family-level health behaviors, utilizing pharmacological approaches with fluoride varnish or silver nitrate, delivering education to health professionals, and conducting research. A majority of programs target urban, poor, and low-income populations. Although little more than a third of programs utilize a logic model, most collect evaluation data and believe their program to be "very" or "somewhat" replicable. Programs tend to depend on multiple funding sources and be largely reliant on grants with foundations as the leading source of support followed by federal grants, state/local grants, and governmental programs such as Head Start. CONCLUSIONS: Programs demonstrate attempts at ECC prevention and management through holistic approaches predicated on behavioral theory, cariology science, and public health principles. Partnerships created by these programs provide unique opportunities to promote oral health. Various strategies could potentially leverage systemic changes in the delivery of dental care for young children.

Assessing the fate of explosives derived nitrate in mine waste rock dumps using the stable isotopes of oxygen and nitrogen.

Ammonium nitrate (NH4NO3) mixed with fuel oil is a common blasting agent used to fragment rock into workable size fractions at mines throughout the world. The decomposition and oxidation of undetonated explosives can result in high NO3- concentrations in waters emanating from waste rock dumps. We used the stable isotopic composition of NO3- (δ15N- and δ18O-NO3-) to define and quantify the controls on NO3- composition in waste rock dumps by studying water-unsaturated and saturated conditions at nine coal waste rock dumps located in the Elk Valley, British Columbia, Canada. Estimates of the extent of nitrification of NH4NO3 in oxic zones in the dumps, initial NO3- concentrations prior to denitrification, and the extent of NO3- removal by denitrification in sub-oxic to anoxic zones are provided. δ15N data from unsaturated waste rock dumps confirm NO3- is derived from blasting. δ15N- and δ18O-NO3- data show extensive denitrification can occur in saturated waste rock and in localized zones of elevated water saturation and low oxygen concentrations in unsaturated waste rock. At the mine dump scale, the extent of denitrification in the unsaturated waste rock was inferred from water samples collected from underlying rock drains.

Comparative Analysis of Three-Dimensional Nasal Shape of Casts from Patients With Unilateral Cleft Lip and Palate Treated at Two Institutions Following Rotation Advancement Only (Iowa) or Nasoalveolar Molding and Rotation Advancement in Conjunction With Primary Rhinoplasty (New York).

OBJECTIVES: To compare 3-dimensional nasal symmetry in patients with UCLP who had either rotation advancement alone or nasoalveolar molding (NAM) followed by rotation advancement in conjunction with primary nasal repair. DESIGN: Pilot retrospective cohort study. MATERIALS AND METHODS: Nasal casts of 23 patients with UCLP from 2 institutions were analyzed; 12 in the rotation advancement only group (Iowa) and 11 in the NAM, rotation advancement with primary nasal repair group (New York). Casts from patients aged 6 to 18 years were scanned using the 3Shape scanner and 3-dimensional analysis of nasal symmetry performed using 3dMD Vultus software, Version 2507, 3dMD, Atlanta, GA. Cleft and noncleft side columellar height, nasal dome height, alar base width, and nasal projection were linearly measured. Inter- and intragroup analyses were performed using t tests and paired t tests as appropriate. RESULTS: A statistically significant difference in mean-scaled 3-dimensional asymmetry index was found between groups with group 1 having a larger measure of asymmetry (4.69 cm3) than group 2 (2.56 cm3; P = .02). Intergroup analysis performed on the most sensitive linear measure, alar base width, revealed significantly less asymmetry on average in group 2 than in group 1 ( P = .013). CONCLUSION: This study suggests the NAM followed by rotation advancement in conjunction with primary nasal repair approach may result in less nasal asymmetry compared to rotation advancement alone.

Fundamental causes of accelerated declines in colorectal cancer mortality: Modeling multiple ways that disadvantage influences mortality risk.

BACKGROUND: Improvements in colorectal cancer (CRC) mortality reflect the distribution of effective preventions. Social inequalities often generate unequal diffusion of medical interventions, resulting in disparate outcomes while preventions are being disseminated throughout the population. This study used a novel method to examine whether Race (Black versus White) and SES influenced when rates of CRC mortality started to decline, and how rapidly they did so. METHOD: Mortality counts from 1968-2010 were derived from death certificates of U.S. residents aged 25 + years. Individuals' race, age, county of residence, and sex were collected from death certificates. County-level SES was measured using the decennial U.S. census. Layered joinpoint regression was used to model CRC mortality trends over time. Acceleration in rates of historical decline were used to indicate preventability within counties. RESULTS: Black race was associated with a 4.1-year delay in colonoscopy-attributable declines in CRC mortality and each standard deviation unit change in SES with a 5.7-year delay in such mortality. Following the onset of a decline, colonoscopy-attributable mortality change was slower by 0.5% among Blacks, and 2.0%/standard deviation in SES. Modifying the rapidity of colonoscopy uptake could have averted 12-14,000 and 83-86,000 deaths among Blacks and residents of lower SES counties, respectively. CONCLUSIONS: Successful interventions do not uniformly benefit the U.S. POPULATION: This study highlighted the notable impact that substantial delays in the provision of interventions, and in the relative rapidity of dissemination, and estimated the extent to which there was a preventable loss of life concentrated amongst the most disadvantaged. A more egalitarian delivery of life-saving interventions could drastically reduce mortality by improving effectiveness of interventions while also addressing inequalities in health.

