Shaping dental contract reform – a clinical and cost effectiveness analysis of incentive-driven commissioning for improved oral health in primary dental care

Objective: To evaluate the clinical and cost-effectiveness of a new blended dental contract incentivising improved oral health compared with a traditional dental contract based on units of dental activity (UDAs). Design: Non-randomised controlled study. Setting: Six UK primary care dental practices, three working under a new blended dental contract; three matched practices under a traditional contract. Participants: 550 new adult patients. Interventions: A new blended/incentive-driven primary care dentistry contract and service delivery model versus the traditional contract based on UDAs. Main Outcomes Measures: Primary outcome was as follows: percentage of sites with gingival bleeding on probing. Secondary outcomes were as follows: extracted and filled teeth (%), caries (International Caries Detection and Assessment System (ICDAS)), oral health-related quality of life (Oral Health Impact Profile-14 (OHIP-14)). Incremental cost-effective ratios used OHIP-14 and quality adjusted life years (QALYs) derived from the EQ-5D-3L. Results: At 24 months, 291/550 (53%) patients returned for final assessment; those lost to follow-up attended 6.46 appointments on average (SD 4.80). The primary outcome favoured patients in the blended contract group. Extractions and fillings were more frequent in this group. Blended contracts were financially attractive for the dental provider but carried a higher cost for the service commissioner. Differences in generic health-related quality of life were negligible. Positive changes over time in oral health-related quality of life in both groups were statistically significant. Conclusions: This is the first UK study to assess the clinical and cost-effectiveness of a blended contract in primary care dentistry. Although the primary outcome favoured the blended contract, the results are limited because 47% patients did not attend at 24?months. This is consistent with 39% of adults not being regular attenders and 27% only visiting their dentist when they have a problem. Promotion of appropriate attendance, especially among those with high need, necessitates being factored into recruitment strategies of future studies

The INCENTIVE Study: a mixed methods evaluation of an innovation in commissioning and delivery of primary dental care compared to traditional dental contracting

Background Over the past decade, commissioning of primary care dentistry has seen contract currency evolving from payment for units of dental activity (UDAs) towards blended contracts that include key performance indicators such as access, quality and improved health outcome. Objectives The aim of this study was to evaluate a blended/incentive-driven model of dental service provision. To (1) explore stakeholder perspectives of the new service delivery model; (2) assess the effectiveness of the new service delivery model in reducing the risk of and amount of dental disease and enhancing oral health-related quality of life (OHQoL) in patients; and (3) assess cost-effectiveness of the new service delivery model. Methods Using a mixed-methods approach, the study included three dental practices working under the blended/incentive-driven (incentive) contract and three working under the UDAs (traditional) contract. All were based in West Yorkshire. The qualitative study reports on the meaning of key aspects of the model for three stakeholder groups [lay people (patients and individuals without a dentist), commissioners and the primary care dental teams], with framework analysis of focus group and semistructured interview data. A non-randomised study compared clinical effectiveness and cost-effectiveness of treatment under the two contracts. The primary outcome was gingivitis, measured using bleeding on probing. Secondary outcomes included OHQoL and cost-effectiveness. Results Participants in the qualitative study associated the incentive contract with more access, greater use of skill mix and improved health outcomes. In the quantitative analyses, of 550 participants recruited, 291 attended baseline and follow-up. Given missing data and following quality assurance, 188 were included in the bleeding on probing analysis, 187 in the caries assessment and 210 in the economic analysis. The results were mixed. The primary outcome favoured the incentive practices, whereas the assessment of caries favoured the traditional practices. Incentive practices attracted a higher cost for the service commissioner, but were financially attractive for the dental provider at the practice level. Differences in generic health-related quality of life were negligible. Positive changes over time in OHQoL in both groups were statistically significant. Limitations The results of the quantitative analysis should be treated with caution given small sample numbers, reservations about the validity of pooling, differential dropout results and data quality issues. Conclusions A large proportion of people in this study who had access to a dentist did not follow up on oral care. These individuals are more likely to be younger males and have poorer oral health. Although access to dental services was increased, this did not appear to facilitate continued use of services. Future work Further research is required to understand how best to promote and encourage appropriate dental service attendance, especially among those with a high level of need, to avoid increasing health inequalities, and to assess the financial impact of the contract. For dental practitioners, there are challenges around perceptions about preventative dentistry and use of the risk assessments and care pathways. Changes in skill mix pose further challenges. Funding The National Institute for Health Research Health Services and Delivery Research programme

“What is my risk really?”: A qualitative exploration of preventive interventions among individuals at risk of rheumatoid arthritis

