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Translating The Clinical Guideline for Treatment of Tobacco ...

  1. 1. Translating The Clinical Guideline for Treatment of Tobacco Use and Dependence into Dental Settings Margaret M. Walsh, Ed.D. Professor Dept of Preventive and Restorative Dental Sciences University of California School of Dentistry San Francisco
  2. 2. Jane Weintraub DMD, MPH, J. Ellison DDS, MPH, Joanna Hill, MA, Umo Isong DDS, Ph.D., S. Gansky DrPH, Steve Silverstein DMD, MPH, Catherine Kavanagh, Jana Murray RN, Barbara Heckman RDH, MS
  3. 3. National Advisory Board
  4. 4. Background <ul><li>Clinical Practice Guidelines are “systematically developed statements to assist practitioner and patient decisions about healthcare for specific clinical circumstances.” (Field et al, 1990) </li></ul><ul><li>Little is known about the process and factors responsible for how practitioners change their practice methods when they become aware of a guideline. </li></ul>
  5. 5. <ul><li>Provide evidence-based practical methods </li></ul><ul><li>Supported by evidence from 2 systematic reviews </li></ul><ul><li>(1975 - 1994 & 1995 – Jan 1999) </li></ul>
  6. 6. <ul><li>Ask: Systematically ID all tobacco users at every visit </li></ul><ul><li>Advise: Strongly urge all tobacco users to quit (non-judgmental) </li></ul><ul><li>Assess: Determine which users are willing to make a quit attempt </li></ul><ul><li>Assist: Aid the patient in quitting </li></ul><ul><li>Arrange: Schedule follow-up contact </li></ul>Strategies for Healthcare Providers: 5 A’s <ul><li>Mecklenburg RE, Christen AG, et al., 1993; Fiore MC, Bailey WC, Cohen SJ, et al., 2000 </li></ul>
  7. 7. Why Dental Settings? <ul><li>46 million adult smokers in the U.S. </li></ul><ul><li>1/3 of all smokers die prematurely </li></ul><ul><li>50% of smokers see a dentist during a year </li></ul><ul><li>If 10% of smokers who see a dentist annually could be influenced to quit, then 2.3 million smokers could be treated and 600,000 premature deaths avoided </li></ul>
  8. 8. Oral Health Effects of Smoking <ul><li>Oral and pharyngeal cancers </li></ul><ul><li>(U.S.Surgeon General Report, 2004) </li></ul><ul><li>Adult periodontitis (50%) </li></ul><ul><li>(Gelsky, 1999; Tomar et al., 2000) </li></ul><ul><li>Failure of periodontal therapy </li></ul><ul><li>(Amer Acad of Perio, 1999) </li></ul><ul><li>Failure of dental implants </li></ul><ul><li>(Chuang et al., 2002) </li></ul><ul><li>Impairs oral wound healing </li></ul><ul><li>(Jones et al., 1992; Preber et al., 1990) </li></ul><ul><li>Increases risk of dental caries </li></ul><ul><li>(Tomar et al.,1999) </li></ul>
  9. 9. Are Dental Practitioners Effective Smoking Cessation Counselors? <ul><li>Dental-office RCTs, dental practitioners were effective </li></ul><ul><ul><li>Gen dental patients quit smoking ( 17% I vs. 8% C) </li></ul></ul><ul><ul><li>(Cohen et al, 1989) </li></ul></ul><ul><ul><li>Gen dental patients quit ST use ( 17% I vs. 9% C) </li></ul></ul><ul><ul><li>(Stevens et al, 1995) </li></ul></ul><ul><ul><li>Periodontal patients quit smoking ( 14% I vs. 5% C) </li></ul></ul><ul><ul><li>(Macgregor, 1996) </li></ul></ul>
  10. 10. 1997 National Survey of Dentists <ul><li>33% Asked most or nearly all patients </li></ul><ul><li>29% Provided some form of tobacco cessation </li></ul><ul><li>assistance </li></ul><ul><li>14% Completed formal training </li></ul><ul><li>20% Felt well prepared to assist </li></ul><ul><li> Dolan et al. JADA. 1997 </li></ul>
