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

项目总结/摘要 东北部的俄亥俄州是口腔疾病（龋齿、牙周炎）发病率最高的地区之一，牙科护理也很差 低收入的老年人。专业组织和国际移民组织建议整合口腔健康 (OH)为减少医疗费用，将保健活动纳入成人初级保健。但是，出版的文献表明， 缺乏结果数据，无法进行有效的医疗-牙科整合。阻碍一体化的因素也是 例如缺乏基于电子健康记录（EHR）的口腔健康（OH）评估和转诊，以及 对医疗服务提供者的健康教育和培训不足。我们的调查数据显示， 提供者希望在初级保健访问（PCV）时传达OH事实，但缺乏教育和资源。 老年人对口腔疾病存在误解，妨碍了定期牙科治疗。的 拟议的多层次干预措施将解决阻碍OH整合的因素， 成年人的自我调节行为。实践（医疗助理，护士）：EHR系统 基于变化的询问，建议，评估，连接（AAAC）。提供者（医生/执业护士）：改善 知识和技能使用自我调节的常识模型（CSM）理论为基础的教育和技能 培训以传达OH事实并强调牙科就诊的重要性。一项随机分组临床试验， 建议测试实施（实践）和行为（提供者）干预，以解决自我监管， 增加55岁以上低收入成年人的牙科就诊率。主要目标是：1）UG 3，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;以及对干预措施进行试点测试 在2个实践中。UH 3，将8个实践随机分为两组，以研究基于EHR的策略在 实践水平要求[OH风险评估]，建议[去看牙医]，评估[转诊意愿]，连接 [电子推荐和/或资源]与提供者CSM理论为基础的教育和技能，以沟通OH 事实与提供者单独（标准或常规口腔保健），以增加牙科就诊率（主要结局）; 并改善OH生活质量、口腔卫生行为和健康的生物测定（次要结局）。 次要目标（UH 3）是探讨：美国农业咨询委员会实施战略的交付和文件编制;以及 调查影响结果的因果途径。样本包括209名提供者和医务人员， 800名参加医疗补助的成年人。数据分析（UG 3）将采用混合方法设计， 定量数据的描述性统计。数据收集（UH 3）将遵循RE-AIM框架：成人 （来自医疗补助索赔、问卷调查、EHR的结果数据）;提供者，实践（问卷调查）;提供者， 实践（过程措施：覆盖范围、忠诚度、采用、审计维护）。广义估计 方程方法将用于评估多层次干预对牙科就诊和其他 结果，同时考虑到实践中的集群。调解方法将决定干预是否有效 通过假设的中介发生。一个可持续的OH护理模式，提出了初级保健临床医生。

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.