Journal of Evidence-Based Dental Practice
Volume 8, Issue 3 , Pages 186-194, September 2008

Enabling General Physicians to Perform Periodontal Screening During Nationwide Periodic Health Examinations

  • Claudia Luciak-Donsberger, PhD, MA, RDH

      Affiliations

    • Corresponding Author InformationCorresponding Author: Claudia Luciak-Donsberger, PhD, MA, RDH, Department of Periodontology and Prophylaxis, Bernhard Gottlieb School of Dentistry, Medical University of Vienna, Austria, Tel 4369912008324 Fax 4319147934, Satzberggasse 8/9, 1140 Vienna, Austria
    • ,
  • Franz Piribauer, MD, MPH
    • ,
  • Nadia C. Taylor, BA

Department of Periodontology and Prophylaxis, Bernhard Gottlieb School of Dentistry, Medical University of Vienna, Austria; Center for Applied Epidemiology and Health Policy, Vienna, Austria; and UC Berkeley Joint Medical Program, Student of medicine/ UC San Francisco, CA, USA

Article Outline

Since 2005, Austrian physicians have screened for periodontal diseases during free-of-charge periodic health examinations (PHE). Various printed and online materials were designed to inform patients and to support general physicians (GPs) to perform this intervention. Aim: The aim of this study was to examine whether existing clinical decision support (CDS) resources effectively enhance the potential benefits of periodontal screening (PS) by physicians. Method: Existing printed and online CDS for PS were analyzed and experts were interviewed to ascertain the utility and use of these resources and the existence of Continuing Education (CE) courses to enable GPs to perform PS. The analysis followed the guidelines of the American Medical Informatics Association on determining the quality of CDS. We asked whether existing CDS for PS provided best knowledge when needed; whether it was easily accessible, accepted, widely used, and improved the quality of care; and whether there was continuing improvement based on feedback, experience, and scientific data. Results: Several Internet-based and printed CDS resources pertaining to PS were identified, with varying degrees of distribution and utilization. However, no formal evaluation had been conducted to determine whether existing CDS systems were used, whether physicians felt that they were of benefit, or whether they enhanced quality outcomes of PS. The findings correlated with other studies and showed that general use of CDS by clinicians was still low. Conclusion: There is no evidence that Austrian physicians perform PS according to mandate. Current CDS requires evaluation and improvement and CE courses should be offered to support GPs in performing PSs.

Keywords::  Periodontal screening, clinical decision support, periodic health examination, prevention, periodontal risk assessment, dental hygiene care, medicine and dentistry interface, general physicians, Austria, evidence-based

 

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Introduction 

Periodic Health Examination (PHE) and Clinical Decision Support (CDS) 

Periodontal Screening as Part of the Periodic Health Examination 

In 2005, a screening procedure for periodontal diseases (PD) was included in the newly revised Austrian National Periodic Health Examination (PHE), a national mass-screening program at the primary care level. Every Austrian resident older than 18 years is eligible to receive one PHE per year free of charge; of a population of 8 million, about 6 million are eligible. PHEs are administered by general physicians (GPs) and are funded by the Austrian Health and Social Insurance Funds (SV). SV provides nearly universal health coverage of the Austrian population and is mandated by law, following the Bismarkian model of health and social insurance coverage.1 Prior to 2005, the PHE consisted of standardized but unspecific interventions. From 1975 to 2004, a total of 13 million annual medical check-ups at GPs and primary care practitioners were reimbursed. From 2005, the PHE interventions were changed to reflect current scientific evidence, and for the first time, include screening for PD. The evidence-based (EB) decision process that led to the inclusion of PD as 1 of 15 target diseases for screening has been described.2 In the Austrian Health Service, Periodontal Screening (PS) consists of a 3-step intervention, based on current knowledge about risks for progression of PD. Step 1 combines an evaluation of systemic and behavioral risk factors based on patient histories. Step 2 consists of self-reports by patients on their perceived clinical symptoms, and Step 3 consists of the results of a brief intraoral screening assessment estimating the presence of disease. This inspection requires a wooden tongue blade, clean gloves, and the best available source of light. Outcomes are scored from 0 to 2. Scores determine oral hygiene recommendations and referral for periodontal diagnosis, prevention, and treatment.