  11. 11. Studies of Barriers to Effecting Change in Dentists’ Behavior* <ul><li>Among the most frequent reasons cited for not providing </li></ul><ul><li>tobacco cessation treatment: </li></ul><ul><ul><li>“ lack of training” </li></ul></ul><ul><ul><li>“ not covered by insurance” </li></ul></ul><ul><ul><li>“ lack of financial incentives” </li></ul></ul><ul><ul><li>Gerbert et al., 1989; Hayes et al., 1997; Gould et al., 1998; Dolan et al., 1997; Albert et al., 200 *Gerbert et al., 1989; Hayes et al., 1997; Gould et al., 1998; Dolan et al., 1997; Albert et al., 2002 </li></ul></ul>
  12. 12. Background <ul><li>In 2003, the NIDCR and the NIDA requested proposals to study ways to translate these guidelines into dental settings </li></ul>
  13. 13. Specific Aim <ul><li>To compare the effects of intensity of training and third-party reimbursement on general dentists’ attitudes and behaviors related to the assessment and treatment of patients’ tobacco use </li></ul>
  14. 14. Hypotheses: <ul><li>At 9 mos post intervention, outcomes would be more favorable in: </li></ul><ul><li>High Intensity training groups compared to Low Intensity training groups </li></ul><ul><li>Reimbursement groups compared to the No Reimbursement groups </li></ul><ul><li>All intervention groups compared to the usual care group </li></ul>
  15. 15. Group-Randomized Controlled Trial <ul><li>Partnered with Delta Dental (Largest U.S. provider of dental insurance) </li></ul><ul><li>250 dental practices </li></ul><ul><li>Dentist eligibility: </li></ul><ul><ul><li>Delta Dental Provider in CA, PA, or WV </li></ul></ul><ul><ul><li>4 days in clinical practice </li></ul></ul>
  16. 16. Practices Randomly Selected from a Master List of Delta Dental Providers in CA, PA, WV Block Randomization:   80% Int 20% UC Usual Care INTERV Recruit, Consent Recruit, Consent Baseline N=200 Baseline N=50 Block Randomization HIT N=50 HIT+R N=50 LIT N=50 LIT+R N=50 12-Mo: Patient Report & DDS Self Report via Mailed Surveys   <ul><ul><li>20% of initial sample randomly assigned to usual care pool for recruitment & baseline assessment </li></ul></ul><ul><ul><li>Remaining 80% randomly assigned to intervention arm pool for recruitment, baseline assessment, & random assignment to intervention group </li></ul></ul>Stratified Randomized Controlled Trial
  17. 17. Usual Care Dentist Recruitment <ul><li>A “consent-form” letter was sent from CDD asking them to participate in a baseline and 9-month follow-up survey to assess preventive services provided in their practice </li></ul><ul><li>Questionnaire was included with the letter, along with a pre-addressed, stamped envelop for return of the survey to UCSF </li></ul><ul><li>$10 Incentive </li></ul>
  18. 18. Intervention Dentist Recruitment <ul><li>A “consent-form” letter sent from CDD explaining the study and highlighting the 4 intervention groups for randomized assignment. </li></ul><ul><li>The letter included a pre-addressed, stamped return postcard for interested dentists to mail back to UCSF for more information. </li></ul><ul><li>Upon receiving the postcard, UCSF study staff called the dentist to answer any questions and to further describe the study. An informed consent form was sent to the dentist to sign and return ($10 incentive) </li></ul>
