PHRN Dental Theme Two Years On

1. PHRN Dental ThemeTwo Years On Martin Tickle Research Director Oral Health Unit - National Primary Care R&D Centre Professor of Dental Public Health & Primary Care School of Dentistry: The University of Manchester

2. Structure • Why do we need research in prisons? • Progress on the research programme of the dental theme of PHRN • Demonstration project – preliminary results • Reflections • Next steps

3. Why do we need research in prisons?

4. Challenges • PCTs responsible for commissioning prison dental services • Major issues • High need populations • Need to provide equivalent care but with restricted resources • Unique environment – security concerns • Workforce issues – recruitment, professional isolation • Poor evidence base

5. Contribution from research • Provides knowledge • To inform commissioning decisions • To inform clinical care delivery

6. Spin off benefits of research • Reduces professional isolation and supports professional development • Improves quality of care • Helps recruitment and retention

7. Progress on the research programme of the dental theme of PHRN

8. PHRN programme • Formal launch – Sharing Good PracticeConference York 4-5th May 2005 • Network of research supportive prisons • Network of research active individuals working in prisons - http://www.phrn.nhs.uk/ • Scoping exercise • Small demonstration projects in each area

9. Scoping exercise • Systematic reviews • Listening exercise • Workshops • Interviews • Identify and prioritise research needs • Feed into DH research commissioning frameworks

10. Dental Theme scoping exercise • Systematic review of literature – complete • Very few papers - all descriptive epidemiology • No information about effectiveness of interventions

11. Research priorities • What interventions are effective in improving health of prisoners? • How can promotion of healthy eating\smoking cessation be supported? • How can the surgery down time be minimised? • Is screening of prisoners effective? • Effective use of skill-mix • A society for prison dentists

12. Evaluation of Prison Dental Services • Specific request from CDO • Strategy for Modernising Dental Services for Prisoners in England – April 2003 • Standards for service delivery • Over £4.5M injected into prison dental services • Has strategy\additional funding improved prison dental services?

13. Demonstration Project Developing and testing a screening tool to identify prisoners with urgent treatment needs

14. Aims of demonstration project • Development and testing of a standardised assessment tool to identify prisoners with urgent treatment needs • Identify and catalogue difficulties of running research projects in the prison setting

15. Background • Recently admitted prisoners have severe dental problems • Remand and short stay prisoners have difficulty keeping appointments • Most services run on a part time basis • On admission all prisoners have 24 hour, then 48 hour health assessment • No standardised system of dental assessment

16. Screening as a process Identify the target population Identify the population at risk via a screening test Attendance for a diagnostic test Identify individuals in need of treatment via a diagnostic test Those in need of treatment receive appropriate treatment

17. Background • Collaboration with Queen Mary’s and GKT • Dental Pain Questionnaire (DePaQ) • 2 page questionnaire • Categorises patients with pain into three groups • Irreversible pulpitis and periapical periodontitis • Reversible pulpitis and dentine sensitivity • Pericoronitis • Successfully tested in NHS – enables categorisation into Urgent and Non-Urgent

18. Methods • All patients on urgent treatment list attending dental services of Brixton and Belmarsh prisons – aimed for N=200 • Pilot questionnaire – literacy issues • Administered by nurses who deliver 48 hour assessment (screening test) • Clinical examinations by trained and calibrated examiners (diagnostic test) blinded to screening test outcomes

19. Results • Lost Belmarsh due to increased security • Fieldwork planned for 6 weeks – took 4 months • Stopped when N=100 • Principal problems • Lack of authorised staff • Prison Officers • Behaviour of prisoners

20. 96 subjects in total 69 categorised at screening & clinical examination 15 stated they had pain at screening but no urgent need at clinical examination 4 no pain at screening and no urgent need at clinical examination 1 no pain at screening but urgent need at clinical examination 5 had an incomplete questionnaireand urgent need at clinical examination 2 prisoners had incomplete questionnaire and no urgent need at clinical examination Flow Diagram

21. Results - frequency distribution at screening

22. Methods Irreversible pulpitis, periapical periodontitis and pericoronitis Urgent treatment need = Reversible pulpitis and dentine sensitivity Incomplete questionnaire no pain Non Urgent Treatment Need =

23. Two by two table for expressing the results of validation study for any screening test Result of screening test Diagnose positive (a+c) Diagnose negative (b+d) Test positive (a+b) True positive (a) False positive (b) Test negative (c+d) False negative (c) True negative (d) Result of gold standard (diagnostic) test Screening Test Validation

24. Screening Tests Sensitivity = True positive rate How good is the test at picking up people who have the condition? a/ (a+c) Specificity = True negative rate How good is the test at correctly excluding people without the condition? d/ (b+d)

25. Results – sensitivity and specificity

26. Conclusions • High sensitivity –efficient at picking up individuals with an urgent need • Poor specificity – inefficient at excluding individuals who have non-urgent treatment needs • Lack of candour will always be a problem? • Subjective vs professional judgement of need? • Is this test useful? • Only need to see ¾ of population but miss 1/5 of those with urgent treatment needs

27. Difficulties of running research projects in the prison setting

28. Problems • No problems with healthcare staff, or the prisons • Prisoners – unpredictable behaviour and unpredictable attendance • Security – getting subjects to the health care facility • Staffing – recruitment of staff with security clearance • Prison officers – institutionalised resistance? • Research a low priority - interferes with prison targets • Dental Issues – low priority compared to other health problems

29. Reflections after 2 years

30. Thoughts on research in prisons • Prison dentistry needs a research base • The PHRN is a first step • Significant difficulties of delivery • Are research outputs worth the effort? • RAE – main driver • High quality outputs

31. Pros Adherence to protocols by prison healthcare staff High disease adult populations Accessible population High consent rates Cons Bizarre behaviour Adherence to protocols by subjects Response bias Additional complexities of ethical approval process Extended recruitment periods Loss to follow up Lack of control Unpredictability Pros and Cons for an Academic

32. What next?

33. Next Steps • Complete demonstration project – qualitative research identifying barriers to undertaking high quality research • Network of research hosting prisons – can they provide solutions and deliver? • Will funding materialise? • PHRN • Other DH funding streams • Will other academics become active in this field?