Trajectories of opioid prescribing by general dentists, specialists, and oral and maxillofacial surgeons in the United States, 2015-2019.

BACKGROUND: Despite decreases in opioid prescribing from 2016 through 2019, some dentists (general, specialists, oral and maxillofacial surgeons) in the United States continue to prescribe opioids at high rates. The authors' objective was to define dentists' trajectories of opioid prescribing. METHODS: The authors identified actively prescribing dentists from the IQVIA Longitudinal Prescription data set, from 2015 through 2019. Group-based trajectory modeling identified opioid prescribing trajectories on the basis of dentists' annual prescribing rates for the overall sample (model 1) and for high prescribers (model 2). The authors used χ2 or Mann-Whitney U tests to characterize the model 2 trajectory groups. RESULTS: In model 1 (n = 199,145 prescribers), group-based trajectory modeling identified 8 trajectories that were grouped into 5 categories. A total of 14.8% were nonprescribers who composed less than 1% of all prescriptions, low prescribers (3 groups; 46.0%) prescribed at low rates (2015: 5.5%-16.9%; 2019: 1.5%-11.9%), decliners (7.3%) decreased prescribing rapidly (2015: 29.4%; 2019: 5.1%), moderately high prescribers (2 groups; 28.5%) prescribed moderately (2015: 28.7% and 39.2%; 2019: 18.1% and 28.8%), and consistently high prescribers (3.4%) prescribed at high rates (2015: 54.6%; 2019: 44.7%). In model 2, from consistently high prescribers (n = 6,845), 4 trajectories were identified. Of these 4 groups, 1 group (7.5%) declined prescribing rapidly. The groups did not differ meaningfully; however, the rapid decliners included fewer oral and maxillofacial surgeons (13.0% vs 18.4%), saw more Medicaid patients (2.5% vs 1.0%), and had higher opioid prescribing rates in 2015 (95.5% vs 91.6%) (P < .001 for all). CONCLUSIONS: The authors identified variations in dentists' opioid prescribing rates. Although 60% of dentists decreased prescribing rates by 30% through 83%, 3.4% of dentists consistently prescribed at high rates. PRACTICAL IMPLICATIONS: Some dentists continue to prescribe opioids at high levels, indicating that additional information is needed to better inform policy and clinical decision making.

Testing a Deliberative Democracy Engagement Intervention to Increase Guideline-Concordance Among Oral Health Providers: Results from the DISGO Cluster-Randomized, Stepped-Wedge Trial.

Background: Dental caries affects billions worldwide and in the U.S. is among the most prevalent noncommunicable diseases in both children and adults. Early in the caries process, it can be arrested by dental sealants, which are non-invasive and thus tooth sparing, however, few dentists have adopted this approach. Deliberative engagement processes enable participants to engage with diverse perspectives on a policy issue and develop and share with policy makers informed opinions about the policy issue. We examined the effects of a deliberative engagement process on the ability of oral health providers to endorse implementation interventions and to apply dental sealants. Methods: Using a stepped wedge design, 16 dental clinics were cluster randomized, and 680 providers and staff were exposed to a deliberative engagement process that included an introductory session, workbook, facilitated small group deliberative forum, and post-forum survey. Forum participants were assigned to forums to ensure diverse role representation. Mechanisms of action examined included sharing voice and diversity of opinion. Three months after each clinic's forum, the clinic manager was interviewed about implementation interventions deployed. There were 98 clinic-months in the non-intervention period and 101 clinic-months in the intervention period. Results: Compared with providers and staff in small clinics, providers and staff in medium and large clinics more strongly agreed that their clinic should adopt two of the three proposed implementation interventions targeting the first barrier and one of the two proposed implementation interventions targeting the second barrier. Compared with the non-intervention period, in the intervention period providers did not place more sealants on occlusal non-cavitated carious lesions. Survey respondents reported sharing both promotive and prohibitive voice. From the beginning to the end of the forums, most forum participants did not change their opinions about the possible implementation interventions. At the end of the forums, there was no significant within-group variability in implementation interventions endorsed. Conclusions: Deliberative engagement intervention may help clinic leadership identify implementation interventions when there is a challenging problem, a network of semi-autonomous clinics, and autonomous providers within those clinics. It remains to be determined whether there is a range of perspectives within clinics. Trial Registration: This project is registered at ClinicalTrials.gov with ID NCT04682730. The trial was first registered on 12/18/2020. https://clinicaltrials.gov/ct2/show/NCT04682730.

Study protocol: A stepped-wedge, cluster-randomized trial of the effectiveness of a deliberative loop in identifying implementation strategies for the adoption of a dental sealant guideline in dental clinics.

