Abstract
Purpose: To 1) quantify practitioner activities of the National Dental Practice–Based Research Network (Network) for which Continuing Education (CE) credits were received (study training, videos, webinars, meetings, and symposia); 2) quantify practitioner coauthoring Network publications and presentations; and 3) test whether practitioner characteristics were associated with participation in these activities.
Methods: A retrospective analysis of 4361 practitioners who enrolled in the Network between April 12, 2012 and October 12, 2018.
Results: Overall, 59% (n = 2586) of practitioners earned CE credit from the Network; among these, 68% (n = 1757) from a video, 38% (n = 993) attended an annual Network meeting, 31% (n = 798) due to training for a Network clinical study, 9% (n = 226) attended a national symposium, and 7% (n = 170) participated in a Network webinar. Members of 2 large group practices earned on average more CEs than practitioners from other practice settings. Four percent (n = 159) of practitioners coauthored a Network presentation or publication. Practitioners who received their dental degree before 2000, were general practitioners, or were members of 2 large group practices, were more likely to have coauthored a publication or presentation.
Conclusion: This Network used a broad range of activities to engage community practitioners. These activities were successful in sustaining a high level of practitioner engagement in clinical research and its relevance to everyday clinical practice.
- Continuing Education
- General Practitioners
- National Institute of Dental and Craniofacial Research
- Practice-Based Research
- Publishing
- Retrospective Studies
Introduction
A practice-based research network (PBRN) is a group of practices that aim to foster quality improvement through participation in research and translation of new knowledge into everyday clinical practice.1 PBRNs have responded to the changing health care landscape by broadening their membership (eg, dental, primary care, pharmacy, ancillary staff, community partners) and embracing diverse research methodologies.2 The PBRN context is a promising means of advancing clinical practice by incorporating practitioners into each step of the research process, engaging them in collegial activities, studying relevant research questions, and obtaining large amounts of clinical research data in a relatively short period.3 Practitioner engagement is crucial to this endeavor. In 2012, the National Institute of Dental and Craniofacial Research funded a single, unified national PBRN called the “National Dental PBRN”.4
The Network recognizes that the ability to sustain an existing PBRN is dependent on the number of studies conducted, the quality of research conducted, successful retention, and above all, recruitment and meaningful engagement of practitioners.5⇓⇓–8 Results from a recent analysis of enrolled Network member participation indicated that the Network has achieved high rates of sustained study participation and has provided an effective research context to obtain data from diverse populations.9 The Network has increased practitioner participation by including practitioners in all aspects of the research process, posing questions that improve the health of patients, minimizing time/workflow pressures, supporting participating practitioners, holding periodic annual meetings, implementing practical and feasible study designs, streamlining protocol training and using quick-reference guides, disseminating study results to practitioners and offering continuing education (CE) credit9.
Similar to medical PBRN's that view offering continuing medical education credits to participating physicians as vital,10 the Network offers CE credit to dental practitioners for completing a Network orientation video, human subject protection training, study protocol training, and for attending sessions about study results presented in various formats, such as videos offered via YouTube, webinars, annual regional practitioner meetings, and American Association for Dental Research (AADR) symposia. Other Network engagement activities include the opportunity to coauthor Network publications and presentations and respond to Quick Polls (brief qualitative surveys about clinical topics).
All engagement activities occur with an eye toward answering questions of daily clinical relevance that have the potential to improve clinical practice and positively affect patients' oral health.3 The purpose of this publication is to 1) quantify practitioner activities of the Network for which CE credits were received (study training, videos, webinars, meetings, and symposia); 2) quantify practitioner coauthoring Network publications and presentations; and 3) test whether practitioner characteristics were associated with participation in these activities.