  19. 19. Dentist Enrollment and Recruitment Pool Given a 15% Participation Rate <ul><li>Enrolled </li></ul><ul><ul><li>Yr 1: 50 </li></ul></ul><ul><ul><li>Yr 2: 75 </li></ul></ul><ul><ul><li>Yr 3: 75 </li></ul></ul><ul><ul><li>Yr 4: 50 </li></ul></ul><ul><ul><li>Total: 250 dentists </li></ul></ul><ul><li>Recruitment pool </li></ul><ul><ul><li>Yr 1: 350 </li></ul></ul><ul><ul><li>Yr 2: 500 </li></ul></ul><ul><ul><li>Yr 3: 500 </li></ul></ul><ul><ul><li>Yr 4: 350 </li></ul></ul><ul><ul><li>Total: 1700 dentists </li></ul></ul>
  20. 20. Patient Recruitment <ul><li>Between 7 and 12 mos post-intervention, up to 100 patients receiving target visits in each study dental practices were sent a questionnaire by California Delta Dental </li></ul><ul><li>Questionnaires were sent with a consent-form cover letter </li></ul><ul><li>Questionnaires asked about preventive services they have received (with special emphasis on tobacco use assessment and treatment) </li></ul>
  21. 21. HIPA Considerations <ul><li>Delta Dental sent out </li></ul><ul><ul><li>initial letters to dentist with questionnaires/postcards but questionnaires sent back to UCSF </li></ul></ul><ul><ul><li>Patient questionnaires. Patients returned to CDD. Names were removed and then sent on to UCSF with coded ID number for affiliated dental practice. </li></ul></ul>
  22. 22. Systems Model of Clinical Preventive Care <ul><li>Focuses on factors that promote or inhibit health care </li></ul><ul><li>providers performance of preventive care. </li></ul><ul><ul><li>Predisposing factors ( beliefs and attitudes ) </li></ul></ul><ul><ul><li>Enabling factors ( skills & resources ) </li></ul></ul><ul><ul><li>Reinforcing factors ( social support ) </li></ul></ul><ul><ul><li>Healthcare system organizational factors ( cost, cues </li></ul></ul><ul><ul><li>to action ) </li></ul></ul><ul><ul><li>Walsh J & McPhee S. Health Education Quarterly, 1992 </li></ul></ul>
  23. 23. 5 Study GROUPS <ul><li>High Intensity, No Reimbursement </li></ul><ul><li>High Intensity, Reimbursement </li></ul><ul><li>Low Intensity, No Reimbursement </li></ul><ul><li>Low Intensity, Reimbursement </li></ul><ul><li>Usual Care </li></ul>
  24. 24. High Intensity Training <ul><li>10-credit CE course (Save a Life) </li></ul><ul><ul><li>Skills-based course for the entire staff </li></ul></ul><ul><ul><li>8 hrs of lec/discussion, processing discomfort through open discussion </li></ul></ul><ul><ul><li>videotapes of positive role modeling, use of scripts, role-playing with student partners to practice behaviors and to gain feedback, </li></ul></ul><ul><ul><li>Homework: work with 1 user </li></ul></ul><ul><ul><li>2-hr F/up session 4wks later </li></ul></ul>
  25. 26. High Intensity Training <ul><li>Chart reminder and checklist system </li></ul><ul><li>Practice-oriented Newsletters </li></ul><ul><li>Tobacco Cessation Counseling Kit </li></ul>
  26. 28. Treatments <ul><li>Not Ready to Quit </li></ul><ul><ul><li>Brief intervention (3 min or less) </li></ul></ul><ul><ul><li>Motivational interview (10 min) </li></ul></ul><ul><li>Ready to Quit </li></ul><ul><ul><li>Brief intervention (15 min) </li></ul></ul><ul><ul><li>Multiple appt in-office program </li></ul></ul>
  27. 29. Multiple Appt Treatment Protocol <ul><li>Assessment </li></ul><ul><li>Motivation enhancement </li></ul><ul><li>Setting a quit date </li></ul><ul><li>Choosing a plan </li></ul><ul><li>Coping skills training </li></ul><ul><li>Social support </li></ul><ul><li>Pharmacotherapy </li></ul><ul><li>Follow-up/Referral </li></ul>
  28. 30. <ul><li>June 2000 Clinical Practice </li></ul><ul><li>Guideline & Quick Reference Guide </li></ul><ul><li>Post-test to receive 3 CE credits </li></ul><ul><li>Cover letter to encourage 5 A’s approach </li></ul><ul><li>and referral to tobacco use quit lines </li></ul><ul><li>Chart reminder and checklist system </li></ul>Low Intensity Training
