Delivery Of Preventive Care Research Articles

Dental hygiene in Australia: a global perspective

This article reports on the practice of dental hygiene in Australia from a global perspective. The aim is to examine how access to qualified dental hygiene care could be improved and how current professional challenges might be met. Secondary source data were obtained from a survey questionnaire presented to members of the House of Delegates of the IFDH or by fax and e-mail to experts involved in the national professional and educational organization of dental hygiene in non-IFDH member countries. Responses were followed-up by interviews, e-mail correspondence, visits to international universities, and a review of supporting studies and reference literature. The introduction of dental hygiene in Australia was inspired by the delivery of preventive care in Great Britain. Today dental hygiene is a paramedical profession, generally studied at institutions of higher education. Study duration is 2 (diploma and associate degree programmes) and 3 years (Bachelor of Oral Health Programs). A recent trend to combine dental therapy and dental hygiene education poses the challenge to maintain a stand-alone degree in dental hygiene as it is practiced worldwide. Low access to qualified dental hygiene care may be a result of insufficient funding for preventive services, social and cultural lack of awareness of the benefits of preventive care, and of limitations inherent in the legal constraints preventing unsupervised dental hygiene practice. These may be a result of gender politics affecting a female dominated profession and of a perception that dental hygiene is auxiliary to dental care. Changes are expected to reflect the global trend towards a decrease in supervision and towards higher education. An example of innovative practice of public health is the involvement of dental hygienists in the educational process of aboriginal health workers in order to promote access to oral health education for indigenous populations.

Physicians' attitudes and preventive care delivery: insights from the DOPC study

Background. Interventions that modify physician attitudes to enhance preventive service delivery are common, yet other factors may be relatively more important in determining whether these services are provided. We assessed associations between physicians' attitudes and delivery of preventive care, compared with factors related to the patient, visit, or practice. Methods. One hundred twenty-eight primary care physicians rated the importance of five preventive services and their effectiveness at delivering them. We assessed whether their patients had received cervical smears, prostate-specific antigen (PSA) testing, smoking cessation advice, recommendation to use aspirin to prevent myocardial infarction, or weight-maintenance counseling, when appropriate. Multilevel models assessed associations between physician attitudinal characteristics and a patient's likelihood of being up to date for each service. Results. Importance of PSA screening and tobacco cessation counseling were weakly associated with patients' receipt of preventive care; no association between attitudes and other services was observed. Factors such as having a visit for well care and use of prevention flowcharts were associated with delivery of preventive services to a greater extent. Conclusions. Physicians' attitudes toward prevention are necessary, but not sufficient in ensuring the delivery of preventive services. Future interventions should address visit- and practice-specific factors more closely associated with preventive care.

Dental hygiene in Slovakia

This article reports on the development of the dental hygiene profession in Slovakia from a global perspective. The aim is to inform about current developments and to examine, how access to qualified dental hygiene care might be improved and how professional challenges might be met. For an international study on dental hygiene, secondary source data were obtained from members of the House of Delegates of the International Federation of Dental Hygienists (IFDH) or by fax and e-mail from experts involved in the national professional and educational organization of dental hygiene in non-IFDH member countries, such as Slovakia. Responses were followed-up by interviews, e-mail correspondence, visits to international universities, and a review of supporting studies and reference literature. Results show that the introduction of dental hygiene in Slovakia in 1992 was inspired by the delivery of preventive care in Switzerland. Initiating local dentists and dental hygienists strive to attain a high educational level, equitable to that of countries in which dental hygiene has an established tradition of high quality care. Low access to qualified dental hygiene care may be a result of insufficient funding for preventive services, social and cultural lack of awareness of the benefits of preventive care, and of limitations inherent in the legal constraints preventing unsupervised dental hygiene practice. These may be a result of gender politics affecting a female-dominated profession and of a perception that dental hygiene is auxiliary to dental care. International comparison show that of all Eastern European countries, the dental hygiene profession appears most advanced in Slovakia. This is expressed in high evidence-based academic goals, in extensive work with international consultants from the Netherlands and Switzerland, in annual congresses of high professional quality, and in the establishment of a profession, which has not been introduced in all Western EU countries.

