Exploring the inclusion of dental providers on interprofessional healthcare teams treating patients with chronic obstructive pulmonary disease: a rapid review

Literature search

A literature search for each objective was conducted on PubMed and Scopus. Inclusion criteria included primary and secondary studies and practise guidelines published between January 2015–May 2020 in either Canada or the United States. Given the nature of a rapid review and the relatively novel topic of this paper, any range shorter than five years may not have produced many results. Papers were excluded if they did not mention any keywords in the title or abstract, were not written in English, were not accessible electronically, were not available in full text, were classified as grey literature, and were not final publications. Search query strings and collected articles were documented on a Microsoft Excel document and Mendeley citation management software. Duplicate papers were removed. For the remaining articles, titles and abstracts were assessed for eligibility by the lead author (NIN), which included whether the paper aligned with the aim of this study or not. The literature search step is summarized in Figure 1. Search query strings for Objectives 1 and 2 are shown in Table 1. The last search was run on the databases on May 1^st, 2020.

Figure 1. Annotated PRISMA flow diagram visualizing the identification and filtration of papers as part of the ‘Literature Search’ step of the rapid review.

(A) Objective 1; (B) Objective 2.

Appraisal

Appraisal checklists specific to each article type were used from the Critical Appraisal Skills Program (CASP) developed by Oxford Centre for Triple Value Healthcare¹⁹. Examples include checklists for systematic reviews, cohort studies, and qualitative studies¹⁹. We used the CASP checklists to assess the quality of study methods to determine if the findings of the eligible articles are trustworthy and meaningful (Extended data²⁰)¹⁸. Articles were examined in more detail during this step. As a result, 12 were removed for Objective 1 and 58 for Objective 2 because they did not align with inclusion or exclusion criteria, or the aim of this study. This step was completed by NIN, GJF, JR, and OMN.

Synthesis

Relevant data from the appraised papers for each objective were extracted based on the aim(s), population/setting(s), methods, results, limitations, relevance to the aim, and applicability to the Canadian healthcare context¹⁸. The co-authors established conclusions and recommendations for each objective by evaluating the commonalities and differences across the studies, weighting the results by their methodological quality, and assessing their relevance to a One Health approach¹⁸. See Extended data for more information²⁰.

Analysis

These conclusions were then analysed for feasibility within the Canadian healthcare context using McMaster University’s Applicability and Transferability Tool²¹. The tool is designed to capture important issues related to proposed policy or program interventions within a given healthcare context²¹.

The interprofessional care approach

Over 90% of papers for Objective 1 found that interprofessional healthcare teams are traditionally restricted to clinical practitioners, yet COPD exacerbations are experiences that, for most patients, extend beyond a physical biomedical episode¹³. Many patients with COPD struggle with social and psychological concerns related to loss of meaning, hope, and fear of death²². One study that investigated the correlation between anxiety and patient treatment interventions documented a 45% reduction in anxiety related to COPD diagnosis after completing a multidisciplinary pulmonary rehabilitation program²³.

For Objective 2, the majority of articles support the addition of oral health practitioners within primary care teams. This interprofessional approach shifts care from curative, reductionist healthcare principles to preventive, patient-centered principles^24–28. The literature suggests that dental providers should adopt a comprehensive approach that accounts for both the patient’s biomedical needs, along with physical and social²⁹. Several articles suggest empowering patients to be contributing members of their treatment teams²⁹. One study showed that when a patient’s role on the care team is ignored, or information is not properly communicated, recovery is negatively affected, and the perception of fragmented care can lead to confusion and distrust from the patient³⁰. Effective communication is enhanced when a care team acknowledges the patient as a whole, including their cultural and linguistic preferences and socioeconomic status^31,32. Studies have found that medical and dental providers agree that basic preventive oral health services should be incorporated into medical visits to reduce the burden of dental disease carried by patients in at-risk, low socioeconomic areas^33,34. Several authors have demonstrated a need to incorporate the social determinants of health into dental education, modeled by interprofessional healthcare teams with diverse knowledge beyond a biomedical approach^33,34.

Interprofessional care in clinical and educational settings

In addition to the significance of interprofessional healthcare teams for patients with COPD, other papers assessed the practicality of these teams in clinical and educational settings^35–41. After the implementation of a COPD interprofessional care program, one study reported the 30-day emergency department revisit rate declined from 49% to 30%. Another study reported a COPD 30-day readmission rate decrease from 22.7% to 14.7%^35,42. In contrast, a study by Bhatt et al. did not report a reduction in 30-day all-cause readmissions from a comprehensive COPD multidisciplinary intervention⁴³. Mansoor et al. propose that interdisciplinary care is beneficial only with well-trained team members, well-established team norms, funded resources, and schedule flexibility³⁴. Another article demonstrated the challenge of miscommunication within healthcare systems, highlighting how a lack of coordination between veteran patients with COPD and community care providers resulted in delayed, missed, or inefficient care⁴⁴. A possible explanation, proposed by Ly et al., is that healthcare professionals experience role changes as threats to their professional identity which may in turn cause resistance to collaboration⁴⁵. Role clarification can improve the efficacy of interprofessional teams and provide valuable insight on how to optimize quality improvement and the performance of these teams in clinical practise⁴⁵. A study that implemented an interprofessional population panel management curriculum targeted to diverse health profession trainees found trainees overwhelmingly reported an increased ability to identify patients who would benefit from interdisciplinary care or referral to another team member⁴⁶.

