Abstract
Background:
An important step in integrating dental and medical care is understanding of the frequency and characteristics of dental practitioners who conduct health risk assessments (HRAs).
Methods:
In 2017 to 2018, active dentist and hygienist members of the South Atlantic Region of the National Dental Practice-Based Research Network (n=870) were invited to participate in a survey evaluating their HRA practices (screening, measuring, discussing, and referring patients) for six health conditions (obesity, hypertension, sexual activities, diabetes, alcohol use, and tobacco use). For each health condition, we used ordinal logistic regression to measure the association between the practitioner’s HRA practices and the practitioner’s characteristics, practitioner’s barriers, and practice characteristics.
Results:
The majority of the 475 responding practitioners (≥72%) reported at least occasionally completing ≥ 1 HRA step for the health conditions except sexual activities. The majority of practitioners screened (i.e., asked about) and gave referrals to affected patients for diabetes (56%) and hypertension (63%). Factors associated with each increased HRA practice for ≥ 2 outcomes were non-Hispanic white compared to Hispanic practitioner (Cumulative Odds Ratio [COR] obesity 0.4, 95% Confidence Interval (CI) 0.2–0.8 and COR diabetes 0.3, 95% CI 0.2–0.8), male compared to female practitioner (COR tobacco 0.3, 95% CI 0.2–0.7 and COR hypertension 0.4, 95% CI 0.20.8), and practitioner discomfort (COR obesity and alcohol use 0.7, 95% CI 0.6–0.9 and COR sexual activities 0.6, 95% CI 0.5–0.8).
Practical Implications:
Dental practitioners are conducting HRA practices for multiple conditions. Interventions should focus on reducing practitioner discomfort and target non-Hispanic white, male practitioners.
INTRODUCTION
Integrated dental and medical care is increasingly being called for within the United States Healthcare system due to the potential for improved quality of care, prevention, and outcomes.1 An estimated 27 million people each year have a dental visit and no medical visit.2 Thus, dental practitioners can help connect patients with health risks or conditions to appropriate medical care.3 It is unclear how frequently and to what extent dental practitioners in the United States are doing so.
Dental and medical integrated care is at the early stages of development with several definitions of the levels of integration, roles, and resources necessary.4–7 One strategy for integrated dental and medical care is for dental practitioners to include health risk assessments (HRAs) in their practices. We define HRA as having four components: screening, measuring, discussing, and referring. Screening is any time a practitioner asks the patient about a given health condition regardless of administration mode (written or oral). Dental practitioners can perform measurements like blood pressure readings, hemoglobin testing, and human immunodeficiency virus (HIV) testing.8–10 Discussions of health risks (e.g., tobacco use, alcohol consumption) can stimulate patients to initiate behavior change and prevent disease.11,12 Finally, dental practitioners can refer patients to medical providers for diagnosis, treatment, and management of diseases or conditions.
Dental practitioners are willing to conduct HRAs, but implementation barriers remain. In the United States, the majority of dental practitioners express willingness to provide health screenings (70–85%), measure health risks with diagnostic tests that yield immediate results (84%), and refer patients (96%).13 However, dental practitioners’ barriers to HRAs include lack of time, concern about patient willingness, lack of training, and concerns about the conditions’ relevance to dental health.14–16
It is unclear how frequently and which characteristics are most associated with dental practitioners conducting HRA practices. For example, the reported percentage of dental practitioners counseling the majority of their patients who smoke ranges from 26% to 66%.17,18 Similarly, in primary care settings, despite a federal mandate of HRA inclusion in annual wellness visits for all Medicare beneficiaries,19 wide ranges of patients do not receive screening or referrals for commonly underdiagnosed conditions, such as diabetes and hypertension. 20–24
Our primary objective was to assess the frequency of South Atlantic (SA) – Florida, Georgia, North Carolina, South Carolina, Virginia – dental practitioners’ HRA practices (screening, measuring, discussing, and referring) for six health conditions (obesity, hypertension, sexual activities, diabetes, alcohol use, and tobacco use). Secondarily, we aimed to identify practitioner and practice factors associated with practitioners’ completing each subsequent step in HRA continuum. We selected these six health conditions for the following reasons: 1) conditions for which the United States Preventive Task Force has straight-forward, primary care A or B grade recommended screenings, 2) present a range of acceptability among practitioners, and 3) cover a wide variety of health conditions.10,16,25–27 Moreover, within each state considered, assessing these conditions is not outside of the dental practitioners’ and hygienists’ scope of practice.28–32 Understanding practitioner characteristics associated with increased HRA practices will help identify intervention targets.
