the evidence base for community preventative services and examples from states of astdd best...
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The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices
Dolores Malvitz, DrPHChief
Surveillance, Investigation, and Research TeamDivision of Oral Health Centers for Disease Control and Prevention
(CDC)Atlanta, Georgia
Texas Oral Health Summit: Advocacy, Equity & AccessAustin, Texas
September 9-10, 2004
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Systematic Reviews and Evidence-Based
Recommendations
Promoting Oral Health
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The Community Guide Is:
• A set of recommendations for action based on the scientific evidence
• Evidence comes from systematic reviews
• Reviews coordinated by CDC staff• Recommendations determined by
independent Task Force
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What Will Be Reviewed in the Community Guide?
• Sociocultural Issues
Specific ConditionsRisk Behaviors
The Environment
• Vaccine Preventable Disease• Pregnancy Outcomes• Violence• Motor Vehicle Injuries• Depression• Cancer• Diabetes• Oral Health
•Tobacco Use •Alcohol Abuse/Misuse• Other Substance Abuse• Poor Nutrition• Inadequate Physical Activity• Unhealthy Sexual Behaviors
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Healthy People 2010
Guide to ClinicalPreventive Services
Priorities for Prevention
Put Prevention
into Practice
The Community Guide is Part of a Family of Federal Initiatives
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Promoting Oral Health
Recommendations from the
Guide to Community Preventive Services
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Oral Health ChapterCommunity Guide
Interventions for Preventing:
• Dental Caries
• Oral and Pharyngeal Cancers
• Sports-related Craniofacial Injuries
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Methods for Conducting Systematic Reviews: Five Steps
• Develop conceptual approach• Search for and retrieve evidence• Rate quality of evidence• Summarize evidence• Translate strength of evidence into
recommendation
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Key Findings
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Oral Health ChapterCommunity Guide
Strong evidence for:• Community water fluoridation
• School sealant programs
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Translate strength of evidence into recommendations
Preventing dental caries• Community water fluoridation
(strongly recommended)• School-based sealant programs
(strongly recommended)
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Oral Health ChapterCommunity Guide
Insufficient evidence for:
• Community-wide sealant promotion programs
• Oral cancer awareness and screening programs
• Promoting use of dental and craniofacial protectors in contact sports
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Insufficient evidence should not be confused with evidence of
ineffectiveness
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Benefits of the Community Guide
• Stronger foundation for advocacy, research, and programs –proof of effectiveness may be better
(semi-quantitative vs. narrative summary)
–recommendations issued by independent, objective Task Force
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www.thecommunityguide.org
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ASTDD Best Practices Project
Putting scienceinto practice
www.astdd.org
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Purpose of the Project
(1)Provide guidance for programs
(2)Meet the Surgeon General’s Call to
Action
(3)Help achieve Healthy People 2010
objectives
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Best Practice Approaches
Dental public health strategies
supported by evidence
of effectiveness.
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Best Practice ApproachesStrength of Evidence
Promising ProvenApproaches....................….….…….....….…
Approaches
Strength of Evidence
Research + Research +++
Expert Opinion + Expert Opinion +++
Field Lessons + Field Lessons +++
Theoretical Rationale +++
Theoretical Rationale+++
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Strong Evidence
Research Evidence
+++ Systematic review
Expert Opinion
+++ Multiple authoritative sources
Field Lessons
+++ Cluster evaluation of several states
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Best Practice ApproachesStrength of Evidence
Best Practice Research Expert FieldTheoretical
Approaches Opinion Lessons Rationale
Surveillance Systems + +++ ++ +++
State Coalitions + +++ ++ +++
State Plans + +++ ++ +++
State Mandate for Program + +++ ++
+++
Community Water Fluoridation +++ +++ ++
+++
School Sealant Programs +++ +++ ++ +++
School Fluoride Programs ++ +++ + +++
Workforce Development + +++ ++ +++
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Community Water Program Evidence Supporting Effectiveness
Summary of Evidence Supporting
Community Water Fluoridation
Research +++
Expert Opinion +++
Field Lessons ++
Theoretical Rationale +++
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School-based Sealant ProgramsEvidence Supporting Effectiveness
Summary of Evidence Supporting
School-based Dental Sealant Programs
Research +++
Expert Opinion +++
Field Lessons ++
Theoretical Rationale +++
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Best Practice Criteria
Effectiveness
Efficiency
Collaboration & Integration
Sustainability
Rationale & Objectives
“Best Practice”
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ASTDD Best Practices Project
Community Water Fluoridation
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Description of a Community Water Fluoridation Program
Legislation & policies
Advocacy & promotion
Supporting communities starting fluoridation
Training, monitoring, surveillance, reporting and inspection
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Description of a Community Water Fluoridation Program
Collaborate with water quality and other partners
Develop human resources to support community water fluoridation efforts
Secure financial resources to support community water fluoridation efforts
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Best Practice Criteria(1) Effectiveness
Review Standard:
Compare % population served by water systems with optimally fluoridated water to HP 2010 target (75%).
