JADA Continuing Education
The use of ‘academic detailing’ to promote tobacco-use cessation counseling in dental offices
DAVID A. ALBERT, D.D.S., M.P.H.,
KAVITA P. AHLUWALIA, D.D.S., M.P.H.,
ANGELA WARD, R.D.H. and
DONALD SADOWSKY, D.D.S., Ph.D.
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ABSTRACT
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Background. The authors conducted this study to ascertain the feasibility of face-to-face educational outreach visits, also called "academic detailing," as a methodology to promote dentists’ adoption and incorporation of tobacco-use cessation counseling activities into their practices.
Methods. The authors obtained a sampling frame of one dental health maintenance organization’s, or DHMO’s, enrolled dentists who practiced in one of four Northeastern states and who had more than 300 DHMO patients. Of 507 eligible dentists, 88 agreed to participate, and the authors randomly assigned them to either intervention (an academic detailing program) or control (practice as usual) conditions. Changes in practice behaviors over time were obtained by questionnaires. The authors used descriptive statistics to analyze data using a statistics software package.
Results. Only 9 percent of dentists who agreed to participate had received any training in decreasing patients’ tobacco use. The authors associated the dentists’ staff members’ considerable resistance to the detailing program with issues such as having to deal with additional paperwork and uncooperative patients, the perception that only a few patients use tobacco and that counseling does not work. Many dentists also expressed concern about their lack of tobacco-use cessation knowledge. Overall, dentists’ resistance to detailing decreased with follow-up detailing visits.
Conclusions. It is feasible to increase and incorporate tobacco-use cessation counseling in dental offices. However, significant barriers must be surmounted first if this goal is to be achieved by use of academic detailing.
Clinical Implications. Using academic detailing, dentists can be effective agents in increasing the longevity, decreasing the morbidity and improving the oral health status of their patients through the promotion of smoking cessation.
Academic detailing" and "data feedback" are terms used to describe two types of educational outreach visits. These visits include face-to-face interaction with the intent of changing a provider’s behavior and his or her clinical practices. Academic detailing—also known as "university-based education detailing," "educational outreach" or "public interest detailing"1—is an intervention that may improve the practice of health professionals by training the provider within his or her own health care setting. Face-to-face counseling of clinicians is a critical aspect of educational outreach. The detailers or educators can be allied health professionals who are well-informed on the subject matter, which enables them to respond to questions on the guidelines or products they are promoting. Literature and materials usually are provided to the dental office by the detailer during the visit, with follow-up materials being provided subsequently to reinforce the encounter. Behavior-change strategies such as academic detailing office visits, usually associated with commercial detailing in the pharmaceutical industry, have been shown to be effective in university-based studies designed to improve physicians’ drug-prescribing behaviors.2,3 It also has been demonstrated that providers are willing to participate in educational outreach using peer-comparison feedback to improve clinicians’ use of tobacco-dependence treatments.4
‘Academic detailing’ visits include face-to-face interaction with the intent of changing a provider’s behavior and his or her clinical practices.
Although academic detailing is one of the few educational interventions that consistently has demonstrated improved physician performance,5 it is not used widely in medicine and it is used even less frequently in dentistry. In a systematic review of 102 clinical trials to improve clinical practice, Oxman and colleagues5 reported that group lectures or conferences that did not include enabling or practice-reinforcing strategies, as well as mailed educational materials, were not effective interventions. Davis and colleagues6 reported that continuing medical education delivery models such as conferences have little direct impact on improving professional practice, suggesting that detailing is more effective. Reminder systems, academic detailing and multiple interventions have a relatively strong effect, while audit and feedback or small-group–based approaches have been found to be moderately effective.7–9
Because recidivism often is associated with interventions that are designed to change behavior, the duration of the planned effect is an important issue.
Some of the most important techniques of academic detailing are
- – conducting interviews to investigate baseline knowledge and motivations for current practice behavior patterns;
- – focusing programs on specific categories of clinicians (for example, specific specialists), as well as on their opinion leaders;
- – defining clear educational and behavioral objectives;
- – using concise, graphic educational materials;
- – highlighting and repeating the essential messages;
- – establishing credibility through a respected organizational identity;
- – referencing authoritative and unbiased sources of information and presenting both sides of controversial issues;
- – stimulating active clinician involvement in the academic detailing process;
- – providing positive reinforcement of improved practices in follow-up visits.