  29. 31. Reimbursement <ul><li>$50 for at least </li></ul><ul><li>15 minutes of counseling </li></ul><ul><li>Claim forms sent by dentists to </li></ul><ul><li> Delta Dental </li></ul><ul><ul><li>Delta Dental billed UCSF </li></ul></ul><ul><ul><li>quarterly </li></ul></ul><ul><ul><li>Patients required to give </li></ul></ul><ul><ul><li>consent for quality assurance </li></ul></ul>
  30. 32. Outcome Measures <ul><li>Primary </li></ul><ul><ul><li>Patient report of dentist’s behavior during target visits 9 mos post- intervention by self-administered questionnaire </li></ul></ul><ul><li>Secondary </li></ul><ul><ul><li>Dentist self-report of behavior based on baseline and 9-month follow-up questionnaires </li></ul></ul>
  31. 33. Patient Evaluation Protocol <ul><li>9 mos post-intervention </li></ul><ul><ul><li>Advance mailing (postcard) </li></ul></ul><ul><ul><li>Patient survey + color insert highlighting drawing for $150 </li></ul></ul>
  32. 34. Patient Questionnaire <ul><li>30 items </li></ul><ul><ul><li>1 Tobacco use </li></ul></ul><ul><ul><li>1 Readiness to quit </li></ul></ul><ul><ul><li>1 Think dental offices should offer </li></ul></ul><ul><ul><li>tobacco cessation services? </li></ul></ul><ul><ul><li>2 Dentist assessment behavior items </li></ul></ul><ul><ul><li>15 Dentist treatment behavior items </li></ul></ul><ul><ul><li>1 Dentist follow-up behavior item </li></ul></ul><ul><ul><li>2 Validation items </li></ul></ul><ul><ul><li>4 Patient personal behavior items </li></ul></ul><ul><ul><li>1 F/up item </li></ul></ul><ul><ul><li>2 Demographic </li></ul></ul>
  33. 35. Baseline and F/Up Dentist Questionnaire <ul><li>106 items </li></ul><ul><li>74 items related to tobacco </li></ul><ul><ul><li>11 assessed attitudes on a 5-point scale </li></ul></ul><ul><ul><li>30 assessed dentists’ behavior </li></ul></ul><ul><ul><li>33 assessed practice characteristics </li></ul></ul><ul><ul><li>*Very Unimportant to Very Important; Strongly Disagree to Strongly Agree; or Not a Barrier to Strong Barrier </li></ul></ul><ul><li>**Almost Never, Sometimes, Often, Almost Always </li></ul>
  34. 36. Data Analysis: Dentist Survey <ul><li>Compared mean positive change scores in dentists’ attitudes and behaviors using The Mann Whitney Test or Chi Square </li></ul><ul><ul><li>Intervention Groups vs. Usual Care </li></ul></ul><ul><ul><li>High Intensity vs. Low Intensity </li></ul></ul><ul><ul><li>Reimbursement vs. No-Reimbursement </li></ul></ul>
  35. 37. Data Analysis: Patient Survey <ul><li>Multivariate GEE models adjusted for age, gender, ethnicity, and for “thinking dental offices should offer services to help patients stop tobacco use </li></ul><ul><li>Compared tobacco use assessment and treatment scores of dentists as reported by their patients </li></ul><ul><ul><li>Intervention Groups vs. Usual Care </li></ul></ul><ul><ul><li>High Intensity vs. Low Intensity </li></ul></ul><ul><ul><li>Reimbursement vs. No-Reimbursement </li></ul></ul>
  36. 38. RESULTS Dentist Survey
  37. 39. Characteristics of Study Dentists (N=265) Gender % Male 86 Female 14 Ethnicity White 79 Asian 10 African American 5 Hispanic 3 Native American 1 Other 2
  38. 40. Characteristics of Study Dentists (N=265) <ul><li>Age Years </li></ul><ul><li>Mean 50 </li></ul><ul><li>Median 51 </li></ul><ul><li>Range 33-61 </li></ul>
