San Diego Dentistry Blog

Even among advantaged women, there’s still a need for enhanced education about the importance of dental care before, during, and after pregnancy.  One of the things that we know is a lack of routine oral health prior to pregnancy is also related to a lack of oral health utilization during pregnancy.  So, we always look at the Life Span approach, and if the point of entry into the health care system is pregnancy, then let’s begin there during pregnancy.  Then, continue through the rest of the life span.

So, there are many reasons why women are less likely to go to oral health care providers during pregnancy, and some of them are personal factors such as finances and employment, not being able to get out work during the hours available for them during the work day when they’re working, and also poor domestic relationships.  I think we can never underestimate the personal stressors in a woman’s life when we’re trying to get some sort of compliance with any kind of recommendation we make.

Then, women also have personal perceptions about dental care.  Studies show that these are also barriers to their receiving care.  So, women have the wrong attitude towards dental providers that we need to listen to, and they have an opinion about the importance and value of oral health.  In some populations, it’s not a cultural norm to receive the same kind of oral health care or any kind of oral health care.

I oversee several OB clinics, and we have woman here from all over the world.  There’s some women who come in for pregnancy, and they’ve never seen a dentist their whole entire life.  They’re really actually very severe periodontal disease.  So, we’re dealing with all sorts of people who bring to the health care experience their own attitudes and beliefs.

So, women have perceptions about the dental experience.  One the things we talk about was oral health and how it could be frightening for women during pregnancy.  So, women with a history of trauma, and Rene’s going to speak with you in detail about this, the dental visit itself can be quite frightening, a woman’s reclined.  She can’t speak.  So, it can really evoke past trauma experience.  So, the perception of the dental experience is really important, something that we have to be cognizant of when we’re trying to advocate women receiving dental care during pregnancy.

Then, we have, again, the problem with perception to pay. Whether women have dental coverage during pregnancy or whether they don’t, the perception or understanding of whether or not they have coverage is really important for us to sit down and talk with them about.

Then, finally, women’s perception about the attitudes of dental providers and their staff might have towards a patient.  Again, I always that we have to have services that are accessible to patients.  So, we also need to have services that are acceptable.  How people perceive providers’ offices, their treatment, and how they’re seen, may or may not be true, but when we’re dealing with perceptions, we need to treat them seriously.

I just want to say a little bit about the impact of domestic violence.  In 30% of women who experience abuse, the first incidence occurs during pregnancy.  It’s also important to note that during pregnancy and soon after the baby’s born, a woman’s at risk for being murdered by her abuser.  So, this is an important issue for oral health, prenatal health.  All of the provider teams that are working with pregnant women, it’s important for us to be aware of that because of the compliance and treatment perception of care and outcomes.  It’s very important for us to be aware of and really understand her pregnancy will focus on the relevance of trauma-informed care and how it relates to oral health care services.

I just want to mention that one of the preventive health benefits for women under the Affordable Health Care Act is for which there is not a cost share is domestic violence screening and counseling.  You can access more information for preventive health services for women under the Affordable Health Care Act at the link I provided for you.

So, I’m going to go back now and tie in what I started with, the health center I work with to the maternity home approach to prenatal care that we have.  During our pregnancy risk assessment, we have an extensive section of that risk assessment around oral health.  So, the questions we ask all pregnant women, every single woman comes so she can have the risk assessment, and the general education and screening we have for them is the first questions is, “When was your last dental cleaning?” We’ll break it down into within 6 months, 6 months to a year, 1 year, 2 years, 3 years, 4 years, 5 years, or over 5 years.

Bringing up the insurance piece again, many of them say to me they can identify their last cleaning from the last time they had insurance.  So, the insurance piece of really important.  Then, we ask, “Do your gums bleed?”  We ask, “Do you floss daily?”  Then, we provide a lengthy piece of health education around oral health, why it’s important to take care of your teeth during pregnancy, not only for the possible relationship to birth outcomes but also because of how pregnancy can impact your teeth and how bad teeth can affect your health in many ways, not just birth outcomes.

We also do an extensive piece on caring for your teeth.  Dr. DeFrancesco mentioned earlier, the whole flossing once a day, brushing twice a day with fluoridated toothpaste.  We talk about using a nonalcoholic mouthwash.  We talk about the last thing you should do before you go to bed at night and explain how bacteria grows.  So, if they have anything but water, they’re likely to grow bacteria during the night.  The heath education thing that impressed me after doing this for so many years is that there’s many things we provide education about like smoking and people know that, but I’ve been really impressed on people not understanding the whole oral health piece.  So, what we do is we offer people an appointment for a cleaning and exam after we do this oral health thing, and we schedule the appointment right on the spot.  We ask them what time is convenient for them.  So, do they want a morning appointment, afternoon, weekend, whatever.  So, we schedule is at their convenience, and we impress it on them that the exam and the cleaning is going to be free of charge. Whether they have insurance or they don’t, it’s written into their prenatal care package.

After collecting this data for five years, we actually went back, and we went through our day-to-day results.  We did a little study about oral health uptake in this particular population.  So, we included all women who did not have a cleaning within the past six months and who agreed to a referral.  All of the women were either with state Medicaid, which is HUSKY A Connecticut, or they were uninsured and were able to have a free cleaning and exam.

The thing that we assessed for were race, ethnicity, marital status, smoking, age, insurance status, anxiety, depression, and interval since their last pregnancy.  We also assessed for location of dental provider.  We were looking at two different prenatal clinics.  One was in rural setting, and the dental office that we have is two towns down county.  The other prenatal clinic is in an urban setting, and we consider that to be a co-located dental office because it’s right across the street from the prenatal care office.

If you can just take a look at what the population looked like, what the breakdown was.  I’ll give you just a second to look at that.  So, what we found was the only factors that were related to lack of oral health uptake were anxiety and depression.  So, it didn’t make a difference if it was co-located, the dental office, or not.  Anxiety and depression were the only factors related to decreased dental uptake.  Again, many of the women with anxiety and depression, we do formal screening and testing around these areas, and many of these women have trauma background.  So, again, I cannot press to any extent how important the whole trauma healthcare piece is when looking at how deliver the oral health services.

So, the recommendations based on my experiences and the literature are to start oral health care early, and we want to look at that Life Span approach.  We want to start our kids in that Home by One, the first visit before they’re one year old and have routine oral health care based on the recommendations that are given to us and continues through pregnancy and after pregnancy.  We want that Life Span approach, and the other thing is a person-centered maternity or pregnancy home with primary care, behavioral health, dental services co-located is ideal, but if we can’t do that and many of us can’t, if we have coordination services which can provide referrals and linkages in the community for dental providers, that’s the next best thing.

Again, we need to enhance the education we’re providing on the important and safety of oral health during pregnancy, not just for the women that we serve but for all of our providers, prenatal providers, dental health providers.  So, as many people as possible, we really need to get this message out there.

Then, I always recommend that we transform how we deliver care to vulnerable populations, and, again, services not only need to be accessible. We need to have access to services for women, but we also need to have services that are acceptable to them.  So, we need to start listening on what would be a comfortable environment that women will feel comfortable receiving these services, and that lends itself to the trauma-informed care practices.

I want to make a few acknowledgments.  One is to Margaret Flinter and Marian Mohegan and to the USDHHS Office on Woman’s Health Region 1 and to Jennifer Sharp.  Thank you all so very much, and if you have any questions for me about anything related to this at all, please feel free to give me a call, shoot me an e-mail.  I’ve included for you a couple of pages of references.  Everything I’ve said is referenced here.

So, thank you all very much.

