Statistical Methods for Panel Studies with Applications in Environmental Epidemiology

Pollution studies have sought to understand the relationships between adverse health effects and harmful exposures. Many environmental health studies are predicated on the idea that each exposure has both acute and long term health effects that need to be accurately mapped. Considerable work has been done linking air pollution to deleterious health outcomes but the underlying biological pathways and contributing sources remain difficult to identify. There are many statistical issues that arise in the exploration of these longitudinal study designs such as understanding pathways of effects, addressing missing data, and assessing the health effects of multipollutant mixtures. To this end this dissertation aims to address the afore mentioned statistical issues. Our first contribution investigates the mechanistic pathways between air pollutants and measures of cardiac electrical instability. The methods from chapter 1 propose a path analysis that would allow for the estimation of health effects according to multiple paths using structural equation models. Our second contribution recognizes that panel studies suffer from attrition over time and the loss of data can affect the analysis. Methods from Chapter 2 extend current regression calibration approaches by imputing missing data through the use of moving averages and assumed correlation structures. Our last contribution explores the use of factor analysis and two-stage hierarchical regression which are two commonly used approaches in the analysis of multipollutant mixtures. The methods from Chapter 3 attempt to compare the performance of these two existing methodologies for estimating health effects from multipollutant sources

Burnout and study engagement among medical students at Sun Yat-sen University, China: A cross-sectional study.

This study aims to investigate burnout and study engagement among medical students at Sun Yat-sen University, China.A cross-sectional survey was conducted among undergraduate medical students of Sun Yat-sen University, China. A total of 453 undergraduate students completed a self-administered, structured questionnaire between January and February, 2016. Burnout and study engagement were measured using the Maslach Burnout Inventory-Student Survey (MBI-SS) and the UTRECHT Work Engagement Scale-Students (UWES-S), respectively. Subjects who scored high in emotional exhaustion subscale, high in cynicism subscale, and low in professional efficacy subscale simultaneously were graded as having high risk of burnout. Independent sample t tests and chi-square tests were used to compare the differences in burnout and work engagement between genders, majors, and grade levels.The means (standard deviations) of the MBI-SS subscales were 3.42 (1.45) for emotional exhaustion, 2.34 (1.64) for cynicism, and 3.04 (1.30) for professional efficacy. The means (standard deviations) of the UWES-S subscales were 3.13 (1.49) for vigor, 3.44 (1.47) for dedication and 3.00 (1.51) for absorption. Approximately 1 in 11 students experienced a high risk of burnout. There were no statistically significant gender differences in burnout and study engagement. There were also no statistically significant differences in burnout and study engagement subscales according to student major. Students in higher grades displayed increased burnout risk, higher mean burnout subscale score of cynicism, lower mean burnout subscale score of professional efficacy, and decreased mean study engagement subscale scores of dedication and absorption. There were strong correlations within study engagement subscales.Chinese medical students in this university experience a high level of burnout. Students at higher-grade level experience more burnout and decreased study engagement compared with students in lower level

Evaluating and improving the usability of a mHealth platform to assess postoperative dental pain

