Section of Social and Behavioral Sciences, College of Dental Medicine, and the Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.
Dental therapists-midlevel dental providers who are roughly analogous to nurse practitioners in medicine-might constitute a disruptive innovation within US dentistry. Proponents tend to claim that dental therapists will provide more equitable access to dental care; opponents tend to view them from a perspective that focuses on retaining the current attributes of the dental profession. Therapists display traits similar to those of disruptive innovations: their attributes are different from dentists', they may not initially be valued by current dental patients, they may appeal to current dental underutilizers, and they may transform the dental delivery system. Whether dental therapists constitute a disruptive innovation will only be determined retrospectively.
"Given the ad hoc approach to dental service organization in the NHS, it is important to determine the most technically efficient model for role-substitution, a priori. In dentistry, role-substitution has the potential to increase efficiency and effectiveness in service provision  and increase the capacity to care , although this may be situation specific . Therefore, it is not only critical to determine the most technically efficient role-substitutive models, it is equally important to explore the values of policy makers and providers to determine the factors affecting the implementation of such innovative designs and how patients would view such a change in service design . "
[Show abstract][Hide abstract] ABSTRACT: Role-substitution describes a model of dental care where Dental Care Professionals (DCPs) provide some of the clinical activity previously undertaken by General Dental Practitioners. This has the potential to increase technical efficiency, the capacity to care and reduce costs. Technical efficiency is defined as the production of the maximum amount of output from a given amount of input so that the service operates at the production frontier i.e. optimal level of productivity. Academic research into technical efficiency is becoming increasingly utilised in health care, although no studies have investigated the efficiency of NHS dentistry or role-substitution in high-street dental practices. The aim of this study is to examine the barriers and enablers that exist for role-substitution in general dental practices in the NHS and to determine the most technically efficient model for role-substitution.Methods/design: A screening questionnaire will be sent to DCPs to determine the type and location of role-substitutive models employed in NHS dental practices in the United Kingdom (UK). Semi-structured interviews will then be conducted with practice owners, DCPs and patients at selected sites identified by the questionnaire. Detail will be recorded about the organisational structure of the dental team, the number of NHS hours worked and the clinical activity undertaken. The interviews will continue until saturation and will record the views and attitudes of the members of the dental team. Final numbers of interviews will be determined by saturation.The second work-stream will examine the technical efficiency of the selected practices using Data Envelopment Analysis and Stochastic Frontier Modeling. The former is a non-parametric technique and is considered to be a highly flexible approach for applied health applications. The latter is parametric and is based on frontier regression models that estimate a conventional cost function.
Maximising health for a given level and mix of resources is an ethical imperative for health service planners. This study will determine the technical efficiency of role-substitution and so address one of the key recommendations of the Independent Review of NHS dentistry in England.
BMC Oral Health 09/2013; 13(1):46. DOI:10.1186/1472-6831-13-46 · 1.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The use of role substitution, where different levels of practitioner undertake the duties of the most qualified clinician, is common in medicine and dentistry. Proponents argue that role substitution has the potential to increase dentists' efficiency and effectiveness, thereby freeing up resources to improve access and reduce oral health inequalities. Given the current global economic climate, many countries are re-examining models of service provision to utilize role substitution. The objective of this study was to determine whether different members of the dental team could meet the diagnostic threshold set by the World Health Organization, when screening photographs of occlusal surfaces for dental caries.
Participants were sampled purposively and included; final-year dental students, final-year hygiene-therapy students, primary care dentists, hygiene-therapists and dental nurses. Following a brief training package, participants were asked to score 102 clinical photographs of both carious and noncarious extracted teeth and determine whether the tooth was 'healthy' or had 'suspected decay'. The time delay between consecutive photographs was set at 8-s. Judgment decisions were compared against the International Caries Detection and Assessment System as the gold standard, with scores of two or less representing 'healthy'. Sensitivity, specificity and predictive values were determined for each participant and clinical group. Kappa was calculated to determine test-retest reliability.
Dental nurses had the highest median sensitivity (87.9%), although all groups were comparable. The median specificity for the groups was lower than their sensitivity scores, with dentists scoring the highest (71.0%). Dentists also scored the highest median positive predictive value (57.8%), whilst dental nurses scored the highest negative predictive value (91.3%). The median level of agreement was high for all groups; the highest median score was for the final-year dental students (88.9%).
Even with minimal training, different members of the dental team show the potential to screen for occlusal caries to a similar standard as primary care dentists. This requires further testing in vivo, but has important implications for the productivity and design of the future dental workforce.
Community Dentistry And Oral Epidemiology 03/2012; 40(3):239-46. DOI:10.1111/j.1600-0528.2012.00671.x · 2.03 Impact Factor
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