Multi-Level Interventions to Reduce Oral Health Disparities among Adults in Primary Care Settings

项目摘要/摘要 俄亥俄州东北部是口腔疾病(龋齿、牙周炎)患病率最高的州之一，而且牙科护理也很差。 在低收入老年人中。专业组织和国际移民组织建议将口腔健康 (O)为成年人开展初级保健活动，以降低医疗费用。但是，出版的文献表明 缺乏结果数据来整合有效的医疗-牙科一体化。阻碍一体化的因素也是 例如缺乏基于电子健康记录(EHR)口腔健康(OH)评估和转介，以及 对医疗提供者的职业卫生教育和培训不足。我们的调查数据显示，大多数 提供者希望在初级保健访问(PCV)中传达OH事实，但缺乏教育和资源。 老年人对口腔疾病存在误解，阻碍了定期牙科治疗。这个 拟议的多层次干预措施将解决阻碍卫生部门一体化的因素，并随后加以改善 成人的自我调节行为。干预措施是：实践(医疗助理、护士)：电子健康记录系统 基于更改以询问、建议、评估、联系(AAAC)。提供者(医生/护士从业者)：改进 基于自我调节(CSM)理论常识模型的知识和技能教育与技能 培训以传达OH事实，并加强牙科就诊的重要性。一项整群随机的临床试验 建议测试实施(实践)和行为(提供商)干预，以解决自律和 增加55岁≥低收入成年人的牙科护理。主要目标是：1)UG3，行为 与利益相关者和实践的定性工作；电子健康记录中基于系统的变化；以及试点-测试干预措施 在2个实践中。UH3，将8种做法随机分成两组，以研究基于EHR的策略的有效性，网址为 咨询[医疗机构风险评估]、建议[去看牙医]、评估[转诊意愿]、联系 [电子推荐和/或资源]与提供商以CSM理论为基础的教育和技能沟通 FACTS与单独的提供者(标准或通常的口腔保健)相比，增加牙科就诊(主要结果)； 并改善生活质量、口腔卫生行为和健康的生物计量指标(次要结果)。 次要目标(UH3)是探讨：交付和记录AAAC实施战略；以及 调查影响结果的因果路径。样本包括209名提供者和医务人员，以及 800名参加医疗补助的成年人。数据分析(UG3)将利用混合方法设计定性和 定量数据的描述性统计。数据收集(UH3)将遵循RE-AIM框架：成人 (医疗补助申请、调查问卷、电子病历的结果数据)；提供者、实践(问卷)；提供者、 实践(过程措施：范围、保真度、采用率、审计维护)。一种广义估计 将使用方程方法评估多层次干预措施对牙科护理和其他方面的影响 结果，同时考虑到实践中的分组。调解方法将决定干预是否会产生效果 通过假想的调解人发生。为初级保健临床医生提出了一种可持续的OH护理模式。

PROJECT SUMMARY/ABSTRACT Northeast Ohio has one of the highest rates of oral diseases (caries, periodontitis) and poor dental attendance among low-income older adults. Professional organizations and the IOM recommend integration of oral health (OH) activities into primary care for adults in order to reduce medical costs. But, published literature indicates a lack of outcomes data to assemble an effective medical-dental integration. Impeding integration are also factors such as lack of an electronic health record (EHR) based oral health (OH) assessment and referral, and inadequate OH education and training for medical providers. Our survey data indicate that the majority of providers would like OH facts to be communicated at primary care visits (PCV) but lack education and resources. There are misperceptions about oral diseases among older adults that prevent regular dental attendance. The proposed multi-level interventions will address factors that impede OH integration, and subsequently improve self-regulatory behaviors in adults. The interventions are: Practice (medical assistants, nurses): EHR systems based changes to ask, advise, assess, connect (AAAC). Provider (physician/nurse practitioner): improve knowledge and skills using Common-Sense Model of Self-Regulation (CSM) theory based education and skills training to communicate OH facts and reinforce importance of dental visits. A cluster-randomized clinical trial is proposed to test implementation (practice) and behavioral (provider) intervention to address self-regulation and increase dental attendance among low-income adults aged ≥55 years. The primary aims are: 1) UG3, Conduct qualitative work with stakeholders and practices; system-based changes in EHR; and pilot-test the interventions in 2 practices. UH3, randomize 8 practices to two arms to investigate the efficacy of a EHR based strategy at the practice level to ask [OH risk assessment], advise [going to dentist], assess [willingness for referral], connect [eReferral and/or resources] together with provider CSM theory-based education and skills to communicate OH facts versus provider alone (standard or usual oral health care) to increase dental attendance (primary outcome); and improve OH quality of life, oral hygiene behavior, and biometric measures of health (secondary outcomes). Secondary aims (UH3) are to explore: the delivery and documentation of AAAC implementation strategy; and to investigate causal pathways that affect the outcomes. The sample includes 209 providers and medical staff, and 800 Medicaid-enrolled adults. Data analysis (UG3) will utilize a mixed method design for qualitative and descriptive statistics for quantitative data. Data collection (UH3) will follow the RE-AIM framework: adults (outcome data from Medicaid claims, questionnaires, EHR); provider, practice (questionnaires); provider, practice (process measures: reach, fidelity, adoption, maintenance from audits). A generalized estimating equations approach will be used to assess effects of multi-level interventions on dental attendance and other outcomes, while accounting for clustering within practice. Mediation methods will determine if intervention effects occur through hypothesized mediators. A sustainable OH care model is proposed for primary care clinicians.