Objectives Intervention in the pre-arthritis phase of rheumatoid arthritis (RA) could prevent or delay the onset of disease. The primary aim of this study was to explore perspectives of being at-risk and potential preventive interventions among individuals at risk of developing RA, and identify factors influencing their engagement with prevention. A secondary aim, established during the analysis process, was to understand and compare different approaches to health-related behaviours related to preventing RA. Methods Anti-cyclic citrullinated peptide positive at-risk (CCP+ at-risk) individuals with musculoskeletal symptoms but no synovitis participated in semi-structured interviews. Data were analysed using reflexive thematic analysis, followed by a secondary ideal-type analysis. Results Nineteen CCP+ at-risk individuals (ten women; age range 35–70) participated. Three overarching themes were identified: i) being CCP+ at risk; ii) aiming to prevent RA; iii) influencers of engagement. Participants described distress related to symptoms and uncertainty about disease progression. Many participants had concerns about medication side effects. In contrast, most participants expressed willingness to make lifestyle changes with the aim of preventing RA. Engagement with preventive measures was influenced by symptom severity, personal risk level, comorbidities, experiences of taking other medications/supplements, knowledge of RA, risk factors and medications, and perceived effort. Three ‘types’ of participants were identified from the data: proactive preventers, change considerers, and fearful avoiders. Overall orientation to health behaviours also impacted on attitude towards preventing RA. Conclusion Findings could inform recruitment and retention in RA prevention research and promote uptake of preventive interventions in clinical practice

A multi-centre study of interactional style in nurse specialist- and physician-led Rheumatology clinics in the UK

Background: Nurse-led care is well established in Rheumatology in the UK and provides follow-up care to people with inflammatory arthritis including treatment, monitoring, patient education and psychosocial support. Aim: The aim of this study is to compare and contrast interactional style with patients in physician-led and nurse-led Rheumatology clinics. Design: A multi-centre mixed methods approach was adopted. Settings: Nine UK Rheumatology out-patient clinics were observed and audio-recorded May 2009-April 2010. Participants: Eighteen practitioners agreed to participate in clinic audio-recordings, researcher observations, and note-taking. Of 9 nurse specialists, 8 were female and 5 of 9 physicians were female. Eight practitioners in each group took part in audio-recorded post-clinic interviews. All patients on the clinic list for those practitioners were invited to participate and 107 were consented and observed. In the nurse specialist cohort 46% were female 71% had a diagnosis of Rheumatoid Arthritis (RA). The physician cohort comprised 31% female 40% with RA and 16% unconfirmed diagnosis. Nineteen (18%) of the patients observed were approached for an audio-recorded telephone interview and 15 participated (4 male, 11 female). Methods: Forty-four nurse specialist and 63 physician consultations with patients were recorded. Roter's Interactional Analysis System (RIAS) was used to code this data. Thirty-one semi-structured interviews were conducted (16 practitioner, 15 patients) within 24 h of observed consultations and were analyzed using thematic analysis. Results: RIAS results illuminated differences between practitioners that can be classified as 'socio-emotional' versus 'task-focussed'. Specifically, nurse specialists and their patients engaged significantly more in the socio-emotional activity of 'building a relationship'. Across practitioners, the greatest proportion of 'patient initiations' were in 'giving medical information' and reflected what patients wanted the practitioner to know rather than giving insight into what patients wanted to know from practitioners. Interviews revealed that continuity of practitioner was highly valued by patients as offering the benefits of an established relationship and of emotional support beyond that of the clinical encounter. This fostered familiarity not only with their particular medical history, but also their individual personal circumstances, and this encouraged patient participation. In contrast, practitioners (mis)perceived waiting times to have a greater impact on patient satisfaction. However, practitioner interviews also revealed that clinic structure is often outside of the practitioner control and can undermine the possibility of maintaining patient-practitioner continuity. Conclusions: This research enhances understanding of nurse specialist consultation styles in Rheumatology, specifically the value of their socio-emotional communication skills to enhance patient participation

A systematic review of the effectiveness and cost-effectiveness of peer education and peer support in prisons.

BACKGROUND: Prisoners experience significantly worse health than the general population. This review examines the effectiveness and cost-effectiveness of peer interventions in prison settings. METHODS: A mixed methods systematic review of effectiveness and cost-effectiveness studies, including qualitative and quantitative synthesis was conducted. In addition to grey literature identified and searches of websites, nineteen electronic databases were searched from 1985 to 2012. Study selection criteria were: Population: Prisoners resident in adult prisons and children resident in Young Offender Institutions (YOIs). INTERVENTION: Peer-based interventions Comparators: Review questions 3 and 4 compared peer and professionally led approaches. OUTCOMES: Prisoner health or determinants of health; organisational/ process outcomes; views of prison populations. STUDY DESIGNS: Quantitative, qualitative and mixed method evaluations. RESULTS: Fifty-seven studies were included in the effectiveness review and one study in the cost-effectiveness review; most were of poor methodological quality. Evidence suggested that peer education interventions are effective at reducing risky behaviours, and that peer support services are acceptable within the prison environment and have a positive effect on recipients, practically or emotionally. Consistent evidence from many, predominantly qualitative, studies, suggested that being a peer deliverer was associated with positive effects. There was little evidence on cost-effectiveness of peer-based interventions. CONCLUSIONS: There is consistent evidence from a large number of studies that being a peer worker is associated with positive health; peer support services are also an acceptable source of help within the prison environment and can have a positive effect on recipients. Research into cost-effectiveness is sparse. SYSTEMATIC REVIEW REGISTRATION: PROSPERO ref: CRD42012002349