Many articles also stressed that collaboration between dental providers and other health professions within both clinical and educational domains is essential for improving health care outcomes for patients with complex medical and oral health needs, especially those with health inequities^47,48. Research assessing the current status of interprofessional collaboration states that in order to improve patient outcomes there needs to be changes made in the type of personnel providing health care services, with more non-dental professionals providing select dental services and dental providers providing select medical services⁴⁹. These changes require better integration of medical and dental education and patient care^49,50. It is expected that this long-term goal will improve health outcomes, increase patient satisfaction, better overall health of populations, and reduce per capita costs of healthcare^49,50. Primary healthcare teams in both rural and urban areas of Quebec have expressed their concerns on the absence of integrated oral health services for treatment purposes⁵¹. They suggest increased implementation of government policies, the prioritization of educational and management measures, and interprofessional collaboration toward innovative care models will facilitate the integration of these health services⁵¹.

There are challenges in incorporating IPE programs successfully at health professional schools largely due to the fact that the integration of these programs are still in their infancy^48,52. One IPE activity for health professional students supported progress toward interprofessional socialization, but student learning was inconsistently demonstrated in teamwork products⁵². Incorporating IPE may be particularly challenging for dental hygiene programs, as their curricula primarily emphasises employment in private practise where providers deliver care intraprofessionally (collaboration only between other dental providers)⁴⁸ and in relative isolation.

Interprofessional care, chronic disease, and multimorbidity

There is a high probability of being diagnosed with other comorbidities along with COPD^53–57. Given this, interprofessional healthcare teams must approach treatment plans with a multi-morbidity (more than one comorbidity) outlook, which requires the inclusion of experts from several different specialties^53–57. One systematic review estimated that ≥1 chronic conditions (such as cardiovascular disease) coexist in >85% of patients with COPD⁵⁴. The authors stated that by utilizing an interprofessional approach, improvements could be made in the management of patients with COPD and other comorbidities⁵⁴. Such models have been associated with a 66% decrease in hospitalisations and a reduction in the number of exacerbations COPD patients experience⁵⁴. For COPD patients living with multimorbidities, the best care option is to change from disease-focused to patient-centred care, whereby providers look beyond the COPD diagnosis and instead see the patient as a whole to better understand the etiology of their comorbidities⁵⁵. Since comorbidities are often associated with a COPD diagnosis, healthcare teams should also shift to a more palliative-focused structure through partnerships with doctors, palliative experts (mainly nurses), and administrative executives to optimise quality of life and mitigate chronic suffering as much as possible⁵⁸.

Like COPD, oral diseases are also often associated with comorbidities^{34,50,59–63}. The inclusion of oral health into treatment plans has benefited patients across the lifespan who are living with chronic diseases^{34,50,59–63}. One case-control study concerning the inclusion of oral healthcare for patients with hemophilia makes a comparison with healthy individuals and reveals that hemophilic patients had higher debris and calculus scores, suggestive of poor oro-dental health status⁵⁹. The perception of childhood obesity as being a medical rather than dental issue, as well as dentists’ unwillingness to suggest interventions due to the fear of being offensive and judgemental, has led to many missed opportunities for screening childhood obesity at the dental office⁵⁰. Patients with syndromic craniosynostosis also pose unique oral health conditions and dentofacial deformities that make it necessary to have oral healthcare providers as part of the interprofessional care team⁶¹. There is also a lack of knowledge surrounding sleep-disordered breathing among pediatric medical professionals; therefore, interprofessional care approaches are needed to benefit from the unique perspectives that dentists have on sleep-disordered breathing⁶². Including dentistry as part of interprofessional healthcare delivery directly addresses the comorbidities associated with dental diseases and can subsequently reduce hospital stays, advance patient well-being, and allow for fiscal savings⁶⁰.

Limitations

Based on preliminary database searches conducted from September to December 2019, search queries were grouped together on the three main components of the study aim: ‘dental providers,’ ‘interprofessional care,’ and ‘COPD.’ This yielded one irrelevant result in PubMed and zero results in Scopus. Arguably a methodological limitation, it also presents as a gap in the literature; therefore, driving the motivation and strength of this study. Finding adequate, eligible papers to analyse was possible under two objectives that grouped together the concept of interprofessional care with COPD and then dentistry, having interprofessional care as the common search term (visualised in Figure 2). This may seem like a limitation as the rapid review methodology does not directly address the three main components of the aim. However, by conducting a literature search on two objectives that commonly share the theme of interprofessional care, the inclusion of dental providers on interprofessional healthcare teams for COPD can be adequately justified and explored in the databases.

Figure 2. Overview of rapid review objectives.

Visualizing how the objectives are a re-grouping of the three main components of the study aim.

Studies harbouring significant results may have been eliminated during the Literature Search step based on the specificity of the search query strings for each objective or simply by gaps in the database algorithms. During the Appraisal step, papers classified as intervention evaluations or case reports did not have corresponding CASP checklists, resulting in possible inaccurate assessments of the study methods, further questioning the significance of the papers. In order to maintain the vigour and validity of the results, intervention evaluations were appraised with CASP economic evaluation checklists in accordance with the Workgroup for Intervention Development and Evaluation Research (WIDER) checklist⁸³. Case reports were evaluated with CASP case-control checklists and consultation from a publication in the Journal of Medical Case Reports⁸⁴. Non-specific literature reviews were also analysed with CASP systematic review checklists.

Underlying data

No data is associated with this article.

Extended data

Dryad: Exploring the inclusion of dental providers of interprofessional healthcare teams treating patients with chronic obstructive pulmonary disease: a rapid review, https://doi.org/10.5061/dryad.31zcrjdjj²⁰.

This project includes the following extended data:

Reporting guidelines

Dryad: PRISMA checklist for ‘Exploring the inclusion of dental providers of interprofessional healthcare teams treating patients with chronic obstructive pulmonary disease: a rapid review’, https://doi.org/10.5061/dryad.31zcrjdjj²⁰.

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).