Periodontal screening by physicians: A controversial issue 

The newly designed EB PHE and, in particular, periodontal screening (PS) have been controversial from the start. There has been resistance from the Austrian medical community to making the fundamental changes required to bring EB practice into the health examination3 (which has been conducted without change for over 30 years), as well as to accept new interventions in which physicians have no prior training.4

The objectives of including PS are to assess risk factors for PD, which in Austria frequently remain undiagnosed and untreated,5, 6 to raise public awareness about prevention and treatment, as well as to refer at-risk persons for periodontal care. However, both the medical and the dental communities voiced concerns about this initiative and appeared to resist collaboration in the detection and treatment of PS. After the inception of PS as part of the PHE, the Austrian Society of Periodontology (ÖGP) and the Austrian Society for General and Family Medicine (ÖGAM) issued statements to the Supreme Advisory Board to the Ministry of Health requesting changes. The ÖGP requested that only Step 2 (self-reports by patients on their perceived clinical symptoms) should be retained and that Step 3 (intraoral inspection) should be eliminated, whereas the ÖGAM requested that the entire screening be replaced by a general (rather than case-specific) recommendation for every patient to visit the dentist. Both sides conceded that the subject of oral health should remain part of the PHE; however, their approach differed and still differs and precludes clinical decision making on part of the physicians to arrive at a risk score. Representatives of both groups have voiced a concern that physicians are insufficiently trained to detect visible signs of PD. However, at present, the initial concept of PS during PHEs is expected to remain in place, and is legally binding in order for GPs to be reimbursed for PHEs. This program currently requires extensive CDS in order to succeed.

Creating CDS to enhance acceptance of periodontal screening by medical and dental communities 

Evidence supports the need to acknowledge the interface between medicine and dentistry. The widely discussed Report of the Surgeon General on Oral Health in America (2000)7 included the following recommendation: “Too little time is devoted to oral health and disease topics in the education of nondental health professionals. Yet all care providers can and should contribute to enhancing oral health. This can be accomplished in several ways, such as including an oral examination as part of a general medical examination, advising patients in matters of diet and tobacco cessation, and referring patients to oral health practitioners for care prior to medical or surgical treatments that can damage oral tissues….Health care providers should be ready, willing, and able to work in collaboration to provide optimal health care for their patients.”

In addition, a number of observational studies suggest an association between PD and various systemic illnesses, such as a potentially increased risk for atherosclerosis, cardiovascular disease, and stroke, as well as adverse pregnancy outcomes.8, 9, 10, 11, 12, 13 Researchers have found that periodontal treatment may improve vascular endothelial function.14, 15 Clearly the time has come to acknowledge the interface between medicine and dentistry and to encourage collaboration between the disciplines.

Quality clinical decision support (CDS) resources have the potential to facilitate the acceptance of PS as part of the PHE by the dental and medical communities and may enhance chair-side decision making.16 Effective CDS must be informative, user friendly, and accessible to physicians, dentists, dental hygienists, and patients when needed. If well designed, CDS may help providers and patients in routine daily practice to provide optimal care. These tools may range from printed forms to computer-based software. Lesson plans and e-learning for medical students or as a Continuing Education (CE) resource for practicing physicians may also enhance the medical community in acknowledging that oral health is connected to general health.

The American Medical Informatics Association has identified 3 major components (referred to as “pillars”) as essential for good-quality CDS.17, 18 These three criteria for evaluating the quality of CDS are formulated as the following questions:

(1)Is the best knowledge available when needed? EB clinical knowledge supporting the decision-making process during PS should be well organized, accessible to all, and written, stored; and transmitted in a user-friendly format. CDS should facilitate workflow and improve the accuracy of the determined risk score for PD.

(2)Is there a high adoption and effective use of the CDS resources? In the case of PS, are resources accessible, extensively used, and produce significant clinical value such as improving the quality of care, while making financial and operational sense to their end-users and purchasers?

(3)Is there continuous improvement of knowledge and CDS methods? Both CDS interventions and clinical knowledge should undergo continuous evaluation and improvement based on feedback, experience, and data that are easy to aggregate, assess, and apply.

