Telemedicine: Is it really worth it? A perspective from evidence and experience.

BACKGROUND:  Although the formal evidence base is equivocal, practical experience suggests that implementations of technology that support telemedicine initiatives can result in improved patient outcomes, better patient and carer experience and reduced expenditure. OBJECTIVE: To answer the questions "Is an investment in telemedicine worth it?" and "How do I make a telemedicine implementation work?" METHODS:  Summary of systematic review evidence and an illustrative case study. Discussion of implications for industry and policy. RESULTS: Realisation of telemedicine benefits is much less to do with the technology itself and much more around the context of the implementing organisation and its ability to implement. CONCLUSION:  We recommend that local organisations consider deployment of telemedicine initiatives but with a greater awareness of the growing body of implementation best practice. We also recommend, for the NHS, that the centre takes a greater role in the collation and dissemination of best practice to support successful implementations of telemedicine and other health informatics initiatives.

Ebola 2014: Setting up a port health screening programme at an international train station.

An outbreak of Ebola virus disease (EVD) began in Guinea in December 2013 and was declared a Public Health Emergency of International Concern by the World Health Organization in August 2014. In October, the UK government tasked Public Health England (PHE) to set up EVD screening at key ports. The key aim of port-of-entry screening was to identify passengers coming from areas with high risk of EVD, and give them advice to raise their awareness of symptoms and what actions to take. Direct flights from Sierra Leone, Guinea or Liberia had all been cancelled, so intelligence on passenger numbers and routes was used to identify the most commonly used routes from the affected countries into the UK. One of these was St Pancras International train station. Screening had never previously been implemented at a UK train station so had to be set up from scratch. Key to the success of this was excellent multi-agency working between PHE, the UK Border Force, Eurostar, Network Rail and the Cabinet Office. This paper gives an overview of the activation of EVD screening at St Pancras International and the subsequent decommissioning.

Mitochondrial proteomic profiling reveals increased carbonic anhydrase II in aging and neurodegeneration.

Carbonic anhydrase inhibitors are used to treat glaucoma and cancers. Carbonic anhydrases perform a crucial role in the conversion of carbon dioxide and water into bicarbonate and protons. However, there is little information about carbonic anhydrase isoforms during the process of ageing. Mitochondrial dysfunction is implicit in ageing brain and muscle. We have interrogated isolated mitochondrial fractions from young adult and middle aged mouse brain and skeletal muscle. We find an increase of tissue specific carbonic anhydrases in mitochondria from middle-aged brain and skeletal muscle. Mitochondrial carbonic anhydrase II was measured in the Purkinje cell degeneration (pcd5J) mouse model. In pcd5J we find mitochondrial carbonic anhydrase II is also elevated in brain from young adults undergoing a process of neurodegeneration. We show C.elegans exposed to carbonic anhydrase II have a dose related shorter lifespan suggesting that high CAII levels are in themselves life limiting. We show for the first time that the mitochondrial content of brain and skeletal tissue are exposed to significantly higher levels of active carbonic anhydrases as early as in middle-age. Carbonic anhydrases associated with mitochondria could be targeted to specifically modulate age related impairments and disease.

Defining a role for hemoglobin in Parkinson's disease.

Hemoglobin (Hb) has been shown to be expressed within dopaminergic neurons and to have a role in maintaining iron and mitochondrial homeostasis. In Parkinson's disease tissues, Hb has been localized to the mitochondrion. Though heme synthesis occurs within the mitochondria, the localization of Hb to this organelle has only recently been described. It is now important to understand whether Hb expression is protective or is a part of the neurodegenerative process. It is possible that the accumulation of neuronal or mitochondrial Hb is initially protective, but over many decades causes pathology. Studying Hb in neurons can give insight into the iron accumulation seen in the brain and the potential role of alpha-synuclein as a ferrireductase. In this review, we discuss the interactions of neuronal and mitochondrial Hb with other proteins and its possible role in pathways relevant to Parkinson's disease.

Effect of school environment on dental students' perceptions of cultural competency curricula and preparedness to care for diverse populations.

Reports of oral health disparities among racial, ethnic, and socioeconomic sectors of the U.S. population have hastened development of strategies to address this issue. Among these strategies is revising dental school curricula in order to develop more culturally competent graduates. The present study uses data from the 2003 American Dental Education Association (ADEA) survey of dental school seniors to assess students' perceptions of the adequacy of their cultural competency training. We hypothesize that these perceptions are influenced by multiple student characteristics and contextual factors, including a school's status with respect to the Pipeline, Professions, and Practice initiative of the Robert Wood Johnson Foundation and The California Endowment. Response data from ADEA survey items reflecting student perceptions of adequacy of curriculum time devoted to cultural competency and their preparedness to treat an ethnically and culturally diverse population were analyzed to assess the influence of selected student and contextual factors. Student gender, marital status, and level of educational debt were found to influence the curriculum time variable, and students at California schools reported higher perceived preparedness levels than students at dental schools nationwide. Dental school environments promoting acceptance and respect of diverse ethnicities/cultures and student race/ethnicity were significantly associated with students' perception of the adequacy of curriculum time for cultural competency and students' perception of their preparedness to provide oral health care for racially and culturally diverse groups. The findings provide insight for development of cultural competency curricula and direction for future study in this area.

