Knowledgeability, Attitude and Practice Behaviors of Primary Care Providers towards managing patient’s oral health in Medical Practice: Wisconsin Statewide Survey

Abstract

Background:

The study sought to explore receptivity, preparedness and current rates of adoption of integrated medical-dental care models (ICMs) in practice setting among primary care providers (PCPs) managing patients with diabetes.

Methods:

An anonymous statewide survey targeting PCPs across a range of Wisconsin-based practice settings was conducted to evaluate knowledgeability, attitude, practice behaviors and perceived barriers to oral health screening in a medical setting. Qualitative analytical approaches included thematic analyses applied to evaluate current status of, and barriers to, ICM adoption.

Results:

Current ICM adoption rate was 34%. Top perceived barriers to ICM adoption included: insurance coverage (71%) and care access (70%). Competency for educating patients on diabetes-periodontitis association was indicated by 39%. While 72% of PCPs indicated optimal periodicity for oral health assessment as ‘frequent’, 39% reported frequently conducting such assessments.

Conclusions:

While PCPs indicate receptivity to ICMs, PCPs identify sub-optimal education, lack of adequate training on oral-systemic disease assessment, and barriers to dental care access as barriers to ICM adoption.

Practical Implications:

ICM adoption in care delivery to diabetic patients remains below average. Interdisciplinary efforts and education are needed to address identified barriers to care integration.

Introduction

Interprofessional collaboration (IC) and education among healthcare providers has evolved as a fundamental competency for achieving delivery of patient-centered care^1,2. IC is critical to evolving healthcare delivery models that target achievement of meaningful goals in healthcare quality improvement by promoting a cultural shift away from the silo system^3–6. The 2016 oral health strategic framework developed by the U.S. Department of Health and Human Services reflects the idea that establishing a common platform for multiple disciplines to work together will promote solutions to the oral health (OH) needs in population⁷.

Evidence-based research continues to support the association between oral diseases such as periodontal disease (PD) and systemic disease including diabetes (DM), cardiovascular diseases, among others^8–10. Notably, a mounting evidence base supports that many oral diseases when proactively diagnosed and managed in early stages, collectively may attenuate pathogenic mechanisms contributing to chronic disease development. A growing number of organizations are now incorporating more integrated care delivery surrounding OH into their practice guidelines incorporating preventive OH care into routine practice^11–16. Jin et al (2016) provides a critical review on global burden of oral disease and its impact on overall health¹⁷. Prevalence among adults in the US of PD is estimated at 46% with approximately 9% having severe periodontitis, an oral condition that may impact overall health¹⁸. Because oral diseases represent the most pervasive chronic disease, the 2000 Surgeon General report designated oral disease as the ‘silent epidemic’ and emphasized importance of OH integration as a component of holistic clinical care practice¹⁹.

To address these gaps, alternative models of care (MOC) are being developed that proactively promote multidisciplinary approaches including care models that strategically incorporate a pivotal role for primary medical care providers (PCPs) in OH screening and appropriate dental referrals as a component of clinical care delivery^11,20. Creating integrated MOCs depends on various factors including interdisciplinary educational training, geographical proximity of dental and medical healthcare facilities, and addressing barriers to healthcare access and integrated care delivery^5,6,12,21,22. Lack of cross disciplinary training among PCPs to support evaluation of oral-systemic associations is associated with suboptimal health outcomes including increased risk for chronic disease exacerbation^23–26. Best practices for developing alternative patient-centered integrated medical-dental MOCs remain under-explored and solutions for interdisciplinary training to establish an integrated care delivery workforce remain to be incorporated into traditional educational curricula^1,27. The 2012 national Medical School Graduation Questionnaire Summary Report found that nearly 99% of surveyed medical students considered themselves to be under-trained in the oral/dental health domain to competently address OH-related issues in the clinical care setting¹. Practicable OH care practice guidelines that enable PCPs to address OH care needs of their patients are needed^13–16. In this context, it is important to evaluate medical providers’ knowledge, work environment and attitudes regarding OH promotion. Identifying and addressing obstacles including inadequate training in recognizing oral disease, appropriately managing oral care triage and limited curriculum on OH is crucial^28,29.