METHODS
Study Setting
Members of the National Dental Practice-Based Research Network (PBRN), a nationwide network of practitioners interested in improving the scientific basis for clinical decision-making and participating in research,33,34 were eligible for the study if they met four criteria: (1) dentist or hygienist; (2) practice in the network’s SA region; (3) have an active license and currently treat patients; and (4) maintain an active practice address. We limited our study to the SA region because its population has some of the highest rates of relevant risk behaviors (e.g., tobacco use35 and obesity36) and chronic diseases (e.g., hypertension37 and cancer38).
Between September 2017 and July 2018, we made four attempts to invite one practitioner per practice to complete a questionnaire: three attempts occurred via email followed by a paper copy via FedEx to non-responders. Per office, among eligible dentists, a randomly selected practitioner was invited. If no dentists were eligible in the office, most often because the dentist was not a PBRN member, then an eligible hygienist was randomly selected. We selected 870 dental practitioners (469 dentists and 401 hygienists). Dentist were selected from practices where only one dentist was eligible (n=426), a dentist and at least one hygienist was eligible (n=27), and multiple dentists were eligible (n=16). Hygienists were selected from practices where one (n=387) or more than one hygienist (n=14) were eligible. Upon completion, providers were sent $75 gift cards. Questionnaire items were adapted from a prior study examining primary care physicians’ attitudes toward completing HRAs during preventive care.34 Question clarity was evaluated by 10 practitioners (5 dentists and 5 hygienists) and the final survey is publicly available and included in Appendix A.39
HRA Practices
Practitioners reported the frequency of their HRA practices (increasing continuum of screening, measuring, discussing, and referring patients) for six health conditions (obesity, hypertension, sexual activities, diabetes, alcohol use, and tobacco use). For questions regarding discussion or referral, practitioners were instructed to consider instances when they identified a patient with the health condition. Practices were measured with the frequency (never, rarely, occasionally, usually, and always) or percentage of patients receiving the care. Few practitioners (<10%) usually or always conducted several practices (e.g., screening for sexual activities). Thus, to enable variability across categories, consider the minimum acceptable level, and allow for flexibility of practitioners to not progress along the continuum due to patient specific circumstances, for analyses, we classified the frequency that the practitioner conducted each practice into two groups: fewer than occasionally (never or rarely) and at least occasionally (including occasionally, usually, and always). For practices measured as percentages, responses of conducting the practice with 25% or more patients was considered at least occasionally. When multiple measures were available for a health condition, we considered practitioners as conducting the practice if they at least occasionally completed any of the reported tasks. For example, we coded a practitioner as at least occasionally screening for obesity if he or she reported at least occasionally screening for sugary foods, sugary beverages, medical history of obesity, or family history of obesity. Questions did not include details on how practices were conducted.
The questions varied by health condition: the full survey is included in Appendix A and the items used for each health condition and HRA category are included in Appendix B For obesity, screening behaviors considered were sugary foods ( survey item 11), sugary beverages (item 12), medical history of obesity (17.f), and family history of obesity (16.d). Obesity measurement was collection of height and weight (18.b). Obesity discussions included discussion of weight (14) or physical activity (13). Obesity referrals included referrals for obesity (23.j) or nutrition counseling (23.k).
For tobacco use, screening included tobacco use (2) or e-cigarette use (3). Tobacco use discussions were any of the following: discuss risks with tobacco users (4), provide nicotine replacement therapy recommendations (5), or provide non-medical tobacco cessation recommendation (6). Practitioners reported the percentage of time they referred tobacco users to resources (23.a).
