Differential Item Functioning of the Jaw Functional Limitation Scale

AIMS: To assess the differential item functioning (DIF) of the Jaw Functional Limitation Scale (JFLS) due to gender, age, and language (English vs Spanish). METHODS: JFLS data were collected from a consecutive sample of 2,115 adult dental patients from HealthPartners dental clinics in Minnesota. Participants with missing data were excluded, and analyses were performed using data from 1,678 participants. Whether the item response theory (IRT) model assumptions of essential unidimensionality and local independence held up for the JFLS was examined. Then, using Samejima's graded response model, the IRT log-likelihood ratio approach was used to detect DIF. The magnitude and impact of DIF based on Raju's noncompensatory DIF (NCDIF) cutoff value of 0.096, Cohen's effect sizes, and test (or scale) characteristic curves were also assessed. RESULTS: Essential unidimensionality was confirmed, but locally dependent items were found on the JFLS. A few items were flagged with statistically significant DIF after adjustment for multiple comparisons. The NCDIF indices associated with all DIF items were < 0.096, and they had small effect sizes of ≤ 0.2. The differences between the expected scores shown in the test characteristic curves were little to none. CONCLUSION: The present results support the use of the JFLS summary score to obtain psychometrically robust score comparisons across English- and Spanish-speaking, male and female, and younger and older dental patients. Overall, the magnitude of DIF was relatively small, and the practical impact minimal.

Comparison of two rating scales with the orofacial esthetic scale and practical recommendations for its application.

PURPOSE: We compared measurement properties of 5-point and 11-point response formats for the orofacial esthetic scale (OES) items to determine whether collapsing the format would degrade OES score precision. METHODS: Data were collected from a consecutive sample of adult dental patients from HealthPartners dental clinics in Minnesota (N = 2,078). We fitted an Item Response Theory (IRT) model to the 11-point response format and the six derived 5-point response formats. We compared all response formats using test (or scale) information, correlation between the IRT scores, Cronbach's alpha estimates for each scaling format, correlations based on the observed scores for the seven OES items and the eighth global item, and the relationship of observed and IRT scores to an external criterion using orofacial appearance (OA) indicators from the Oral Health Impact Profile (OHIP). RESULTS: The correlations among scores based on the different response formats were uniformly high for observed (0.97-0.99) and IRT scores (0.96-0.99); as were correlations of both observed and IRT scores and the OHIP measure of OA (0.66-0.68). Cronbach's alpha based on any of the 5-point formats (α = 0.95) was nearly the same as that based on the 11-point format (α = 0.96). The weighted total information area for five of six derived 5-point response formats was 98% of that for the 11-point response format. CONCLUSIONS: Our results support the use of scores based on a 5-point response format for the OES items. The measurement properties of scores based on a 5-point response format are comparable to those of scores based on the 11-point response format.

Commonalities among dental patient-reported outcomes (dPROs)-A Delphi consensus study.

Improvement of patients' oral health-related quality of life (OHRQoL) is the main goal of oral health care professionals. However, OHRQoL is not a homogenous construct and how to assess it is challenging because of the large number of currently available instruments. Investigating available instruments and what they have in common would be necessary for consolidation and standardization of these instruments into a smaller set of tools. If the OHRQoL dimensions including Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact are the fundamental building blocks of the dental patient's oral health experience, then these dimensions should be measured by generic multi-item dPROMs. In this study, a panel of 11 international dentists use the Delphi consensus process to determine how well 20 of these instruments measured the four OHRQoL dimensions. All 20 dPROMs questionnaires assessed at least one OHRQoL dimension while all four OHRQoL dimensions were measured by at least one dPROM instrument, i.e., the four OHRQoL dimensions were essential components of the patient's oral health experience. This shows that the currently available generic multi-item dPROMs have a lot in common, in that they share Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact as targeted dimensions. Based on these commonalities, it is plausible and desirable to move towards a single four-dimensional metric to assess oral health impact in all clinical, community-based, and research settings. This step is necessary to advance evidence-based dentistry and value-based oral health care.