Oral health findings for HIV-infected adult medical patients from the HIV Cost and Services Utilization Study.

BACKGROUND: The HIV Cost and Services Utilization Study (HCSUS) was conducted by a consortium of private and government institutions centered at the RAND Corp. to provide national estimates of adult medical patients who are HIV-positive. This article presents descriptive oral health findings from that study. METHODS: The National Opinion Research Center (NORC) conducted four interviews of a nationally representative sample of adults with HIV who made a medical visit for regular care in early 1996. This article uses data from the second interview conducted between December 1996 and July 1997. The authors constructed analytical weights for each respondent so the 2,466 interviewees represented a population of 219,700. RESULTS: Most adult medical patients with HIV rated their oral health as at least "good," but 12 percent (representing a population of 25,300) rated it as "poor." Xerostomia was the most commonly reported symptom (37 percent) to arise in the time since the previous interview. Twenty-nine percent had a dental benefit under Medicaid and 23 percent had private insurance. Eighteen percent had not revealed their HIV status to the dentist they usually saw. CONCLUSIONS: National data on adult medical patients with HIV provide a context for local or convenience sample studies and can help give direction to public health and public policy programs directed to the oral health needs of this population. CLINICAL IMPLICATIONS: The attitudes and beliefs of adult HIV patients should be taken into account in the creation of community health education programs and continuing education for dentists. Medicaid programs should include adult dental benefits.

Pipeline, profession, and practice program: evaluating change in dental education.

This article describes the conceptual and analytical framework that will be used to assess the effectiveness of the Pipeline, Profession, and Practice: Community-Based Dental Education Program. The evaluation will use a mixed method qualitative and quantitative data collection, analysis, and triangulation. Baseline measures are reported using data from the 2003 ADEA survey of dental school seniors. Baseline measures show the dental schools are confronting a major recruitment challenge that will require short and long pipeline efforts to attract and retain underrepresented and low-income (URM/LI) persons. Gaps were found between the perceptions of URM and non-URM students in the adequacy of the curricula. The majority of all seniors described the current extramural clinical rotations as positive experiences, but URMs were more likely to report the experience improved their ability to care for diverse groups.

Oral white patches in a national sample of medical HIV patients in the era of HAART.

OBJECTIVES: Several types of HIV-related oral mucosal conditions have been reported to occur during the course of HIV disease progression. Of these, few may be manifested as 'white' lesions and many are noticeable to the patient. This paper examines the relationships between social, behavioral and medical aspects of HIV infection and reporting an occurrence of oral white patches (OWP) by HIV-infected patients. METHODS: The subjects are participants in all three interviews in the HIV Cost and Services Utilization Study (HCSUS). The subjects were selected using a three-stage probability sampling design. The multivariate analysis is based on 2109 subjects with nonmissing binary outcome variable for all three waves representing a national sample of 214 000 individuals. The multivariate model was fitted using generalized estimating equations (GEE) by implementing the XTGEE command in STATA. RESULTS: We estimate that 75 000 persons (35%) reported at least one incident of OWP, of these 14 000 reported having OWP during all three interviews, and that the rate of reporting declined over the three HCSUS waves. The multivariate analysis showed seven variables that were significant predictors of at least one report of OWP. CONCLUSIONS: Compared with persons on HAART therapy, patients on other regimens or taking no antiviral medications were 23-46% more likely to report an incident of OWP. Compared with whites, African Americans were 32% less likely to report OWP, while current smokers were 62% more likely than nonsmokers. Being diagnosed with AIDS and having CD4 counts less than 500 significantly increased the likelihood of reporting OWP.

A longitudinal analysis of unmet need for oral treatment in a national sample of medical HIV patients.

This longitudinal study examines perceived unmet dental need in a nationally representative probability sample of HIV-infected persons in medical care. A logistic regression analysis modeled the relationship between unmet need and explanatory variables. We estimate that 40% of HIV/AIDS patients report an unmet need associated with being male, being unemployed, injecting drugs, being heterosexual, lacking dental insurance, and having less education. Disparities in unmet need are related to socioeconomic status rather than to disease stage or ethnicity.