For diabetes, screening reflects providers asking for a medical history of diabetes (17.a), measuring was conducting a blood glucose screen (18.d), and referring as making referrals for diabetes (23.e). For hypertension, screening (17.b) and referral (23.f) were specified. Hypertension measurement was reporting of taking blood pressure readings (18.a). For alcohol use, practitioners were asked if they screen (7), discuss risks (8), or make referrals (23.b). For sexual activities, screening was asking about risky behaviors (e.g., oral or unprotected sex) that may contribute to development of sexually transmitted infections (9), measuring was testing for HIV (18.c), discussing was discoursing risky sexual behavior (10), and referring was referrals for sexually transmitted infections (23.d).
To examine progression of practitioner practices along the care continuum, we created a composite of increasing HRA practices for each health outcome. We used a general strategy and collapsed categories when necessary because of not-collected constructs or sample size limitations. We combined screening and measuring practices because both mechanisms detect potential patient needs and not all outcomes had questions regarding measurement. Appendix C provides HRA practice categories considered for each health outcome. In general, the following seven categories were created: (a) no reported activities, (b) screening or measuring for the outcome, (c) discussing or referring for care, (d) discussing after screening or measuring (e) referring after screening or measuring, (f) discussing and referring after screening or measuring, and (g) completing all activities – screening, measuring, discussing and referring. Sample sizes in a and c categories for obesity, tobacco, diabetes, and hypertension were too small to evaluate separately (n ≤ 27); thus, for analysis, we collapsed the first three categories (a-c). The reference category when a-c are combined becomes conducting two or fewer of the HRA practices excluding the most useful combinations of screen and discuss or measure and discuss. For alcohol use, we collapsed the two referral categories (e and f). For sexual activities, we created four categories: no activities and screening and measuring (a and b), discussing or referring for care (c), screen and measure with discuss or refer (d and e), and screen and/or measure, discuss, and refer (f and g).
Predictors
As predictors, we considered dental practitioners’ characteristics, their barriers to health care continuum practices, and characteristics of their dental practices. Practitioners were asked to select the frequency (never, rarely, occasionally, usually, always) each factor presents a barrier to conducting HRAs in their practices. We obtained dental practice characteristics and practitioners’ race and ethnicity from the National Dental PBRN enrollment questionnaire. 34
Statistical Analysis
We calculated frequencies of characteristics of practitioners, their practices, and their health care continuum practices. For each health outcome, we used cumulative odds ordinal logistic regression to evaluate the associations between the progression of practitioners’ HRA continuum practices and practitioner’s characteristics, practitioner’s barriers, and practice characteristics. Models were restricted to practitioners with complete data. The most common missing variables were practitioner-reported barriers with 73 practitioners skipping one or more variables. The SCORE test indicated the proportional odds assumption was satisfied. Statistical significance was measured by 95% confidence intervals that do not include the null value. All analyses were performed using SAS 9.4 (Cary, NC).
RESULTS
Practitioner and Practice Characteristics
A total of 475 dental practitioners completed at least the screening items on the survey (Response rate = 55%). Except in listed cases, approximately 55% of invited practitioners responded across demographic groups. Response rates were lower among non-Hispanic Black (48%), non-Hispanic Asian (47%) and Hispanic (49%) practitioners. Only 46% of practitioners with patient panels comprising a majority of ≤ 18-year-olds participated. In contrast, 65% of practitioners from rural areas or South Carolina participated.
Approximately half of the respondents were dentists (56%) or females (60%) (Table 1). The majority (77%) of dental practitioners were non-Hispanic White, worked full time (78%) and practiced in Florida (62%). Most providers reported that the majority of patients in their practices were privately insured (62%), attending non-emergent visits (75%), non-Hispanic White race (75%), and adults (92%). About a quarter of practices had agreements with primary care providers (28%) or community-based agencies (19%). Nearly all practitioners used the internet in their practices (98%) and over two-thirds used the internet chairside (70%) or had electronic patient records (74%).
Table 1.