State population with optimally fluoridated water
Illinois 99%
Indiana 95%
Texas 66%
Arkansas 60%
Mississippi 39%
California 29%
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Best Practice Criteria(1) Effectiveness
Review Standard:
Document number of communities or public water systems with optimally fluoridated water.
In 2002: 44 of the 50 largest cities in the U.S. fluoridated
Illinois: 860 of the 1800 community water systems adjust their fluoride levels
Indiana: 482 water systems adjust their fluoride levels
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Best Practice Criteria(2) Efficiency
Estimating costs
Initial cost of capital equipment
Replacement cost of capital equipment
Annual operational costs (chemicals, human resources, maintenance & repairs)
Review Standard:
Compare average state cost for fluoridation (cost per per person year) to national estimates.
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Best Practice Criteria(3) Sustainability
State Community Water Fluoridation Programs
Indiana since 1950’s
Oklahoma since 1950’s
Missouri since 1960’s
Virginia since 1980’s
Review Standard:
Demonstrate sustainability through the number of years that identifiable water fluoridation program at state level has operated.
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Best Practice Criteria(4) Collaboration & Integration
Fluoridation PartnersProfessional association
Grant makers
Health departments
Water authorities
Universities
(dental, medical and public health schools)
Dental hygiene programs
Local community leaders
Review Standard:
Demonstrate partnerships & coalitions with stakeholders and organizations to provide political, financial and scientific expertise to local constituents.
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Best Practice Criteria(5) Rationale & Objectives
Healthy People 2010 Objective 21-9
Increase proportion of U.S. population served by community water systems with optimally fluoridated water
2010 target: 75%
Review Standard:
Program is linked to state &/or national goals and objectives.
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ASTDD Best Practices Project
School-basedDental Sealant Programs
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Description of School-based Sealant Programs
Program conducted within the school setting
Provide education to increase awareness of the benefit of sealants
Obtain parental consent for screening/sealants
Program provider teams include dentists, dental hygienists and dental assistants
Utilize portable dental equipment or a fixed dental facility within the school setting
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Description of School-based Sealant Programs
Usual practice: Dentists examine the children and prescribe the sealants; dental hygienists apply the sealants
For quality assurance, children re-examined within 1 year after sealant placement to check on retention and need for repair
The program should address unmet dental care needs of children
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State Practice Examples
Illinois Dental Sealant Grant Program
Ohio Dept. of Health School-based Dental Sealant Program
Arizona Dental Sealant Program
New Mexico School-based Dental Sealant Program
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Best Practice Criteria(1) Effectiveness
Review Standard:
Program delivers to a large number of high risk children.
Sealant Programs
Ohio 28,000 children
Illinois 21,000 children
Target Schools50-65% students infree & reduced lunch programs
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Best Practice Criteria(1) Effectiveness
Review Standard:
Program maintains a quality assurance system.
Sealant retention
Arizona
1-week assessment
1-year assessment
New Mexico
1-year assessment
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Best Practice Criteria(1) Effectiveness
Sealant Prevalence
Ohio children aged 8:
11% in 1988
30% in 1999
New Mexico 3rd graders:
47-52% in health district
with program
19% in health district
without program
Review Standard:
Documentation of program benefits or outcomes.
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Best Practice Criteria(2) Efficiency
New Mexico
Dentists screen children
Dental hygienists apply sealants
Dental assistants also apply sealants
Review Standard:
Program uses the least expensive personnel permitted by state law.
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Best Practice Criteria(3) Sustainability
Sealant Programs
New Mexico 26 yrs.
Ohio 20 yrs.
Illinois 19 yrs.
Arizona 17 yrs.
Funding
Ohio…MCH/Tobacco $
Arizona………Medicaid
Review Standard:
Program with a track record or a plan for covering program expenses.
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Best Practice Criteria(4) Collaboration & Integration
Sealant PartnersLocal health departments
Community agencies
School health services
Medicaid
Primary Care Office
Foundations
Private dentists & dental hygienists
Review Standard:
Partnerships are established to administer & sustain the program.
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Best Practice Criteria(5) Rationale & Objectives
Healthy People 2010 Objective 21-8:
Increase of childrenwho have receivedsealants on theirmolar teeth
Aged 8 years 50%
Aged 14 years 50%
Review Standard:
Program is linked to state &/or national goals and objectives.
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ASTDD Best Practices Project
Putting scienceinto practice
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www.astdd.org
Best Practice Approach Reports
ASTDD Web Site
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www.astdd.org
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Building a System:Ongoing and Dynamic Development
IdentifyBest
Practices
Cultivate Best
Practices
PromoteBest
Practices
Collaborate& Integrate
Science& Art
Supportive
Environment