Here you have the opposite.  Don’t be fooled by the chart with little bars.  This graph starts at 80% of the population.  If you look at national data, you can see that in the childbearing age, 20 to 34, almost 85% of women have already had caries experience.  Once you pass 40, 90% of people have had cavities.  So, we all have Streptococcus mutans.

What about that childhood caries?  Again, we want to delay caries and not have caries if possible.  There’s probably some of you out there in the audience that have never had a cavity, but you’re definitely in the minority.  If you’re going to get cavities, the later the better because having caries in baby teeth is the highest risk factor for having caries in your permanent, leading to a lifetime of cavities.  Getting cavities in the baby teeth very young, again, leads to loss of function, failure to thrive, unequal expenditure because a lot of these cases have to be fixed in the hospital in the operating room, and there’s always morbidity associated with treatment or with not getting treatment.  Children have died both while being treated for dental caries because of the sedation or from not having treatment, resulting in abscesses as [30:11] over five years ago.

There are disparities in early childhood prevalence.  Let me decipher this slide for you.  Here, you can see, if you look at 2 to 4 year olds across the United States, percentage of 2 to 4 years olds that have untreated decay.  If you go from left to right, it’s basically 1 out of 5 Caucasian children, 1 out of 4 African-American children, and more than 1 out of 3 Mexican-American children in the United States, ages 2 to 4, already have untreated decay.  If you look at this NHANES survey, the latest one, caries rates actually improved in every other demographic group, seniors, adults, teenagers, elementary school children.  Only in the very youngest, 2 to 4, are the caries rates actually going up from the last survey that was done 10 years prior.

So, when you’re looking at the influence of children’s oral health, you can see that you need a tooth, some bacteria, and some sugar in order for you to get a cavity, but it’s really the whole community and your whole near biological components.  It’s the way, again, because it’s the lifestyle we use.  So, it’s the way that your family, your community, everything influences.

This is why mom becomes such a key component, on multiple levels, because if you have a mom that has high caries rates, you’re probably going to have a child that has high caries rates.  This ties into not just the bacterial piece of it.  Yes, there are genetic.  The genetics of some strains of Streptococcus mutans is more virulent than other strains, and again the transmissibility.  Again, because caries is a multifactorial lifestyle disease.  The influence of diet, what’s give, how it’s given, home care of the teeth, and just in terms of attitudes and beliefs of going to the dentist, the importance of primary teeth in oral health.  They are all really modulated by the primary treatment of the caregiver in the family.  That’s usually mom.

So, again, it makes it doubly important not just for mom’s own health but also for the child.  This is why pregnancy is so unique.  It provides a great opportunity to do a two-for-one.  It really introduces risk reduction and self-management strategies for both mom and the child as well as a chance to stabilize the mom’s periodontal status as well as impact the cycle of Streptococcus mutans transmission by eliminating, lowering Sreptococcus mutans count in the mom from getting treatment while pregnant.

Again, as I stated previously, especially for low income women and at risk populations, sometime when you’re pregnant, you’re going to be in contact with the health care delivery system more frequently than usual through the monthly perinatal.  At that time, the women may be more interested in oral health and how their oral health impacts and influences their babies’ oral health.  They may be more open to have education messages not just on their own oral health but how it’s going to impact the child and, at least here in California (every state is different), in California, that’s really the only time that a woman has more comprehensive dental insurance coverage through Medicaid, when she’s pregnant.  However, again, the flip side of that is in some places that’s actually the only time you can go to the dentist.

There’s research that pregnant women receive dental care less frequently than the general female population, interestingly, regardless of the insurance source.  So, we’re talking about both primary dental insurance and Medicaid populations.  Women will tend to go to the dentist less frequently when they’re pregnant than when they’re not pregnant.  So, again, that speaks to the education that probably needs to happen in the perinatal piece of it to get women to come over to the dental piece while they’re pregnant.

So, we found in all the work that we’ve done at the health center in my county where I work and other health centers throughout the United States that basically you have to have this loop of perinatal part of your organization educating women about the importance of dental care while pregnant.  We will refer them to a group of dentists that is willing to treat them while they’re pregnant, and it just goes around and around.  If you don’t have either piece, you’re not going to be able to make an impact.

So, here’s some resources on perinatal oral health.  Again, this is super [35:36].  The first one is the New York State guidelines that were published in 1996.  The second one is the California oral health perinatal guidelines that were published in 2010, which really gives you the fine clinical procedures that you can do both for the perinatal provider and from the dental, which is what you want to do when you want to treat pregnant women.

There’s actually going to be, probably in about a month, there’s going to be a national consensus statement on perinatal oral health that is going to be released, and this has been three years in the making, a collaboration between HRSA, Bureau of Maternal and Child Health, ACOG, and the American Dental Association.  This is going to be a statement paraphrasing what we are saying today which is that oral health during pregnancy is important and say that your perinatal provider should refer one for dental care, and the dentist should provide dental care while pregnant.  Hopefully that will be the end of any reluctance on either side to rethink that we now improve women and children’s oral health because this is the goal of everything that we’re trying to do and have people be healthy and happy.

So, thank you.

Jennifer:

Great, thank you so much.  Thank you so much Dr. Hilton.  We are now going to turn the presentation over to Amy Gagliardi, and Amy?

Amy Gagliardi:

Hi, Jenn. I can hear just fine.  So, welcome everyone.  Morning, afternoon, or evening, depending on your time zone.

So, I’d like to give you just an overview of what we’re going to cover today.  We’re going to look at how periodontal disease might be related to adverse birth outcomes, how maternal oral health is connected to the oral health of their children.  We’re going to look at oral health utilization studies and barriers to care among pregnant women.  Then, I’m going to share an oral health uptake study that we’ve conducted in our workplace, and then, I’ll follow that with recommendations.

I work at Community Health Center, which is a federally qualified health center in Connecticut, and we serve the largest population of Medicaid throughout our state.  We are an NCQA level III health center, and we have multiple interventions, which you can read on the bottom left hand side of our screen.   The medical home status that we have is really pertinent to the type of prenatal care that we deliver, and I just want that as a backdrop to the study that we do.  We have integration of primary medical care, prenatal care, general care, and behavioral health care under one roof.  So, it’s a very interesting place to work and exciting.

So, the American Academy of Pediatric Dentistry has come out with really strong and clear guidelines for mothers and children around oral health care.  They say that all pregnant women should receive oral health care and counseling during pregnancy and that infants should have oral health care and an oral health risk assessment before their first birthday. I know in Connecticut, we have a program called Home by One, and that’s really to capture that second piece of recommendation.

So, periodontal disease and adverse birth outcomes.  There are multiple studies supporting the theory that there is a relationship between periodontal disease during pregnancy and birth outcomes.  However, it’s important to note that the presence of maternal periodontal disease does not always result in adverse birth outcomes.

Now, there was a large randomized control study that suggested that the treatment of periodontal disease did not prevent preterm birth.  However, Dr. Steven Offenbacher who’s done a lot of research in this area strongly suggested that there is a relationship between periodontal disease and poor pregnancy outcomes but that we need to learn to treat the disease better in women before we can understand the systemic implications.  He suggests that perhaps the more intensive treatment approach will impact birth outcomes or perhaps periodontal disease is not a treatable cause of poor birth outcomes or perhaps preterm birth and periodontal disease share an underlying commonality such as an exaggerated inflammatory response.  However, his suggestion was that pregnant women continue to receive exams and treatment.

So, as you can see from the information and research out there, we still have more questions than answers.  So, Jeffcoat’s another researcher.  He’s done a lot of work in this field, and he’s done a lot of studies that suggest that there is a relationship but the relationship between periodontal disease and birth outcomes is a relational one rather than a causal relationship.