  39. 41. Characteristics of Study Dentists (N=265) Location % CA 42 PA 35 WV 23 Smoked 100+ cigarettes in lifetime 23 In practice 15+ years 74
  40. 42. Does Your Health History Form Ask About? <ul><li>CA PA WV </li></ul><ul><li>% % % </li></ul><ul><li>Caries 57 52 61 </li></ul><ul><li>Diabetes 96 97 100 </li></ul><ul><li>Perio 71 66 75 </li></ul><ul><li>Tobacco 87 88 100* </li></ul><ul><li>*p=0.016 </li></ul>
  41. 43. Patient Education Materials Provided by State <ul><li>CA PA WV </li></ul><ul><li>% % % </li></ul><ul><li>Caries 69 79 75 </li></ul><ul><li>Diabetes 26 39 36 </li></ul><ul><li>Perio 89 97 94 </li></ul><ul><li>Tobacco 45 66 74* </li></ul><ul><li>WV Dentists provide Tobacco Pt. Ed. Material more than CA or PA </li></ul><ul><li>* P = .003 </li></ul>
  42. 44. Dentists’ Baseline Attitudes (N=265) Agreed/strongly agreed: % Very Important as part of the Dentist’s Role to Intervene with Tobacco Use 58 I Know how to assess for tobacco use 46 I feel well-prepared to intervene 26 I am quite effective intervening 18
  43. 45. Dentist’s Report of 5 A’s Behaviors at Baseline (N = 265) * Highest of five ordered categories Behavior % Verbally Ask about tobacco use 74 Advise to quit 78 Assess readiness to quit 19 Assist : Talk about ways to quit 39 Arrange follow-up 4
  44. 46. Dentist Reported Behaviors at Baseline * Highest of five ordered categories % Recommend nicotine replacement 36 Provide written materials 20 Assessed previous quit attempts 20 Assessed symptoms of depression 4 Prescribe Buproprion 3 Helped set a quit date 6 Offer in-office cessation assistance 2 Refer to telephone quit line 7 Refer to other external quit program 6
  45. 47. Dentists’ Barriers to Tobacco Cessation Counseling (N=265) Strong Barrier (4,5 on a 5 point Likert scale) % Patient Resistance 66 Insurance does not reimburse 56 Not knowing where to refer 49 Lack of time 32 Not interested 17
  46. 48. Practice Environment related to Tobacco Control (N=265) Practice Environment % Asks on health history form 90 Use of patient education materials 58 Adequate staff support (Agree 4,5 on a 5 point Likert scale) 53 Reminder system 23 Service to address tobacco use 22 Office Policy 13
  47. 49. OUTCOMES Intervention Groups vs. Usual Care
  48. 50. In general the attitudes and behaviors of all intervention group dentists improved from baseline to follow-up compared to the Usual Care group and the results were statistically significant
  49. 51. Example % Positive Dentist Behavior Change Scores for All Interventions vs. Usual Care Behavior Any % change UC % change OR 95% CI Refer to a community cessation program 45 21 2.7 1.4 - 5.3 Offer in-office cessation assistance 41 15 3.2 1.6 – 6.7 Refer to telephone quit line 57 0.2 3.9 2.0 – 7.6
  50. 52. OUTCOMES Reimbursement Groups vs. No-Reimbursement Groups
  51. 53. <ul><li>There were no significant differences in dentists’ attitudes and tobacco-use assessment and treatment behaviors between the Reimbursement and No-Reimbursement Groups </li></ul>
  52. 54. Example % Positive Dentist Behavior Change Scores for Reimbursement (R) vs. No-Reimbursement (NR) Groups Behavior R % No-R % OR 95% CI Assess Readiness to Quit 51 52 1.1 0.59– 2.1 Ask about previous quit attempts 57 50 0.85 0.45– 1.6 Suggest ways to cope with temptation 54 48 0.89 0.46– 1.7
  53. 55. OUTCOMES High Intensity Training vs. Low Intensity Training Groups