Methods
A retrospective analysis was conducted of practitioners who enrolled between April 12, 2012 and October 12, 2018 and activities as of December 17, 2018. Once these were quantified, we tested whether specific practitioner characteristics were associated with practitioner engagement in these activities. At Network enrollment, practitioners completed an Enrollment Questionnaire to describe themselves, their practice(s), and their patient population. Questionnaire items, which had documented test/retest reliability, were taken from previous work in a practice-based study of dental care.5⇓⇓–8,11 The full questionnaire is publicly available.12
CE Credit
The Network offers free CE for its members. Network membership is also free. The Network offers this service as a courtesy to the members to assure they can maintain their required credits as well as stay engaged and informed of the latest Network study results. CE credits awarded are described by source (Table 1) and include:
Study training: required for participation in each of the Network's clinical studies (1 CE credit per study);
Network study results dissemination: videos (n = 4) and webinars (n = 3) were organized centrally through the University of Alabama at Birmingham but available online to all members in each region of the Network (1 CE each). The videos were offered via YouTube;
Network orientation: participants could view an orientation video after completing the Enrollment Questionnaire (0.5 CE);
Human Subject Protection Training: the Southwest region offered a video on protection of human subjects, a training required by Institutional Review Boards (IRBs) for clinical study participation (1 CE);
Practitioner Network Meetings: each regional node typically had an annual meeting to which members were invited to meet with fellow colleagues, learn about study results, and earn 4 to 7 CE credits;13
AADR symposia: practitioners attended these symposia and represented their respective regions to learn more about the breadth of oral health research (2 to 7 CEs).
Sources of Continuing Education for Dentists: National Dental Practice–Based Research Network, April 2012 through December 2018
Publications and Presentations
The Network makes a point of giving practitioners opportunities to serve as authors on peer-reviewed and nonpeer-reviewed publications and presentations at scientific and clinical meetings. For each practitioner, we ascertained whether they coauthored a presentation or publication, and categorized it as whether or not it was peer reviewed.
Statistical Analysis
We describe the number of CE sources with which practitioners engaged as well as the distribution of the number of times each practitioner engaged in a given CE source type. We calculated descriptive statistics, namely, mean with standard deviation (SD), and median with interquartile range (IQR), of the total number of CEs and for each type of CE source. The frequencies of whether a practitioner earned a CE credit, separately for those earning only 0.5 for the orientation video and for those earning 1 or more CEs, were obtained according to practitioner and practice characteristics; chi-square tests were used to assess the significance of the differences. To identify independent associations, logistic regression was used with an entry criterion of P < .10 and a retention criterion of P < .05. Odds ratios and 95% CIs were calculated from the models. Some categories were collapsed based on bivariate analysis. These analyses were repeated for whether a practitioner coauthored a publication or gave a presentation. For total number of CEs, general linear models, with analysis of variance (ANOVA) was used. Pearson's correlation coefficients were used to evaluate possible collinearity of characteristics before entering them into a general linear model. All analyses were performed using SAS software (SAS v9.4, SAS Institute Inc., Cary NC).
Results
Network Members
Overall, 4361 dentists were Network members. Table 2 shows members' demographic characteristics. The mean age at enrollment was 50 years (SD = 12), with a median of 51 years (IQR, 39 to 59 years) and a range of 24 to 92 years. Most members (74%, n = 3227) were general practitioners, and 82% (n = 3512) were in private practice, of whom 2917 were owners. Few (5%, n = 201) were in large preferred provider/managed care plans of HealthPartners Dental Group (HPDG) or Permanente Dental Associates (PDA) practices, or in public/community health practices 4% (n = 179). Slightly more were in academic, federal, or other managed care plans (10%, n = 412). Network regional representation ranged from 13% to 20%.
Distribution of Practitioner Characteristics, by Whether the Practitioner Earned Any Continuing Education Credits and Whether the Practitioner Coauthored Any Presentation or Publication; National Dental Practice–Based Research Network, April 2012 through December 2018
Quick Polls
Forty Quick Polls were conducted from June 2014 to June 2018. The mean number of responses was 476 (SD = 130), with a median of 444 (IQR, 394 to 549) and a range of 277 to 782. The number of Quick Polls conducted per calendar year was 6 in 2014, 11 in 2015, 9 in 2016, 7 in 2017, and 7 in 2018. Response was less in 2016 than in other years (377 vs 505, P = .007).
CE
Overall, 59% (n = 2586) of practitioners earned some CE; among these, 68% (n = 1757) did so through a video, 38% (n = 993) through an annual Network meeting, 31% (n = 798) through training for study participation, only 9% (n = 226) through national symposia, and 7% (n = 170) through a Network webinar. Table 3 shows the number of CE sources (eg, videos, meetings) in which a practitioner earned CEs, and for each source type, the number within that type for which the practitioner earned CE credit. Overall, 61% (n = 1580) earned CEs through 1 type of source, 28% (n = 724) through 2 types, and 8% (n = 215) through 3 types. This was similar for regional meetings, symposia, and study trainings, while for videos and webinars a higher majority earned a CE through only 1, namely, 82% (n = 1444) for videos and 85% (n = 144) for webinars.