There’s some very good studies that suggest that we need some additional studies to explore how that relationship really interacts.  Is it the severity of periodontal disease and the relation of it, and is there a risk not just for preterm birth but for preeclampsia, gestational diabetes, early and late term miscarriage?  So, there’s strong evidence to suggest that the severity and progression of maternal periodontal disease during pregnancy is related to the more severe birth outcomes.

Now, the relationship between maternal and child oral health is more clear cut.  We do know the vertical transmission of Streptococcus mutans between mother and infant.   There is a vertical transmission.  Mothers with high levels of Streptococcus mutans in their saliva is associated with an earlier establishment of bacteria in their children, and that’s important because this early colonization of the bacteria places children at risk for early childhood caries.  So, we know that the prevention of early childhood caries in children begins with the oral health and health education of their moms.  All of us in maternal health care are aware that you can’t really separate the [43:26] from everything that we do in maternal child health.

So, what do we know about oral health utilization during pregnancy?  My colleagues who presented before me both noted that pregnancy is a portal for the health care system and may be the only time in a long time that women have health insurance.  So, even with having health insurance, we know that utilization of oral health during pregnancy is low, and it is especially low for at risk women.

original post: http://besttoothpaste.net/fluoride-free/the-best-toothpaste-is-homemade-infographic/

Dr. Hilton:

Good morning, everyone.  Okay, I’m Irene Hilton.  I’m from the San Francisco Department of Public Health, and, also, I’m faculty at the UCSF School of Medicine and School of Dentistry.  The objectives for my part of this session today is to talk about so we can understand the effect of maternal oral health on families, learn how periodontal disease is related to birth outcomes, describe why pregnancy provides opportunity to provide oral health interventions for women.

Just a little bit, on my part, talking about periodontal disease.  There’s so much information we’re trying to get to.  This is going to be really brief.  You can see out of all the slides, these for pictures, the one on the upper left hand corner, that’s the healthy one.  This isn’t the only sign.  When you look inside a woman’s mouth, don’t go straight to the throat, step back a little bit and look at the teeth and the gums.  If you see redness, that’s some type of inflammation just like it is in pretty much any part of the body.  If you see red gums, that’s definitely a reason why you want to refer a woman for a dental visit.  You can show the woman the red gums and encourage them to get that in order to get that treated is one reason why they would want to go to the dentist while they’re pregnant.

To understand the issues and the research about periodontal disease and adverse outcomes, we’ll just talk a little bit, one slide on the process of periodontitis.  There’s two types of periodontal disease. One is gingivitis, which is totally reversible, and that’s what happens when you don’t brush and floss for a couple of days.  Then, you get back to doing it, and you get a little bit of bleeding.  It goes away once you clean everything.

Periodontitis is about the disease process that is a chronic process.  In that disease process, toxic products from the bacteria in the gingival crevice, the area between the tooth and the gum, induce an immune modulated response that results in destruction of bone.  These are basically Gram-negative, anaerobic species, and this is really a chronic disease process because you get bone loss throughout your whole life.  The important part is that it’s an inflammatory process mediated by your own immune system.

So, here’s a representation of that, again.  So, you can see how that leads to potential associations with systemic disease because right here there’s the tooth, and right here is the bone level.  Right here is junk, all junk and bacteria, and over time, if it’s not cleaned out, these substances produce these fatty acids that circulate throughout the blood steam.  This is what initiates in inflammatory response.  You can see tumor necrosis factor, interleukins, and prostaglandins.  These are the same type of inflammatory mediators that you find, for example, in diabetics and people that have had cardiovascular events.  Again, you can see that periodontal bacteria also result in the expression of these mediators in the bloodstream, and that’s why you get all these associations.  The inflammatory process is the same in periodontitis like all these other diseases.

That brings us to these researches also that show association.  Here’s a quick slide.  This is a bang for your buck slide.  It has lots of things in it, but basically, what you want to know in relation to periodontal disease and child bearing age is if you look at the prevalence in the population, it’s actually relatively low.  Periodontal disease is age-related.  So, the older you get, the more chance and more prevalence there will be in the population.

So, for women of childbearing age, when you’re looking at women that have the level of periodontal disease that has been associated with these adverse birth outcomes, it’s a relatively low percentage, but you can see that most women complain of gum bleeding when they’re pregnant.  Again, it’s important to have them go to the dentist so that we can do our diagnosis and measurement so we can tell what level of periodontal disease we’re talking about because sometimes in the mouth, it all looks the same.  You want to get more diagnostic testing done.

The other thing that you want to be able to see is there’s three bars here, and the one in the middle, the almost lime green bar, is African-American.  So, no matter what age group you’re talking about, there’s a higher prevalence of periodontal disease in the African-American population.  So, again, there is a disparity in health status which, again, impacts periodontal disease as well as other potentially related conditions.

So, the idea of the association between periodontitis, periodontal disease, and adverse birth outcomes, the earliest research you can see has been almost 15 years. You have case-control and prospective studies that have been done over this time that have shown both association.  Both types of studies have shown association, again, depending on the study between low birth weight, pre-term birth weight, or preeclampsia with all the other factors being controlled.

There’s been so many studies that have been done in relation to that that there’s been a meta-analysis of all the analyses that have been down showing association.  Again, this meta-analysis, which was done last year in 2011, was 125 studies during the last 12 years.  Basically, the outcome of this meta-analysis is there is association between a certain level of periodontal disease and preeclampsia and prematurity.

When you try to cross that bridge between association and direct causation, you have to have a biologically plausible mechanism to explain it, and two of the most common roads that people have thought of in terms of how to explain this possible association is, again, there’s generally two trains of thought.  One is that you have periodontal bacteria circulating from the mother’s mouth through the body, and triggers this immune-modulated response, cytokine release and prostaglandin release in the uterus that could potentially be what triggers muscle contraction.  The other train of thought is some of the periodontal bacteria and toxins can actually cross the placental barrier and colonize in the fetal-placental unit, and, again, trigger and inflammatory response.

You have several stages that have shown different periodontal-causing bacteria in the amniotic fluid or in stillbirth.  For example, one of them, P. gingivalis, is one of the bacteria that’s most responsible for periodontal disease.  So, we have these studies showing association. We have some biologically plausible mechanisms, and in the hierarchy of showing causation, you have to go to randomized clinical trial in order to get your causation. When you actually go to the randomized clinical trials, you find that they show, at least the two largest clinical trials, both funded by the National Institute of Health, and we can see was published in the OPT and the New England Journal of Medicine MOTOR and Obstetrics and Gynecology. We can even look at the motor, 1800 subjects, incredible how difficult because very few women have the level of periodontitis associated with the adverse outcomes.  To be able to get 1800 and to be able to put them in the treatment arts and all the resources that were expended for this, but both of the studies did not show significant difference, again, between the women that had their periodontal disease treated by scaling and root [22:47] while they were pregnant and the ones that did not.

So, now, we have had even enough intervention studies, again randomized clinical studies, to be able to do a meta-analysis of the clinical trials.  In the last two years, 2010 and 2011, there have been three meta-analyses aggregating all of the clinical trials all over the world, not just in the United States, doing interventions, scaling and root planing versus treatment after birth.  Again, in the aggregate, they have not shown any effect on the adverse birth outcomes.  At the same time, there’s still bench research because we continue to have this association.  These researches are what we have up to this point.  So, things still continue to go on like I’ve said.

This is an example of a study that was done last week, and this is a bench study showing, again, that this particular bacteria, again, another periodontal bacteria, can induce cell death in placental precursors.  So, again, research continues to happen.  Hopefully, sometime in the future, it will become clear what the mechanism for adverse birth outcomes is and periodontal disease, if it does play a disease, how does that really work at the biological cell level.