Approximately 7.4% of the adult residents in Wisconsin have been diagnosed with DM and approximately $5.5 billion in direct and indirect costs were spent on providing care for both diagnosed and undiagnosed DM in 2017³⁰. The current study aimed to access preparedness of medical providers in addressing OH needs of diabetic patients in the state of Wisconsin. ‘Preparedness’ was assessed from multiple perspectives via a survey which included domains that examined: 1) status of medical dental integration, 2) knowledgeability surrounding OH and DM, 3) adequacy of training during healthcare education to achieve integrated care delivery, 4) access to continuing education resources, 5) opinions and self-assessment of preparedness. Although this study represents an extension of a similar survey study by Shimpi et al¹, the current study incorporated additional questions for the expanded statewide survey of actively practicing PCPs to support comprehensive assessment of preparedness. The study undertook high level analysis of overall preparedness across all PCP types to gain more granular insight into preparedness gaps where interventional training might be needed based on survey response.

Materials and Methods

a. Survey tool

A 29-question survey tool was developed. Institutional Review Board review determined that the study met exemption criteria from ongoing review. Trained research team members and four experts representing expertise in medicine, dentistry and biostatistics tested face and content validity of the survey tool. The survey tool, (see Appendix ‘A’), was first piloted by twelve professionals from fields of internal medicine, dentistry, education and biostatistics before dissemination.

The survey tool was organized into four subsections: demographics, clinical practice behaviors, knowledgeability and opinion. The demographic section captured providers’ age, gender, specialty, current role, and year of graduation from their health-related school, name of health-related professional school and total years of professional experience. The clinical practice behaviors sub-section assessed PCPs’ current practice activities surrounding oral examinations, encountering dental emergencies, identifying oral diseases, educating patients on DM–PD relationship, referrals to dental providers and resources engaged to remain updated on OH. Response options to survey questions assessing clinical practice behavior, training and extent of integrated medical-dental care delivery in their practices were formatted using a 5-point Likert scale. The “opinions” section consisting of attitude-related questions captured medical providers’ view on medical-dental integration and on incorporating OH services into their practice via multiple choice responses. The “knowledgeability” sub-section included three questions focused on DM manifestations (including one image-based question and one case history-based question), two questions focused on PD (including one image-based question), on potential oral manifestations of medication exposure and integrated approaches to OH management of DM patients.

b. Dissemination and data collection

Comprehensive lists of all practitioners (by type) licensed to practice in Wisconsin were purchased, and represented a finite number of providers. Response rate was subset to PCP type and to clinical role. The survey tool was disseminated statewide over a period of 4 weeks. PCP types spanned physicians (MD/DO), nurse practitioners and physician assistants in the following medical domains: family medicine (FM), internal medicine (IM), pediatrics (Peds), emergency/urgent care (ER/UC) and obstetrics/gynecology (OB/Gyn). A letter of invitation to participate in the survey, hard copy of the survey and a postage-paid envelop to return paper surveys was mailed to all eligible providers. Survey participation was voluntary and anonymous and estimated time for completion was 5–8 minutes. Potential participants were given the choice of three options to complete the survey: paper-based survey, web-based format using REDCap platform and phone-based survey with details to support their preferred response method provided in the cover letter^31,32. Participants had an opportunity to enter a raffle with a chance to win one of two electronic toothbrushes.

c. Data analysis

Surveys collected by any venue at the end of fourth week were combined and converted into SAS-formatted datasets using SAS version 9.4(SAS Institute Inc., Cary, NC). Missing data elements were excluded from the analysis except for demographic data. For example, questions were analyzed on a per question basis and only participants who responded to that question were included in analysis for that question. Thus, participant response denominators varied across questions and participants submitting incomplete surveys were still included in analysis based on questions for which they completed responses. Content analysis of open–ended responses was conducted by two members from the study team for three questions, by grouping responses into larger categories. The three open-ended queries were: 1) resources consulted to remain updated on OH, 2) barriers to medical-dental integration and 3) factors contributing to medical-dental integration. In addition to existing themes presented to participants to opine using Likert answer options, the two researchers also defined additional new themes. The inter-rater reliability between the two researchers was calculated using Cohen’s kappa statistics.

