Testing Clinical Decision Support for Treating Tobacco Use in Dental Clinics (New York)

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Summary:

Despite considerable progress, smoking remains the leading preventable cause of death in the United States. Although safe and effective treatments for tobacco dependence exist, only a small proportion of the 40 percent of smokers who try to quit each year use cessation therapies. With more than half of smokers visiting a dentist each year, dentists are in an ideal position to provide cessation treatment, but less than 25 percent routinely do so. Barriers to routine smoking cessation interventions include lack of time, limited training in behavioral assessment and intervention, a lack of office-based systems to facilitate preventive care, and a lack of referral resources.

This project implemented and evaluated a Web-based clinical decision support system (CDSS) to help dentists provide guidance on tobacco cessation during patient encounters. Based on the patient information entered, the system helped dentists recommend and prescribe approved pharmacotherapy; facilitate referral of patients to local counseling resources; print handouts with patient-specific smoking cessation recommendations, instructions, and cessation resources; and document the visit for the patient’s dental record.

The specific aims of this project were as follows:

  • Test the hypothesis that a CDSS will improve the rate at which dentists assist their patients with smoking cessation by providing information and recommendations on smoking cessation resources. 
  • Assess whether exposure to information and recommendations facilitated by the CDSS would: 1) increase the rate at which patients make at least one quit attempt in the month following the dental visit and 2) increase the reported use of counseling and pharmacotherapy during those attempts over that observed with a tobacco use identification system alone. 
  • Evaluate the acceptance of the CDSS into the workflow of dental clinics. 

A cross-sectional pre-post study design was used to assess the impact and acceptability of the CDSS in six general dental clinics. The study demonstrated that implementation of the system was feasible and facilitated treatment of tobacco use. In qualitative interviews, dentists reported that the CDSS was easy to use and helpful for patient care, and that it provided trustworthy information. Patient interviews conducted after a visit found that there were no significant changes in rates of cessation assistance after the system was implemented. However, patient telephone surveys found that patients were significantly more likely to report a quit attempt, read the patient self-help materials, and contact a Quitline.

The study concluded that CDSS has the potential to enhance quality and consistency of tobacco cessation treatment in dental health care settings. The research team recommended that future studies focus on measuring clinical outcomes, identifying facilitators and barriers of integrating the CDSS into provider workflow, and testing the system in a non-academic environment.

Testing Clinical Decision Support for Treating Tobacco Use in Dental Clinics - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality through Health Information Technology (IT) (R21)
  • Grant Number: 
    R21 HS 021002
  • Project Period: 
    September 2011 - September 2013
  • AHRQ Funding Amount: 
    $171,412
  • PDF Version: 
    (PDF, 249.19 KB)

Summary: Smoking remains the leading preventable cause of death in the U.S. The U.S. Public Health Service Guidelines have established that tobacco dependence treatment, including cessation pharmacotherapy and brief counseling, can produce significant and sustained reductions in tobacco use and should be delivered to all smokers seeking routine health care. Dentists are in a good position to provide tobacco cessation treatment because: 1) they have regular access to a broad population; 2) they have access to patients who do not receive other health care services; 3) multiple patient dental visits per year are common, allowing for repetitive dental provider opportunities to offer tobacco cessation counseling and interventions; and 4) evidence shows that tobacco cessation assistance delivered by dental providers can increase tobacco cessation. Currently, however, dentists generally do not provide routine tobacco cessation treatment to their patients who smoke. Dentists often cite barriers—such as concern about increased patient visit time, limited training in behavioral assessment and intervention, a lack of office-based systems to facilitate preventive care, and a lack of referral resources—to providing cessation treatment.

Dr. Donna Shelley and her research team are working to reduce these barriers by implementing and evaluating a Web-based clinical decision support system (CDSS) to help dentists provide guidance on recommended tobacco use treatment during patient encounters. Based on the patient information entered, the system helps dentists recommend and prescribe approved pharmacotherapy; facilitate referral of patients to local counseling resources; print handouts with patient-specific smoking cessation recommendations, instructions, and cessation resources; and document the visit for the patient’s dental record.

Dr. Shelley is using a cross-sectional pre-post study design to assess the impact and acceptability of the CDSS. The intervention has been implemented in four general dental care clinics at the New York University College of Dentistry. At baseline, patients who smoked were identified in the clinic waiting rooms by completing a brief survey prior to seeing the dentist. Those who consented were administered an exit survey after their dental visit to collect baseline data on dentist adherence to the Public Health Service Guidelines and on patient quit behavior. After collecting baseline data, dentists in the four clinics received training on how to access and use the CDSS. Approximately 1 month after the system was implemented, researchers administered the patient exit interviews again. At the end of the intervention, the research team plans to conduct qualitative interviews with dental students from the four clinic sites to collect data on use and acceptance of the CDSS.

The Web-based CDSS is a promising tool to help dentists provide evidence-based smoking cessation assistance. This study will provide an initial assessment of its potential impact and use and will inform future testing and implementation of the CDSS in dental health clinics throughout the United States.