So, what do we know?  Again, we know that we have this association.  We believe that it’s probably related because we have [24:37] periodontal disease, there’s adverse birth outcomes, has some kind of inflammatory component.  What we need to remember is that having gum disease, having periodontal disease in pregnancy is a disease/pathological state, and that restoring a woman, while pregnant, to periodontal health has value in itself regardless of whether or not there is a link with some other types of outcomes, system outcomes for both the woman and child. Again, we want to be healthy in all parameters.

On the flip side, the flip side of all these studies has been that you can see there have been thousands and thousands of women in the United States, all across the world that have had dental treatment done while they were pregnant, and they didn’t have a higher incidence of adverse birth outcomes.  So, you can also see that getting treatment, not just periodontal treatment but on some of these studies, there are arms where women were getting routine dental care, fillings and extractions, that also did not have worse birth outcomes through dental treatment.  Again, these studies show that it’s obviously safe to do dental work while pregnant.

So, let’s talk a little bit about another disease process that we’re quite, quite clear about, the relationship between maternal status and the status of the child, and that’s dental caries.  Dental caries is actually a bacterially modulated disease that once you acquire the cavity-causing bacteria, you basically have to manage this disease risk pretty much throughout the rest of your life.  In that way, again, it is acquired in a transmissible fashion, but it’s managed like a chronic disease like diabetes or hypertension or, depending on your lifestyle factors, there’ll be times in your life where you’ll be at a higher risk of having a disease or lower risk of having that disease.

Cavities, what the dentist drills and fills every day, is basically the surgical removal of the end stage of the caries process.  Again, dental caries is a multifactorial disease with multiple bacteria associated with it.  The most common one are Streptoccus mutans and Streptococcus sobrinus and Lactobacilli.  So, then how do we get cavity-causing bacteria?  We know now, through years of research, if you look at this, Berkowitz’s research, you can see is 1981 were the first studies showing that the maternal transmission from mom to child is the most common way to acquire Streptococcus mutans.  You can have horizontal transmission from kids or even other people, but there’s always the highest fidelity with the mom.  Of course, we know this now with DNA sequencing of the Streptococcus mutans bacteria as cavities of mom and child match.

So, here’s some examples of how you get Steptococcus mutans transmission.  It’s really pretty common, and we all have levels of Streptococcus mutans in our mouths.  It’s just a question of whether we have high or low.  Remember, we can’t really avoid transmission, but what you can hope is to slow the rate down or have it be at very, very low levels.  All the research shows that women with high counts of Streptococcus mutans, their children will get cavities faster, earlier, more than women with low counts of Streptococcus mutans.

original source: http://besttoothpaste.net/fluoride-free/dental-anxiety/

Original Video:  http://vimeo.com/51529561

Jennifer:

Healthy babies, and we are delighted to bring this presentation to you today on the importance of perinatal oral health.  We have a fabulous panel, and we have a very packed agenda.  So, I am going to move rather quickly and let our speaker present, to let them present their fabulous information.  Before I move into our speakers, I want to offer a very big thank you to the US Department of Health and Human Services, Office on Women’s Health Region 1 who has made this possible today.  We really appreciate their support, and I hope that you all enjoy this as much as we all enjoy providing this to you.

Moving on, I just want to introduce our four speakers for you today.  Our first speaker is Dr. Mark DeFrancesco who is secretary with the American College Obstetricians and Gynecologists and is also the chief medical officer of Women’s Health Connecticut.  I will be posting the biographies online for the presentation for you all so that you will be able to read about these fabulous speakers in more detail.

Following Dr. DeFrancesco is Dr. Irene Hilton who is a past dentist at the San Francisco Department of Public Health.  She is also a board certified in dental public health and is on faculty at the University of California San Francisco School of Medicine and School of Dentistry.  Following Dr. Irene Hilton, we have Amy Galiardi who has been involved in working maternal child health for more than 20 years, working in clinical care management, research, and policy.  She is currently with the Community Health Center, Inc., which is a federally qualified health care center in Connecticut, and she’s also the Chief Operating Officer for Lily’s Kids, Inc., a non-profit organization.

Then, following Amy is Rene Andersen who is a consultant trainer and developer for recovery-focused programs focusing on recovery from addiction, trauma, and/or extreme states.   She’s currently a consultant for the Massachusetts Department of Public Health Services and Bureau of Substance Abuse Services.

As you will see, these individuals have an awful lot to present today.  So, without further ado, I’m going to turn this over to Dr. DeFrancesco.

Dr. DeFrancesco:

Great.  Thank you so much, Jennifer, for the introduction.  This is a very important topic. I think it’s also a very underappreciated topic.  So, I’m very excited to be here to talk about this to our audience today.  I think in the past, in particular, we, obstetrical providers, were, I would say, vaguely aware that in pregnancy, women had more problems with their oral health, but we tend to think of it as basically just a hyperemic gingiva, a little bit more bleeding gums.  In pregnancy, there may be some susceptibility to cavities but thought it was limited to the mouth kind of problem, and I don’t think it raised major concerns.

I don’t think it was until quite recently that we realized how important oral health is, and this could negatively impact not only the mother’s health but the baby and the progress of the pregnancy itself.  I think our method today, really, is that pregnant women need dental care.  Untreated disease can actually harm the mother and the baby, and they negatively impact the pregnancy being, in part, be responsible for premature labor as well as low birth weight.  I think there’s a lot more research that needs to be done in that area, but there sure seems to be a [4:13] there.  We certainly know there’s vertical transmission of cariogenic oral bacteria in pregnancy when good oral health is not attended to.

There are new questions that we’ve certainly heard over the past few years.  Even outside of pregnancy, there are possible links between a poor oral health and heart disease.  Another question about future premature labor also in question here and other health problems that might be mediated by inflammation.  Possibly, the inflammation in the mouth may be, in part, responsible for things.  The question, of course, is are these associated issues or are they causally related?  I think the ongoing research will hopefully answer some of those questions.

Basically, what we do know is that a good oral health helps protect a woman’s health and her quality of life.  Pregnancy is an ideal time to do oral health screening as it may be the only time some women have insurance coverage.  In pregnancy, some women may be more teachable in some respects and more reachable about the importance of oral health for themselves and or their babies, but there are many barriers to care, especially during pregnancy.

On the OB’s side, there’s a general lack of knowledge, I have to say, about the full impact of poor oral health on the mother and the pregnancy.  As you know, we often don’t think about the mouth when we do an examination, especially pregnancy related.  I think, in general, we think that is not our problem.  I think people in the obstetrics need more education about this.

On the dental, there’s often a lack of knowledge but more based on the fear of treatment.  Could we possibly hurt the pregnancy?  Clearly, there are concerns about professional liability and malpractice claims if, somehow, following treatment, the outcome of the pregnancy.  So, clearly, there is a need for good information, good education in this area also.

Out in California, in the past several years, the California Dental Association partnered with District IX of the American College of Obstetricians and Gynecologists in a really excellent piece of work entitled Perinatal Oral Health Practice Guidelines.  This is easily found on the ACOG website and probably just Google.  Basically, there were two fundamental findings that came out from this piece of work.  First, the benefits of oral health outweigh the risk of oral health care.  This is not only because it can reduce the transmission of oral bacteria, but treatment appears not to have increased miscarriage risk associated with it.  Those are two very important things, especially the second.  Again, first, do no harm.  Nobody wants to do harm in treating patients.  Secondly, more globally related to that, of course, is to prevent.  Diagnosis and prevention of oral diseases are highly beneficial to the patient and can be undertaken during pregnancy.  These are two key findings of the study by the American College and by the California Dental Association.