Clinical decision support for periodontal screening in Austria 

Since 2005, a number of CDS resources have been funded, designed, and distributed by the Austrian SV, with the objective to improve outcomes of the PHE. Informative Web links have been established to support physicians in performing the new screening activities. Internet resources were also developed for the public to learn the important facts about the PHE, including PD prevention and treatment.19 Of interest is who contributed to the design of these products, whether or not utilization has been monitored or evaluated, if and to what extent screenings are conducted according to directives, and whether or not these resources are affecting outcomes according to the criteria mentioned above. The aims of this study were therefore to examine whether or not CDS materials (1) were widely used and accepted, (2) facilitated screening outcomes for PD, (3) enhanced the willingness of physicians to perform PS, (4) improved the accuracy of the determined risk scores for PS, and (5) resulted in increased referrals to periodontal care.

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Method 

Currently available CDS resources that have potential to enhance outcomes of PS as part of the PHE were analyzed to examine their effectiveness according to the guidelines of the American Medical Informatics Association (AMIA) on clinical decision support. The authors examined the official websites of the Federal Ministry of Health, the Federal Medical Association and the SV, for specific information pertaining to the PHE, and followed the links to further information on PS intended for physicians or patients.

Relevant resources were described and analyzed according to the 3 major components identified by the AMIA as essential to high-quality CDS.17, 18 The following questions were asked:

•Does existing CDS for PS provide best knowledge when needed?

•Is the existing CDS for PS easily accessible, accepted, widely used, and does it improve the quality of care?

•Is there continuing improvement of the existing CDS interventions based on feedback, experience, and scientific data?

Furthermore, experts designated by the SV to manage and evaluate the new PHE were interviewed and asked what kind of CDS materials had been produced and distributed and whether or not these resources had been evaluated through physician or patient feedback. Enquires were made about their frequency of distribution and use, and whether or not the actual performance of PS had been evaluated, ie, whether physicians assigned risk scores for periodontal disease as legally mandated, whether or not the determined risk scores were clinically accurate, and whether or not there was information about referrals for periodontal care or the outcomes.

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Results 

Existing CDS Resources for Periodontal Screening 

Resources identified include EB clinical guidelines, patient data reports and documentation templates, diagnostic support, and clinical workflow tools. It appeared that there were no CE courses to guide physicians in performing PS. The following printed and online resources were found:

(1)A reference book for physicians titled PHE New - Scientific Basic Principles, explaining the EB rationale for each of the 15 target-conditions screened for during the PHE, including PS20;

(2)A summary pamphlet for physicians based on the EB reference book21;

(3)Forms (health histories by SV and ÖGAM and health information summaries by SV) to determine and record risk scores for PD, and to report findings to the SV22, 23, 24;

(4)Resources for the public informing about and advertising the PHE, including the rationale for PS.25, 26

The SV created and funded elaborate computerized information to support the implementation of the revised PHE. The information is accessible online at the main page for the SV under the term “Vorsorgeuntersuchung” (German for PHE).19 On the main Web page pertaining to PHEs (Figure 1), the public is informed that the SV and the Austrian Chamber of Physicians have implemented an innovative preventive health program based on current EB findings. The scientific rationale for the inclusion of PS is specifically mentioned, as well as the fact that Austrians carry a comparatively high burden of PD and that there is an objective to promote better periodontal care for the population.

This site provides access to each of the resources listed below and to photographs showing physicians performing various steps of PHEs.27 According to information from the SV, the number of visits to their general Web page or to the PHE information page or downloads of any of the resource links was and is not presently being monitored. Therefore use was impossible to evaluate. Monitoring is expected to commence sometime in 2008.

EB reference book for physicians 

Concurrent with the inception of the revised PHE, the SV contracted the production of a 201-page online and printed reference book for physicians titled Revised PHE -Scientific Basic Principles. This book constitutes the first published EB guidelines for a PHE. Twenty-one chapters describe the EB rationale for each of the 15 target conditions. A printed version was intended to be distributed to all approximately 4700 GPs who conduct PHEs. However, in order to reduce costs, the book was placed online for downloading.28 Printed copies were and are available on order for Euro 19 (30 USD) (Figure 2).

The book was designed with the objective of presenting scientific facts in an accessible, user-friendly language. It contains summary tables and suggestions on how to proceed during the screening process. A 9-page chapter on PS, titled “Periodontal Diseases: Prevention and Early Detection,” provides the referenced EB rationale for this intervention, including information on the multifactorial etiology of PD, disease progression, estimates of the morbidity in Austria, and, most importantly, EB preventive measures. The chapter provides the rationale for the 3 steps of PS, describes what to look for during the intraoral inspection, and how to arrive at a risk score. There are no pictures included to show how to discern periodontal health from disease.