Practice-based continuing education combined with process improvement methods improves delivery of preventive services to children

Question Does continuing medical education in combination with process improvement methods to implement office systems, increase rates of delivery of preventive care to children? Study design Cluster randomised controlled trial. Main results Significantly more children enrolled in intervention practices received all four preventive services compared with control practices after 30 months (change in proportion of children receiving all four preventive services: 7% to 34% with intervention vs 9% to 10% with no intervention; 4.6-fold increase with intervention compared with control, 95% CI 1.6 to 13.2, see Table 1). Table 1 Mean percentage of children receiving preventive services at baseline and 30 months follow up. Baseline At 30 months follow-up Significance Preventive service Intervention 22 practices (%) Control 22 practices (%) Intervention 22 practices (%) Control 22 practices (%) Ratio of change in prevalence, intervention v control All 4 services 11 12 34 10 4.6, 95 CI 1.6 to 13.2 Immunisations 66 64 Data presented graphically, no absolute numbers given No significant difference between groups Tuberculosis screening 39 36 54 32 p<0.05 Anaemia screening 65 64 79 71 p<0.05 Lead screening 32 29 68 30 p<0.05 Authors’ conclusions Practice-based continuing medical education in combination with process improvement methods increases the rate of delivery of preventive care services to children.

The use of patient and physician reminders for preventive services: results from a National Study of Physician Organizations

Background. Clinical preventive services improve patient health, and reminder systems can increase the use of such services. However, physician organizations often underutilize clinical preventive service reminders. Little is known about the incentives, capabilities, and organizational characteristics associated with the use of reminders by physician organizations. Methods. The predictors of patient and physician reminder system use were examined in a sample of 1,104 US physician organizations. The cross-sectional sample was obtained through a telephone survey with a 70% response rate. Results. Fifty-one percent of physician organizations used mammogram reminders, 41% used influenza immunization reminders, and 26% used eye exam reminders for patients. Eighteen percent of physician organizations used computer-generated reminders to physicians. Required reporting of data ( P = 0.0006), public recognition for quality ( P = 0.0002), and IT capabilities ( P < 0.0001) were strongly associated with patient reminder use. Medical groups were more likely to use patient-level reminders than independent practice associations (IPAs) ( P < 0.0001). Physician reminder use was related to required reporting of data ( P < 0.0001) and IT capabilities ( P < 0.0001). Conclusions. Physician organizations have relatively low use of preventive service reminders to patients and physicians. Offering quality incentives to physician organizations and improving their IT capabilities may increase the use of preventive service reminders and improve the delivery of preventive care.

Practice based education increases delivery of preventive health care to children

Practice based education increases delivery of preventive health care to children

Practice based education to improve delivery systems for prevention in primary care: randomised trial

Objective To examine the effectiveness of an intervention that combined continuing medical education with process improvement methods to implement “office systems” to improve the delivery of preventive care to children.Design...

Quality of care in stroke prevention: results of an audit study among general practitioners

Background. In identifying opportunities to improve the quality of stroke prevention in general practice, insight in areas of suboptimal care is essential. This study investigated the quality of care in stroke prevention in general practice and its relation to the occurrence of stroke. Methods. Retrospective case-based audit with guideline-based review criteria and final judgment of suboptimal care by an expert panel. Results. A total of 292 stroke patients were identified through stroke registers of two main referral hospitals for stroke in Rotterdam. The general practitioners (GPs) ( n = 95) of these patients were approached. The overall response rate from GPs was 81%, and a total of 193 patients from 77 GPs were included in the study. Data on the process of care at patient level were collected by chart review and by structured interviews with GPs during site visits. All cases were presented to a six-member panel of GPs and neurologists. In 44% of the cases, suboptimal care was identified (31% judged as possibly or likely failing to prevent stroke). Of the total number of identified shortcomings, 52% was related to inadequate hypertension control, particularly lack of follow-up after established hypertension. Another 17% of identified shortcomings concerned inadequate cardiovascular risk assessment. Conclusions. A substantial number of shortcomings in care, particularly in the domain of hypertension control and the assessment of patient's risk profiles for cardiovascular disease (CVD), were identified. This study suggests that improving preventive care delivery in general practice could reduce the occurrence of stroke.