These techniques have been shown to reduce inappropriate prescribing, as well as unnecessary health care expenditures.10
Because recidivism often is associated with interventions that are designed to change behavior, the duration of the planned effect is an important issue. One study of the durability of change in physician practices after interventions involving academic detailing indicated that changes persisted two years after the intervention had concluded.11 Similar improvements and durability were noted in a study of physicians’ breast and colorectal cancer early detection/screening behaviors following an intervention, which included an office-based system and a continuing medical education program for physicians.12
The oral health results of smoking are readily apparent: stained, yellowed teeth and an increase in periodontal disease—particularly gingivitis. Tobacco use also is the most important risk factor in the genesis of oral cancers. However, national surveys suggest that only between 30 and 50 percent of U.S. dentists, and 25 percent of dental hygienists, ask their patients about smoking.13,14 The cessation advice provided in dental offices has been described as "rather ad hoc and somewhat superficial,"15 with less than 20 percent of dentists using an office-based smoker identification system,14 and less than 5 percent providing follow-up services to help patients quit.14 A recent study indicated that fewer than 20 percent of dentists asked more than 80 percent of their patients about tobacco use during the past month.16 Twenty-six percent of dentists advised patients to quit smoking at every or almost every visit, but only one-half of these dentists indicated that they had a specific strategy for discussing tobacco-use cessation with patients who smoke. Meanwhile, only 12 percent recorded counseling behaviors in the charts of 80 percent of their patients.
A study that attempted to compare the quality and quantity of tobacco-use cessation services provided by different health care providers such as physicians, dentists, mental health counselors and by social workers concluded that cessation interventions by dental providers ranked lowest in terms of both quantity and quality.17 Dentists were least likely to have a routine smoker identification system, explain the dangers of smoking and advise patients to stop smoking. In addition, dentists were least likely to provide specific cessation activities, such as setting a quit date or prescribing nicotine replacement therapy, or NRT, such as nicotine gum, nicotine patch or both.
Lack of training and financial incentives are cited most often to explain the reluctance of dentists and dental hygienists to provide tobacco-use cessation interventions.16 Tobacco-use cessation education provided in dental schools is neither comprehensive nor systematic; much of the effort is directed at the consequences of smoking and little attention is paid to cessation activities.18 Nearly 25 percent of dental schools and 36 percent of dental hygiene schools in Canada and the United States do not include questions about tobacco on their health history forms,19 there are few continuing education courses that specifically address tobacco-use cessation,20 and only 19 percent of dentists or dental hygienists have completed formal training in tobacco-use cessation.14 Columbia University’s (New York City) Addressing Tobacco in Managed Care program reported that only 9 percent of the providers surveyed at baseline had received training in tobacco control; however, 95 percent indicated that they were willing or very willing to receive training.16
For a cessation intervention to be truly effective in the dental office, it must become a routine part of dental practice.
Despite the lack of use of tobacco-use cessation activities in the dental office, more than 50 percent of smokers make annual visits to their dentist.21,22 Dental patients, especially those who have insurance, receive dental care on a regular basis. Dental treatment often necessitates dentists’ having frequent contact with patients over an extended period, thus ensuring a mechanism for long-term contact and reinforcement. In addition, the dental provider is in the position of being able to associate cessation advice with readily visible changes in oral status.
There is an increasing emphasis on cosmetic dentistry in dental offices. Patients are more acutely aware of their appearance, and they are requesting whitening agents, porcelain laminate overlays on anterior teeth, crowns and resin-based composites.23–25 All of these treatments counter the effects of staining and poor oral appearance that are caused by smoking. The opportunity to introduce smoking cessation activities as a feature of dental practice is a "natural" in this context. Assuming that dentists’ knowledge and experiences may affect patients’ subsequent practices, an effective way to influence a change in dentists’ tobacco-use cessation activities may be through office-based educational interventions targeting the dental provider.
Our primary goal in conducting this study was to determine whether a tobacco-use cessation–related system could be created, facilitated and maintained within a dental provider’s office. Our secondary goal was to determine whether an office-based educational intervention could increase the prevalence of cessation activities within the dental practices. For a cessation intervention to be truly effective in the dental office, it must become a routine part of dental practice. In this regard, any tobacco-related systems changes introduced into the dental care delivery system must be simple and easily implemented, maintained and enforced. In addition, such a change must be acceptable to the provider.
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METHODS
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We obtained a sampling frame of dentists who were enrolled in a dental health maintenance organization, or DHMO; who had more than 300 DHMO patients; and who practiced in one of four Northeast states (New York, New Jersey, Connecticut or Pennsylvania). We contacted 507 eligible dentists by mail. Of these, 88 agreed to participate, and we randomly assigned them to either an intervention (academic detailing) or a control condition (practice as usual). The institutional review board of Columbia University approved our informed consent procedures.
