Oral Health and Primary Care: Exploring Integration Models and Their Implications for Dental Hygiene Practice

Background: Historically, the oral health care system has been separated both administratively and clinically from the larger health care delivery system. Despite this historical separation, providing oral health care services lies within the scope of all health care professionals' practices. Current efforts to shift the compartmentalized American health care system to a total patient care model provide an opportunity to integrate oral health care with primary care in order to improve the population's oral health. This article seeks to acquaint dental hygienists, the oral health care professionals focused on disease prevention, with new and emerging models of oral health care delivery and interprofessional collaborative practice in the hope that they soon will participate in and expand the implementation of these practice models. Methods: This study focused on five health centers, all of which have been identified as organizational leaders in the development and implementation of models designed to support the integration of oral health care with primary care. Quantitative information on each health center was derived from annual reports submitted to the Uniform Data System (UDS) and information on the integration models was obtained through structured key informant interviews. Results: Each organization has incorporated oral health risk assessment, clinical assessments, education, preventive interventions, and dental care coordination into primary care services. One organization provides oral health care as part of its outreach services and programs. The health care team members involved in integration vary. Some of the health centers primarily call on doctors to implement integration of oral health care while others employ dental hygienists, nurses, medical assistants, and outreach team members. Interprofessional collaboration was observed in each organization but took on different forms. Conclusions: Although their methods of integrating oral health care with primary care differed, the five health centers described in this study successfully used integration to improve the delivery of oral health care services to their patients. All of these organizations placed a high value on interprofessional collaboration regardless of the particular collaborative model employed and identified a champion tasked with overseeing the improvement of oral health care delivery.The development of this article was supported by the National Association of Community Health Centers through funding provided by the DentaQuest Foundation

Development of a Diagnostic Test Set to Assess Agreement in Breast Pathology: Practical Application of the Guidelines for Reporting Reliability and Agreement Studies (GRRAS)

Diagnostic test sets are a valuable research tool that contributes importantly to the validity and reliability of studies that assess agreement in breast pathology. In order to fully understand the strengths and weaknesses of any agreement and reliability study, however, the methods should be fully reported. In this paper we provide a step-by-step description of the methods used to create four complex test sets for a study of diagnostic agreement among pathologists interpreting breast biopsy specimens. We use the newly developed Guidelines for Reporting Reliability and Agreement Studies (GRRAS) as a basis to report these methods

Surgical implications and variability in the use of the flat epithelial atypia diagnosis on breast biopsy specimens.

OBJECTIVES: Flat epithelial atypia (FEA) is a relatively new diagnostic term with uncertain clinical significance for surgical management. Any implied risk of invasive breast cancer associated with FEA is contingent upon diagnostic reproducibility, yet little is known regarding its use. MATERIALS AND METHODS: Pathologists in the Breast Pathology Study interpreted one of four 60-case test sets, one slide per case, constructed from 240 breast biopsy specimens. An electronic data form with standardized diagnostic categories was used; participants were instructed to indicate all diagnoses present. We assessed participants\u27 use of FEA as a diagnostic term within: 1) each test set; 2) 72 cases classified by reference as benign without FEA; and 3) six cases classified by reference as FEA. 115 pathologists participated, providing 6900 total independent assessments. RESULTS: Notation of FEA ranged from 0% to 35% of the cases interpreted, with most pathologists noting FEA on 4 or more test cases. At least one participant noted FEA in 34 of the 72 benign non-FEA cases. For the 6 reference FEA cases, participant agreement with the case reference FEA diagnosis ranged from 17% to 52%; diagnoses noted by participating pathologists for these FEA cases included columnar cell hyperplasia, usual ductal hyperplasia, atypical lobular hyperplasia, and atypical ductal hyperplasia. CONCLUSIONS: We observed wide variation in the diagnosis of FEA among U.S. pathologists. This suggests that perceptions of diagnostic criteria and any implied risk associated with FEA may also vary. Surgical excision following a core biopsy diagnosis of FEA should be reconsidered and studied further

Characteristics associated with requests by pathologists for second opinions on breast biopsies.

AIMS: Second opinions in pathology improve patient safety by reducing diagnostic errors, leading to more appropriate clinical treatment decisions. Little objective data are available regarding the factors triggering a request for second opinion despite second opinion consultations being part of the diagnostic system of pathology. Therefore we sought to assess breast biopsy cases and interpreting pathologists characteristics associated with second opinion requests. METHODS: Collected pathologist surveys and their interpretations of 60 test set cases were used to explore the relationships between case characteristics, pathologist characteristics and case perceptions, and requests for second opinions. Data were evaluated by logistic regression and generalised estimating equations. RESULTS: 115 pathologists provided 6900 assessments; pathologists requested second opinions on 70% (4827/6900) of their assessments 36% (1731/4827) of these would not have been required by policy. All associations between case characteristics and requesting second opinions were statistically significant, including diagnostic category, breast density, biopsy type, and number of diagnoses noted per case. Exclusive of institutional policies, pathologists wanted second opinions most frequently for atypia (66%) and least frequently for invasive cancer (20%). Second opinion rates were higher when the pathologist had lower assessment confidence, in cases with higher perceived difficulty, and cases with borderline diagnoses. CONCLUSIONS: Pathologists request second opinions for challenging cases, particularly those with atypia, high breast density, core needle biopsies, or many co-existing diagnoses. Further studies should evaluate whether the case characteristics identified in this study could be used as clinical criteria to prompt system-level strategies for mandating second opinions