Distribution of Continuing Education (CE) Credits Earned by Network Practitioners, by Number of Sources of CE, and by Number within Each Type of Source
The mean number of CE credits earned, was 6.0 (SD = 9.0), median = 2.0 (IQR, 0.5 to 7.5). The descriptive statistics for each source of CEs are presented in Table 3.
As videos were the most common source of CE, and the orientation video was the mostly commonly watched video (n = 1560), overall CE analysis was repeated excluding the orientation video (n = 811, 19%). A total of 1775 (41%) practitioners earned at least 1 CE credit from engagement activities; the same number did not earn any CE. The distribution by number of types of sources of CE among the 1775 who earned at least 1 CE, excluding watching the orientation, was similar to the distribution before the exclusion, namely, 64% (n = 1128) had 1 type of source, 26% (n = 462) had 2, and 8% (n = 142) had 3 types of sources; 26% (n = 465) earned a CE through video. Excluding the orientation video only raised the mean number of CE credits earned from 6.0 to 8.3 (SD = 10.0) and median from 2.0 to 5.0 (IQR, 1.0 to 11.5). The mean number of CE credits earned from videos increased from 0.8 to 1.3 (SD = 0.7) and median from 0.5 to 1.0 (IQR, 1.0 to 1.0). The mean increased because excluding the relatively large number (n = 811) whose only CE was from the orientation (only 0.5 CE), skewed the mean to smaller value.
Publications and Presentations
Overall, 4% (n = 159) coauthored a publication or gave a presentation (Table 4). A total of 19% (n = 30) coauthored only peer reviewed, 31% (n = 49) only nonpeer reviewed, and 50% (n = 80) both (Table 4). In terms of whether an item was an abstract, presentation, or publication (not mutually exclusive): 72% (n = 114) coauthored an abstract, 50% (n = 80) gave a presentation, and 60% (n = 95) coauthored a publication. The distribution of each of these 3 presentation/publication items according to whether it was peer reviewed is presented in Table 4. Presentations were primarily (88%, n = 70) nonpeer reviewed. In contrast, abstracts and publications were largely peer reviewed.
Distribution of the Publication Types Coauthored by Network Practitioners
Associations of Practitioner/Practice Characteristics with Whether Earned Any CE Credits or Coauthored a Network Publication
Male practitioners; those who were either Hispanic, non-Hispanic White, or African-American (compared with Asians and other races); older in terms of age when enrolled in the Network or earlier year when graduated dental school; or a general practitioner (compared with a specialist), were more likely to earn any CE, compared with members who earned no CEs (Table 2). As age at Network enrollment and year graduated dental school were strongly, inversely correlated (r = −0.92; P < .001), only the latter was used when assessing independence of associations (models using multiple regression). Year graduated dental school; general practitioner versus specialist; and inverse association with being from the Western region; were each independently associated with a practitioner earning 0.5 CE from the orientation video compared with practitioners not earning any CE.
All bivariate associations described above retained significance when comparing practitioners who earned 1 or more CE credit to those earning none (Table 5). The only item that differed between practitioners who earned 1 or more CEs and those who only earned 0.5 CE from watching the orientation video was the region in which they practiced. Only Western region practitioners were more likely to have earned 1 or more CEs than 0.5 CEs when compared with practitioners from other regions. However, practitioners from the other 5 regions were more likely to have earned 0.5 CE versus none as well as more likely to have earned more than 1 CE versus none.