We implemented an academic detailing program in the intervention offices. The program consisted of an initial in-office continuing education lecture provided by dentist educators. It lasted about one hour and introduced tobacco-use cessation into the dental office. This first visit was followed by three short visits by a dental hygienist detailer. These visits averaged nine minutes in duration and were scheduled at intervals of about one month apart (Box
). We offered dentists $100 to participate in the program, and they were reimbursed by the DHMO for smoking cessation encounters with their patients. Eleven offices dropped out at various stages of the study.
During the continuing education sessions provided to clinicians, dentist educators instructed the clinicians in the "Four As"—Ask, Advise, Assist and Arrange—promulgated by the U.S. Public Health Service, or USPHS.26 USPHS added a fifth "A"—Assess—to the clinician guidelines after the field period ended.27 In addition, dentists received information on tobacco’s oral and systemic effects. They were provided both oral and written instructions on the prescription of NRT. We targeted the "opinion leader" in the office—most typically the office owner—for the intervention; however, we invited the entire dental office team to participate in the tobacco-use cessation continuing education seminar. We offered participants continuing education credits. We used the principles of academic detailing, as defined by Soumerai and Avorn,10 and paid particular attention to identifying clear educational objectives and establishing credibility from an organizational perspective, in this case, the academic/corporate sponsorship of the program. The materials we provided were concise, detailed and highlighted the essential message. The follow-up visits provided positive reinforcement of the message. The detailers maintained a log for expenditures. We restricted analyses of data collected by the academic detailers at each of the four office visits to the use of descriptive statistics using a statistical software package (SPSS, Version 11, SPSS, Chicago).
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RESULTS
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Resistance to academic detailing.
We found that there was some resistance to academic detailing in the dental-office setting. The academic detailers defined this in their logs as participants’ concerns about patient confidentiality, an excess of paperwork and the belief that patients would not cooperate. Barriers to academic detailing included the concern that patients would be uncooperative (25 percent), that there were no or few patients who were tobacco users (22 percent) and lack of knowledge (3 percent). Academic detailing visits appeared to reduce the amount of resistance the academic detailers first encountered and appeared to increase clinicians’ knowledge and confidence over time (Figure 1).
The detailer’s notes reflected significant resistance by front-office staff members to detailing visits. The contact person for academic detailing most frequently was the office manager (70 percent) followed by the owner dentist (33 percent). Other personnel included other nonowner dentists, dental hygienists, dental assistants and receptionists (Figure 2).
Cost of academic detailing.
Cost elements for the intervention component of the research program varied according to geographical location and included recruitment, travel, training and academic detailing time, educational materials, follow-up mail, telephone contact, personnel costs and food provided at each visit. Each session averaged nine minutes in duration, at an average cost of $71 per visit. We estimated personnel costs for the academic detailer, dentist, dental hygienists, dental assistants and office managers for the New York, New Jersey, Connecticut and Pennsylvania locations where we conducted the study. The total average cost for academic detailing was $208.53 per office. The average follow-up contact costs by an academic detailer was $50.29 per office. These follow-up costs included expenses incurred for telephone calls and mailings, and for the personnel required to maintain contact with the participating offices.
The DHMO incurred costs for supporting the detailing and educational efforts through the distribution and creation of tobacco-use cessation booklets to patients identified as tobacco users by the dental office, the provision of supporting time by network managers, administrative support and payment to dentists in the intervention arm for tobacco-use cessation. We determined these payments by calculating the average amount of time allocated to the tobacco-use cessation intervention (three-four minutes) and the average salary of the dental providers in each of the four Northeastern states involved in the study; we obtained average salaries from the Economic Research Institute.28 We took care not to over- or underincentivize dental offices for the time provided. The average cost per intervention office was $433.
The additional compensation for counseling was determined by calculating the average amount of time allocated to the tobacco cessation intervention (three-four minutes) and on the average salary of the dental providers in each of the four Northeastern states involved in the study (average salary amounts were obtained from the Economic Research Institute28). Care was taken not to over- or underincentivize dental offices for the time provided.