Characteristics of Responding Practitioners and Their Practices
| Number of practitioners | Frequency | |
|---|---|---|
| Practitioners | 475 | |
| Sex | ||
| Male | 189 | 40% |
| Female | 286 | 60% |
| Mean Age | 472 | 50.4 ± 11.8 |
| Race/ethnicity | ||
| Non-Hispanic White | 361 | 78% |
| Non-Hispanic Black | 23 | 5% |
| Non-Hispanic Asian | 16 | 3% |
| Hispanic | 55 | 12% |
| Other | 10 | 2% |
| Type | ||
| Dentist | 269 | 57% |
| Hygienist | 206 | 43% |
| Employment Status | ||
| Full time | 370 | 78% |
| Part time | 103 | 22% |
| Years since dental license in 2018 | 24.5 ± 12.5 | |
| Practice characteristics | ||
| State in which the practice is located | ||
| Florida | 294 | 62% |
| Georgia | 92 | 19% |
| North Carolina | 43 | 9% |
| South Carolina | 19 | 4% |
| Virginia | 27 | 6% |
| Population density of practice location | ||
| Inner city | 62 | 13% |
| Urban | 138 | 29% |
| Suburban | 224 | 47% |
| Rural | 48 | 10% |
| Majority of patient panel | ||
| <= 18 yrs. | 34 | 8% |
| White race | 345 | 75% |
| Non-emergent visits | 343 | 75% |
| Privately insured | 277 | 62% |
| Practice agreements with Community Based Agencies | ||
| No | 316 | 67% |
| Yes | 92 | 20% |
| Unknown | 63 | 13% |
| Existing PCP referral system | ||
| No | 299 | 63% |
| Yes | 132 | 28% |
| Unknown | 40 | 8% |
| Chairside internet use | ||
| No | 144 | 30% |
| Yes | 331 | 70% |
| Internet use in practice | ||
| No | 8 | 2% |
| Yes | 467 | 98% |
| Electronic patient records | ||
| No | 123 | 26% |
| Yes | 348 | 74% |
Practitioner Barriers to Conducting Multiple HRAs
The most common barrier reported was lack of time (42%) (Table 2). Lack of reimbursement (52%) or not having referral resources (57%) was rarely or never a barrier. Practitioners were fairly evenly distributed across whether their own comfort or their perception of patient discomfort was a barrier.
Table 2.
Frequency Each Factor Presents a Barrier to Practitioners in Conducting Multiple Health Risk Assessments
(N= 475)
| Always n (%) | Usually n (%) | Occasionally n (%) | Rarely n (%) | Never n (%) | |
|---|---|---|---|---|---|
| Lack of time | 56 (13%) | 124 (29%) | 136 (32%) | 76 (18%) | 38 (9%) |
| My patients will be uncomfortable | 34 (8%) | 126 (29%) | 151 (35%) | 70 (16%) | 55 (13%) |
| Lack of reimbursement | 81 (18%) | 82 (18%) | 55 (12%) | 71 (16%) | 164 (36%) |
| Not comfortable with screening for multiple health risks | 34 (8%) | 96 (22%) | 140 (32%) | 82 (19%) | 88 (20%) |
| I do not have referral resources | 23 (5%) | 59 (13%) | 111 (25%) | 121 (27%) | 135 (30%) |
HRA Practice Continuum by Health Condition
The percentage of dental practitioners who at least occasionally conduct HRAs varied by health condition (Table 3). Most (range 72% to 99%) practitioners at least screened for the health conditions assessed; except for sexual activities for which 40% of practitioners conducted any HRA practices and half of these practitioners only discussed and/or referred patients. For obesity, practitioners split fairly evenly into three groups: 31% screened and/or measured, 30% added discussion, and 28% added discussion and referral. For tobacco, most practitioners (90%) screened and discussed with (38%) or without referrals (52%). For diabetes and hypertension, over half of the practitioners referred patients after screening and/or measurement (56% for diabetes and 63% for hypertension), but over a third of practitioners (43% for diabetes and 35% for hypertension) stopped their HRA activities at screening and/or measurement. For alcohol use, the most common practitioner activities were screening with discussion (28%).
Table 3.