For high level evaluation of some responses, the survey respondents’ options were grouped into categorical ranges. For example age was grouped into six age ranges (18–30; 31–40; 41–50; 51–60; 61–70 and 71–80); years of graduation was grouped into 6 categories (≤1970; 1971–1980; 1981–1990; 1991–2000; 2001–2010; ≥2011) region was categorized into four (midwest, northeast, south and west) and years of experience were categorized into 5 groups (≤10; 11–20; 21–30; 31–40 and >40). Similarly, Likert scale responses were dichotomized reflecting degree of positive engagement compared to ‘other’ response.

Results:

Participant Demographics

A response rate of 11.4% (n=345/3028) was achieved for the survey returned (n=99 for online survey and n=243 for paper based survey). The response rate analysis according to PCP provider type and practice type is shown in Table 1. As shown in table 1, response rates were representative across most of the categories except Emergency room/Urgent Care. These data further support presence of representative samples across all PCP practice type and provider type. Table 2 summarizes demographics and other characteristics of participants who responded to the survey (Q1 to Q7, Appendix A).

Table 1:

Overview of Survey Data

Overview of Survey Data
Recipient Characteristics		Survey data
I. Primary care practice type	Total sent	Number returned	Response rate
FM/IM	1814	272	15%
Gyn/Ob	357	69	19%
Peds	200	23	12%
ER/UC	189	12	6%
Other categories*	247	18	0.07%
II. Role
Physician Assistant (PA)	272	41	15%
Nurse Practitioner (NP)	478	70	15%
Physicians (MD/DO)	1882	230	12%

Other categories= hospital administrators, CEO, President; Hospital staff (not specified)

Table 2:

Shows the summary of the demographics and other characteristics of the participants who responded to the survey.

Characteristics	Total N	n	%
I. Age Range	342
18–30 years		5	1.5
31–40 years		71	20.8
41–50 years		84	24.6
51–60 years		134	39.2
61–70 years		44	12.9
71–80 years		4	1.2
II. Gender	342
Male		128	37.4
Female		214	62.6
III. Role	341
Physician Assistant (PA)		41	12.0
Nurse Practitioner (NP)		70	20.5
Physicians (MD/DO)		230	67.5
IV. Year of Graduation	331
1970		3	0.9
1971–1980		27	8.2
1981–1990		102	30.8
1991–2000		93	28.1
2001–2010		92	27.8
>2011		14	4.2
V. Specialty	342
Specialty		6	1.8
Emergency Room/ Urgent Care (ER/UC)		12	3.5
Pediatrics (Peds)		23	6.7
Obstetrics/Gynecology (OB/Gyn)		30	8.8
Internal Medicine (IM)		69	20.1
Family Medicine (FM)		203	59.2
VI. Region	327
West		10	3.1
South		18	5.5
Northeast		12	3.7
Midwest		287	87.8
VII. Years of Experience	341
<10 years		73	21.4
11 −20 years		98	28.7
21–30 years		101	29.6
31–40 years		58	17
>40 years		11	3.2

Practice Behaviors

Overall 86.2% (294/341) of the total respondents indicated that they received inadequate training (limited training + not sure + no training) by their health–related schools to address oral/dental health topics (Q8, Appendix A). Figure 1 summarizes the ratings assigned by respondents when asked about receiving OH training broken out by role and years of experience. For Q12a, 70% (240/343) were comfortable conducting visual exams of all the oral components.