BACKGROUND: The American Dental Association (ADA) recommends dental providers apply dental sealants to the occlusal surfaces of permanent molars for the prevention or treatment of non-cavitated dental caries. Despite the evidence-based support for this guideline, adherence among general dentists is low, ranging from less than 5 to 38.5%. Thus, an evidence-to-practice gap exists, and it is unclear which implementation strategies would best support providers in adopting and implementing the evidence-based practice. One potential approach to selecting and tailoring implementation strategies is a deliberative loop process, a stakeholder-engaged approach to decision-making. This trial aims to test the acceptability, feasibility, and effectiveness of using a deliberative loop intervention with stakeholders (i.e., providers and staff) to enable managers to select implementation strategies that facilitate the adoption of an evidence-based dental practice. METHODS: Sixteen dental clinics within Kaiser Permanente Northwest Dental will be cluster randomized to determine the timing of receiving the intervention in this stepped-wedge trial. In the three-part deliberative loop intervention, clinic stakeholders engage in the following activities: (1) receive background information, (2) participate in facilitated small-group discussions designed to promote learning from each other's lived experiences and develop informed opinions about effective clinic-level implementation strategies, and (3) share their informed opinions with clinic leaders, who may then choose to select and deploy implementation strategies based on the stakeholders' informed opinions. The primary outcome of Reach will be defined as patient-level receipt of guideline-concordant care. Secondary outcomes will include the cost-effectiveness, acceptability, and feasibility of the deliberative loop process. Implementation strategies deployed will be catalogued over time. DISCUSSION: These results will establish the extent to which the deliberative loop process can help leaders select and tailor implementation strategies with the goal of improving guideline-concordant dental care. TRIAL REGISTRATION: This project is registered at ClinicalTrials.gov with ID NCT04682730. The trial was first registered on 12/18/2020. https://clinicaltrials.gov/ct2/show/NCT04682730.

A comparison of crown preparation grading via PrepCheck versus grading by dental school instructors.

Recent reports in the literature demonstrate the influence that digital dentistry is having on the preclinical training of dental students. However, none of these articles have discussed the use of PrepCheck (Sirona Dental Systems) in the evaluation of preparation taper in a preclinical environment. The present study compared the subjective grading of student tooth preparations by experienced, well-calibrated faculty with objective digital grading of the same preparations by means of the PrepCheck software. Sixty-nine sophomore dental student preparations were first subjectively graded by their dental instructors, and then the preparations were evaluated by the PrepCheck software. Neither the students nor the instructors were aware that the second PrepCheck evaluation was going to occur. The statistically significant results of this study conclude that the subjective instructor grades were inflated compared with the digital PrepCheck grades. The inflated grading by the instructors may give students a sense that their progress is better than it actually is. The objective, exact nature of the PrepCheck evaluation gives students immediate feedback regarding their preclinical preparations. Although taper was the only parameter examined in this study, PrepCheck allows the operator to examine many other features of a student's preparation. Also made evident in this study is the fact that the present standard for preparation taper is unattainable in a preclinical environment and needs to be readjusted to a wider, attainable range.

Overweight or Obese Individuals at Eighteen Years of Age Develop Pancreatic Adenocarcinoma at a Significantly Earlier Age.

BACKGROUND: Adolescent obesity is a national epidemic that recently has been shown to increase risk for pancreatic adenocarcinoma (PC) and is associated with an earlier age of PC onset. We hypothesized that PC patients who are overweight or obese at age 18 would have an earlier age of PC onset. METHODS: Retrospective review of 531 patients in our PC registry was completed. Self-reported weight at age 18 and maximum lifetime weight were used to calculate body mass index (BMI) at age 18 (BMI-18) and maximum lifetime BMI. RESULTS: Complete BMI and baseline covariate data was available in 319 PC patients. Mean age (in years) of PC diagnosis for patients whose BMI-18 was overweight (64.0) or obese (59.9) was significantly different when compared to patients with a normal BMI-18 (66.7). No significant difference was observed in the mean age of PC diagnosis in those patients who maintained a normal BMI-18 when compared to those patients who subsequently became overweight or obese (67.0 versus 66.6; p = 0.65). CONCLUSIONS: An elevated BMI at age 18 is associated with an earlier age of PC onset and should be factored into determining the optimal age of beginning screening for patients at high risk for PC.

Barriers to sealant guideline implementation within a multi-site managed care dental practice.

BACKGROUND: The purpose of this study was to identify barriers frequently endorsed by dentists in a large, multi-site dental practice to implementing the American Dental Association's recommendation for sealing noncavitated occlusal carious lesions as established in their 2016 pit-and-fissure sealant clinical practice guideline. Although previous research has identified barriers to using sealants perceived by dentists in private practice, barriers frequently endorsed by dentists in large, multi-site dental practices have yet to be identified. Identifying barriers for these dentists is important, because it is expected that in the future, the multi-site group practice configuration will comprise more dental practices. METHODS: We anonymously surveyed the 110 general and pediatric dentists at a multi-site dental practice in the U.S. The survey assessed potential barriers in three domains: practice environment, prevailing opinion, and knowledge and attitudes. Results were summarized using descriptive statistics. RESULTS: The response rate to the survey was 62%. The principal barrier characterizing the practice environment was concern regarding liability; endorsed by 33% of the dentists. Many barriers of prevailing opinion were frequently endorsed. These included misunderstanding the standard of practice (59%), being unaware of the expectations of opinion leaders (56%) including being unaware of the guideline itself (67%), and being unaware of what is currently being taught in dental schools (58%). Finally, barriers of knowledge and attitudes were frequently endorsed. These included having suboptimal skill in applying sealants (23% - 47%) and lacking knowledge regarding the relative efficacy of the different ways to manage noncavitated occlusal carious lesions (50%). CONCLUSIONS: We identified barriers frequently endorsed by dentists in a large, multi-site dental practice relating to the practice environment, prevailing opinion, and knowledge and attitudes. All the barriers we identified have the potential to be addressed by implementation strategies. Future studies should devise and test implementation strategies to target these barriers.