Distribution of Practitioners at Least Occasionally Completing Condition-Specific Care Continuum Processes
| No activities | Screen, measure, or screen and measure | Discuss, refer, or discuss and refer | Screen and/or measure and discuss | Screen and/or measure and refer | Screen or Measure, Discuss, and Refer | Screen, Measure, Discuss, and Refer | |
|---|---|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | n (%) | n (%) | n (%) | n (%) | |
| Obesity | 5 (1%) | 145 (31%) | 1 (0.2%) | 143 (30%) | 41 (9%) | 77 (16%) | 58 (12%) |
| Tobacco use | 12 (3%) | 8 (2%) | 27 (6%) | 247 (52%) | 0 (0%) | 180 (38%) | -- |
| Diabetes | 5 (1%) | 200 (43%) | 1 (0.2%) | -- | 264 (56%) | -- | -- |
| Hypertension | 9 (2%) | 164 (35%) | 2 (0.4%) | -- | 297 (63%) | -- | -- |
| Alcohol use | 135 (28%) | 51 (11%) | 69 (15%) | 131 (28%) | 5 (1%) | 83 (18%) | -- |
| Sexual activities | 281 (60%) | 17 (4%) | 96 (20%) | 35 (7%) | 3 (0.6%) | 36 (8%) | 1 (0.2%) |
Characteristics Associated with Increased HRA Continuum
The characteristics most commonly associated with practitioners completing additional steps on the HRA continuum were practitioner race/ethnicity, gender, and discomfort conducting HRAs (Table 4). The odds of completing additional steps on the HRA continuum was reduced by 60% for obesity and 70% for diabetes among non-Hispanic white compared to Hispanic practitioners (Cumulative Odds Ratio [COR] obesity 0.4, 95% Confidence Interval (CI) 0.2–0.8 and COR diabetes 0.3, 95% CI 0.2–0.8). For tobacco and hypertension, males had lower odds than female practitioners of completing each additional step on the HRA continuum (COR tobacco 0.3, 95% CI 0.2–0.7 and COR Hypertension 0.4, 95% CI 0.2–0.8). For three of the six conditions, the odds of practitioners completing each additional step on the HRA continuum was reduced by 30–40%, depending upon outcome, among practitioners who were uncomfortable compared to practitioners who were comfortable: COR obesity and alcohol use 0.7, 95% CI 0.6–0.9 and COR sexual activities 0.6, 95% CI 0.5–0.8).
Table 4.
Proportional odds of at least occasionally completing each subsequent step in HRA continuum for each health outcome by practitioner characteristics
| Cumulative Odds Ratios and 95% Confidence Intervals | ||||||
|---|---|---|---|---|---|---|
| Obesity N = 359 | Tobacco N = 360 | Diabetes N = 360 | Hypertension N = 360 | Alcohol N = 360 | Sexual Activities N = 358 | |
| Practitioner characteristics | ||||||
| Race/ethnicity | ||||||
| Hispanic | - | - | - | - | - | - |
| Non-Hispanic Asian | 2.1 (0.7 – 6.5) | 1.5 (0.4–5.3) | 0.9 (0.2–4.2) | 1.7 (0.3–10.0) | 2.1 (0.7–6.6) | 1.5 (0.4–5.1) |
| Non-Hispanic Black | 0.5 (0.2–1.4) | 0.5 (0.2–1.6) | 0.3 (0.1–1.2) | 0.4 (0.1–1.4) | 0.9 (0.3–2.6) | 0.5 (0.2–1.8) |
| Non-Hispanic White | 0.4* (0.2–0.8) | 0.6 (0.3–1.3) | 0.3* (0.2–0.8) | 0.5 (0.2–1.1) | 0.7 (0.4–1.3) | 0.7 (0.4–1.5) |
| Other | 0.2 (0.0–1.0) | 0.3 (0.0–1.6) | 0.1 (0.0–1.0) | 0.2 (0.0–1.3) | 0.5 (0.1–2.7) | 0.4 (0.1–2.8) |