Specific Aims:

  • Test the hypothesis that a clinical decision support system will improve the rate at which dentists assist their patients with smoking cessation by providing information and recommendations on smoking cessation resources. (Ongoing)
  • Assess whether exposure to information and recommendations facilitated by the CDSS will: 1) increase the rate at which patients make at least one quit attempt in the month following the dental visit; and 2) increase the reported use of counseling and pharmacotherapy during those attempts over those observed with a tobacco use identification system alone. (Ongoing)
  • Evaluate the acceptance of the CDSS into the workflow of dental clinics through semi-structured interviews of dentists and focus groups with staff at the conclusion of the trial, and by measuring the range of use of the CDSS with a log on the server that collects aggregate data of each dentist’s access of specific CDSS screens by time. (Ongoing) 

2012 Activities: The pre-intervention study was completed during 2012, with a total of 152 patients enrolled at the four clinics. The project team has begun analyzing the qualitative and quantitative data from this component of the project. The post-intervention study was initiated and as of December 31, 2012, 105 patients in the four clinics had been enrolled. Recruitment and data collection for the post-intervention will continue into 2013.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track and the project budget funds are somewhat underspent. Dr. Shelley has been able to staff the project with students in need of internships for their graduate programs and as a result has saved on costs previously anticipated to fund project staff salaries.

Preliminary Impact and Findings: Preliminary findings suggest good adoption of the CDSS. Among the 200 dental students and faculty, 59 percent used the tool at least once. Preliminary qualitative assessments indicate the tool is simple to use, trusted by providers, and facilitates treatment.

Target Population: Adults

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

Testing Clinical Decision Support for Treating Tobacco Use in Dental Clinics - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality through Health Information Technology (IT) (R21)
  • Grant Number: 
    R21 HS 021002
  • Project Period: 
    September 2011 - September 2013
  • AHRQ Funding Amount: 
    $171,412
  • PDF Version: 
    (PDF, 175.29 KB)

Summary: Smoking remains the leading preventable cause of death in the U.S. Research shows that smoking cessation can reduce the risk of lung cancer and other diseases by 20 to 90 percent. The U.S. Public Health Service Guidelines have established that tobacco dependence treatment, including cessation pharmacotherapy and brief counseling, can produce significant and sustained reductions in tobacco use and should be delivered to all smokers seeking routine health care. Dentists are in a good position to provide tobacco cessation treatment because: 1) they have regular access to a broad population (50 percent of current smokers report at least one annual dental visit); 2) they have access to patients who do not receive other health care services (10 percent of dental patients do not see a physician regularly); 3) multiple patient dental visits per year are common, allowing for repetitive dental provider opportunities to offer tobacco cessation counseling and interventions; and 4) evidence shows that tobacco cessation assistance delivered by dental providers can increase tobacco cessation. Currently, however, dentists generally do not provide routine tobacco cessation treatment to their patients who smoke. Dentists often cite barriers-such as concern about increased patient visit time, limited training in behavioral assessment and intervention, a lack of office-based systems to facilitate preventive care, and a lack of referral resources-to providing cessation treatment.

Dr. Donna Shelley and her research team are working to address these barriers. They are implementing a clinical decision support system that uses a previously developed smoking cessation personal digital assistant (SC-PDA). This system involves the use of a handheld PDA to help dentists provide evidencebased guidelines on smoking cessation during patient encounters. Based on the patient information entered, the system helps dentists recommend and prescribe approved pharmacotherapy; facilitates referral of patients to local counseling resources; prints handouts with patient-specific smoking cessation recommendations, instructions, and cessation resources; and documents the visit for the patient's dental record.

This study is using a cross-sectional pre-post study design to assess the impact and acceptability of the SC-PDA. The intervention is being implemented in six general dental care clinics including five New York University College of Dentistry clinics and the Institute of Family Health, a federally-qualified dental health center. Each clinic uses a tobacco use identification system (TUID) to identify patients who are eligible for the study. Patients who consent to the study are administered an exit survey after their dental visit to collect baseline data on dentist adherence to the Public Health Service Guidelines and on patient quit behavior. After collecting baseline data, dentists in all six clinics receive training on the SC-PDA. Two weeks after implementation, clinics again use the TUID to identify patients for the study. Exit surveys are administered to collect data from patients during the intervention period of the study. At the end of the intervention, the research team plans to conduct focus groups with staff from the six clinic sites to collect data on use and acceptance of the SC-PDA.

The SC-PDA is a promising tool to help dentists provide evidence-based smoking cessation assistance. This study will provide an initial assessment of its potential impact and use and will inform future testing and implementation of the SC-PDA in dental health clinics throughout the U.S.

Specific Aims:

  • Test the hypothesis that a clinical decision support system will improve the rate at which dentists assist their patients with smoking cessation by providing information and recommendations on smoking cessation resources. (Ongoing)
  • Assess whether exposure to information and recommendations facilitated by the SC-PDA will: 1) increase the rate at which patients make at least one quit attempt in the month following the dental visit; and 2) increase the reported use of counseling and pharmacotherapy during those attempts over that observed with a tobacco use identification system alone. (Upcoming)
  • Evaluate the acceptance of the SC-PDA into the workflow of dental clinics through semi- structured interviews of dentists and focus groups with staff at the conclusion of the trial, and by measuring the range of use of the SC-PDA with a log on the server that collects aggregate data of each dentist's access of specific PDA screens by time. (Upcoming)

2011 Activities: During the last quarter of 2011, the team revised and updated the SC-PDA tool. The tool was tested in one clinic and is ready for implementation. Participant recruitment was initiated at two of the six dental clinic sites to collect baseline data on provider adherence to tobacco use treatment guidelines.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track and project budget spending is roughly on target.

Preliminary Impact and Findings: This project has no findings to date.

Target Population: Adults

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Synthesis and Dissemination

Testing Clinical Decision Support for Treating Tobacco Use in Dental Clinics - Final Report

Citation:
Shelley D. Testing Clinical Decision Support for Treating Tobacco Use in Dental Clinics - Final Report. (Prepared by New York University School of Medicine under Grant No. R21 HS021002). Rockville, MD: Agency for Healthcare Research and Quality, 2014. (PDF, 417.7 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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