In addition to that, most of the slides I’m going to be presenting in my brief talk really come from that report.  Particularly, we’re focusing on the role of obstetrical providers, and these are various talking points in discussing this with our OB providers that we should be really assuming some responsibility to educate patients about the importance of oral health.  We should try to be encouraging dental referrals.  If the patient is resistant to a dental referral, we should certainly ask because many times we find that patients are concerned about the safety of treatment during pregnancy, and we should be able to reassure them.  So, always find out if the patient doesn’t want to follow-up with the problem like that what the root of that is.  Certainly, advise the patient that dental care is safe, and it’s good for her and her children and the baby.

We should also document if the patient is under the care of an oral health professional.  So, in general, just like when we ask patients when they come to us as new patients who their primary care provider is, we should also know who provides them their oral health.  If we find that a referral is needed, we should not only make the referral but also document that we made it.  We should also develop a referral form that’s pretty simple and straight forward to reassure to the dental provider that hopefully it’s acceptable to treat the patient because many times, we often do hear from dentists who may call us and say, “We have so and so here.  She’s pregnant.  Is it okay if I give her this or give her this or give her that drug?”  Again, working collaboratively with the oral health care provider is good, and sometimes you can make that simpler and streamline the process by having a little form to refer a patient, and you should maintain a list of local resources because, as you may know, it’s not unusual to find that the patients are not connected in the dental health world.  They should know who they can see in the area.

As a part of our routine initial examination, actually, before there’s a problem, we should conduct and document an oral health exam, and we don’t have to be dentists to provide this kind of exam.  I think we know enough about an inflammation and about lesions and about [9:40] that we can certainly inspect the mouth, look at the teeth, the gums, the palate, the mucosa and look for any sign of destruction, lesion, or anything that we’re not sure about.  We should share appropriate information with the dental health provider if we are going to make a referral for any question, and we should, as always, encourage the quality advice of their oral health provider.

Behaviors.  We can certainly remind patients about things that we should all be doing.  In any event, brushing twice a day at least.  Use a fluoridated product and floss daily.  Take prenatal vitamins and pay attention to nutrition and the right foods, folic acid, of course.  Chewing xylitol gum four or five times daily after eating, that could be cleansing and reduce caries and inflammation and things of that nature.  So, it’s a good thing that patients can be advised to do and encouraged to do during pregnancy.

In addition to that, remind them not to delay any necessary treatment, and this is good for pregnant and non-pregnant people and for people like us, too.  Limit foods with sugars or simple carbohydrates.  Limit our drinking of juice and soda, including diet sodas, in between meals.  So, this is the second thing that we can also get people to do things that are right, nutritionally, for themselves, and that’s a good thing we should work on.

As far as protecting the baby, we can recommend certain behaviors that will help once the baby comes, including wiping the infant’s gums or teeth with soft cloth, brushing the child’s teeth after there are some teeth to brush.  Fluoride is okay after two years of age.  Avoid putting the baby to bed with a bottle or sippy cup with anything but water in it, and avoid saliva-sharing behaviors.  Again, we’re looking there to decrease the vertical transmission of cariogenic bacteria.

Remember, ultimately, that good oral health is part of good health, in general, especially in pregnancy.  For many women, we’re the only regular connection with the health care system and obstetrics, and if we don’t check on them, no one else will.

I think the rest of our talk this afternoon will be discussing the status of oral health during pregnancy, the importance of oral health screening and care in the perinatal period, barriers to providing good oral health care during pregnancy, and also a little bit about trauma-informed care.

We’re going to discuss, in much more detail, our panel of experts of group of people will be talking in more detail about oral health issues.  I will offer suggestions on how to improve oral health screening in the prenatal office also and discuss the barriers that we’ve touched upon already and share some practices surrounding trauma-informed care.  Basically, I’m looking forward to a great and timely discussion of a very important issue.  I commend you all for tuning in to this.  I think it’s great for you to take some of this to your practice, and now, I’m going to turn it over to Dr. Hilton.

Dr. Eastman:

Should this become, Ralph, let’s talk about it here.  I know Sharp is represented here today.  One of the leaders in quality in this community for a long time, have a quality event.  A week from this morning, Scripps is having its fifth annual quality summit, and I would invite all of you if you are interested in coming.  It’s at the Del Mar Marriot at the same time.

It’s going to take a little different approach.  The title of that is “From the Genome to the Bedside,” but it talks about some of the issues.  The keynote speaker is Abraham Verghese, professor of medicine at Stanford, author of Cutting for Stone, and we’re going to have a panel where he is going to be paired opposite of Eric Toppel who’s just published a rather provocative book on the creative destruction of medicine.  It’s all about technology.

So, we’re going to have Abraham Verghese who talks about getting back to the basics, the stethoscope, and listening to the patients, and Eric Topol, a futurist, clinician, cardiologist, who says he hasn’t used a stethoscope in five years.  He thinks we should be using hand ultrasound and look at the heart.  You’re all invited.  If you want more information, we’d be happy to provide it.

Other questions?  Yes?

Scott Musikan:

Thank you.  I’m Scott Musikan.  I’m one of the vascular surgeons here in town.  I have a question about the concept of the electronic health record and the fact that it seems like unless there’s the integration of all the hospital systems with an electronic health record, costs are never going to be improved, information’s never going to be shared.

I mean we have patients that go from Sharp and get transferred over to Scripps, and you know all their studies are being repeated once they get there because they can’t see the information.  So, I want to know what’s being done to try to integrate the electronic systems so that costs go down and things are not repeated.

Chris Van Gorder:

That’s part of the government’s push to use meaningful health records.  There’s actually a time frame built in for information exchanges that will connect the systems together.  So, I, Sharp, Kaiser, and the government are working towards that point where we will be able to talk to each other.  That’s one of the requirements that we’ll use.

Dr. Hoyt:

One of the big debates is between the type of data you can get with risk-adjusted clinical outcome versus so-called administrative data.  One of the barriers is that it takes a NFTE in each hospital to collect clinical data, but we’re working very hard with EPIC, with the federal government, with several large medical record vendors to focus on a way in which EMRs can drive data directly into EMR systems so you can see a time in the future where the cost of actually sustaining these data systems would go way down because we get rid of a lot of the NFTEs.

Dr. Eastman:

We probably have time for one or two more questions, then I do want the panelists to have a change to make a final comment.

Dr. Tyner:

Jeff Tyner, a thoracic surgeon at Scripps.  As such we’ve been part of the STS database for quite some time.  My understanding is it’s the oldest single database system in medicine.  It has a lot of data, and it’s been a real treasure for us.  It’s allowed us to move extra patients sooner, reduce extra transfusion, and look at readmissions, all of which have reduced readmission costs but there’s two real issues we’ve identified along the way:  One is whoever gathers this data is very important.  I’m interested on how you plan on establishing that because there’s a huge difference in definitions and who gathers this information.  It really goes to the quality of the data.

The second issue as David Chang mentioned is that it’s very, very important.  Very few people from the public or probably in this room understand confidence limits or standard deviation.  So, when it comes to public reporting, you have to be very careful how you release this data, not that it shouldn’t be released, but it should be in some sort of palatable form.  I’m interested in how that’s being addressed.

Dr. Eastman:

David, you might want to speak to that, and certainly, any of the panelists that do.  Very important question.

Dr. Hoyt:

Yeah. I think with regard to the first part, we will see, but by formatting adequately, the field choices in electronic medical records, you can drive consistency in data entry.  That’s still theoretical, but that’s the hypothesis. In the meantime, NSQIP data is only reflected by trained nurses who are subsequently audited in the concurrence rate of [1:24:18], and it’s low.