  54. 56. Percent of Dentists with Positive Attitude Change in Feeling Prepared to Intervene in High vs. Low Intensity Training Groups * Almost 3 times more likely to report positive change I feel well prepared to intervene with patients to address tobacco use. % Pos Change OR (95%CI) High Intensity (n=99) 76 2.83* (1.4-6) Low Intensity 54 (n=100)
  55. 57. Percent Dentists with Positive Attitude Change about Feeling that they Know How to Assess in High vs. Low Intensity Training Groups * 4 times more likely to report positive change I know how to assess patients’ tobacco use. % Pos Change OR (95%CI) High Intensity (n=99) 87 4.4* (1.8-10.6) Low Intensity 62 (n=100)
  56. 58. Percent with Positive Dentist Behavior Changes in High vs. Low Intensity Training Groups Behavior High % Low % OR 95% CI Assess Readiness to Quit 61 38 2.2 1.2 - 4.3 Ask about previous quit attempts 57 38 2.3 1.2 – 4.5 Suggest ways to cope with temptation 62 38 2.8 1.4 – 5.5
  57. 59. Percent with Positive Dentist Behavior Changes Between High vs. Low Intensity Training Groups Behavior High % Low % OR 95% CI Help set a quit date 56 29 2.6 1.3 - 5.1 Screen for depression 40 21 2.6 1.3 – 5.3 Assess level of nicotine dependence 62 22 5.8 1.4 – 5.5
  58. 60. Percent with Positive Dentist Behavior Changes Between High vs. Low Intensity Training Groups Behavior High % Low % OR 95% CI Refer to a community cessation program 57 35 2.3 1.1 - 4.4 Offer in-office cessation assistance 53 31 2.8 1.4 – 5.7 Refer to telephone quit line 78 39 5.4 2.6–11.5
  59. 61. Percent with Positive Dentist Behavior Changes Between High vs. Low Intensity Training Groups Behavior High % Low % OR 95% CI Recommend NRT 65 44 2.2 1.1 - 4.4 Encourage to tell others for support 67 38 2.4 1.2 – 4.7 Provide educational materials (nrq) 72 37 4.8 2.3 – 10
  60. 62. Percent with Positive Dentist Behavior Changes Between High vs. Low Intensity Training Groups Behavior High % Low % OR 95% CI Ask about barriers to quitting and inform how treatment can help 55 34 2.4 1.2 - 4.6 Inform available when ready 77 37 5.9 2.8 –12.6
  61. 63. RESULTS Patient Survey
  62. 64. Characteristics of Study Patients (N=8,435) Gender % Male 35 Female 65 Ethnicity White 86 Asian 5 African American 5 Hispanic 3 Native American 1 Other <1
  63. 65. Prevalence of Tobacco Use Among Study Patients by State <ul><li>% (n) </li></ul><ul><li>Pennsylvania 11 431/3886 </li></ul><ul><li>West Virginia 8 164/2001 </li></ul><ul><li>Californi a 5 125/2489 </li></ul>
  64. 66. Patient Responses (N=8,435) <ul><li>62% of respondents </li></ul><ul><li>thought dental offices should </li></ul><ul><li>offer services to help patients </li></ul><ul><li>stop tobacco (n=4,765) </li></ul><ul><li>9% were current smokers (n=720) </li></ul>
  65. 67. Overall Patient Report of Dentists’ Behavior (N = 8,435) * Highest of five ordered categories % Verbally asked about tobacco use 21 Among users (n =720) Advised users to quit 36 Talked about dental problems from using tobacco 29 Asked if would like to try quit 14 Ask about roadblocks 8 Provide written materials on quitting 7 Helped set a quit date 3 Refer to telephone quit line 3 Offer in-office cessation assistance 1
  66. 68. OUTCOMES Intervention Groups vs. Usual Care
  67. 69. Tobacco-using Patient Report of Their Dentists’ Assessment and Treatment of Tobacco Use in Intervention vs. Usual Care Groups Behavior Interv % UC % OR 95% CI Advise users to quit 39 28 1.7 1.1-2.6 Assist with the quitting process (Q4 &5) 42 33 1.5 >1.0-2.3
  68. 70. OUTCOMES Reimbursement vs. No-Reimbursement Groups
