The utility of survey and administrative data to generate information for research and outcomes-based oral health services development

The aim of this research, which focused on the Irish adult population, was to generate information for policymakers by applying statistical analyses and current technologies to oral health administrative and survey databases. Objectives included identifying socio-demographic influences on oral health and utilisation of dental services, comparing epidemiologically-estimated dental treatment need with treatment provided, and investigating the potential of a dental administrative database to provide information on utilisation of services and the volume and types of treatment provided over time. Information was extracted from the claims databases for the Dental Treatment Benefit Scheme (DTBS) for employed adults and the Dental Treatment Services Scheme (DTSS) for less-well-off adults, the National Surveys of Adult Oral Health, and the 2007 Survey of Lifestyle Attitudes and Nutrition in Ireland. Factors associated with utilisation and retention of natural teeth were analysed using count data models and logistic regression. The chi-square test and the student’s t-test were used to compare epidemiologically-estimated need in a representative sample of adults with treatment provided. Differences were found in dental care utilisation and tooth retention by Socio-Economic Status. An analysis of the five-year utilisation behaviour of a 2003 cohort of DTBS dental attendees revealed that age and being female were positively associated with visiting annually and number of treatments. Number of adults using the DTBS increased, and mean number of treatments per patient decreased, between 1997 and 2008. As a percentage of overall treatments, restorations, dentures, and extractions decreased, while prophylaxis increased. Differences were found between epidemiologically-estimated treatment need and treatment provided for those using the DTBS and DTSS. This research confirms the utility of survey and administrative data to generate knowledge for policymakers. Public administrative databases have not been designed for research purposes, but they have the potential to provide a wealth of knowledge on treatments provided and utilisation patterns.

Development of an intervention to support medication management in patients with multimorbidity in primary care

The overarching aim of this thesis was to develop an intervention to support patient-centred prescribing in the context of multimorbidity in primary care. Methods A range of research methods were used to address different components of the Medical Research Council, UK (MRC) guidance on the development and evaluation of complex interventions in health care. The existing evidence on GPs’ perceptions of the management of multimorbidity was systematically reviewed. In qualitative interviews, chart-stimulated recall was used to explore the challenges experienced by GPs when prescribing for multimorbid patients. In a cross-sectional study, the psychosocial issues that complicate the management of multimorbidity were examined. To develop the complex intervention, the Behaviour Change Wheel (BCW) was used to integrate behavioural theory with the findings of these three studies. A feasibility study of the new intervention was then conducted with GPs. Results The systematic review revealed four domains of clinical practice where GPs experienced difficulties in multimorbidity. The qualitative interview study showed that GPs responded to these difficulties by ‘satisficing’. In multimorbid patients perceived as stable, GPs preferred to ‘maintain the status quo’ rather than actively change medications. In the cross-sectional study, the significant association between multimorbidity and negative psychosocial factors was shown. These findings informed the development of the ‘Multimorbidity Collaborative Medication Review and Decision-making’ (MY COMRADE) intervention. The intervention involves peer support: two GPs review the medications prescribed to a complex multimorbid patient together. In the feasibility study, GPs reported that the intervention was appropriate for the context of general practice; was widely applicable to their patients with multimorbidity; and recommendations for optimising medications arose from all collaborative reviews. Conclusion Applying theory to empirical data has led to an intervention that is implementable in clinical practice, and has the potential to positively change GPs’ behaviour in the management of medications for patients with multimorbidity.