Variation in treatment:an analysis of dental radiographs using matched patient provider data

Variation in health care, whether it be in terms of the utilisation of resources, observed health outcomes, costs, quality or access to health care is a well recognised and ever present feature of the modern day health care system. Health care variations challenge basic assumptions about the nature of the health care economy and raise questions about efficiency, equity and where best to direct policy instruments in health care markets. Despite the vast literature documenting variation, and the many discussions around ways to reduce variations in health care markets, the field of dental care has received little interest, in comparison to that of general medical care. This thesis will address this gap and will analyse the variation observed in a specific dental care treatment (dental radiographs) within NHS Scotland, with particular emphasis on the contribution of both dentist and patient unobserved heterogeneity. The thesis takes its focus from two strands of the literature; the underlying theoretical aspect draws on the literature concerning the theory of incentives and physician agency, whilst the empirical component makes use of recent advances in micro-econometric methods, documented in the labour economics literature. Although the thesis is predominantly an empirical analysis, the estimation strategy combines ideas from both the theoretical and empirical literature. A matched patient provider dataset from NHS Scotland is used to conduct an analysis of the variation in dental radiographs, in the presence of, and controlling for unobserved dentist and patient heterogeneity. The results indicate that the remuneration structure alone has little or no impact on the treatment decision to provide a radiograph. When a dentist changes from being on a fixed salary contract to being paid on a fee-for-service basis, they are in fact less likely to provide a radiograph. This result changes in the presence of insurance (identified as being when patients are exempt from the patient charge) and indicates that when the self employed dentist can identify the patient as being exempt, they are more likely to provide a radiograph. This result provides some support for the theory that in the presence of insurance, financial incentives do influence the treatment decision. A final result of the study highlights the importance of accounting for unobserved patient and provider heterogeneity, a factor that has had little attention in the healthcare literature. The results suggest that patient variation, as opposed to the variation across dentists, is much more important in explaining total variation. This is a similar result to that found in both the labour and education literatures.EThOS - Electronic Theses Online ServiceMedical Research Council Capacity Building StudentshipGBUnited Kingdo

Barriers and facilitators of evidence-based management of patients with bacterial infections among general dental practitioners:a theory-informed interview study

Background: General dental practitioners (GDPs) regularly prescribe antibiotics to manage dental infections although most infections can be treated successfully by local measures. Published guidance to support GDPs to make appropriate prescribing decisions exists but there continues to be wide variation in dental antibiotic prescribing. An interview study was conducted as part of the Reducing Antibiotic Prescribing in Dentistry (RAPiD) trial to understand the barriers and facilitators of using local measures instead of prescribing antibiotics to manage bacterial infections. Methods: Thirty semi-structured one-to-one telephone interviews were conducted using the Theoretical Domains Framework (TDF). Responses were coded into domains of the TDF and sub-themes. Priority domains (high frequency: ≥50 % interviewees discussed) relevant to behaviour change were identified as targets for future intervention efforts and mapped onto 'intervention functions' of the Behaviour Change Wheel system. Results: Five domains (behavioural regulation, social influences, reinforcement, environmental context and resources, and beliefs about consequences) with seven sub-themes were identified as targets for future intervention. All participants had knowledge about the evidence-based management of bacterial infections, but they reported difficulties in following this due to patient factors and time management. Lack of time was found to significantly influence their decision processes with regard to performing local measures. Beliefs about their capabilities to overcome patient influence, beliefs that performing local measures would impact on subsequent appointment times as well as there being no incentives for performing local measures were also featured. Though no knowledge or basic skills issues were identified, the participants suggested some continuous professional development programmes (e.g. time management, an overview of published guidance) to address some of the barriers. The domain results suggest a number of intervention functions through which future interventions could change GDPs' antibiotic prescribing for bacterial infections: imparting skills through training, providing an example for GDPs to imitate (i.e. modelling) or creating the expectation of a reward (i.e. incentivisation). Conclusions: This is the first theoretically informed study to identify barriers and facilitators of evidence-based management of patients with bacterial infections among GDPs. A pragmatic approach is needed to address the modifiable barriers in future interventions intended to change dentists' inappropriate prescribing behaviour.</p

An audit and feedback intervention for reducing antibiotic prescribing in general dental practice:the RAPiD Cluster Randomised Controlled Trial

Acknowledgments: We thank the TRiaDS Research Methodology Group, including Irene Black, Debbie Bonetti, Heather Cassie, Martin Eccles, Sandra Eldridge, Jill J. Francis, Jeremy M. Grimshaw, Lorna Macpherson, Lorna McKee, Susan Michie, Nigel Pitts, Derek Richards, Douglas Stirling, Colin Tilley, Carole Torgerson, Shaun Treweek, Luke Vale, and Alan Walker for their guidance and contribution to the design and development of the study. We also thank Maria Prior for overseeing the running of the study, drafting of the published protocol, and her contribution to the design and analysis of the process evaluation. Thanks are also extended to Jill Farnham, Jenny Eades, Sarah Blackburn, and Lorna Barnsley for providing invaluable administrative support for this study. The views expressed in this article are those of the authors and may not reflect those of the funder. Funding: This study was conducted as part of the TRiaDS programme of implementation research which is funded by NHS Education for Scotland (NES). The Health Services Research Unit which is funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates supported the study. The funder had no influence over the design, conduct, analysis and write up of the study. Data Availability: Researchers can request to access the data from the Information Services Division of NHS National Services Scotland http://www.isdscotland.org/. Some restrictions may apply for the protection of privacy and appropriate usage of the data.Peer reviewedPublisher PD