To estimate the actual utilization of this reference book, it was of interest to know how frequently it was downloaded or ordered in print. Although the number of downloads or print orders were not monitored officially, it is estimated that about 115 printed copies have been requested.

The book provides the best EB knowledge available justifying PS and a practical guideline for its clinical application. It is readily available (if physicians know where to look), but complicated to download. The 201-page book is too extensive for day-to-day use, but whether or not GPs accepted this resource or considered it beneficial or whether or not it improved the outcomes of PS is unknown. In order to answer these questions, physician surveys are needed. An upcoming survey among GPs as part of the legally mandated evaluation of the entire PHE may include an inquiry about the utilization of the guide. Informal interviews suggested that many GPs and dentists have never seen it so it may be desirable to distribute the printed version free of charge.

Since the reference book has not been updated or evaluated, it can be concluded that no improvements based on feedback, experience, and scientific data have been made.

Summary pamphlets for physicians based on the EB reference book 

In 2005, a 48-page summary of the EB reference book was produced. Only one of the original authors participated in the design of this resource. It can be downloaded,21 but was also distributed in print free of charge to GPs. The SV reported that 11,310 copies were printed and distributed between 2006 and 2008.

In the process of condensing the reference book, some of the original EB recommendations regarding PS were changed. Among other significant changes, patient recommendations from the EB reference book in relation to risk scores have been shortened and altered. For instance, there is no mention of referral to professional preventive care or to periodontists, or of the management of behavior risk factors (such as smoking).

When evaluating the above CDS according to AMIA criteria, this resource no longer provides the best EB information available to conduct PS or to guide patient recommendations. Greater care should have been taken to retain EB facts guiding clinical decision making; however, this resource is easily accessible and well distributed. Online downloads are not monitored and there has been no evaluation of the extent to which GPs use this resource, or if they consider it beneficial to clinical decision making or whether it promotes accuracy in the determination of periodontal risk scores. These aspects need to be addressed in the upcoming physician survey.

Health questionnaires and health information summary forms for patients and physicians 

In 2005, as none existed, new computer-readable forms had to be designed to document findings and assist work flow. The contents were in part based on research by an independent institution from the Netherlands Institute of Primary Care Research (NIVEL) and EB facts presented in the reference book.29

Forms include 2 patient questionnaires (a health history and a voluntary questionnaire to detect problematic alcohol consumption) and a printed, computer-readable or fully electronic health information summary form (HIS) to be completed by physicians who record diagnostic findings and risk scores.

The health history forms include questions about systemic health required to complete Step 1 of PS (systemic and behavioral risk factors) and the self-evaluation quiz of Step 2 (questionnaire about potentially perceived clinical symptoms of PD).22 The HIS includes results of Step 3 of PS (intraoral inspection) as well as a section for determining a risk score for PD based on integrating all 3 steps.23 HIS forms must be sent to the SV. However, GP reimbursement of Euro 75 (around 110 USD), is independent of form completion, and based on an electronic chip card charge for insured persons.

On the SV health history forms, questions pertaining to Step 2 of PS (self-reports on their perceived clinical symptoms) were consolidated from the original 6 into 4, without prior testing of their effectiveness. ÖGAM has created its own health history form.24 Here, the original version of 6 questions for Step 2 of PS remains unchanged. It is unknown on what grounds some EB recommendations were eliminated.

For PS, the change is potentially significant and may explain the negative reaction of the Austrian Society of Periodontology (ÖGP). Not only are several EB referenced guidelines on what to look for during the intraoral inspection missing, but there are also no guidelines on how to integrate results from Steps 1, 2, and 3 to arrive at a risk score. Table 1, Table 2 show what was left on the HIS of the original risk-score-dependent recommendations from the EB reference book. Efficacy of PS is thus dependent on the use of the EB reference book or on additional physician training. So far, there are no CE courses to prepare GPs for PS. Informal interviews with about 30 physicians suggest that many who have objected to PS have never read the chapter on PD in the EB reference book.