DATA AVAILABILITY : The data underlying this article will be shared on reasonable request to the corresponding author.OBJECTIVES : The use of interactive mobile health (mHealth) applications to monitor patient-reported postoperative pain outcomes is an emerging area in dentistry that requires further exploration. This study aimed to evaluate and improve the usability of an existing mHealth application. MATERIALS AND METHODS : The usability of the application was assessed iteratively using a 3-phase approach, including a rapid cognitive walkthrough (Phase I), lab-based usability testing (Phase II), and in situ pilot testing (Phase III). The study team conducted Phase I, while providers and patients participated in Phase II and III. RESULTS : The rapid cognitive walkthrough identified 23 potential issues that could negatively impact user experience, with the majority classified as system issues. The lab-based usability testing yielded 141 usability issues.; 43% encountered by patients and 57% by dentists. Usability problems encountered during pilot testing included undelivered messages due to mobile phone carrier and service-related issues, errors in patients’ phone number data entry, and problems in provider training. DISCUSSION : Through collaborative and iterative work with the vendor, usability issues were addressed before launching a trial to assess its efficacy. CONCLUSION : The usability of the mHealth application for postoperative dental pain was remarkably improved by the iterative analysis and interdisciplinary collaboration.LAY SUMMARY : In this research study, we wanted to understand how much pain patients were feeling after getting dental treatment. To figure this out, we used a mobile phone app where patients could tell us how much pain they had. Before starting this main study on a large group of patients, we wanted to make sure the app was easy to use. We tried different ways to test the app and make it better. We asked the study team, dentists, and patients for feedback. Dentists and patients talked about problems with the app and how hard it was to use. When we did a test run at real dental places, we found more issues like messages not getting through, mistakes when entering phone numbers, problems with training, and registration issues. The main thing we learned is that it is important to check if an app is easy to use in different ways and to include feedback from dentists and patients. We worked closely with the company that made the app to fix these problems before starting the main study to see if the app could help patients with their dental pain after surgery.Agency for Healthcare Research and Quality.https://academic.oup.com/jamiaopenhj2024Dental Management SciencesSDG-03:Good heatlh and well-bein

Presence of management, entrepreneurship, leadership and marketing topics in the dental school curriculum in Brazil

INTRODUCTION : To analyse the presence and characteristics of curricular components related to management, entrepreneurship, leadership and marketing as part of the structure and teaching methods of undergraduate courses in dentistry in Brazil. MATERIALS AND METHODS : This is an observational study that used the Ministry of Education's Undergraduate Course Accreditation Platform, which included 424 undergraduate courses in Dentistry on the last date of collection (August 31 2019). The following items were analysed as follows: the existence of curricular components in relation to the proposed themes, the most recurring denominations of curricular components, minimum and maximum workload, mandatory/optional classification, theoretical/practical teaching condition and in which year the curricular components were inserted. RESULTS : 367/424 (86.6%) of dentistry courses in Brazil included at least one of the topics: management, entrepreneurship, leadership and marketing curricular components in their curriculum, whilst 57/424 (13.4%) did not have these curricular components in their curricular structure. The most frequent names were "Management" 99 (45.21%) and "Entrepreneurship" 80 (36.5%). There was a predominance of the “theoretical method” and the number of hours varied considerably, with the most common course hours between 40 and 60 h. The majority of curricular components were inserted in the third to fifth year and offered on a compulsory basis. CONCLUSION : Most curricular matrices of dentistry courses in Brazil had components related to the topics studied. However, due to the variety of curricular components' names, hours, periods of courses and different teaching methodologies, there is a need to redesign the teaching and learning process, defining educational and evaluation models with common curricular components.http://www.wileyonlinelibrary.com/journal/ejehj2023Dental Management Science

Translating periodontal data to knowledge in a learning health system

BACKGROUND : A learning health system (LHS) is a health system in which patients and clinicians work together to choose care on the basis of best evidence and to drive discovery as a natural outgrowth of every clinical encounter to ensure the right care at the right time. An LHS for dentistry is now feasible, as an increased number of oral health care encounters are captured in electronic health records (EHRs). METHODS : The authors used EHRs data to track periodontal health outcomes at 3 large dental institutions. The 2 outcomes of interest were a new periodontitis case (for patients who had not received a diagnosis of periodontitis previously) and tooth loss due to progression of periodontal disease. RESULTS : The authors assessed a total of 494,272 examinations (new periodontitis outcome: n = 168,442; new tooth loss outcome: n = 325,830), representing a total of 194,984 patients. Dynamic dashboards displaying performance on both measures over time allow users to compare demographic and risk factors for patients. The incidence of new periodontitis and tooth loss was 4.3% and 1.2%, respectively. CONCLUSIONS: Periodontal disease, diagnosis, prevention, and treatment are particularly well suited for an LHS model. The results showed the feasibility of automated extraction and interpretation of critical data elements from the EHRs. The 2 outcome measures are being implemented as part of a dental LHS. The authors are using this knowledge to target the main drivers of poorer periodontal outcomes in a specific patient population, and they continue to use clinical health data for the purpose of learning and improvement. PRACTICAL IMPLICATIONS : Dental institutions of any size can conduct contemporaneous self-evaluation and immediately implement targeted strategies to improve oral health outcomes.US Department of Health and Human Services, National Institutes of Health, and National Institute of Dental and Craniofacial Research.https://jada.ada.orgam2023Dental Management Science