Evaluating an audit and feedback intervention for reducing antibiotic prescribing behaviour in general dental practice (the RAPiD trial): a partial factorial cluster randomised trial protocol

BACKGROUND: Antibiotic prescribing in dentistry accounts for 9% of total antibiotic prescriptions in Scottish primary care. The Scottish Dental Clinical Effectiveness Programme (SDCEP) published guidance in April 2008 (2nd edition, August 2011) for Drug Prescribing in Dentistry, which aims to assist dentists to make evidence-based antibiotic prescribing decisions. However, wide variation in prescribing persists and the overall use of antibiotics is increasing. METHODS: RAPiD is a 12-month partial factorial cluster randomised trial conducted in NHS General Dental Practices across Scotland. Its aim is to compare the effectiveness of individualised audit and feedback (A&F) strategies for the translation into practice of SDCEP recommendations on antibiotic prescribing. The trial uses routinely collected electronic healthcare data in five aspects of its design in order to: identify the study population; apply eligibility criteria; carry out stratified randomisation; generate the trial intervention; analyse trial outcomes. Eligibility was determined on contract status and a minimum level of recent NHS treatment provision. All eligible dental practices in Scotland were simultaneously randomised at baseline either to current audit practice or to an intervention group. Randomisation was stratified by single-handed/multi-handed practices. General dental practitioners (GDPs) working at intervention practices will receive individualised graphical representations of their antibiotic prescribing rate from the previous 14 months at baseline and an update at six months. GDPs could not be blinded to their practice allocation. Intervention practices were further randomised using a factorial design to receive feedback with or without: a health board comparator; a supplementary text-based intervention; additional feedback at nine months. The primary outcome is the total antibiotic prescribing rate per 100 courses of treatment over the year following delivery of the baseline intervention. A concurrent qualitative process evaluation will apply theory-based approaches using the Consolidated Framework for Implementation Research to explore the acceptability of the interventions and the Theoretical Domains Framework to identify barriers and enablers to evidence-based antibiotic prescribing behaviour by GDPs. DISCUSSION: RAPiD will provide a robust evaluation of A&F in dentistry in Scotland. It also demonstrates that linked administrative datasets have the potential to be used efficiently and effectively across all stages of an randomised controlled trial. TRIAL REGISTRATION: Current Controlled Trials ISRCTN49204710

STUDY PROTOCOL Open Access

Evaluating an audit and feedback intervention for reducing antibiotic prescribing behaviour in general dental practice (the RAPiD trial): a partial factorial cluster randomised trial protoco

Internet-assisted delivery of cognitive behavioural therapy (CBT) for childhood anxiety:systematic review and meta-analysis

Aim: To conduct a systematic review and meta-analysis of the literature to assess efficacy of internet-delivered cognitive behavioural therapy (CBT) for child anxiety disorder.Method: A systematic search of 7 electronic databases was conducted to assess CBT intervention for children with anxiety problems with remote delivery either entirely or partly via technology. Six articles reporting 7 studies were included.Results: The findings together suggested that CBT programmes involving computerised elements were well received by children and their families, and its efficacy was almost as favourable as clinic-based CBT. The mixture of children and adolescents included the studies, diverse range of programmes, and lack of consistency between study designs made it difficult to identify key elements of these programmes or draw conclusions on the treatment efficacy.Conclusions: Analysis supports online delivery for wider access of this evidence-based therapy. Areas in need of improvement for this new method are indicated.</p

Summary results for secondary outcome prescribing rates.

<p>Summary results for secondary outcome prescribing rates.</p

Practice and dentist flow diagram.

<p>Abbreviations: A&F—audit and feedback comprising a line graph plotting an individual dentist’s monthly antibiotic prescribing rate. BCM—written behaviour change message comprising text added below a dentist’s individualised line graph synthesising and reiterating national guidance recommendations for antibiotic prescribing. HB—health board comparator comprising addition of a line to the individualised line graph plotting the monthly antibiotic prescribing rate of all dentists in that dentist’s health board. 0,6—allocated intervention delivered at months 0 and 6. 0,6,9—allocated intervention delivered at months 0, 6, and 9. Trial Comparisons: Groups 1,2,3,4 versus Groups 5,6,7,8 test the written behaviour change message main effect. Groups 1,3,5,7 versus Groups 2,4,6,8 test the health board comparator main effect. Groups 1,2,5,6 versus Groups 3,4,7,8 test the frequency of feedback main effect. Dentists without both baseline and follow-up data were not included in the analyses (control <i>n</i> = 114; intervention <i>n</i> = 469). Practices without at least one dentist with both baseline and follow-up data were not included in the analysis (control <i>n</i> = 6; intervention <i>n</i> = 19).</p