Should the frequency, severity, or both response scales be used for multi-item dental patient-reported outcome measures?

BACKGROUND: The Oral Impacts on Daily Performances (OIDP) index asks the respondents to indicate both, the frequency and severity of the impact. However, it is not clear if the two scaling methods are correlated, and if using one scale is sufficient. The purpose of the study was to investigate the correlation between frequency and severity rating scales of the OIDP instrument, and whether only one of the rating scales can be used instead of both. METHODS: A battery of patient-reported outcome questionnaires were administered to a consecutive sample of adult dental patients from HealthPartners dental clinics in Minnesota (N = 2,115). Only those who responded to any of the OIDP items were included in the analysis for this study (N = 873). We assessed correlations between the frequency and severity scales for all OIDP items, and for the summary scores of the two OIDP response scales. We additionally fit a categorical structural equation model (SEM) (or an item factor analysis model) and examined the correlation between two latent variables (Frequency and Severity). RESULTS: The correlation estimates for all OIDP items were greater than 0.50, indicating large correlations between the frequency and severity scores for each OIDP item. The correlation estimate between the two summary scores was 0.85 (95% CI [0.82-0.86]). When we calculated the correlation coefficient using a latent variable model, the value increased to 0.96 (95% CI [0.93-1.00]). CONCLUSION: Our study findings show that OIDP frequency and severity scores are highly correlated, which indicates the use of one scale only. Based on previous evidence, we recommend applying the frequency rating scale only in research and clinical settings.

DENTAL THERAPY AND DENTAL PATIENT-REPORTED OUTCOMES (dPROs).

Dental therapy was introduced into the dental team as an advanced practice provider with the intention to increase access to care while providing high quality care in a cost-effective manner. It is essential that the dental therapist is able to provide patient-centered care to minimize patients' suffering. In order to assess patients' suffering, it is critical to understand the impact of care and dental patient-reported outcomes (dPROs). The use of dPROs in evidence-based clinical practice can assess the impact that the advanced practice provider has in dentistry. The presence of dPROs in evidence-based clinical practice will show the equivalence and differences in impact of the dental therapist and dentist. Currently, there is limited research regarding the use of dPROs in dental therapy. A roadmap in this paper demonstrates possible ways to collect dPROs in dental therapy and advance evidence-based dental practice. Recommendations in ways to achieve the roadmap, possible research designs, and expansion in knowledge of dental therapy and dPROs are provided. It is important to explore the advanced practice provider and the possibilities in evidence-based dentistry with the usage of dPROs.

Development of a one-item version of the Orofacial Esthetic Scale.

OBJECTIVES: Orofacial appearance is increasingly recognized as an important dental patient-reported outcome making instrument development and refinement efforts to measure the outcome better necessary. The aim of this study was to derive a one-item version of the Orofacial Esthetic Scale (OES). MATERIALS AND METHODS: OES data were collected from a consecutive sample of a total of 2113 adult English- or Spanish-speaking dental patients from HealthPartners dental clinic in Minnesota. Participants with missing data were excluded and analysis were performed using data from 2012 participants. Orofacial appearance was assessed with the English and the Spanish language version of the OES. Linear regression analysis was performed, with the OES item 8 ("Overall, how do you feel about the appearance of your face, your mouth, and your teeth?") as the predictor variable and the OES summary score as the criterion variable, to calculate the adjusted coefficients of determination (R2). RESULTS: The value of adjusted R2 was 0.83, indicating that the OES item 8 score explained about 83% of the variance of the OES summary score. The difference in R2 scores between the two language groups was negligible. CONCLUSION: The OES item 8 can be used for the one-item OES (OES-1). It is a psychometrically sound instrument for measuring orofacial appearance. CLINICAL RELEVANCE: Due to its easy application and sufficient psychometric properties, the OES-1 can be used effectively as an alternative to longer OES instruments in all areas of dental practice and research.