Multiple Regression Models Relating Practitioner Characteristics to Whether the Practitioner Earned Any Continuing Education Credits or Whether the Practitioner Coauthored Any Publication or Presentation
Among practitioners earning 1 or more CE credits, those who were members of either HPDG or PDA practices earned on average more CE credits than practitioners from other practice settings (number of CE credits: 12.0 [SE = 1.0]; 8.1 [SE = 0.2]; P < .001), as did practitioners from the Midwest and Western regions (regions where HPDG and PDA are located) (10.4 [SE = 0.5]; 7.5 [SE = 0.3]; P < .001). When considered together, only region retained significance. Of the 159 practitioners who coauthored a publication or presentation, 156 earned 1 or more CEs and the remaining 3 earned 0.5 from the orientation video. Practitioners who received their dental degree before 2000, were general practitioners, were members of either HPDG or PDA practices, and were not from either the Southwest or Northeast region, were more likely to have coauthored a publication or presentation (Table 2). These associations retained significance when considered together (Table 5).
Discussion
This Network used a broad range of strategies and activities to engage community practitioners, many of which provided the opportunity to earn CE. Most, if not all, activities pertained to evidence-based dentistry and improving oral health, such as clinical research studies, disseminating results of Network clinical studies (including use of videos or webinars), or a combination of disseminating results and fostering “collegiality and interaction” among the practitioners via face-to-face meetings and symposia. Our results showed that 60% (n = 4361) of members in the Network were engaged in at least 1 of the activities for which CEs were earned. Earning CE credit is a requirement for continued dental practice licensure in most states.14 Sinclair-Lian et al15 and others have found that physician members of medical PBRNs associate opportunities to earn CE credit with their willingness to sustain their involvement with the clinical research studies conducted by a PBRN.
Participation in research has benefited medical clinicians by providing intellectual stimulation that has been associated with retention of clinicians in rural, underserved communities and with long-term change in clinical practice behavior.16 The National Dental PBRN has disseminated study results that provide guidance for clinical practice change, 1 example being the Suspicious Occlusal Caries Lesions study. The findings suggested that noninvasive management is appropriate and that clinicians should consider long-term monitoring when making treatment decisions about these lesions.17 These results were disseminated via webinars, research updates, videos, and numerous presentations where CE was provided for it. Other studies have shown how practices can improve patient health by using a nonphysician-dependent, clinical team approach to human papillomavirus (HPV) screening in dental offices by collecting oral rinses for HPV detection18 and the feasibility of implementing blood glucose testing in community dental practices.19,20 The Network has also demonstrated beneficial practice change with regard to evidence-based treatment of early dental decay;8 the impact of PBRN engagement was most significant for the most-engaged practitioners and consistent with a spillover effect onto same-clinic providers who were not PBRN engaged.
Our results showed that 18% (n = 798) participated in clinical studies, while 41% (n = 1775) were engaged in the benefit of learning from the studies' preliminary findings (before publication) through videos, webinars, meetings and symposia, and through the latter 2 activities, discussion with colleagues. Meetings enable professional networking, which is desired by PBRN participants, but which has been described as difficult to achieve.21 Highly interactive meetings with fellow practitioners have been reported as effective means to translate scientific findings into clinical practice. Furthermore, practitioners have stated intentions to change practice behavior as a consequence of study results disseminated at meetings.13 Videos were the most common source of CE credit, and even though members were not able to earn CE credit for all the videos available because of their short duration, videos remain effective engagement tools because they disseminate the Network's research in a convenient, usually short informative format. Many industries seem to be moving toward the shorter time frame presentation style to maintain the audience's attention while still delivering the desired take-away information.22
Dental practitioners have an important role in improving oral health by participating in research and implementing the results of studies in their practices.8 The Network conducted 40 Quick Polls based on topics in which practitioners expressed interest. Although responses to the Quick Polls were not linked to participating members' identifiers, they did offer an easy way for members to give input about ideas for Network studies. PBRN study ideas often come from the practitioners themselves in a bottom-up approach to study selection.23 To our knowledge, the National Dental PBRN is the only Network that successfully uses Quick Polls as a means to gauge interest in future study topics.
The Network embraces the concept of a “learning health system,” that is, an organization where science, informatics, incentives, and culture are aligned for continuous quality improvement and innovation.23,24 The practitioners are engaged at each step of the research process, from study topic selection to results dissemination, presentation, publication, and implementation of relevant practice changes.25 A multifaceted approach for eliciting study ideas described as “bottom-up” is popular in medical PBRNs, where both practitioners and academic researchers are active in identifying study questions.26,27 The Network produced 156 peer-reviewed scientific publications during the 2005 to 2019 funding period and most included a Network practitioner as a coauthor in the writing process. A total of 159 (4%) practitioners coauthored a Network presentation or publication. Although the absolute number of practitioners engaged in publications was relatively small, their input during the early discussion of interim findings and preparation of the manuscript was invaluable. Some practitioners were willing to present Network study results at annual meetings or other dental conferences, instead of or in addition to participating in peer-reviewed publications. This can be valuable to the practitioners in the audience during these presentations because they are able to hear from 1 of their own peers directly, thereby validating the importance of practitioners' participation in the full study development, implementation, and dissemination process.