Provider Satisfaction in Clinical Encounters With Ethnic Immigrant Patients

To determine whether physicians' satisfaction in clinical encounters with ethnic immigrant patients differs from satisfaction in clinical encounters with white patients in the local community. Postvisit assessments from primary care physicians were collected for matched pairs of ethnic and control patients at the Mayo Clinic in Rochester, Minn, during a 10-week study (April 2-June 9, 2001). Ethnic patients were defined as first-generation Somalian, Cambodian, and Hispanic immigrants. Control patients were American-born white patients who were seen by the same physician and matched to the ethnic patients in age, sex, and type of visit. T tests and Hotelling T2 tests were used to analyze differences in physician responses between groups; regression analysis was used to identify the relationship between physicians' satisfaction and ethnicity in the presence of covariates. Physicians were considerably less satisfied with ethnic patient visits compared with control patient visits. Larger differences in satisfaction were reported in the areas of patient efforts with disease prevention and management of chronic diseases. Smaller differences in satisfaction were reported for issues related to communication and cultural beliefs and practices. These differences persisted after controlling for patient demographics, physician, and visit characteristics. Patients' ethnicity affects physician satisfaction with clinical encounters, particularly in the delivery of preventive care and chronic disease management.

The effects of gender disparities on dental hygiene education and practice in Europe

In Europe, over 96.5% of dental hygienists are women. The objective of this report was to examine the impact of gender role stereotyping on the image of the dental hygiene profession and on disparities in educational attainment and work regulations within Europe. Data pertaining to regulated or non-regulated dental hygiene practice in 22 European countries were analysed according to possible gender impact on access to education and on the structure of the delivery of care. It was examined whether there is a correlation between national differences found in the dental hygiene profession and gender related disparities found in other work-related areas. Results show that the gender bias in the dental hygiene profession has an effect on equal access to education, and on equal occupational opportunities for dental hygienists within the European Union (EU) and beyond. In northern Europe, higher educational attainment in the field of dental hygiene, more extensive professional responsibilities and greater opportunities for self-employment in autonomous practice tend to correlate with greater equality in the work force. In eastern Europe, lower educational and professional opportunities in dental hygiene correlate with greater gender disparities found in other work-related areas. In some western European countries, the profession has not been implemented because of the political impact of organised dentistry, which expects financial loss from autonomous dental hygiene practice. In order to fulfil mandates of the EU, initiatives must be taken to remove the gender bias in the delivery of preventive care and to promote equal access to educational attainment and to professional development in the whole of Europe for those who choose to do so.

Explaining the de-prioritization of primary prevention: physicians' perceptions of their role in the delivery of primary care.

BackgroundWhile physicians are key to primary preventive care, their delivery rate is sub-optimal. Assessment of physician beliefs is integral to understanding current behavior and the conceptualization of strategies to increase delivery.MethodsA focus group with regional primary care physician (PCP) Opinion Leaders was conducted as a formative step towards regional assessment of attitudes and barriers regarding preventive care delivery in primary care. Following the PRECEDE-PROCEED model, the focus group aim was to identify conceptual themes that characterize PCP beliefs and practices regarding preventive care. Seven male and five female PCPs (family medicine, internal medicine) participated in the audiotaped discussion of their perceptions and behaviors in delivery of primary preventive care. The transcribed audiotape was qualitatively analyzed using grounded theory methodology.ResultsThe PCPs' own perceived role in daily practice was a significant barrier to primary preventive care. The prevailing PCP model was the "one-stop-shop" physician who could provide anything from primary to tertiary care, but whose provision was dominated by the delivery of immediate diagnoses and treatments, namely secondary care.ConclusionsThe secondary-tertiary prevention PCP model sustained the expectation of immediacy of corrective action, cure, and satisfaction sought by patients and physicians alike, and, thereby, de-prioritized primary prevention in practice. Multiple barriers beyond the immediate control of PCP must be surmounted for the full integration of primary prevention in primary care practice. However, independent of other barriers, physician cognitive value of primary prevention in practice, a base mediator of physician behavior, will need to be increased to frame the likelihood of such integration.