Is assessment of oral health-related quality of life burdensome? An item nonresponse analysis of the oral health impact profile.

AIM: This study aimed to investigate if in the 49-item Oral Health Impact Profile (OHIP): (i) more missing data occurred when participants answered more questions, (ii) more missing data occurred in a particular item or set of related items, and (iii) item missingness was associated with the demographic characteristics and oral health-related quality of life (OHRQoL) impairment level. METHODS: We used OHIP data from the Dimensions of OHRQoL (DOQ) project, which consolidated data from 35 individual studies. Among these studies, we analyzed OHIP data from 19 studies (4,847 surveyed individuals, of which 3,481 were completed under supervision and 1,366 were completed unsupervised) that contained some missing information. We computed descriptive statistics to investigate the OHIP missingness. We also used logistic regression analyses, with missing information as the dependent variable, and number of questions filled in (OHIP item rank) as the independent variable for samples with and without supervision. To investigate whether missing data occurs more in a particular item or set of related items we fitted regression models with individual OHIP items and the OHRQoL dimensions as indicator variables. We also investigated age, gender, and OHRQoL level as predictor variables for missing OHIP items. RESULTS: We found very low levels of missingness across individual OHIP items and set of related items, and there was no particular item or set of related items that was associated with more missing data. Also, more missing data did not depend on whether the participants answered more questions. In studies without supervision, older persons and females were 5.47 and 2.66 times more likely to have missing items than younger persons and females. However, in studies with supervision, older persons, and participants with more OHRQoL impairment were 1.70 and 2.65 times more likely to have missing items. CONCLUSION: The study participants from general and dental patient populations did not find OHIP-49 burdensome. OHIP item missingness did not depend on a particular OHIP item or set of related items, or if the study participants responded to a greater number of OHIP items. We did not find a consistent pattern of the influence of sociodemographic and OHRQoL magnitude information on OHIP missingness. The amount of missing OHIP information was low making any potential influence likely small in magnitude.

Including the patient's oral health perspective in evidence-based decision-making.

BACKGROUND: How to approach the assessment of patient-perceived oral health is of fundamental importance for the evaluation of clinical and public health interventions because the patient's assessment should be used as an adjunct to objective dental findings in order to decide which interventions work. AIM: This review article aims to provide an overview of the principles, current status, and future outlook for how a patient's oral health perception can and should be assessed. REVIEW FINDINGS: The hierarchical position of dental patient-reported outcomes, oral health-related quality of life (OHRQoL), and dental patient-reported outcome measures within the hierarchical concepts of quality of life and its component, health-related quality of life, is presented. The Mapping Oral Disease Impact with a Common Metric project is outlined as an international effort to describe current approaches to standardize the measurement of oral impact using the four OHRQoL dimensions of oral function, orofacial pain, orofacial appearance, and psychosocial impact. CONCLUSION: Ultimately, these four dimensions of OHRQoL provide a practical and psychometrically solid way to collect and analyze OHRQoL data for all oral diseases in all settings, and eventually for all treatments through the use of a standardized, universal measurement tool. This universal impact metric capturing the patient's oral health perspective is the key to moving evidence-based dentistry and value-based oral health care forward.

Item and scale properties of the Oral Health Literacy Adults Questionnaire assessed by item response theory.

OBJECTIVES: a) To evaluate the item and scale properties of the Oral Health Literacy Adults Questionnaire (OHL-AQ) in an adult general population. b) To determine precision or accuracy of the respondents' estimated scores along the Oral Health Literacy (OHL) spectrum using item response theory (IRT) modeling. METHODS: Survey data were collected from a convenience sample of 405 adult attendees of the 2014 Minnesota State Fair. We used the two-parameter logistic (2PL) model for the item response theory (IRT) analyses of OHL-AQ data and calibrated items to estimate model-based item difficulty and discrimination parameters. Item and scale properties were also assessed by plotting and interpreting item characteristic curves (ICCs), test characteristic curve (TCC), and test information function (TIF). RESULTS: Based on interpretation of model coefficients, statistical testing, and model fit criteria, we deemed the 2PL model superior and selected this model to examine item and scale properties. Scale reliability was shown to be good through the test information function (TIF). TIF from our analysis showed that higher levels of OHL were measured less precisely than lower levels of OHL. CONCLUSION: We demonstrated OHL-AQ as a whole has promising psychometric properties. However, for equiprecise measurement across the scale range, the scale needs more items for measuring higher levels of OHL.