Table 1. Patient recommendations from evidence-based reference book in relation to risk scores for periodontal diseases
Periodontal Risk Scores Recommendations
Risk score 0, 1, 2: Brush teeth at least once every 24 hours with a fluoride toothpaste, and clean interdental spaces with floss or interdental brushes. Professional consultation and instruction is required to ensure efficacy.
Risk score 1: Referral to professional preventive care (such as oral hygiene instruction, scaling and/or rootplaning at a dental office. Management of behavior risk factors such as smoking.
Risk score 2: Immediate referral to a periodontist or dentist who offers periodontal care and collaborates with dental hygienists for oral hygiene instruction, conservative and, if indicated, additional periodontal therapy.
Table 2. Health History Summary Form: What was left of evidence-based practice: Periodontal Screening—PD risk scores and abbreviated recommendations
Periodontal Risk Score
Healthy gingiva □ yes = 0 □ no □ 0: careful cleaning every 24 hrs
Calculus/Plaque/Mundgeruch Smoking/Hormon change (z.B. Puberty, Menopause)/Diabetes mellitus/Motor impairment
Interfering with hygiene □ yes = 1 □ no □ 1: Referral to professional cleaning
Redness, swelling, mobility □ yes = 2 □ no □ 2: Referral to dentist

Mundgeruch = halitosis; z.B. = for example.

When applying AMIA criteria to determine the quality of this CDS resource, it is highly accessible and widely distributed and controls the work flow for every PHE and PS conducted, provided findings are documented as mandated. Health histories make it impossible to ignore Step 1 and Step 2 of PS. However, missing EB guidelines on how to arrive at a risk score and altered recommendations invite error and negligence and increase the likelihood that false positives or negatives are assigned. Greater care should have been taken to retain EB facts guiding clinical decision making. The extent to which GPs fill out risk scores for PD, consider the shortened instructions sufficient to support clinical decision making, or whether or not they require or desire additional resources has not been evaluated. These aspects need to be addressed in the upcoming physician survey.

Resources for the public informing about and advertising the PHE 
Online information about PS as part of PHE 

A 41-page pamphlet titled “Benefits of the new PHE” (similar but not identical to the summary pamphlet for physicians) can be downloaded as a PDF file by people who want to know more about the PHE and the EB rationale underlying its specific target-interventions.25

The EB information on PD and PS was downscaled to 1 page. The wording of the recommendations was changed with an emphasis on oral hygiene, including interdental cleaning, on professional dental hygiene care and periodontal therapy for patients with elevated risk scores, as well as on behavior management such as smoking cessation. The layout of this resource is not as user friendly as the summary pamphlet for physicians (less colorful, missing tables, and so forth) and the language sometimes lacks adaptation to “lay” vocabulary. This pamphlet has not been distributed in print nor has the SV monitored the frequency of downloads. Furthermore, the above-mentioned patient satisfaction survey does not include questions about the utilization of or the satisfaction with this resource. Quality standards according to AMIA therefore cannot be evaluated, as it is unclear if this resource is used at all.

Brief introductory pamphlet advertising the PHE 

As part of an extensive marketing campaign for the PHE, the SV produced a colourful 2-page pamphlet to be distributed to patients in print and online. In order to reach members of Austria's largest minorities, the folder has been translated from German into Serbian, Croatian, Turkish, and Bosnian and recently into English.26 Readers are informed of the target interventions of the PHE and their objectives. For PD, the stated objective is prevention. No mention is being made that they can successfully be treated. Some of the medical terminology (“periodontal disease” rather than “gum disease”) may be difficult to understand for some lay people. The English translation pertaining to PS is factually incorrect and we advised to SV to revise (Figure 2). Since 2006, 436,085 copies have been printed and distributed in German. There has been no evaluation, whether and to what extent this folder has been read by patients or whether it has had an impact on encouraging patients to go to the PHE. A patient satisfaction survey did not inquire about the utilization of or satisfaction with this resource.

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Discussion 

The above-mentioned CDS resources show that the Austrian SV has made a variety of materials available in print and online, with the intention of informing physicians and the public about the newly designed PHE and to improve work flow and transparency of data. To evaluate the quality of these resources, the criteria of the AMIA for the assessment of quality CDS were applied.17, 18 A range of shortcomings were found and we see room for improvements.