Figure 1:

Summarizes the ratings assigned by respondents when asked about receiving oral health training broken out by role and years of experience

Oral health knowledgeability

A total of seven multiple answer questions were included in the survey tool to understand the gaps in the knowledgeability of medical providers on oral-systemic relationship. Symptoms associated with untreated DM were correctly identified by 85% (285/337) of the respondents (Q14). Approximately 54% (183/339) of the respondents correctly answered the question related to the effects of medications on OH (Q15)³⁴. However 37.5 % (127/339) of them believe that beta blockers do not increase the risk of developing dental erosions (Q15). Oral complications of DM were correctly identified by 83% (280/337) of the respondents (Q16)³⁵. The question relating to the recommended action for the case of uncontrolled DM and smoking was correctly identified by 76.7% (257/335) participants (Q17). The correct response to cross disciplinary action for managing DM and OH was identified by 97.3% (329/338) of total participants (Q18). Only half of the participants (50.5%[169/335]) correctly answered the image-based question surrounding the erythematous gum lesion. ‘Smoking’, ‘clenching or grinding of teeth’ and ‘stress’ as the risk factors for developing PD were correctly identified by 76% (257/335) of the respondents (Q20)^36,37.

Providers’ opinions relative to oral health

The opinions of providers regarding barriers to medical-dental integration are summarized in Figure 2.

Figure 2:

Opinions provided by the participants regarding perceived barriers to medical-dental integration

Approximately 72% (248/343) of all respondents indicated that frequent assessment of OH status of DM patients is important and 60% (205/341) of them indicated that providing educational materials to diabetic patients on oral-systemic health associations is also crucial (Q22c). The majority of the providers (86% (294/342)) opined that referring diabetic patients to dental providers and counseling diabetic patients on OH-related issues (68% (232/340)) are not only important for improved care delivery but are also essential factors contributing to medical-dental integration across health care institutions (Q22b). The features contributing to medical-dental integration as reported by the PCPs are shown in Table 3.

Table 3:

Self-reported features according to PCPs that contribute to medical-dental integration in their practice settings

Features reported by PCPS that contribute to medical- dental integration in their practice settings	Percentages
Counseling patients on oral health-related issues	55.10% (190/345)
Referring patients with diabetes to dental providers	53.90% (186/345)
Having medical and dental facilities in close proximity	44.90% (155/345)
Providing patient education on oral-systemic association topics	33.60% (116/345)
Conducting a comprehensive oral health screening as a standard care of practice	29.3% (101/345)
None of the 5 features (listed above) in the survey questionnaire (Q24)	17.10% (59/345)
Other* suggested comments (Identified by thematic analysis)
For Q 9: personal experience, patient feedback, information from colleagues and information from internet
For Q 21 : not having medical and dental facilities in close proximity and provider education
For Q 22: Providing more preventive dental care in medical settings and improved infrastructure to facilitate referral, record sharing and communication between PCP and dental provider	13.04% (45/345)

^*“Providing more preventive dental care in medical settings” and “Improved infrastructure to facilitate referral, record sharing and communication between Primary Care Provider (PCP) and dental provider”

Thematic Analysis Outcomes

Thematic analysis of open-ended responses was performed by two study team members. Apart from the existing themes/categories, four new themes/categories were identified and are shown in Table 3.

Discussion

Among major impediments to medical-dental integration identified by respondents, top selections included lack of insurance coverage (71% (244/345)), lack of access to care coverage (70% (243/345)), lack of interdisciplinary communication (55% (190/345)) and inadequate time (52% (178/345)), highlighting a need to address these barriers. Notably, state Medicaid policies to reimburse for preventive dental services are increasing³⁸, with 42/50States including Wisconsin, implementing policies that supporting access to preventive and dental service delivery by non-dental care professionals³⁹. A recent qualitative study that we conducted in State of Wisconsin among the practicing providers identified similar factors as barriers (Figure 2) to medical-dental integration⁴⁰.

Notably, PCPs reporting higher comfort levels with oral cavity examination and identification of oral pathology also reported higher levels of referrals to dental practitioners. These observations supports that better oral health training for PCPs promotes higher levels of integrated care delivery. A recent survey conducted among medical students further validated importance of educational training, noting that comfort levels in conducting oral examinations rose from 27% prior to oral health session lecture to 82% after the training⁴¹. This finding suggests a need for incorporation of oral and systemic health education as a component of PCP training to increase knowledgeability regarding oral and systemic health associations. Moreover, implementing OH educators in medical settings along with oral-systemic health provider training module(s) would also promote confidence levels of providers for engaging patient education and referrals to dental providers^1,13,40.