Patient and dentist perspectives on collecting patient reported outcomes after painful dental procedures in the National Dental PBRN

SUPPLEMENTARY MATERIAL 1: Provider and patient semi-structured interview questionsDATA AVAILABILITY : The datasets generated and/or analyzed during the current study are not publicly available as they consist of transcripts that convey the thoughts and opinions of the providers and patients that were interviewed. Informed consent was obtained for using these data as part of the specific study only and not for wider sharing or distribution. Fully deidentified data are however available from the corresponding author upon reasonable request.BACKGROUND : Dental Patient Reported Outcomes (PROs) relate to a dental patient’s subjective experience of their oral health. How practitioners and patients value PROs influences their successful use in practice. METHODS : Semi-structured interviews were conducted with 22 practitioners and 32 patients who provided feedback on using a mobile health (mHealth) platform to collect the pain experience after dental procedures. A themes analysis was conducted to identify implementation barriers and facilitators. RESULTS : Five themes were uncovered: (1) Sense of Better Care. (2) Tailored Follow-up based on the dental procedure and patient’s pain experience. (3) Effective Messaging and Alerts. (4) Usable Digital Platform. (5) Routine mHealth Integration. CONCLUSION : Frequent automated and preferably tailored follow-up messages using an mHealth platform provided a positive care experience for patients, while providers felt it saved them time and effort. Patients thought that the mHealth questionnaires were well-developed and of appropriate length. The mHealth platform itself was perceived as user-friendly by users, and most would like to continue using it. PRACTICAL IMPLICATIONS : Patients are prepared to use mobile phones to report their pain experience after dental procedures. Practitioners will be able to close the post-operative communication gap with their patients, with little interruption of their workflow.The National Institutes of Health through a grant from the National Institute of Dental and Craniofacial Research with additional infrastructure and study-specific funding from NIDCR.https://bmcoralhealth.biomedcentral.comhj2024Dental Management SciencesSDG-03:Good heatlh and well-bein

Caries risk documentation and prevention : eMeasures for dental electronic health records

BACKGROUND: Longitudinal patient level dataavailable in the electronic health record (EHR)allows for the development, implementation, and validations of dental quality measures (eMeasures). Objective We report the feasibility and validity of implementing two eMeasures. The eMeasures determined the proportion of patients receiving a caries risk assessment (eCRA) and corresponding appropriate risk-based preventative treatments for patients at elevated risk of caries (appropriateness of care [eAoC]) in two academic institutions and one accountable care organization, in the 2019 reporting year. METHODS: Both eMeasures define the numerator and denominator beginning at the patient level, populations’ specifications, and validated the automated queries. For eCRA, patients who completed a comprehensive or periodic oral evaluation formed the denominator, and patients of any age who received a CRA formed the numerator. The eAoC evaluated the proportion of patients at elevated caries risk who received the corresponding appropriate risk-based preventative treatments. RESULTS: EHR automated queries identified in three sites 269,536 patients who met the inclusion criteria for receiving a CRA. The overall proportion of patients who received a CRA was 94.4% (eCRA). In eAoC, patients at elevated caries risk levels (moderate, high, or extreme) received fluoride preventive treatment ranging from 56 to 93.8%. For patients at high and extreme risk, antimicrobials were prescribed more frequently site 3 (80.6%) than sites 2 (16.7%) and 1 (2.9%). CONCLUSION: Patient-level data available in the EHRs can be used to implement process-ofcare dental eCRA and AoC, eAoC measures identify gaps in clinical practice. EHR-based measures can be useful in improving delivery of evidence-based preventative treatments to reduce risk, prevent tooth decay, and improve oral health.U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research.http://www.thieme.com/books-main/clinical-informatics/product/4433-aci-applied-clinical-informaticsDental Management Science