Downloads and use of current CDS were not monitored and physician acceptance of these materials were not evaluated. In addition, EB facts were lost through various steps of shortening and consolidating information. For these reasons, it is impossible to evaluate these resources according to the criteria of the AMIA, as there is no information about whether they are beneficial or improve outcomes.

A survey of patient satisfaction with the PHE, conducted by the organization contracted to perform the mandated evaluation of the PHE, was sent out to 27,000 patients who had engaged in a PHE (response rate 8000). However, this survey did not include questions about PS, or, more specifically, whether or not GPs performed an intraoral inspection or whether or not they informed patients about risk scores for PD or gave recommendations on prevention and treatment referral.

Since PS is an additional and contested target intervention of the PHE program, quality could be assessed at this “weak link” in the chain of interventions. We contend that asking patients whether oral “gum inspection and assessment” has occurred during their PHE would be a reliable measure for the coverage of PS and thus for the completeness of program performance during the examination. Informal interviews with person who underwent a PHE suggest that some GPs performed PS and others did not. Quality management criteria consider an assessment of patient experience, ie, if a specific service activity has or has not occurred, to be significant feedback for improving a complex service program.30

Despite the planned comprehensive central electronic data collection (HIS forms) performance data are still lacking. If filled out as mandated, 800,000 computer-readable paper forms are generated each year resulting in as many periodontal risk score assignments. These results would constitute an invaluable potential resource for an evaluation of utilization and outcomes. However, no investment has been made to scan the forms and store the data electronically. The paper forms are stored in boxes with the various state health insurance providers of the SV and do not appear to be used for further evaluation. As a consequence of this handling, it was decided not to use the forms for evaluations, and to dismiss an idea to draw a small representative sample and use statistical estimations for the legally mandated evaluation of the PHE. Therefore, current evaluations do not include findings from HIS forms or monitor any type of possible follow-up (preventive activity, referral, early treatment, outcomes in connection with risk scores).

No investment was made to enter data from paper HIS forms online, since it was hoped that physicians would transmit their data electronically into the central SV database. In practice, nearly all physicians have refused to do this, although the technology has been available since 2007. On the fully electronic version of the HIS, for PS there is a specific section to enter risk factors generated by the 3-step approach. The computer has the capacity to calculate a risk score for PD. Online assistance is provided on how to use these forms.31

In the first 6 months of 2007, only a tiny fraction of physicians (0.1%) delivered their data electronically (350 HIS were collected in the central database). Apparently, Austrian physicians, for a variety of reasons (fear of transparency, concern of anonymity) have boycotted electronic data collection.32 From a recent comparative research project, in which one of us participated, it is known that in Germany and Austria there is greater reluctance than in other EU countries to hand in individual sensible data to central authorities. The main reason stated is a lack of trust that data will not be misused for yet unstated purposes.33

Expert interviews with a representative of the SV suggest that the Austrian Chamber of Physicians may be close to accepting electronic data submission. When this is achieved, data could be easily accessed and the quality of epidemiological and outcome evaluations would be greatly enhanced. The willingness and the ability of GPs to assign risk scores for PD could be statistically analyzed. This could promote an open discussion on the quality of CDS needed or desired to improve accuracy of risk determination.

The question remains, whether entirely electronic data collection is absolutely necessary to measure performance and quality? While data would certainly be better organized and accessible than is currently the case (hundreds of thousands of HIS forms are collecting dust in boxes), complete electronic data on 800,000 PHEs per year are not essential for statistical evaluations. Since random sampling is a more reliable statistical method than an always-incomplete total data collection, analyzing 8000 HIS per year (a 1% sample) would generate reliable national estimates of the performance and quality of PS documentation. As the HIS were designed to be read in by high-speed scanners, the extraction of electronic data from the paper forms was already prepared for. The cost for the statistic sampling mentioned above can easily be justified, in light of an expense of around 65 Mio Euro (100 million USD) spent to reimburse PHEs in Austria.34

Very obvious is the lack of teaching materials for GPs to support screening for PD. Examples of teaching materials for preventive services can be found in the Australian green book of the Australian Royal College of Physicians.35 One of us has prepared visual aids and a PowerPoint lecture with hands-on practical exercises, intended to teach the process of PS during PHEs (Figure 3). The course was delivered on March 19, 2008, to second-year medical students at the University of California San Francisco/University of California Berkeley joint medical program and was well received. This lesson may also be suitable as CE course for GPs. Effectiveness is being currently evaluated and will be published upon analysis completion.