Assessment of differential item functioning across English and Spanish versions of the Orofacial Esthetic Scale.

OBJECTIVES: To investigate differential item functioning across the Spanish and English versions of the Orofacial Esthetic Scale (OES). METHODS: OES data were collected from a consecutive sample of a total of 622 adult dental patients (311 English- and 311 Spanish-speaking adults) from HealthPartners dental clinics in Minnesota. We inspected boundary characteristic curves (BCCs) based on item response theory (IRT) in English speakers and Spanish speakers to examine differential item functioning (DIF). Using the Samejima's graded response model, we used the item response theory log-likelihood ratio (IRTLR) approach to test whether DIF was statistically significant. RESULTS: Inspection of the BCCs did not reveal substantial differences in item difficulty and discrimination between English speakers and Spanish speakers. When IRTLR tests were performed for the seven OES items, no item was flagged with significant DIF after P-values were adjusted for multiple comparisons. CONCLUSIONS: Pooling of Orofacial Esthetic Scale (OES) data from English and Spanish-speaking dental patients for analysis and interpretation is supported by the absence of differential item functioning (DIF) across the two language groups.

Defining "Community" from the Perspectives of Individuals with Sickle Cell Disease in Rural Georgia.

Individuals with sickle cell disease (SCD) often struggle to transition from pediatric to adult-centered medical environments. One probable cause is that many transition programs do not focus on what happens when patients leave the medical environment and return to their communities. Little is known about how individuals with SCD define community. Therefore, we worked with health care providers at four rural Georgia SCD outreach clinics to conduct qualitative interviews with 21 individuals who had transitioned to adult SCD care. The biopsychosocial ecological model was the framework for the study. Findings indicated that individuals with SCD describe five aspects of community that span across the family, community, and society-levels of the biopsychosocial ecological model: 1) immediate family, friends, and social circle; 2) relationships with medical providers; 3) geographic community/neighbors; 4) church/spiritual support; and 5) society. Interventions designed to improve SCD in rural communities may be most effective if they include not only support from family but also enhanced neighborhood supports and links between adults with SCD and relevant community organizations.

Medical Education in Decentralized Settings: How Medical Students Contribute to Health Care in 10 Sub-Saharan African Countries.

PURPOSE: African medical schools are expanding, straining resources at tertiary health facilities. Decentralizing clinical training can alleviate this tension. This study assessed the impact of decentralized training and contribution of undergraduate medical students at health facilities. METHOD: Participants were from 11 Medical Education Partnership Initiative-funded medical schools in 10 African countries. Each school identified two clinical training sites-one rural and the other either peri-urban or urban. Qualitative and quantitative data collection tools were used to gather information about the sites, student activities, and staff perspectives between March 2015 and February 2016. Interviews with site staff were analyzed using a collaborative directed approach to content analysis, and frequencies were generated to describe site characteristics and student experiences. RESULTS: The clinical sites varied in level of care but were similar in scope of clinical services and types of clinical and nonclinical student activities. Staff indicated that students have a positive effect on job satisfaction and workload. Respondents reported that students improved the work environment, institutional reputation, and introduced evidence-based approaches. Students also contributed to perceived improvements in quality of care, patient experience, and community outreach. Staff highlighted the need for resources to support students. CONCLUSIONS: Students were seen as valuable resources for health facilities. They strengthened health care quality by supporting overburdened staff and by bringing rigor and accountability into the work environment. As medical schools expand, especially in low-resource settings, mobilizing new and existing resources for decentralized clinical training could transform health facilities into vibrant service and learning environments.