I forgot the second question.  Public reporting.  We had a project with CMS, and, in fact, SCS, is part of that project as well.  SCS has been a leader in public reporting, and we’re working with consumer reports as I’m sure you’re aware, in developing metrics that are clear to the public but account for the variability that you’re talking about.  Consumer reports have done.

The second is CMS, and they’re looking very carefully at this as well.  On a prototype basis, you’ll start to see on a hospital compare website, those hospitals that want to post some of their NSQIP data as they get some experience.

The third opportunity, which is one of the strongest, is the California Healthcare Foundation obviously here in California.  It has put out an RFA to work to start putting out reports on three diagnoses:  Normal deliver, cancer, and, I believe, orthopedic procedures because their concept is that these are usually out in the distance a bit so there’s actually the opportunity for patients to shop around.  So, we’re probably going to work with them, in the cancer area to try to develop relevant metrics which would achieve the goal of public reporting.

Dr. Eastman:

Final question with Dr. Centurion.

Dr. Centurion:

Thank you, Dr. Eastman and Dr. Hoyt for all your leadership.  It’s a real bright shining light on San Diego’s contribution on the national level of surgical and physician leadership.  My question is on never events.  As you know never events are adverse episodes that occur in the hospital setting which Medicare will no longer pay.  These things include pressure sores, hospital-acquired infections, and falls.  It also includes DVTs, and I was at a forum in Dallas last where I had the chance to ask the medical director of CMS why it is that a hospital that is using A1 protocols for DVT prophylaxis starting the chemoprocess at the right time, using it in the right doses, at the right sequence, with no missed doses, and for the right period of time.  If that person gets a DVT, that’s a never event.  In other circumstance, if a person has no DVT prophylaxis or the DVT prophylaxis is administered inappropriately, that’s also a never event.

These things should be driving quality, not used as schemes for avoiding payment.  I asked him that exact question.  He said, “We don’t really care about quality.  We’re just trying to find out ways to save money,” and I would ask the American College of Surgeons to modify the way never events are being administered.  It is abjectly unfair to penalize a hospital for a never event when the patient care is perfectly organized around bedded protocols.

Dr. Eastman:

Thank you.  Everybody in favor raise your hand.  I think we all wrestle with that.  I hope in the area of surgery, that the College of Surgeons, the relationship with David Hoyt is building, we’ll see something else from the Joint Commission and people in Washington we can address that because it is blatantly unfair.  Hopefully, adhering to guidelines that are approved by people like the College of Surgeons will also be a defense in the whole medical liability issue that we haven’t discussed.

Well, in order to make our time limit, I would like to start with Dr. LaBelle.  I would just like each of you to make one point that you have heard today, questions you heard, something you didn’t get to say. Dr. LaBelle.

Dr. LaBelle:

I would just like to reiterate that even with the outcomes based data, it’s still a requirement of physician leadership to drive change in the system.

Dr. Chang:

I just want to thank that comment about patient informing, and again, I think the bigger message is we should learn to empower patients in this process. Again, this goes back to the eminence-based medicine. It’s not just medicine.  Patients also believe in that, and I think we could change that from eminence-based medicine on both sides to a more patient-drive, patient empowerment approach.

Dr. Schumacher:

I’ll say that NSQIP has given us a powerful tool and is the basis of quality improvement and being able to look at our data and look at our processes, but we don’t have to be afraid of the white elephant in the room of culture.  There is a systematic way to go about analyzing change in your culture, and I urge you, at your peril, not to ignore it.

Dr. Dilley:

Yes.  I’d just like to reiterate my last point.  It just takes one percent in surgical complications to have a very, very significant increase in quality and decrease in cost.  Every group should be able to figure out how to cut the post-operative complications by at least one percent and make that a goal for the year.

Dr. Eastman:

Dr. LaBelle, before we hear from the Captain, what is the waste in healthcare that if we decrease what is inappropriate will save?

Dr. LaBelle:

I think nationwide, the estimate is anywhere from $500 billion to $700 billion of waste in the system.

Dr. Kobelja:

For me, all hospital systems are integrated because patients move around.  We can’t lose sight of that.  Then, the question about the EHR spoke directly to that, us recognizing that the silo systems in military is just as bad at this as everybody else.  It is part of the problem, and we need to work at the leadership level to systemically break down those barriers.

Dr. Talamini:

My point would be with regard to the electronic health record, which UCSD made a major investment in five or six years ago, actually wen David Hoyt was still at UCSD.  Dr. Socha pushed this huge investment, inconvenient for the physicians, no question, but incredibly valuable when it came to quality improvement because of the data you can collect.

So, a related issue in our Center for the Future of Surgery, one of the approaches we’re trying to take.  My colleague Dr. Horgan makes the point that in a soccer game, if you commit one foul you get a yellow card.  If you get three, you get a red card, and you’re out.   Right now, with surgeons, for the State Board of California, there’s only a red card, and we need to figure out a way to retrain surgeons and help them at the yellow card stage.  I believe that we can do this in a place like we’ve created at Centers for the Future of Surgery.  I think it’s very important.

Dr. Eastman:

A very innovative concept.  Chris, you can have the last word.

Chris Van Gorder:

Okay.  Well, dudes.  I do market music every day, and I survey all the literature that’s out there about healthcare reform that I can get my hands on and managed in a day.  There are a lot of people out there saying that the sky is falling as it relates to healthcare.  I have never been more bullish about the future of healthcare.  I think we’re doing the right things.  I think we’re moving healthcare from sick to wellness.

It doesn’t mean we’re not going to have hospitals dealing with acutely ill patients.  Of course, we will, but I think we’re moving in the right direction.  I’ve never seen this level of collaboration in more than 30 years of healthcare administration, the doctors and administrators, all of us working together.  We’re actually going to improve the healthcare system, create more value for our patients and society.  So, I’ve never been more bullish.

Dr. Eastman:

Thank you, Chris, and I’ll take the opportunity to conclude by thanking Dr. Hoyt and the American College of Surgeons for allowing us to be the community to have the first forum West of the Mississippi, maybe and certainly the first on the West Coast that has to do with nepotism and Dr. Hoyt’s foundation here.

Dr. Cochrane, we really appreciate you being here as a physician-scientist who helped to train David Hoyt.  Thank you very much for a good one.

Because we’re in a rapidly evolving environment in healthcare, it’s a little bit of a struggle to keep up with the various aspects of how we’re moving forward with quality and the deal with affordability issues as well.  I think it really comes down to how we build a system of the future, how we re-engineer care, and physician engagement is crucial to that.  In systems which drive measurements of outcomes rather than processes other than processes is important to the individual physician.

If I can speak to you with risk-adjusted data around mortality rates or particular complications, then we can have broader conversations around the entire system of care than a particular measure which looks at, “Did I provide DVT prophylaxis for the patient?”  I think that this is crucial because until we can recognize that our systems of clinical care evolved and were never engineered in the first place and have deep conversations laying out how we want patients to get cared for and how key performance indicators are that support that care process, we’re not going to get to those systems that reduce complications and prove the efficiency of care.

I think that in this world, we simply don’t have a choice to go about that.  The affordability issue in healthcare is almost to the point now where it precludes conversations about quality, and until we can connect those two tightly, we’re not going to be able to make that work, which comes back to what Scripps Health is doing to make this happen. I think that what’s happened at Scripps over the past 18 months is building a management infrastructure to support the physicians in change.

Chris spoke briefly about the horizontal management structure, which is really about doing things at the same place at the same way.  It’s not really about having the same labor standards or using the same supplies, it’s about building systems of care that apply the same things in the same way in the same place.