Policies and Procedures That Facilitate Implementation of Evidence-Based Clinical Guidelines in U.S. Dental Schools.

The aim of this study was to determine the degree to which dental schools in the United States have policies and procedures in place that facilitate the implementation of evidence-based clinical guidelines. The authors sent surveys to all 65 U.S. dental schools in 2014; responses were obtained from 38 (58%). The results showed that, of the nine policies and procedures examined, only two were fully implemented by 50% or more of the responding schools: guidelines supported through clinical faculty education or available chairside (50%), and students informed of guidelines in both the classroom and clinic (65.8%). Although 92% of the respondents reported having an electronic health record, 80% of those were not using it to track compliance with guidelines. Five schools reported implementing more policies than the rest of the schools. The study found that the approach to implementing guidelines at most of the responding schools did not follow best practices although five schools had an exemplary set of policies and procedures to support guideline implementation. These results suggest that most dental schools are currently not implementing guidelines effectively and efficiently, but that the goal of schools' having a comprehensive implementation program for clinical guidelines is achievable since some are doing so. Future studies should determine whether interventions to improve implementation in dental schools are needed.

Increased Serum Insulin Exposure Does Not Affect Age or Stage of Pancreatic Adenocarcinoma Diagnosis in Patients With Diabetes Mellitus.

OBJECTIVES: In considering whether medications that increase insulin levels accelerate pancreatic adenocarcinoma (PC) development, we hypothesized that PC patients with diabetes mellitus (DM) who used exogenous insulin or insulin-stimulating medications should have an earlier age at diagnosis or present with more advanced disease. METHODS: Patients enrolled in our PC registry from June 1, 2003, to May 31, 2012, were stratified according to treatment solely with insulin, insulin-stimulating medications, or insulin-independent medications. Age at PC diagnosis, PC stage, and years between DM and PC diagnoses were analyzed among the cohorts. RESULTS: Of 122 DM patients (mean age, 67.4 ± 10.2 years), the mean ages at PC diagnosis within the insulin-only (n = 40), insulin-stimulating (n = 11), insulin-independent (n = 71), and non-DM (n = 321) cohorts were 68.7 ± 10.5, 69.6 ± 10.8, 66.3 ± 9.7, and 65.5 ± 10.5 years, respectively. No significant difference among the age at PC diagnosis was observed based on duration or type of DM treatment. There was no correlation between PC stage and increased insulin exposure. CONCLUSIONS: Anti-DM medications that increase exposure to insulin do not appear to accelerate PC development using outcomes of mean age at PC diagnosis, PC stage, or duration between DM and PC diagnoses.

Measures of discrimination for latent group-based trajectory models.

In clinical research, patient care decisions are often easier to make if patients are classified into a manageable number of groups based on homogeneous risk patterns. Investigators can use latent group-based trajectory modeling to estimate the posterior probabilities that an individual will be classified into a particular group of risk patterns. Although this method is increasingly used in clinical research, there is currently no measure that can be used to determine whether an individual's group assignment has a high level of discrimination. In this study, we propose a discrimination index and provide confidence intervals of the probability of the assigned group for each individual. We also propose a modified form of entropy to measure discrimination. The two proposed measures were applied to assess the group assignments of the longitudinal patterns of conduct disorders among young adolescent girls.

Posttransplant biliary complications in the pre- and post-model for end-stage liver disease era.

Biliary complications remain a cause of morbidity after liver transplantation. The aim of this study was to determine whether changes in clinical practice in the era of the Model for End-Stage Liver Disease (MELD) has affected biliary complications after liver transplantation. We retrospectively reviewed all deceased donor liver transplants at a single center. Patients were categorized as pre- or post-MELD (transplant before or after February 28, 2002). A total of 1798 recipients underwent deceased donor liver transplants. Biliary stricture was more common in the post-MELD era (15.4% versus 6.4%, P < 0.001). The strongest risk factors for stricture development were donor age (odds ratio [OR] = 1.01), presence of a prior bile leak (OR = 2.24), use of choledochocholedochostomy (OR = 2.22), and the post-MELD era (OR = 2.30). Bile leak was more common in the pre-MELD era (7.5% versus 4.9%, P = 0.02), with use of a T-tube as the strongest risk factor (OR = 3.38). Surgical factors did not influence the biliary complication rate. In conclusion, even when employing multivariate analysis to allow for factors that may influence biliary strictures, transplant in the post-MELD era was an independent predictor for stricture development. Further studies are warranted to determine the etiology of this increase.