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DISCUSSION
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The Cochrane Collaboration has reviewed many studies in which effectiveness of academic detailing has been examined. In a literature review that included 18 studies that were conducted to examine the prescribing practices of physicians, the Cochrane group found that all of the studies reported that academic detailing influenced clinician behavior. In addition, three of the 18 studies reviewed also examined preventive behaviors that included tobacco-use cessation. Another review conducted by the Cochrane group focused on the training of health professionals in smoking cessation. It found that training clinicians had a significant impact on changing patients’ smoking behaviors.29 The effects noted in these studies were small-to-moderate but may have been of practical importance.1
Our study of dentists participating in a large managed care organization plan was a randomized clinical trial of a multicomponent outreach program including written materials, in-office continuing education conferences, reminders, chart audits and feedback to dentists. Despite an intensive effort and the provision of monetary incentives, dentists’ initial willingness to participate in a smoking cessation program was modest; however, once they were enrolled in the program, we observed changes in the clinicians’ practices. It was apparent that reinforcement of the detailing message was necessary to maintain dentists’ tobacco cessation counseling behaviors. We expect that counseling will diminish if detailing no longer is provided. Our experience, however, indicates that having detailers who are energetic, have good interpersonal skills, and have the ability to adapt to a variety of office surroundings, interactions and situations, is essential as is a clear concise message such as the importance of the dentists in cessation counseling.
Although it is feasible to do academic detailing in the dental office, other methodologies may be more efficient and effective. The inclusion of compulsory courses on tobacco-use cessation for licensure, such as the one recently implemented by the New York State Department of Professional Licensing, may have a pronounced effect on dental clinicians’ acceptance of cessation counseling. The concomitant increase in didactic information on tobacco and tobacco counseling within the pre- and postdoctoral dental school curriculum also can have a positive effect on cessation adoption in practice. Detailing of dental offices by pharmaceutical detailers who represent companies promoting tobacco-use cessation products such as NRTs that are available over the counter as patch or gum, or by prescription as lozenges, sprays or inhalers and non-NRT such as bupropion has been sporadic and inconsistent.
Face-to-face academic detailing for tobacco-use cessation in dental offices is labor-intensive and expensive, but it can succeed if contact is frequent. The acceptance of a tobacco-use cessation program increases with each succeeding detailing visit. Regular contact, reinforcement and repetition reduce clinicians’ concern and apprehension. Front-office staff members are critical to the success of a program in a practice. In our study, however, front-office staff members presented the detailer with obstacles to implementing the program. Resistance of dental practice staff members fell into the following categories: reluctance to schedule initial educational visit, skepticism about the efficacy of tobacco-use cessation counseling, belief that patients would not cooperate, confidentiality issues, unwillingness to deal with additional paperwork and lack of knowledge. Therefore, for the program to be successful, these concerns first must be addressed and resolved.
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CONCLUSIONS
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Face-to-face academic detailing would be costly to implement in a large dental network and requires significant time expenditure. Front-office staff members are critical to its success. Dental offices require incentives if they are asked to enlist the cooperation of patients. Much of the resistance encountered during the earlier detailing visits appeared to dissipate at the second and third academic detailing visits. This may reflect the fact that regular contact, reinforcement and repetition reduce concern and apprehension.
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Dr. Albert is an associate professor, Clinical Dentistry, Division of Community Health, Columbia University School of Dental and Oral Surgery, New York City, and is an assistant professor, Clinical Public Health, Division of Health Administration, Mailman School of Public Health, Columbia University. Address reprint requests to Dr. Albert at Columbia University School of Dental and Oral Surgery, 630 West 168th St., New York, N.Y. 10032, e-mail "daa1{at}columbia.edu".
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Dr. Ahluwalia is an assistant professor, Clinical Dentistry, Division of Community Health, Columbia University School of Dental and Oral Surgery, New York City.
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Ms. Ward is the coordinator, Tobacco Cessation Program, Division of Community Health, Columbia University School of Dental and Oral Surgery, New York City.
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Dr. Sadowsky is professor emeritus, Clinical Dentistry, Division of Community Health, Columbia University School of Dental and Oral Surgery, New York City, and is professor emeritus, Clinical Public Health, Division of Sociomedical Sciences, Mailman School of Public Health, Columbia University.
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FOOTNOTES
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This study was supported in part by grants from the Robert Wood Johnson Foundation and Aetna Dental.
The authors wish to thank Drs. Ed Schooley, Marvin Zatz and Thomas Gotowka for their support and assistance in implementing this project within the managed care organization that participated in the study. The authors also would like to acknowledge the assistance of Deepa Prasad and Faith Miller-Sethi, graduate students in the Mailman School of Public Health, Columbia University, New York City.
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TOP
ABSTRACT
METHODS