The engagement activities that the Network offers seem to attract and retain a broad spectrum of members. Our results showed that certain practitioner characteristics (gender and race) were modestly associated with being engaged in activities for which at least 1 CE was earned, while being a general practitioner (vs specialist) and being older in terms of when the practitioner graduated dental school, were more strongly associated with these activities. Results also showed that members of HPDG or PDA practices and general practitioners were more likely to have coauthored a publication or presentation. This may reflect a supportive culture within these large practice groups and that these groups were part of a regional PBRN that preceded the National Dental PBRN.
This study has limitations that should be considered when interpreting its findings. Although Network practitioners have much in common with dentists at large, they may not be representative of a wider representation of dentists.7,28 Network members are not recruited randomly, so factors associated with Network participation (eg, an interest in clinical research) may make Network dentists unrepresentative of dentists at large. While we cannot assert that Network dentists are entirely representative, we can state that they have much in common with dentists at large, while also offering substantial diversity in these characteristics. This assertion is warranted because 1) substantial percentages of Network general dentists are represented in the various response categories of the characteristics in the Enrollment Questionnaire; 2) findings from several Network studies document that Network general dentists report patterns of diagnosis and treatment that are similar to patterns determined from non-Network general dentists29⇓⇓–32 and the similarity of Network dentists to non-Network dentists based on characteristics reported in the 2010 American Dental Association (ADA) Survey of Dental Practice.33
Conclusion
This Network used a broad range of strategies and activities we judge can be used to engage community practitioners of all health profession types. These activities were successful in sustaining a high level of practitioner engagement in clinical research and its application to everyday clinical practice. This may serve as a model and provide valuable information to other PBRNs to increase participation rates, whether they engage physicians, dentists, or personnel in other health care professions. We believe that PBRN research will continue to be valuable in transforming dental practice, and the use of these activities can contribute to the overall success of the PBRN mission.
Acknowledgments
Authors are very grateful to the practitioners who have participated in Network studies and numerous other Network activities. Authors are also very grateful to the Regional Coordinators who ensured high-quality studies and created successful member relations (Midwest Region: Emily Durand, BS, RDH; Tracey Shea, RDH, BSDH; Kimberly Johnson, RDH, MPH; Sarah Basile, RDH, MPH; Christopher Enstad, BS, RDH. Western Region: Stephanie Hodge, MA; Lisa Waiwaiole, MS; Natalia Tommasi, MA; Celeste Machen, BA; Sacha Reich, BA, PMP. Northeast Region: Vi Luong, MS; Kathy Bohn, AAS; Rita Cacciato, RDH, MS; Patricia Ragusa, BA; Christine O'Brien, RDH. South Atlantic Region: Deborah McEdward, RDH, BS, CCRP; Brenda Thacker, RDH, BS, CCRP, AS; James D. Johnson. South Central Region: Shermetria Massingale, MPH, CHES; Ellen Sowell, BS. Southwest Region: Stephanie Reyes, BA; Meredith Trejo, MPH; Colleen Dolan, MPH), and the Network's program manager (Andrea Mathews, BS, RDH), and program coordinator (Terri Jones).
Notes
This article was externally peer reviewed.
Conflicts of interest: None.
Funding: This work was supported by National Institutes of Health Grants U19-DE-22516 and U19-DE-28717. Opinions and assertions contained herein are those of the authors and are not to be construed as necessarily representing the views of the respective organizations or the National Institutes of Health. An Internet site devoted to details about the Nation's Network is located at http://NationalDentalPBRN.org.
To see this article online, please go to: http://jabfm.org/content/33/5/687.full.
- Received for publication September 25, 2019.
- Revision received January 16, 2020.
- Accepted for publication January 21, 2020.