| Age (years) | 1.0 (1.0–1.1) | 1.0 (1.0–1.1) | 1.0 (1.0–1.1) | 1.0 (1.0–1.1) | 1.0 (1.0–1.1) | 1.1* (1.0–1.1) |
| Type | ||||||
| Dentist | - | - | - | - | - | - |
| Hygienist | 1.5(0.8–2.8) | 1.0(0.5–2.0) | 0.4*(0.2–0.8) | 0.4(0.2–1.0) | 0.7 (0.4–1.2) | 0.8 (0.4–1.7) |
| Year of license | 1.0 (1.0–1.0) | 1.0 (1.0–1.1) | 1.0 (0.9–1.0) | 1.0 (1.0–1.1) | 1.0 (1.0–1.0) | 1.0 (1.0–1.1) |
| Sex | ||||||
| Female | - | - | - | - | - | - |
| Male | 0.7 (0.4–1.3) | 0.3 (0.2–0.7)* | 0.5 (0.2–1.0) | 0.4 (0.2–0.8)* | 0.7 (0.4–1.2) | 0.6 (0.3–1.2) |
| Employment status | ||||||
| Full Time | - | - | - | - | - | - |
| Part Time | 0.8 (0.5–1.3) | 0.6 (0.3–1.0) | 0.8 (0.4–1.4) | 1.2 (0.6–2.3) | 0.8 (0.5–1.3) | 0.6 (0.3–1.1) |
| Practice Characteristics | ||||||
| 10% increase in percentage of patient panel characteristic | ||||||
| Majority ≤ 18 yrs | 1.0 (0.9–1.1) | 0.8* (0.7–0.9) | 0.8 (0.7–1.0) | 0.8 (0.7–1.0) | 0.9 (0.8–1.0) | 0.9 (0.8–1.0) |
| Majority White race | 0.9 (0.8–1.0) | 0.9 (0.8–1.0) | 0.9 (0.8–1.0) | 1.0 (0.8–1.1) | 0.9 (0.8–1.0) | 0.9 (0.8–1.0) |
| Majority regular visits | 1.0 (0.9–1.1) | 1.0 (0.9–1.1) | 1.0 (0.9–1.1) | 0.9 (0.8–1.1) | 0.9 (0.8–1.1) | 1.1 (0.9–1.2) |
| Majority privately insured | 0.9 (0.8–1.0) | 0.9 (0.8–1.0) | 0.9 (0.8–1.0) | 0.9 (0.8–1.0) | 1.0 (0.9–1.1) | 1.0 (0.9–1.1) |
| Chairside internet use | 1.3 (0.8–2.1) | 0.8 (0.5–1.4) | 0.90 (0.5–1.5) | 1.2 (0.7–2.1) | 1.4 (0.9–2.3) | 0.9 (0.5–1.5) |
| Internet use in practice | 1.6 (0.3–7.6) | 0.80 (0.1–5.2) | 1.2 (0.2–7.6) | 2.2 (0.2–22.4) | 2.2 (0.4–10.8) | 2.2 (0.4–12.3) |
| Electronic patient records | 1.3 (0.8–2.1) | 1.0 (0.6–1.8) | 1.4 (0.8–2.6) | 1.4 (0.8–2.7) | 1.1 (0.6–1.8) | 0.9 (0.5–1.7) |
| Community Based Agency Agreement | ||||||
| No | 2.5* (1.2–5.2) | 1.0 (0.5–2.2) | 1.2 (0.5–2.8) | 1.4 (0.6–3.4) | 0.7 (0.3–1.4) | 0.5 (0.2–1.0) |
| Yes | 4.2* (1.8–9.9) | 0.9 (0.4–2.1) | 1.3 (0.5–3.5) | 1.6 (0.6–4.4) | 0.7 (0.3–1.5) | 0.7 (0.3–1.8) |
| Unknown | - | - | - | - | - | - |
| Existing PCP referral system | ||||||
| No | 0.5 (0.2–1.1) | 1.4 (0.6–3.5) | 0.6 (0.2–1.8) | 0.6 (0.2–1.7) | 1.1 (0.5–2.5) | 1.8 (0.7–4.7) |
| Yes | 0.8 (0.3–1.9) | 1.9 (0.7–5.0) | 0.8 (0.3–2.2) | 0.8 (0.3–2.6) | 2.0 (0.9–4.8) | 2.3 (0.9–6.2) |
| Unknown | - | - | - | - | - | - |
| Practitioner reported barriers | ||||||
| Discomfort conducting HRA | 0.7* (0.6–0.9) | 0.9 (0.7–1.1) | 0.8 (0.6–1.0) | 0.8 (0.6–1.0) | 0.7* (0.6–0.9) | 0.6* (0.5–0.8) |
| Perceived patient discomfort receiving HRA | 0.9 (0.7–1.1) | 0.8 (0.6–1.0) | 0.9 (0.7–1.2) | 1.0 (0.8–1.4) | 0.8 (0.6–1.0) | 0.8 (0.6–1.0) |
| Lack of time to conduct HRA | 1.0 (0.9–1.3) | 1.1 (0.9–1.4) | 1.1 (0.8–1.3) | 1.0 (0.8–1.3) | 1.1 (0.9–1.3) | 1.1 (0.8–1.3) |
| Lack of reimbursement to conduct HRA | 1.0 (0.8–1.1) | 1.2 (1.0–1.4) | 1.1 (0.9–1.3) | 1.2 (1.0–1.4) | 1.2 (1.0–1.3) | 1.1 (1.0–1.3) |
| Lack of referral sources | 0.9 (07–11) | 0.9 (07–11) | 0.9 (07–11) | 0.8 (06–10) | 0.9 (0.8–1 1) | 1.0 (08–13) |
HRA = health risk assessment
= statistically significant based on 95% Confidence Interval not including the null value.