The present study found that only half of the participants correctly identified xerostomia as a risk factor for developing dental caries. According to the American Dental Association (ADA), xerostomia prevalence in general population ranges from 0.9 to 64.8%; while it reaches 100% in certain conditions such as Sjögren’s syndrome and patients receiving radiation therapy in head and neck cancers⁴². Notably, this finding supports the need for availability of additional training of healthcare professionals through continuing education courses and other educational exposures such as journal clubs⁴³.

The current study findings showed that the extent of medical-dental integration presently was low (34%). These findings support that development of new MOC promoting medical-dental integration requires proactive support during training of PCPs. This finding reflected current screening trends reported recently in the qualitative study by Glurich et al.⁴⁰ Future studies might undertake documentation of the frequency of referrals from medical practices to dental practices based on documented referral patterns captured in electronic health records and integrated electronic health records^44–46.

The mounting evidence base supporting oral-systemic associations, especially in the context of chronic health conditions that is driven by underlying oral infectious and inflammatory processes, justifies intensifying focus on OH care in medical settings^47,48. A recent study conducted among medical providers in an integrated medical-dental environment showed that medical providers were interested in having relevant patient dental information in electronic health records to inform holistic treatment for patients⁶. Notably, more than half of PCPs in the current study reported using scientific journals as resource for making clinical decisions at the point of care. Responses to oral-systemic knowledge questions in the current study indicated high levels of knowledgeability among participants of the present survey.

This study acknowledges some limitations. The information provided by the respondents were self-reported, hence validation of these finding will require additional studies across targeted populations to determine generalizability. . While participation rate for this study appears low at 11.3%, this response rate falls within the 11–39% range of response rates reported by a study which monitored response rates to surveys of dental and medical professional across a ten year window³³. Their findings were further supported by an additional study which reported that surveys targeting medical professionals as participants had response rates 13% lower on average than those reported for non-medical participants.³³. However, studies with modest response rates may be representative and free of bias. Because non-response analysis was precluded based on anonymity of the study design, it was not possible to determine whether survey respondents were representative of the statewide population or whether responses of the subset of individuals who chose to participate were biased, so generalizability of these findings to other populations is pending further analysis. Notably, analyses of the returned surveys showed only modest levels of medical dental integration. Moreover, cross-disciplinary triage and higher comfort level with dental examination also suggested correlation with extent of training received to conduct such examinations. Whether these observations are replicable in other PCP populations would be important to explore since these data suggest that educational intervention during medical training or opportunities for post graduate training could improve adoption rates of more integrated, holistic care delivery models. The question “How frequently do you thoroughly examine all of the oral cavity components of your patients during an office visit” was specifically aimed at health maintenance and prevention visits for example: preventive care visit. However, we felt that the way the question was framed was more open to interpretation by the providers and we do not know how the participants interpreted this question, hence we do not report any information on this question. We did not assess the time dedicated by the PCPs to OH training programs or CE courses. This survey was anonymous; hence the survey did not look at the difference in practice by location and by medical-dental integration practices. The survey topic may have attracted participation by PCPs with higher knowledgeability with respect to delivery of OH procedures and OH assessments. A potential bias associated with the study is that a survey surrounding integrated care delivery may have elicited participation from more informed practitioners with higher acceptability for promoting models of integrated care delivery.

Conclusions:

Whereas participants in the study appeared knowledgeable and favorably inclined towards adopting integrated care delivery models, survey results indicated a number of perceived barriers to achieving integrated care delivery. Based on the self-reported levels of the OH training in their health related schools, improved educational and training model for medical professionals surrounding OH competencies emerged as an important variable to target in promoting practice of integrated care delivery (Q8). This would require a paradigm shift to promote achievement of holistic care delivery. Additionally, from the public health perspective, study participants perceived lack of adequate access to care and insurance coverage among the top barriers that remain to be addressed in accelerating adoption of integrated care delivery across medical and dental domains. Finally, the study showed only modest adoption of integrated care delivery practices among survey participants. Improvements are contingent on innovative approaches to addressing perceived barriers.