I’d like to give one example that’s related to my profession.  About a year and a half ago, the ERs of Scripps recognized that we weren’t performing to a level that we needed to perform, neither in turnaround times, access to our physicians in the emergency departments, or frankly our bypass times for the EMS system.  We had to have a hard conversation as to why that was, and we came to the realization, as a group of ER physicians, across the system, that it was really our leadership, or relative lack of leadership that resulted in this.

We were, in fact, using triage and the EMS system to modulate the number of patients that were coming into our emergency rooms for our convenience, not built around the patients.  What’s more is the processes that we had built in the ER were really a physician-centric.  We weren’t communicating well with the nurses, and we weren’t engineering processes the met the needs of the patients.

That was a struggle to recognize, and I think that was a prototype of the kinds of conversations that we had at every venue and it could only be had by physician leaders.  Surgeons play a particular leadership role in the hospital in that the most expensive care and the highest risk to the patient is around the surgical care in the patient.  There’s almost nothing in the hospital that isn’t touched by the surgeon.

Suffice to say, our conversations came around, and we realized that it was no longer an option to use triage as a way to hold patients in the waiting room.  We had to allow our patients to go in the back immediately and get care.  We eliminated largely the triage function in a lot of our ERs.  It was no longer an option for the ER physicians to go separately to the patient from the nurse and make the patient have conversations twice with the nurse and the physician around the same historical data.  We needed to go together as a team.

I think this teamwork and collaboration piece is going to be reflected and echoed throughout our culture, and it’s going to feel great when we recognize how difficult it is to work as a team when we’re used to autonomy and not collaboration.  I think that one of the core ideals around NSQIP, and the fact that we’re using risk-adjusted data that has been vetted by peers is that it rouses deep conversations that really requires collaboration between surgeons.

Dr. Eastman:

Thank you so much, Dr. LaBelle.  Well, thank you.  It’s a daunting task to say everything you have to say with the expert thing here in five minutes, but you did it.  We do have the remaining time to open it up for questions.  What we would like to do is have succinct questions and direct it to one panelist.  If the others have something to add, they can.  So, are there any questions?

Yes?  Would you identify yourself, what you do, and your question.

Audience:

[1:11:22] I just really wanted to say thank you, but I really want to acknowledge Dr. Chang because what I think you’re actually saying is true, how to reach out into the community, and your advocates can be that bridge.  Reach out to your advocates, seek associations, and act as advocates.  Thank you.

Dr. Eastman:

Thank you.  One for Dr. Chang.  Zero for the rest of the panel.

Dr. Dan:

[1:12:26]  I don’t know who I should direct it to.  I’m going to throw it out.  How can we explain different outcomes and processes that are being used for quality improvement or quality measurement, either with the same system or among different hospitals and having different results while they are using exactly the same measures.  Let me say for the urinary tract infection for using the ventilator-related pneumonias.  Different places are actually using the same measures to prevent those but coming out with different results.

Dr. Eastman:

If anyone understands the question, I would like you to answer it.  Good question, Ahmad.

Dr. Talamini:

I think your question really revolves around the issue of risk-adjustment, and that’s where NSQIP has made a major contribution to this world of data collection and analysis.  The problem, of course, is that no risk-adjustment system is perfect, and I think we recognize that the NSQIP risk-adjustment system is also not perfect.  That doesn’t mean that we shouldn’t try and make it as good as we can, and I think the College is committed and already has modified the system as we go forward on the basis of researchers like Dr. Chang and others to continually improve it.

I think we just have to acknowledge that no risk-adjustment is going to be perfect enough to exactly compare one hospital’s result to another, but that doesn’t mean we shouldn’t do it.

Dr. Dilley:

I think it’s very important question, too, and I would just like to add to what Mark said.  When we looked at the urinary tract infections, not a single member of our group felt that was anything wrong with it.  We were doing everything right, but until you actually look at all of the information, case by case.  You look at how they were cared for.  You, then, bring up these very, very small variations between practitioners that ultimately cause an increase in urinary tract infections.

So, I would say that if each hospital using the same outcomes program like NSQIP, looked at their conditions in very great detail, we would have a lot of unanimity of opinion.

Chris Van Gorder:

I’d also like to speak of the risks.  We’ve grown up as silos, all of our hospitals working differently, picking different systems and using the data in different ways.  I think there’s great importance with using standardization in terms of the systems we use and the data we use.

We’ve just now migrated to a common lab information system.  Prior to that time with the electronic health record, we practically had two different lab results with different standards.  Going the same way with electronic health record, actually, we have the same risk.  So, we have to standardize the systems we use, then we’ll be talking the same language.

Dr. Eastman:

Thank you.  Yes, Ralph?

Audience:

First of all, wonderful clarity on the presentation.  You’ve got all the pieces together.  Patient advocate here obviously addressed some of concerns.

I’m sorry.  I’m Ralph O’Campbell, retired general surgeon, former CMA president, if I may be allowed to say that.  So, I’ve been in medical politics for a long time, but that’s not what I’m addressing here.  I have a question for you Brent.  Is this going to become an annual event?  Then, the second question is, since this affects so much of our community, for instance, the Chamber has a health committee, wouldn’t it be appropriate to always invite non-physicians to events like this?  This cube is so easy to understand.  I understand it, and if they understood it, maybe they could help us.

Dr. LaBelle is probably, for all of these institutions, going to represent the type of individual that’s going to put this into effect.

Dr. Eastman:

Thank you, Ralph.  I’ll ask Dr. David Hoyt, too.  I think we would be happy in the San Diego chapter of the American College of Surgeons to make this an annual event if there was an interest, and perhaps, David Hoyt and Nancy can tell us if that’s in the works.  She talked about this being continued.

Secondly, I’ll let you know that we sent out 1,000 invitations to date.  We tried very hard so that we just didn’t have the people from just our quality committees and our surgeons, which is what we have.  We had really hoped to get, Ralph, the people you had talked about.  We didn’t accomplish that so maybe we ought do it again.

I will tell you, we also invited out surgical colleagues from Mexico because we have a chapter from Baja, California.  Some responded, they were not able to come.  Some are probably still waiting to try to get across the border, but they, too, would like to get more involved in this.

David, do you want to comment about making this an annual event?  What’s your plan?

Dr. Hoyt:

I had hoped that this would be important enough to the conversation across the systems of care across San Diego that you would want to do this on an annual basis.  I think that is a dream that we could see this occurring in every community, really to foster ultimately the communication.

David, perhaps you could tell the story of what the College did in the 1920s and 1930s that you shared with us this morning that’s pertinent to this concept.

Dr. Hoyt:

Yeah.  We think ideas are always new, but really, in the history, it turns out that based on our chapter of distribution of membership in the organization, that became the central form.  This is before the internet, video, before any of the modern technology.  Literally, the educational show was taking on the road community by community.

In addition to spending the day teaching each other how to do surgical procedures, they would convene in the afternoon and invite the public to actually come and listen to what was going on.  It actually became one of the most popular sessions in communities, oftentimes drawing 200 to 500 people from the community in a small community to come find out what’s going on in the community.

So, maybe we can go back there.

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Dr. Schumacher:

Hi.  I’m Mark Schumacher.  I’m a general surgeon and the physician director of the patient services at San Diego.  I want to expand on something that Dr. Kobelja touched on at the end of this talk.  That has to do with institutional culture.  Kaiser is a big support of NSQIP, but ultimately, the outcomes are dependent on the people that institute the processes that you’re trying to change.  That’s one of the realizations that we had a while back.

About a year and a half ago, we started a process of looking at our culture and seeing the opportunities to improve it.  We started out with an objective measurement.  We used the safety attitudes questionnaire that Peter Provonost and others have shown correlates well with clinical outcomes.  We found that we had opportunities for improvement in our culture.