For specific health conditions, other provider characteristics were also important predictors. For obesity, the odds of each increased step along the HRA continuum was higher when practitioners knew rather than did not know of existing agreements with community-based agencies (yes versus unknown COR 4.2, 95% CI 1.8 to 9.9 and no versus unknown COR 2.5, 95% CI 1.5 to 5.2). For every 10% increase in the percentage of patients 18 years old or younger, the odds of completing each additional step of the HRA for tobacco was reduced 20% (COR=0.8, 95% 0.7–0.9). For diabetes, hygienists were 60% as likely as dentists to conduct each increased HRA step (OR 0.4, 95% CI 0.2 to 0.8).
DISCUSSION AND CONCLUSIONS
Nearly all practitioners in the SA region of the National Dental PBRN reported at least occasionally conducting at least screening for obesity, tobacco use, diabetes, and hypertension. Practitioners reported completing the most HRA practices for tobacco, diabetes, and hypertension. Despite practitioners stating lack of time as the most common barrier to HRA activities, the most limiting factors across health conditions were practitioners’ own discomfort discussing HRA activities. This is the first study, to our knowledge, that examines predictors of increased HRA practices among dental practitioners across multiple health outcomes.
Our results suggest that most dental practitioners at least occasionally complete HRA activities. Adding to a continued increasing trend in integrated tobacco care in dental settings (dentists advising smokers to quit raised from 60% in 1997 to 71% in a 2003–2004 to 79% in 2004–2008). 26, 41–42 90% of SA PBRN practitioners screened, and discussed tobacco use. Moreover, our findings of the majority of practitioners participating in screening and referral or discussion for diabetes, hypertension, obesity adds to the prior studies showing a wide range of practitioner acceptance and feasibility in condition-specific intervention studies.15,43–44
Consistent with and expanding prior assessments of practitioner barriers to HRA practices to additional health conditions, 15,45 we identified practitioner discomfort as predictive of practitioner activities across three of the six conditions. Patients consistently report comfort with medical screenings and measurements in dental offices 41,46–49 and even report willingness to pay for these services. To increase practitioner participation in HRAs, interventions should consider relieving practitioner discomfort with education materials, sharing patient comfort levels, and increasing self-efficacy as well as normalizing HRAs in dental offices to limit potential fears of patient loss.
This study has three main strengths. Compared to similar studies,50,51 our sample size (n=475) is large, thereby enabling increased confidence in the robustness of the results and conduct of regression analyses with multiple variables. Additionally, we assessed HRA practices as a continuum allowing us to identify the referral step as a key limitation. Lastly, we compared practitioner characteristics associated with each increasing step across the care continuum for six different health conditions. This variety of conditions allowed us to differentiate practitioner characteristics that are associated with the care continuum in general from characteristics associated with specific conditions.
This study has three main limitations. First, for feasibility reasons we did not structure the questions to identify the mechanisms of HRA practices. Second, while we did ask if dental practitioners ask about each step in the HRA practice continuum for all health conditions, we only asked about measurements taken at the point of care for blood pressure, glucose testing, weight, and HIV testing.
