Dental-Medical Integration: An Innovative Approach to Immunizations
By Lisa Waiwaiole, Project Director
The Dental Care Program at Kaiser Permanente Northwest proves to be a great laboratory for immunization research.
Immunizations aren’t just for infants—teens and tweens need them, too. But while national immunization rates are fairly high for adolescent vaccines such as Tdap (tetanus, diphtheria, pertussis) (88%) and MCV4 (meningococcal conjugate vaccine) (79%), rates for human papillomavirus (HPV) and influenza are much lower. Current national HPV immunization rates for completing the series are 42% for girls and 28% for boys, and the influenza vaccination rate stands at 59%.
Any attempt to boost coverage rates for teens and preteens will have to reckon with one major obstacle: this group simply does not seek medical care as frequently as their younger counterparts. Furthermore, unlike single-dose adolescent vaccines, up until very recently a complete HPV vaccine required three doses. As of October 2016, the Advisory Committee on Immunization Practice recommends two doses, six months apart.
As a working mother, I have spoken to more than one colleague who admitted struggling to get our own kids to the doctor for all of the required doses of this important cancer prevention vaccine.
How could dental clinics be part of the solution?
The HPV vaccination is of particular concern to the dental care community since there is a link between HPV and oropharyngeal cancers (cancers of the head and neck). According to the American Dental Association, about 63 percent of oropharyngeal cancers each year—more than 11,000 cases—are associated with HPV infection, and the incidence is rising. (You can read the ADA’s full Statement on Human Papillomavirus and Squamous Cell Cancers of the Oropharynx online.)
Knowing this, CHR epidemiologists (Sheila Weinmann and Allison Naleway) and dental researchers (Jeff Fellows and I) met to discuss research opportunities in this area. We agreed that there was strong potential for dentists to play a larger role in improving HPV immunization rates and other aspects of preventive care. Dental clinics at Kaiser Permanente Northwest (KPNW) were already routinely giving patients a printed, individualized list of recommended vaccinations. We wanted to design a study that would build on that success and focus on adolescent immunizations specifically.
Dental Adolescent Immunization Study
With a grant from the Pfizer Independent Grants for Learning & Change, Allison Naleway developed an intervention and study plan along with Dan Pihlstrom, Michelle Henninger, David Mosen, and me. We randomized eight KPNW dental clinics to an intervention arm and eight KPNW dental clinics to usual care. The intervention itself was straightforward, building on what was already in place in the dental program. We asked dental team members in intervention clinics to:
- Provide all 11-17 yr olds and/or their parents with a printed, individualized list of vaccinations due (i.e., “care gap report”).
- Verbally recommend that the adolescent get the vaccine(s), using scripts that we provided.
- Provide a study brochure that described adolescent vaccines, how and where to get vaccinated at KPNW (no appointment required), and the locations of nurse treatment room throughout the region.
As part of the study, we also surveyed providers about their knowledge and comfort with recommending vaccines and we surveyed parents about their comfort receiving a recommendation from a dental provider.
As the only Kaiser Permanente region with its own dental care program, KPNW is an ideal setting for this type of research. In fact, the program has its roots in research, having begun as a demonstration project in the 1960s under the leadership of CHR’s first director, Mitch Greenlick. Our dental care program has always been ahead of the curve in integrating medical and dental care.
Did It Work?
We are encouraged by what we’ve learned so far, though many of our findings are still to be determined. Using KP’s electronic medical record system, we will compare the vaccine coverage of adolescents in the intervention clinics to that of adolescents in the usual care clinics. From our surveys, we have found:
About 80% of dental providers agreed that they should be discussing preventive medical care with their patients. Hygienists tended to have the highest vaccine knowledge compared to dentists or dental assistants. Dental providers said the biggest barriers to discussing vaccines were parents’ concerns about vaccine safety and providers’ own vaccine knowledge.
Almost 75% of parents were comfortable or neutral about receiving vaccine recommendations from dental providers. Acceptance from dental staff was mixed. One staff member said, “If everybody had this conversation [about vaccinations] every chance they got, then this intervention would be effective.” Some staff shared concerns they had about viewing members’ private health information. Dental staff agreed that most parents appreciated the vaccine reminder.