The origin and evolution of a regional pediatric practice-based research network: Practical and methodological lessons from the pediatric practice research group

T he vast majority of child health care delivery occurs in the community setting and centers on preventive care. A broad range of patients, varying in severity of illness, seeks care in officebased settings. However, much of child health research is concentrated at academic medical centers. In that setting, the major focus of research often is directed toward clinical and functional outcomes of children with serious illnesses. A limitation of studies in the hospital setting is that they are subject to Berkson's bias, that is, they provide a limited view of health as the result of the types of patients and severity of illnesses seen in the hospital. 1.2 Therefore, research conducted in the community is needed to address the health issues that arise there. The Pediatric Practice Research Group (PPRG), an 18-year-old, regional, practice-based research network, was formed to meet the need for a communitybased research laboratory for child health research focused on issues central to the delivery of preventive pediatric care and across the spectrum of health and illness. In addition, research located in the practice setting can provide the opportunity to study normal children and their development, obtain normal control

Origins and benefits of dental hygiene practice in Europe

Origins and benefits of the practice of dental hygiene were investigated in order to provide guidelines to countries where initiatives are being taken to introduce the profession. In Europe, so far the profession has been introduced in the Czech Republic, Denmark, Great Britain, Finland, Italy, Latvia, Lithuania, the Netherlands, Norway, Portugal, Sweden, Switzerland and Spain. Programmes in Ireland, Poland, and Romania are not presented in this article. Information for this study was obtained using questionnaires and followed up by e-mail correspondence with additional experts, supporting studies and reference literature. All experts consulted are involved in the professional and educational organisation of dental hygiene in their countries. Results show that dentists and dental hygienists who had been inspired by the delivery of preventive care in the US, initiated the European dental hygiene movement. In some countries, opposition of organised dentistry had to be overcome. In countries where the population has limited access to qualified dental hygiene care, such as in Austria, Belgium, Germany and France, a high prevalence of untreated periodontal disease has been reported. There, the lucrative practice of delegating dental hygiene tasks to dental assistants without qualifying education has slowed efforts to implement the profession and resulted in negative health and vocational outcomes. This leads to the conclusion that an implementation of legislation governing the practice and the educational process of dental hygiene in the EU and beyond would contribute to an equitable standard of health care as well as to equal opportunities in education and employment.

A comprehensive annotated reminder tool increased appropriate screening in primary care

(2001) J Fam Pract 50, 767; Shannon KC, Sinacore JM, Bennett SG, et al. . Improving delivery of preventive health care with the comprehensive annotated reminder tool (CART). . Sep;...

What factors hinder women of color from obtaining preventive health care?

This commentary examines how women of color fare on the use of preventive care. Logistic regression models of women's use of preventive care were computed with data from the 1994 Commonwealth Fund Minority Health Survey. It was found that having a regular doctor was the most consistent predictor of the use of preventive care, irrespective of the women's racial/ethnic background, socioeconomic circumstances, or place of residence. These findings reinforce the importance of physicians in the delivery of preventive care. Suggestions for improving the use of preventive services by women of color are provided.

The Cochrane HIV/AIDS Review Group and Evidence-Based Practice in Nursing

The nursing profession has long recognized the importance of research and the incorporation of research findings into the clinical environment. The paradigm shift from traditional and intuition-driven practice to evidence-based practice can be witnessed in all areas of health care. Models for change to evidencebased practice help guide nurses and other health care professionals through a systematic process incorporating research findings into the clinical setting. This practice is more likely to occur in environments that value the integration of new knowledge and provide resources to access this information (Rosswurm & Larrabee, 1999). Nurses, physicians, public health practitioners, policy makers, and consumers are deluged with unmanageable amounts of information about the best approaches to prevention, treatment, and health care delivery. The development of comprehensive HIV/ AIDS-care programs has been based and revised on numerous clinically based observations since the outset of the pandemic. With the exponential increases in scientific knowledge about most diseases and HIV/ AIDS in particular, many practitioners often turn to journal review articles, which are usually narrative reviews. These articles may be useful reminders of the main issues and published evidence, but they are notoriously prone to bias, with concluding remarks often at odds with the evidence discussed in the article. This is because such review articles are rarely performed in a structured and explicit way (Cook, Sackett, & Spitzer, 1994). To address this problem, a movement called evidencebased health care has arisen that seeks to have practitioners and consumers make informed decisions based on the best available scientific evidence. These systemic reviews and evidence-based practice have become invaluable tools for nurses and other health care practitioners. The Cochrane Collaboration seeks to provide systematic reviews of all health care interventions since the first randomized controlled trial (RCT) was conducted in 1948. How nurses may contribute to and access this database, specifically the HIV/AIDS Review Group, will be discussed.