As we began to analyze our culture, we realized that in the operating room and the pre-operative areas, we had high functioning individuals, but each individual had an expectation that they were infallible and the other people around them were infallible.  Another thing is inducing stress in others is something that would increase performance.

So, we took this on, starting out with group messaging.  We had off-sites and meetings where we presented to our folks, what would happen to our institution if this continues.  We also gave them the message that we want to invest in you.  We wanted to invest in a change.

We brought in an outside consultant and an educator to teach effective communication skills to people.  We taught our managers the concept of just culture.  Just culture is the concept of holding people accountable, but it’s also recognizing that we’re not going to be able to eliminate systems issues.  More importantly, we’re not going to be able to eliminate human errors by punishing people.  Instead, it’s more important to learn from adverse outcomes that it is to meet out punishment.

We invested in giving people in the front lines the support that they needed to identify the problems and making the changes to solve these problems themselves as opposed to a top-down management style.  We’ve done this through using unit-based teams and to patient-safety teams that are constituted of front-line people.

We’ve also done one-on-one work.  The leaders in the organization were encouraged to focus on problem children within their management structure and work with them one-on-one.  We’ve instituted scripted leadership rounding to promote safety and communication.  We’ve got a new on-boarding curriculum for new hires that stresses the importance of teamwork, and we’ve done consistent messaging.  You have to keep bringing this message back to your people over and over and over again in as many different forms in as many different ways possible.

So, in this last year and a half, I’ve seen some dramatic changes within the institution on my own executive rounds, and I’m looking forward to this fall when we’re going to have our next executive rounds of the safety attitude questionnaire that I’m convinced is going to show us objective measurements of change in our culture.

Dr. Eastment:

Thank you very much, Mark.  That’s a very different perspective, and hopefully, we’ll elicit some response to that particular approach.

Our next panelist, David Chang, is not a surgeon.  He’s not a physician.  He’s a PhD.  He might be the smartest person on the podium.  David came from Johns Hopkins, as did Mark Talamini.  Actually, we’ve rated Johns Hopkins, but David, I’ve had the opportunity to write a paper with David.  He’s a true academician in the realm of healthcare policy.  I think you’ll see his name more and more as he’s really producing the evidence we all talk about.

So, David?

David Chang:

Thank you, Dr. Eastman.  It’s a great honor to be here.  I guess I’m the only outsider in this panel.  I am a health services researcher by training with a background in health policy.  I am actually fortunate to be in departments of surgery all my professional life, first at Johns Hopkins and now at UCSD.

So, I come to this with an outsider perspective.  I’m fortunate to have mentors like Dr. Futchlock, Dr. Talamini, Dr. Eddie Quinwell who got me into this.  I have three points to make:  First is what does this mean to me as a policy person.  I think from a health policy perspective is that this is an attempt at more organization in healthcare, and this is what Dr. Hoyt talked about with the Institute of Medicine report.

The Institute of Medicine report had talked about this issue with the lack of scientific evidence in healthcare.  This is a problem that’s causing medical errors.  This is a problem that’s causing fragmentation like we talked about before, and I think NSQIP presents a unique, innovative effort at more organization in healthcare.

Before you really think about this, we actually don’t have a lot of organization in healthcare today with the notable exception in trauma as has been pointed out.  I think it’s not a surprise that we’re here today with surgeons like Dr. Hoyt and Dr. Eastman who started this in San Diego decades ago.  In fact, the trauma system innovations like the National Trauma Databank came under UCSD under Dr. Hoyt’s leadership.

So, when we talk about quality, what I see as a health policy person is more organized systems of health care, and I’m excited because I think it’s time that we push the system’s message out into the policy world.  I’m excited to hear the concept of professionalism that should be equal to accountability.  That’s an issue I think hasn’t really been addressed in healthcare.  I’m also excited of this move from eminence to evidence-based medicine.

Again, that’s why I’m in the audience.   I’m probably the most junior person on the audience, and I think this culture of evidence-base allow someone like me to be able to speak out.  This is something where I work with a lot of medical students and residents.  I really try to encourage them to speak out with evidence.  So, that’s what I see as a policy person.

What I think this represents to the people in the policy world is this message that we should be focusing on quality.  The problem with policy makers is they often focus on money, and that’s the only thing they understand.  If you think about the discussion on policy, the question is how to really spend money.  I think this is really inappropriate, at least when it comes to healthcare, because focusing on money is really misguided.  It won’t actually save money.  We would spend more money in the long run.

So, what we should do is focus on quality.  As the data has shown, focusing on quality actually reduces cost.  So, you might spend a little money up front, but we should see that as an investment, and ultimately, we will save money in the long run.

I think this is an important message to get out to the policy makers, and so, I’m glad that the American College of Surgeons has actually involved policy makers in this processes.  That’s what we’re trying to do in UCSD at the local level, engaging some of the policy makers here in California.

I think, as policy person, what’s important is what this represents to the larger society outside healthcare, and I think that might be the missing point in this whole debate.  WE might be preaching to the choir.  Everyone in this audience understands this quality message, but it occurred to me when I started working with medical students that medical students don’t understand NSQIP.  Most of the medical students who rotate to surgery have never heart of NSQIP.  They don’t know this concept of risk adjustment, and if students don’t understand this, I bet you 99% of the patients there don’t know about NSQIP.

I’m glad to hear the approach that the College is taking.  This housekeeping seal of approval.  This is what we really need to get out to the society that the objective work is to measure quality, and patients need to demand for this.  Again, this is a bigger problem than NSQIP.  The society, in general, does not understand quality, does not know that quality can be objectively measured.  This is actually a problem that the government outreach has put out a huge RFA to look at how to report quality in a way that the public understands.  So, this is something where I’m glad the College is actually taking the lead.

So, it’s surprising, in closing, that in the state of Facebook and Yelp, that most of us still pick our doctors based on an alphabetical list provided by our insurance companies with no quality data to guide us.  So, I think we’re very lucky to have leaders like Dr. Eastman, Dr. Hoyt, Dr. Martelini and others on the panel.

We could actually get this started, but I don’t think we can do the work ourselves.  We really need to get the public involved, and I think I really like the video at the end of Dr. Hoyt’s presentation.  That’s probably the funnest way to deliver this message of quality that I’ve heard of because when people think of quality, they should really try applaud.  That’s probably the coolest video I’ve ever seen about quality.

It actually reminded me of a video that one of the UCSD students made.  It’s a rap video in our medical school, about how they studied for the boards the library.  Maybe that’s the next step, get one of the medical students to make a rap video about quality.  Thank you.

Dr. Eastman:

Thank you, David.  Our last panelist, I’m particularly pleased to introduce, but I’m right on time.  I really think that Jim LaBelle at Scripps has recognized two things.  First, he talked about horizontal integration.  He talked about coal management that we’re never going to see going forward if we’re not managed by a very collaborative relationship between physicians and hospitals.

We read the history, David, has come and gone.  There have been chasms in the past.  Jim LaBelle was really only one of the two new appointments in the whole structure that Chris created, and it is the vice-president of medical management, co-management, and quality.  So, I thought that Jim could tell us what the heck that means.

Jim LaBelle:

Thank you, Brent.  My name is Jim LaBelle.  I’m an emergency physician who sometimes pretended to be a surgeon, but I recently took a role at Scripps which the title is corporate vice-president of quality, medical management, and physician co-management.  I briefly wanted to touch on why those are connected because I think that we’ve gone from a world in which quality’s a department in a hospital, and it really has become an attribute to an organization. Intimate to that is how we connect quality to the bedside, and it really is about physician leadership and engagement around that.