Faculty Development for Metro New York City Postdoctoral Dental Program Directors: Delphi Assessment and Program Response.

Faculty development for dental academicians is essential to cultivate a continuous faculty workforce, retain existing faculty members, enhance their teaching skill sets, and remain responsive to changing program requirements and curricular reforms. To maximize the utility of dental faculty development, it is important to systematically assess and address faculty members' perceived training needs. The aims of this study were to determine priority topics among one group of postdoctoral program directors and to translate those topics into faculty development programs as part of Columbia University's Health Resources and Services Administration (HRSA)-sponsored faculty training program for primary care educators. The study was conducted in 2013-16. A Delphi consensus technique was implemented with three sequential surveys of 26 New York City metropolitan area general, pediatric, and public health dentistry residency program directors. On the first survey, the five respondents (19% response rate) identified 31 topics. On the second survey, 17 respondents (response rate 65%) rated the 15 most important topics. In the third and final round, 19 respondents (73% response rate) ranked teaching research methods and teaching literature reviews as the topics of greatest interest. Overall, the responses highlighted needs for faculty development on teaching research methods, motivating trainees, trainee evaluation, and clinical care assessment. Based on these results, a series of six Faculty Forums was developed and implemented for dental educators in the metropolitan area, starting with the topic of teaching research methods. The process flow used for assessing training needs and developing and evaluating training can be applied to a variety of populations of educators.

A Social History of Disease: Contextualizing the Rise and Fall of Social Inequalities in Cause-Specific Mortality.

Fundamental cause theory posits that social inequalities in health arise because of unequal access to flexible resources, including knowledge, money, power, prestige, and beneficial social connections, which allow people to avoid risk factors and adopt protective factors relevant in a particular place. In this study, we posit that diseases should also be put into temporal context. We characterize diseases as transitioning through four stages at a given time: (1) natural mortality, characterized by no knowledge about risk factors, preventions, or treatments for a disease in a population; (2) producing inequalities, characterized by unequal diffusion of innovations; (3) reducing inequalities, characterized by increased access to health knowledge; and (4) reduced mortality/disease elimination, characterized by widely available prevention and effective treatment. For illustration, we pair an ideal-types analysis with mortality data to explore hypothesized incidence rates of diseases. Although social inequalities exist in incidence rates of many diseases, the cause, extent, and direction of inequalities change systematically in relation to human intervention. This article highlights opportunities for further development, specifically highlighting the role of stage duration in maintaining social inequalities in cause-specific mortality.

Perspectives on evolving dental care payment and delivery models.

BACKGROUND: Health care reform is well under way in the United States as reflected in evolving delivery, financing, and payment approaches that are affecting medicine ahead of dentistry. METHODS: The authors explored health systems changes under way, distinguished historical and organizational differences between medicine and dentistry, and developed alternative models to characterize the relationships between these professions. The authors explored a range of medical payment approaches, including those tied to objective performance metrics, and their potential application to dentistry. RESULTS: Advances in understanding the essential role of oral health in general health have pulled dentistry into the broader discussion of care integration and payment reform. Dentistry's fit with primary and specialty medical care may take a variety of forms. Common provider payment approaches in dentistry-fee-for-service, capitation, and salary-are tied insufficiently to performance when measured as either health processes or health outcomes. CONCLUSIONS: Dentistry can anticipate potential payment reforms by observing changes already under way in medicine and by understanding alternative payment approaches that are tied to performance metrics, such as those now in development by the Dental Quality Alliance and others. PRACTICAL IMPLICATIONS: Novel forms of dental practice may be expected to evolve continuously as medical-dental integration and payment reforms that promote accountability evolve.

Increasing Knowledge and Health Literacy about Preterm Births in Underserved Communities: An Approach to Decrease Health Disparities, a Pilot Study.

INTRODUCTION: Health disparities can negatively impact subsets of the population who have systematically experienced greater socioeconomic obstacles to health. For example, health disparities between ethnic and racial groups continue to grow due to the widening gap in large declines in infant and fetal mortality among Caucasians compared to Black non-Hispanic or African Americans. According to the American Congress of Obstetricians and Gynecologists, preterm birth remains a leading cause of infant morbidity and mortality. The purpose of our study is to determine if the computer-based educational modules related to preterm birth health literacy and health disparity with a pre-test and post-test can effectively increase health knowledge of our participants in targeted underserved communities within the Richmond-metro area. METHODS: This was a pilot study in the Richmond-Metro area. Participants were required to be over the age of 18, and had to electronically give consent. Descriptive statistics, means and standard deviations, and Paired t-tests were conducted in SPSS 22.0. RESULTS: There were 140 participants in the pilot study. P<.05 was set as significant and all four modules had a P<.000. The males were not significant with modules: Let's Talk Patient & Provider Communication P<.132 and It Takes a Village P<.066. Preterm birth status yes all of the findings were statistically significant P<.000. Preterm birth status no Let's Talk Patients & Provider Communication was not significant P<.106. CONCLUSION: Overall, researchers found that with a strong research methodology and strong content relevant to the community, the participants demonstrated an increase in their knowledge in health literacy and preterm birth.