  69. 71. <ul><li>There were no significant differences in patient report of dentists’ tobacco-use assessment and treatment behaviors between the Reimbursement and No-Reimbursement Groups </li></ul>
  70. 72. OUTCOMES High Intensity Training vs. Low Intensity Training Groups
  71. 73. Tobacco-using Patient Report of Their Dentists’ Assessment Behavior in High Intensity vs. Low Intensity Training Groups Behavior High % Low % OR 95% CI Assessment Asked about tobacco use and readiness to quit (Q1 & 6) 43 55 1.7 1.1 - 2.6
  72. 74. Tobacco-using Patient Report of Their Dentists’ Treatment Behavior in High Intensity vs. Low Intensity Training Groups (n=463) Behavior High % Low % OR 95% CI Treatment Advised to quit and talked about ways to quit (Q 4 & 5) 55 70 1.1 0.7 – 1.7
  73. 75. Group Comparisons of Patient Reporting “Yes” Their Dentists Asked about Tobacco Use Comparison Yes % P-value Low vs. UC (n=5210) 61 vs. 39 <.001 High vs. UC (n=5379) 57 vs. 43 0.91 High vs. Low (n=5901) 46 vs. 54 <.001
  74. 76. Multivariate GEE Model for Patient Report of Dentists’ Tobacco Assessment and Treatment Behaviors for All Groups Findings indicate women and older patients were less likely to report positive dentist behavior scores; whereas those who thought dental offices should offer help for patients to stop tobacco use were more likely to report positive scores * Scores were calculated by summing the patient reported positive dentist assessment behaviors for tobacco use ** Scores were calculated by summing the patient reported positive dentist advising and assisting behaviors for tobacco control (treatment) P-value OR 95% CI Assessment user score* (n=662 ) Gender (female) Age (in yrs) 0.01 0.02 0.6 0.9 0.5 - 0.9 0.9 - <1.0 Treatment user score** (n=661) Gender (female) Think 0.0004 0.02 0.6 1.5 0.4 - 0.8 1.1 – 2.1
  75. 77. Limitations <ul><li>Self-report </li></ul><ul><li>65% dentist participation rate (265/410) </li></ul><ul><li>38% patient participation rate </li></ul><ul><li>(8,435/22,085) </li></ul>
  76. 78. Conclusions <ul><li>Positive changes in dentists’ attitudes and behaviors were significantly better in: </li></ul><ul><ul><li>the Intervention Groups compared to the Usual Care Group </li></ul></ul><ul><ul><li>the High Intensity Groups compared to the Low Intensity Groups </li></ul></ul><ul><li>Reimbursement at the level offered made no significant difference in dentists’ attitudes and behaviors </li></ul>
  77. 79. Conclusions <ul><li>Patients whose dentists were exposed to low intensity training reported significantly more positive dentist tobacco use assessment and treatment behaviors than patients in any of the other groups </li></ul><ul><li>In all groups, older patients and women were less likely to report positive tobacco assessment and treatment behaviors among their dentists. </li></ul><ul><li>Further exploration of our findings is needed in these areas </li></ul>
  78. 80. Recommendations <ul><li>Benefit should be offered to employee groups for tobacco use assessment and treatment in the dental office since the majority of patients supported this activity </li></ul><ul><li>All Delta Dentists should be provided with the Low Intensity Counseling Package </li></ul><ul><li>High intensity courses should be selectively targeted to Delta Dentists and Periodontists who have a large proportion of patients who smoke </li></ul><ul><li>Further research is needed to determine what mediated the effectiveness of the low intensity training. </li></ul>

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