Self-reported oral health of enrollees in capitated and fee-for-service dental benefit plans.

BACKGROUND: This article examines the impact of different dental plan types, dental markets, premiums, out-of-pocket costs and enrollee demographics on the enrollees' perceived oral health status. METHODS: The authors randomly sampled enrollees in dental benefit plans offered by eight Fortune 500 companies and interviewed them regarding their experiences with their plans, including perceived oral health status. The sample consisted of 2,340 respondents, of whom 42.3 percent were enrolled in capitation, or CAP, plans, and 57.7 percent were enrolled in fee-for-service, or FFS, plans. RESULTS: The authors used chi2 tests, analysis of variance and multinomial logistic regression. They set significance at P < .05. Results indicate that nonwhites, CAP-plan enrollees and those with higher out-of-pocket cost were less likely to rate their oral health "good," "very good" or "excellent" compared with whites, FFS-plan enrollees and those with lower out-of-pocket costs, respectively. CONCLUSIONS: CAP-plan enrollees rated their oral health more poorly than did FFS-plan enrollees. Further studies are necessary to determine if adverse selection occurs and if CAP plans provide inferior quality of care. PRACTICE IMPLICATIONS: Practitioners' awareness of and willingness to address the variety of factors that influence perceived oral health status may improve their patients' perceived oral health status and satisfaction with care.

Self-reported satisfaction of enrollees in capitated and fee-for-service dental benefit plans.

BACKGROUND: This article examines the impact of capitated, or CAP, and fee-for-service, or FFS, dental benefit plans on the enrollees' satisfaction with their plans and their satisfaction with their dentists. METHODS: The authors selected four dental markets: California, New Jersey, Michigan and North Carolina. Eight Fortune 500 companies participated. Enrollees were selected randomly and interviewed about their experiences with their dental plans. The sample consisted of 2,340 respondents, of whom 42.3 percent were enrolled in CAP plans and 57.7 percent in FFS plans. RESULTS: The major findings were that those enrolled in FFS plans were four times more likely to be very satisfied than dissatisfied with their dental plans than were those in CAP plans. The FFS plan enrollees were 16 times more likely to be very satisfied than dissatisfied with their dentists than were those in CAP plans. CONCLUSION: Enrollees generally were satisfied with their plans and their dentists but those in FFS plans were the most satisfied. The higher the premium paid, the higher the level of satisfaction. PRACTICE IMPLICATIONS: Enrollees with perceived unmet needs were less satisfied with their dental benefit plans and dentists. Taking care of needs is the most significant thing dentists can do to affect patients' satisfaction.

Pediatric dentists' participation in the California Medicaid program.

PURPOSE: The purpose of this study was to determine pediatric dentists' participation in the California Medicaid program and investigate barriers to participation. METHODS: A 24-question mail-in survey with a follow-up was sent to all pediatric dentists in California with questions including demographics, Medicaid participation, and barriers to participation. Data were analyzed using descriptive statistics, chi-square tests, bivariate analysis, and multivariate logistic regression. RESULTS: Pediatric dentists returned 364 useable mail-in surveys for a response rate of 70%. Forty-five percent participated in the Medicaid program, one third of which would accept all patients and two thirds of which placed some restriction on their participation. Twenty-five percent of respondents had at least 10% Medicaid patients in their practice, and 25% accepted 6 or more new Medicaid patients per month. Dentists in rural areas were significantly more likely than those in urban or suburban areas to accept a new Medicaid patient (P < .05). Eighty-nine percent of all respondents reported low fees and 82% reported broken appointments as important reasons for not participating or limiting participation. CONCLUSIONS: Participation of California pediatric dentists in Medicaid is low compared to other states that have participation studies. Pediatric dentists in rural areas are most likely to participate. Among the reasons that contribute to California dentists not participating in the Medicaid program, the major ones appear to be low fees, broken appointments, and denial of payment.

Identifying and responding to competing needs: a case study of a dental school-operated community dental clinic.

Dental schools face challenges and competing needs when they seek to initiate or expand their community dental programs. This article uses a dental school community clinic as a case study to frame the tensions between competing needs of educational requirements, access to dental care, financial viability, and service to the community that clinics must learn to manage if they are to be successful. The identification of competing needs provides community-oriented dental school clinics the ability to examine factors that come into play as communities and their environments change. The outcome of this assessment process is strategies that can facilitate the provision of a higher level of services more efficiently, while at the same time taking into account future limitations in availability of resources. The concluding section of this article presents a model for a community-based dental clinic that is directed more toward patient care, involves dentists/specialists as primary providers, allows postdoctoral residents to take on more responsibility, and allows dental students to provide patient care on a more regular and longitudinal basis.