Race and preventive services delivery among black patients and white patients seen in primary care.

Numerous studies have documented racial disparities in delivery of health care treatment services, but there is little information to determine whether similar disparities exist in the delivery of preventive services. To determine if disparities exist in preventive service delivery to non-Hispanic white patients and black patients in primary care. Multimethod study using direct observation of patient encounters, medical record review, and patient exit questionnaire. Four thousand three hundred thirteen outpatients presenting to 138 family physicians. Delivery of 15 screening, 24 health-habit counseling and 11 immunization services recommended by the US Preventive Services Task Force. Using multilevel linear regression analysis, no significant racial differences were found in rates of delivery of screening services or immunizations. However, black patients were more likely to receive preventive health-habit counseling (mean percent of patients up-to-date on all recommended counseling services, adjusted for covariates: 11.6% for black patients, 9.5% for whites, P = 0.003). Black patients able to access primary care receive preventive services at rates equal to or greater than white patients. This suggests that efforts to increase delivery of preventive care in black patients need to focus on access to primary care.

Improving preventive service delivery through office systems.

Rates of childhood immunizations and other preventive services are lower in many practices than national goals and providers' own estimates. Office systems have been used in adult settings to improve the delivery of preventive care, but their effectiveness in pediatric practices is unknown. This study was designed to determine whether a group of primary care practices in 1 community could implement office-based quality improvement systems that would significantly improve their delivery of childhood preventive services. The study was part of a larger community-wide intervention study reported in a preceding study. All the major providers of primary care to children in 1 community were recruited and agreed to participate (N = 8 practices). Project staff worked on-site with improvement teams in each practice to develop tailored systems to assess and improve the delivery of immunizations and screening for anemia, tuberculosis, and lead exposure. Office-based quality improvement systems typically involved some combination of chart prescreening, risk assessment forms, Post-it prompts, flow-sheets, reminder/recall systems, and patient education materials. Office systems also often involved redistributing responsibilities among office staff. All 8 participating practices created improvement teams. Project staff met with the practices 10 to 15 times over 12 months. After the period of office assistance, the overall rates for all preventive services except tuberculosis screening increased by amounts that were both clinically and statistically significant. Absolute percent improvements included: complete immunizations at 12 months, 7%; complete immunizations at 24 months, 12%; anemia screening, 30%; lead screening, 36%. The amount of improvement achieved varied considerably between practices. Office systems and the principles of quality improvement that underlie them seem to be effective in improving the delivery of childhood preventive services. Important predisposing factors may exist within practices that affect the likelihood that an individual practice will make significant improvements. prevention, immunizations, improvement, office systems, primary care.

EDITORIAL

EDITORIAL

Preventive service delivery for children in a managed care environment: contrasts and lessons from Israel

This document describes the Israeli models of preventive health care delivery focusing on the incorporation of preventive health services into a regulated managed care approach. It also addresses the risks and advantages of such changes and provides recommendations on the direction of public health practice in the US and Israel. Preventive services in Israel are provided by the Ministry of Health or its designees through a system of mother and infant neighborhood clinics called Tipat Halav which are similar to public health clinics in the US. In assessing the exportability of programs on preventive health care such programs must be viewed in the context of societal and cultural perspective of the `importing country. In this regard this document demonstrates that the effective Israeli system of Tipat Halav could not likely be imported into the US successfully. Three factors account for this: the existing political imperatives/trends accepted patterns of care delivery and structure of managed care delivery. Hence it is recommended that the US must take deliberate steps to ensure that the changes of responsibility for preventive services must be handled appropriately. Moreover a new payment structure must be instituted to deliver such services to an increasing percentage of their enrollees.