Third, the study population consists of dental practitioners from the SA region of National Dental PBRN which may limit the generalizability of our results. SA region practitioners may differ from national network dental practitioners as regional variation existed in the early stages of the PBRN. 52 Compared to the National Dental PBRN members participating in network activities from 2005 to 2017, our participants were more likely to be female (60% sample vs 27% PBRN) and Hispanic (11% ours vs. 6% BRN).53
Compared to practitioners at large, historically PBRN practitioners have similar characteristics (e.g., racial/ethnic distribution, sex distribution, patient waiting time). 54 Comparing to the American Dental Association (ADA) 2018 survey, our participants are more likely to be female than dentist nationwide (60% vs 32%).52 Furthermore, network members may not be representative of dental practitioners nationwide because network members are not recruited randomly and may be more likely to be interested in clinical research and quality improvement. Yet, findings from prior PBRN and non-network general dental practitioners report similar patterns of diagnosis and treatment.55–58
PRACTICAL IMPLICATIONS
Many dentists and dental hygienists in the South Atlantic Region of the National Dental PBRN are conducting at least one step screening and referral or discussion for obesity, tobacco use, diabetes, and hypertension. Dental practitioners perceived lack of time as the biggest barrier, but our multivariable analyses suggest practitioner comfort and characteristics are more important predictors. The dental profession can potentially address each of these barriers by engaging dental practitioners and patients in developing and testing strategies to increase practice involvement with the care continuum. Economic analysis suggests that if all dental practitioners screen, counsel, and refer for three conditions alone (diabetes, hypertension, and hypercholesterolemia), the United States health system at large could experience substantial cost savings.59 More importantly, widespread dental involvement in linkage of patients to care could improve health outcomes and save lives.60,61
Supplementary Material
Acknowledgements:
NIH grants U19-DE-22516 and U19-DE-28717 supported this work. Opinions and assertions contained herein are those of the authors. Readers should not construe these opinions and assertions as necessarily representing the views of the respective authors’ organizations or the National Institutes of Health. The researchers obtained informed consent from all human subjects who participated in this investigation after they fully explained the nature of the procedures to participants.
Authors’ Responsibilities
Stephanie Staras led the writing of the manuscript and oversaw the data analysis.
Yi Guo conducted the data analysis and contributed to the writing of the manuscript.
Valeria Gordan provided expertise related to the National Dental Practice Based Research Network and collaborated on the conceptualization of the study design, study implementation and writing of the manuscript.
Gregg Gilbert provided leadership related to the National Dental Practice Based Research Network and collaborated on the conceptualization of the study design and writing of the manuscript
Deborah McEdward co-led the study implementation and data collection and participated in manuscript preparation.
Douglas Manning conceptualized the discussion related to the implications of conducting multiple risk assessments in dental practices and the overall editing of the manuscript.
Jennifer Woodard co-led the study implementation and data collection and participated in manuscript preparation.
Elizabeth Shenkman conceptualized the overall study design, led the study implementation and led the writing of the paper and oversaw the data analysis with Dr. Staras.
Footnotes
Disclosure. None of the authors reported any disclosures.
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Contributor Information
Stephanie A. S. Staras, Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida,2004 Mowry Road; Gainesville, FL 32608.
Yi Guo, Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 2004 Mowry Road; Gainesville, FL 32608.
Valeria V. Gordan, Department of Restorative Dental Services, College of Dentistry, University of Florida, 1395 Center Drive; Gainesville, FL 326010-0415.
Gregg H. Gilbert, Department of Clinical and Community Sciences, School of Dentistry, University of Alabama, 1919 7th Ave S, Birmingham, AL 35294.
Deborah L. McEdward, National Dental Practice-Based Research Network, Restorative Dental Sciences, University of Florida, 1395 Center Drive; Gainesville, FL 326010-0415.
Douglas Manning, DentaQuest, 465 Medford Street, Boston, MA 02129.
Jennifer Woodard, Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 2004 Mowry Road; Gainesville, FL 32608.
Elizabeth Shenkman, Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 2004 Mowry Road; Gainesville, FL 32608.
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