Interpreting outcome following foot surgery in people with rheumatoid arthritis

BACKGROUND: Foot surgery is common in RA but the current lack of understanding of how patients interpret outcomes inhibits evaluation of procedures in clinical and research settings. This study aimed to explore which factors are important to people with RA when they evaluate the outcome of foot and ankle surgery. METHODS AND RESULTS: Semi structured interviews with 11 RA participants who had mixed experiences of foot surgery were conducted and analysed using thematic analysis. Responses showed that while participants interpreted surgical outcome in respect to a multitude of factors, five major themes emerged: functional ability, participation, appearance of feet and footwear, surgeons' opinion, and pain. Participants interpreted levels of physical function in light of other aspects of their disease, reflecting on relative change from their preoperative state more than absolute levels of ability. Appearance was important to almost all participants: physical appearance, foot shape, and footwear were closely interlinked, yet participants saw these as distinct concepts and frequently entered into a defensive repertoire, feeling the need to justify that their perception of outcome was not about cosmesis. Surgeons' post-operative evaluation of the procedure was highly influential and made a lasting impression, irrespective of how the outcome compared to the participants' initial goals. Whilst pain was important to almost all participants, it had the greatest impact upon them when it interfered with their ability to undertake valued activities. CONCLUSIONS: People with RA interpret the outcome of foot surgery using multiple interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than anticipated. These factors can help clinicians in discussing surgical options in patients

Erratum to: Methods for evaluating medical tests and biomarkers

[This corrects the article DOI: 10.1186/s41512-016-0001-y.]

Evidence synthesis to inform model-based cost-effectiveness evaluations of diagnostic tests: a methodological systematic review of health technology assessments

Background: Evaluations of diagnostic tests are challenging because of the indirect nature of their impact on patient outcomes. Model-based health economic evaluations of tests allow different types of evidence from various sources to be incorporated and enable cost-effectiveness estimates to be made beyond the duration of available study data. To parameterize a health-economic model fully, all the ways a test impacts on patient health must be quantified, including but not limited to diagnostic test accuracy. Methods: We assessed all UK NIHR HTA reports published May 2009-July 2015. Reports were included if they evaluated a diagnostic test, included a model-based health economic evaluation and included a systematic review and meta-analysis of test accuracy. From each eligible report we extracted information on the following topics: 1) what evidence aside from test accuracy was searched for and synthesised, 2) which methods were used to synthesise test accuracy evidence and how did the results inform the economic model, 3) how/whether threshold effects were explored, 4) how the potential dependency between multiple tests in a pathway was accounted for, and 5) for evaluations of tests targeted at the primary care setting, how evidence from differing healthcare settings was incorporated. Results: The bivariate or HSROC model was implemented in 20/22 reports that met all inclusion criteria. Test accuracy data for health economic modelling was obtained from meta-analyses completely in four reports, partially in fourteen reports and not at all in four reports. Only 2/7 reports that used a quantitative test gave clear threshold recommendations. All 22 reports explored the effect of uncertainty in accuracy parameters but most of those that used multiple tests did not allow for dependence between test results. 7/22 tests were potentially suitable for primary care but the majority found limited evidence on test accuracy in primary care settings. Conclusions: The uptake of appropriate meta-analysis methods for synthesising evidence on diagnostic test accuracy in UK NIHR HTAs has improved in recent years. Future research should focus on other evidence requirements for cost-effectiveness assessment, threshold effects for quantitative tests and the impact of multiple diagnostic tests

Erratum to: Methods for evaluating medical tests and biomarkers

[This corrects the article DOI: 10.1186/s41512-016-0001-y.]

Challenges and Facilitators to the Secondary Use of Routinely Collected Oral Health Data from Multiple European Countries

This research aimed to identify and explore perceived challenges and facilitators to acquiring routinely collected oral healthcare data for research in six European countries with the aim of generating practical solutions for future initiatives. Seventeen participants from the UK, Denmark, Germany, Hungary, Ireland and the Netherlands participated who were either data requestors or data providers for the ADVOCATE project. Focus groups using the nominal group technique were undertaken using PESTLE as a theoretical framework to guide the discussion. The data were analysed using content analysis. Four main challenges were identified: 1) legality rules influencing the data available, 2) variations in data standardisation/coding between countries, 3) relationships and responsibilities between stakeholders, and 4) data not available for secondary use. The facilitators included: 1) having a framework in place to guide the process, 2) having strong relationships between stakeholders, 3) having technical elements in place to support the process, and 4) taking a pragmatic approach to the available data. It is hoped that identifying these challenges will raise awareness of potential issues for undertaking such research and that tackling these and building on the facilitators will establish stronger foundations for the sharing of data within and across disciplines and countries