At a National Immunization Conference, representatives from several state organizations approached Allison Naleway with questions about how to enlist dental providers to promote the HPV vaccination. Incorporating dentists in overall health just makes sense—especially on a topic like HPV, where there is so much medical and dental overlap. Since Kaiser Permanente is already leading the way in so many aspects of preventive medical care, it is not surprising to be out ahead in this area of medical-dental integration as well.
"Mfano wa ""Dental Care"" ni mpango wa matibabu ya meno na matibabu ya meno ulioanzishwa na Kaiser Permanente Northwest, ambayo ni sehemu ya utafiti wa matibabu ya meno." Chanjo si kwa ajili ya watoto wachanga tu - matineja na vijana wadogo wanahitaji chanjo pia. Lakini wakati viwango vya kitaifa vya chanjo ni vya juu kwa chanjo za vijana kama vile Tdap (tetanasi, diphtheria, pertussis) (88%) na MCV4 (manjiko la meningococcal conjugate) (79%), viwango vya virusi vya HPV na homa ni chini sana. Kiwango cha sasa cha chanjo ya HPV kwa ajili ya kukamilisha mfululizo ni 42% kwa wasichana na 28% kwa wavulana, na kiwango cha chanjo ya mafua ni 59%. Jitihada yoyote ya kuongeza viwango vya chanjo kwa vijana na vijana watakuwa na kukabiliana na kikwazo kimoja kikubwa: kundi hili kwa urahisi haitafuti huduma za matibabu mara nyingi kama wenzao wadogo. Kwa kuongezea, tofauti na chanjo za vijana za kipimo kimoja, hadi hivi karibuni chanjo kamili ya HPV ilihitaji dozi tatu. Tangu Oktoba 2016, Kamati ya Ushauri juu ya Mazoea ya Chanjo inapendekeza dozi mbili, miezi sita mbali. Kama mama anayefanya kazi, nimezungumza na zaidi ya mwenzangu mmoja ambaye alikiri kuwa anajitahidi kupata watoto wetu kwa daktari kwa dozi zote zinazohitajika za chanjo hii muhimu ya kuzuia saratani. Kliniki za meno zinawezaje kuwa sehemu ya suluhisho? Chanjo ya HPV ni muhimu kwa wagonjwa wa meno kwa sababu kuna uhusiano kati ya HPV na saratani ya mdomo na shingo. Kulingana na Shirika la Daktari wa Meno la Marekani, karibu asilimia 63 ya saratani ya mdomo na pua kila mwaka - zaidi ya visa 11,000 - inahusishwa na maambukizo ya HPV, na idadi hiyo inaongezeka. "Kama ilivyoelezwa katika taarifa ya ADA ya ""Statement on Human Papillomavirus and Squamous Cell Cancers of the Oropharynx"" (Statement on Human Papillomavirus and Squamous Cell Cancers of the Oropharynx) iliyochapishwa na shirika la WHO, ""Ugonjwa wa saratani ya utumbo wa utumbo wa utumbo wa utumbo wa utumbo wa utumbo wa utumbo wa utumbo wa utumbo wa utumbo wa utumbo wa utumbo wa utumbo wa utumbo wa utumbo wa utumbo wa utumbo." Kwa kuzingatia hili, wataalamu wa magonjwa ya kuambukiza wa CHR (Sheila Weinman na Allison Naleway) na watafiti wa meno (Jeff Fellows na mimi) walikutana kujadili fursa za utafiti katika eneo hili. "Tunakubaliana kwamba kuna uwezekano mkubwa kwa madaktari wa meno kucheza jukumu kubwa katika kuboresha viwango vya chanjo ya HPV na mambo mengine ya utunzaji wa kuzuia. """ Kliniki za meno za Kaiser Permanente Northwest (KPNW) tayari zilikuwa zikitoa kwa kawaida kwa wagonjwa orodha iliyochapishwa, ya mtu binafsi ya chanjo zilizopendekezwa. """Tulitaka kuunda utafiti ambao ungejenga juu ya mafanikio hayo na kuzingatia chanjo za vijana hasa." "Kwa msaada wa ""Fizzer Independent Grants for Learning and Change,"" Allison Naleway aliunda mpango wa uingiliaji na utafiti pamoja na Dan Pilsdorf, Michelle Henninger, David Mosen na mimi." Kwa mfano, kliniki za meno nane za KPNW zilikuwa na uwezo wa kutoa matibabu ya kawaida. Uingiliaji wenyewe ulikuwa wa moja kwa moja, ukijenga juu ya kile kilichokuwa tayari mahali katika programu ya meno. "Wanafunzi wa matibabu ya meno katika kliniki za matibabu ya meno waliwaomba watoto wote wenye umri wa miaka 11-17 na wazazi wao kutoa orodha ya chanjo za kibinafsi zilizochapishwa, ""ripoti ya upungufu wa huduma.""" - Kupendekeza kwa mdomo kwamba kijana apate chanjo (s), kwa kutumia maandishi ambayo tulitoa. - Kutoa broshua ya utafiti ambayo ilielezea chanjo za vijana, jinsi na wapi kupata chanjo katika KPNW (hakuna uteuzi unaohitajika), na maeneo ya chumba cha matibabu ya muuguzi katika mkoa wote. Katika utafiti huo, wataalamu walihoji wazazi kuhusu ujuzi wao na faraja ya kupendekeza chanjo, na walihoji wazazi kuhusu faraja yao kupokea pendekezo kutoka kwa mtaalamu wa meno. Kama eneo pekee la Kaiser Permanente lenye programu yake ya huduma ya meno, KPNW ni mazingira bora kwa aina hii ya utafiti. Kwa kweli, programu hiyo ina mizizi yake katika utafiti, baada ya kuanza kama mradi wa maonyesho katika miaka ya 1960 chini ya uongozi wa mkurugenzi wa kwanza wa CHR, Mitch Greenleaf. Programu yetu ya huduma ya meno daima imekuwa mbele ya curve katika kuunganisha huduma ya matibabu na meno. Je, Ilifanikiwa? Sisi ni kutiwa moyo na kile tumejifunza hadi sasa, ingawa mengi ya matokeo yetu bado ni kuamua. Kwa kutumia mfumo wa rekodi za elektroniki za matibabu, tutaweza kulinganisha chanjo ya vijana katika kliniki za uingiliaji na ile ya vijana katika kliniki za kawaida za huduma. Katika utafiti wa hivi karibuni, karibu asilimia 80 ya madaktari wa meno wanakubaliana kwamba wanapaswa kujadili matibabu ya kuzuia na wagonjwa wao. Wataalamu wa usafi wa mwili walikuwa na ujuzi wa juu zaidi wa chanjo ikilinganishwa na madaktari wa meno au wasaidizi wa meno. Wataalamu wa afya ya meno wanasema vikwazo vikubwa vya kujadili chanjo ni wasiwasi wa wazazi kuhusu usalama wa chanjo na ujuzi wa chanjo wa wataalamu. Karibu asilimia 75 ya wazazi walikuwa na wasiwasi au hawakuhisi wasiwasi kuhusu kupokea mapendekezo ya chanjo kutoka kwa watoa huduma za meno. Wafanyakazi wa madaktari wa meno walikubaliana na jambo hilo. "Mfanyakazi mmoja alisema, ""Ikiwa kila mtu angekuwa na mazungumzo haya [kuhusu chanjo] kila nafasi wanayopata, basi uingiliaji huu ungekuwa na ufanisi.""Wafanyakazi wengine walishiriki wasiwasi waliokuwa nao juu ya kuona habari za kibinafsi za afya za wanachama." Wafanyakazi wa daktari wa meno walikubali kwamba wazazi wengi walifurahia ukumbusho wa chanjo. Katika mkutano wa kitaifa wa chanjo, wawakilishi kutoka mashirika kadhaa ya serikali walimkaribia Allison Naleway na maswali juu ya jinsi ya kuajiri watoa huduma za meno kukuza chanjo ya HPV. Kuingiza madaktari wa meno katika afya ya jumla ni busara tu - hasa juu ya mada kama HPV, ambapo kuna mengi ya matibabu na meno overlap. Kwa kuwa Kaiser Permanente tayari inaongoza katika nyanja nyingi za huduma ya matibabu ya kuzuia, haishangazi kuwa mbele katika eneo hili la ushirikiano wa matibabu na meno pia.