A further area of improvement would be the program management of the PHE initiative. National program management teams would include an Execution Steering Group (RESG) that would stimulate, coordinate, and guide CDS efforts outlined according to the critical Pathway and Roadmap as it was proposed by the AMIA. The RESG mission and structure should address the need for developing and maintaining an ongoing forum for dialogue, consensus, and action by CDS stakeholders.

These might include the SV, the Austrian Association of Physicians, the University Department of Periodontology, the Austrian Society of Periodontology, or the Austrian Association of Dental Hygienists, the Austrian Federal Health Institute (ÖBIG), and the Supreme Advisory Board to the Government on general and oral health matters (OSR), representatives of the oral health care industry, and so forth. The goal of this dialogue would be to promote dissemination and application of best CDS implementation practices (learned from successful sites) as a means of increasing use of currently available CDS interventions. With regard to PS, specifications should be developed for coordinated, collaborative projects aimed at demonstrating the feasibility, scalability, and value of CDS to improve work flow and the accuracy of risk determination. After implementation, it should be analyzed whether CDS resources are outcome enhancing. Existing data should determine next steps for broader CDS development and implementation as an outgrowth of the activities above.

Developing effective computerized CDS is recommended because evidence suggests that it is at least somewhat effective. Its highest utility has been demonstrated in the prevention of medical errors, especially when coupled with computerized medical records and individualized patient data, such as the electronic HIS, and directly intercalated into the care process.36

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Conclusion 

Periodontal screening by general physicians during periodic health examinations creates a unique opportunity for the medical and dental communities to collaborate and prevent and treat this highly prevalent disease. However, since screening for periodontal diseases and assigning risk scores is unfamiliar to most general physicians, effective clinical decision support is required to enable them to carry out this activity successfully and, thus, to hopefully reduce resistance against it. The wealth of existing CDS materials shows that the Austrian SV has provided numerous resources, apparently at a high cost, with the intention of informing physicians and the public about the newly designed periodic health examination and its target interventions. These materials have the potential to improve work flow and transparency of data. We see this as a very positive start on which to build.

However, there is lack of evidence that the SV have followed up properly in evaluating whether the new PHE is performed according to mandate and whether current CDS is effective. This also pertains to PS. The main reasons for this conclusion are connected with evaluation methodology. From a patient and taxpayer perspective, this is highly unfortunate. When applying the suggested criteria of the AMIA for the assessment of quality CDS, it was found that, due to the absence of monitoring of utilization frequency and physician acceptance, existing CDS materials could not be evaluated according to their quality or potential benefits. Legally mandated evaluations of the PHE in Austria have not identified whether or not physicians assign risk scores for PD, how their decisions were arrived at, if they refer patients for treatment, and which type of CDS they might need and use. It appears that both the production of the existing CDS resources and their implementation was, in many ways, a hit-or-miss processes, with failure still a distinct possibility.

Our findings correlate with studies cited by the Institute of Medicine (IOM) about underuse, overuse, and misuse of care and with studies,18 which identified a low acceptance rate for different types of CDS.37 At present, there is reason to believe that, for the most part, PS during PHEs in Austria “frequently falls short in its ability to translate knowledge into practice.” 38 Performance and quality of PS by GPs will be evaluated in an upcoming validation study by the first author. The need for quality EB usable CDS and CE courses, which are widely available and accessible to providers, when they need it, has been identified. Effective CDS integrated into the clinical work flow has the potential to profoundly affect the cost and quality of health care delivery.37

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Acknowledgments 

The authors thank Mag. Romana Ruda, of the Austrian SV, Dr Jürgen Soffried and Dr Ursula Reichenpfader, members of the PHE evaluation team contracted by the SV to evaluate the PHE (Wissenschaftszentrum of the VAEB), and Mr Christian Linzbauer of the ÖGAM for their time and expert knowledge in assisting us with our questions. We also thank Professor Kenneth A. Eaton for his helpful comments.

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PII: S1532-3382(08)00128-0

doi:10.1016/j.jebdp.2008.06.005

Journal of Evidence-Based Dental Practice
Volume 8, Issue 3 , Pages 186-194, September 2008

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