Development of an inventory of dental harms : methods and rationale

OBJECTIVES : While adverse events (AEs) are all too prevalent, their underlying causes are difficult to assess because they are often multifactorial. Standardizing the language of dental AEs is an important first step toward increasing patient safety for the dental patient. METHODS : We followed a multimodal approach building a dental AE inventory, which included a literature review; review of the MAUDE database; a cross-sectional, self-administered patient survey; focus groups; interviews with providers and domain experts; and chart reviews. RESULTS : One hundred eight unique allergy/toxicity/foreign body response, 70 aspiration/ingestion of foreign body, 70 infection, 52 wrong site/wrong patient/wrong procedure, 23 bleeding, 48 pain, 149 hard tissue injury, 127 soft tissue injury, 91 nerve injury, 171 other systemic complication, and 177 other orofacial complication were identified. Subtype AEs within the categories revealed that allergic reaction, aspiration, pain, and wrong procedure were the most common AEs identified among known (i.e., chart reviews) and hypothetical (i.e., interviews) sources. CONCLUSIONS : Using a multimodal approach, a broad list of dental AEs was developed, in which the AEs were classed into 12 categories. Hard tissue injury was noted frequently during interviews and in actuality. Pain was the unexpected AE that was consistently identified with every modality used. PRACTICAL IMPLICATIONS : Most AEs result in temporary harm with hard tissue injury being a common AE identified through interviews and in actuality through chart reviews. Acknowledging that AEs happen is an important step toward mitigating them and assuring quality of care for our patients.The Agency for Healthcare Research and Quality (AHRQ) and the National Institute of Dental and Craniofacial Research.http://www.journalpatientsafety.com2023-09-01hj2023Dental Management Science

Influence of the Posterior Mandible Ridge Morphology on Virtual Implant Planning.

PURPOSE The purpose of this study was to examine the anatomy of the mandibular posterior region to develop an anatomical categorization for implant-prosthodontic planning. MATERIALS AND METHODS Using cone beam computed tomography scans, 313 cross-sectional views of edentulous posterior mandibular sites were evaluated with respect to the anatomical ridge morphology. Virtual implant planning was performed, and the need for bone grafting was assessed. The level of complexity for planning implants in those positions was assessed. Sites were classified as straightforward, advanced, or complex sites based on the need for bone grafting. RESULTS Five well-defined cross-sectional configurations were observed: straight (53.6%), oblique (26.2%), s-shape (7.4%), hourglass shape (1.9%), and basal bone (10.8%). There was a statistically significant association between the ridge shape and the feasibility of placing an implant with or without bone grafting; the straight and oblique ridge shapes were more likely to be associated with a favorable anatomy for implant placement. CONCLUSION The ridge shape significantly influenced the ease or difficulty of placing an implant. The s-shape, hourglass, and basal bone posterior mandibular cross-sectional shapes were associated with a higher degree of difficulty

Increasing value, reducing waste: tailoring the application of dental sealants according to individual caries risk

OBJECTIVES: Despite a significant national investment in oral health, there is little understanding of the return in terms of quality. Value-based payments aim to refocus provider reimbursement based on the value created to the patient. Our objectives were to apply a set of dental quality measures to help determine the value of preventive dental care provided to children at two academic dental school clinics. METHODS: We queried the institutional electronic health records (EHRs) for patients between the ages of 6-14 years with sealable first or second permanent molars, determined caries risk status, identified if dental sealants were placed, and finally if the teeth showed evidence of new caries experience. In order to determine the cost-effectiveness of EHR-based triage of applying dental sealants, we calculated the incremental cost-effectiveness ratio (ICER) for the dental quality measures supported sealing program. RESULTS: Between the two academic sites, there were 6,155 unique children for a total of 12,302 eligible teeth without a sealant and 32,811 eligible teeth with a sealant. Teeth without a sealant were more likely to have decay (4.8 percent) than those with a sealant (1.7 percent). At both sites, patients with high caries risk were more likely to benefit from sealants compared to those patients with low risk. CONCLUSION: Implementation of caries risk stratified fissure sealant quality measures demonstrates the potential for extracting better value in oral health care