Integrating Oral and General Health Through Health Literacy Practices Proceedings of a Workshop (2019) / Chapter Skim
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6 Developing a Research Agenda for Integration
6 Developing a Research Agenda for Integration
Pages 63-76
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From page 63... ...
6 Developing a Research Agenda for Integration1 The need to expand the evidence base to drive policy was a theme both of the commissioned paper and of earlier discussions in the workshop, said Jane Weintraub, moderator of the final panel at the workshop, alumna, distinguished professor, and former dean at the University of North C arolina School of Dentistry, and adjunct professor in the University of North Carolina Gillings School of Global Public Health. During the panel session, Weintraub posed to four experts a series of research-related questions on the relationship between oral health and general health: Hugh Silk, medical director of a wellness and primary care center in Massachusetts as part of Community Healthlink, and professor in the Department of Family Medicine and Community Health at the Harvard School of Dental Medicine; Cassandra Yarbrough, lead public policy analyst for the Health Policy Institute at the American Dental Association; Ira Lamster, dean emeritus of the College of Dental Medicine at Columbia University and clinical professor at the Stony Brook University School of Dental Medicine; and Wendy 1 This chapter is based on presentations by Ira Lamster, dean emeritus of the College of Dental Medicine at Columbia University and clinical professor at the Stony Brook University School of Dental Medicine; Wendy Mouradian, associate dean and professor emerita of pediatric dentistry and strategic advisor for the Regional Initiatives in Dental Education program at the University of Washington; Hugh Silk, medical director of a wellness and primary care center in Massachusetts as part of Community Healthlink, and professor in the Department of Family Medicine and Community Health at the Harvard School of Dental Medicine; and Cassandra Yarbrough, lead public policy analyst for the Health Policy Institute at the American Dental Association.
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From page 64... ...
The Center for Integration of Primary Care and Oral Health, a joint endeavor of several academic organizations supported by the Health Resources and Services Administration (HRSA) and based at the University of Massachusetts Medical School, has done surveys to determine what is happening across the country and not just in places where integration is happening.2 Based on this research, Silk and colleagues reported that hours of oral health training in family medicine decreased from 2012 to 2017 (Silk et al., 2018)
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From page 65... ...
WHAT PATIENTS WANT Yarbrough recounted a recent talk by Don Berwick, former administrator of the Centers for Medicare & Medicaid Services and current senior fellow at the Institute for Healthcare Improvement, in which he mentioned a clinic in Germany that has refocused its care on what matters most to patients being treated for prostate cancer. As a result, the clinic directed attention to improving erectile dysfunction rates and incontinence, "and you could see that their improvements in those areas skyrocketed compared to all the other clinics treating prostate cancer across Germany," said Yarbrough.
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From page 66... ...
"If we really want to integrate these two, we're going to have to start buckling down on not separating dental in any capacity." Finally, she mentioned the need to measure the return on investment of integrating oral health into whole-body health. A number of studies have shown the effects of dental care on lowering health care costs for diabetic patients and individuals with heart disease.
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From page 67... ...
Though this is not the only relationship between oral health and a chronic disease, it is the one for which the volume and breadth of the data are greatest. Almost 10 percent of adults have diabetes mellitus, 25 percent of whom are undiagnosed.3 Patients with diabetes mellitus develop a wide range of changes in the oral cavity and contiguous structures, including not just periodontal disease but reduction in salivary flow, burning mouth syndrome, and swelling of the parotids.
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From page 68... ...
Lamster also described an ongoing study of the Medicaid population in New York State, which is producing comparably promising results for patients with diabetes mellitus, cardiovascular disease, cognitive impairment, and respiratory disease. This study is suggesting that the health care dollars that are saved are actually greater among Medicaid patients than among patients who have private insurance.
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From page 69... ...
Such an initiative would also generate a large amount of useful data for research as dental students learn about primary care tasks that they can apply in their professions. Finally, Mouradian observed that primary care providers need to involve dental providers more in general health care, and that dental providers need to be prepared to get involved.
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From page 70... ...
You could put a number of these important pipeline paradigms together, including underrepresented minority students, but also the opportunity to expose these students to a breadth of richness in integration." OUTCOME MEASURES A major issue in the work of his center on the impact of oral health training for primary care clinicians, said Silk in response to a question on the greatest gaps in research, has been the use of outcome measures. He mentioned several valuable studies that have been done, including the Q ualis Health study on workflow, the HRSA project that Joskow mentioned, the Medical Oral Expanded Care (MORE Care)
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From page 71... ...
For example, because fluoride varnish reduces caries, increasing fluoride varnish rates would imply that the caries rate should go down, though "we still have to be careful with that inference." The tool they are developing could be applied in a federally qualified health center or a private practice to work from process measures to better outcome measures, Silk said. A related problem is the difficulty that clinics have communicating with each other.
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From page 72... ...
She recommended producing a background paper like the one generated for the workshop on the unintended consequences and larger costs of failing to integrate oral health with general health, because considerable data and research are available on the subject. Such a background paper should also look at the ethical, legal, and social dimensions of integration, just as those were studied for the human genome project, she said.
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From page 73... ...
THE POWER OF ANECDOTES Yarbrough called attention to an issue that goes beyond the cost argument that better oral health would save money: what she called the "storytelling" aspect of policy. Shortly before the workshop, the state of Maryland added an adult Medicaid dental benefit to their program.
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From page 74... ...
Teledentistry can be a valuable application both with rural populations and other populations, such as in the prison system. The MORE Care project, he observed, is focused on workflow issues in rural settings so that primary care teams are not overwhelmed.4 Qualis Health is another organization working on these issues.5 Mouradian mentioned the RIDE program, which includes a component that sends dental students into rural areas.
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From page 75... ...
With regard to the patient portal, Weintraub noted that many dental practitioners still are not using electronic health records. However, the system is moving in that direction, "so a pilot project would be great." TRANSITIONING THROUGH AN INFLECTION Lamster observed that dentistry is at an inflection point.
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From page 76... ...
She suggested further exploring the possible consequences of physicians missing oral health diagnoses, because "physicians are very fear driven, we're very afraid of missing something important." In response to a question about value-based care, Yarbrough observed that a preventive health care system requires team-based primary care, including a dentist or some other sort of oral health provider. Echoing Mouradian, she called for a large pilot project that would measure the return on investment of such care, in part to determine the value of integrating dental care into primary care.
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