Policy entrepreneurship and policy networks in healthcare systems - the case of Israel's pediatric dentistry reform.

BACKGROUND: Can the entry of a policy entrepreneur challenge the equilibrium of a policy network and promote changes that might clash with the goals of powerful civil-servants and/or interest groups and, if so, why and how? Our goal is to examine two sides of the same coin: how does an in-depth analysis of Israel's dental care reform enrich our understanding of policy networks and policy entrepreneurship? Second, how does the literature on policy networks and policy entrepreneurship help us understand this reform? Based on a theoretical framework that appears in the literature of policy entrepreneurship and policy networks, we analyze the motivations, goals and strategies of the main actors involved in the process of reforming pediatric dental care in Israel. We demonstrate how a policy entrepreneur navigated within a policy network and managed to promote a reform that, until his appearance, no one else in that network had succeeded in enacting. METHODS: Our goals are advanced through a case study of a reform in pediatric dentistry implemented in Israel in 2010. It rests on textual analyses of the literature, reports, committee minutes, parliamentary proceedings, print and online media, and updates in relevant legislation and case law between 2009 and 2015. In addition, the case study draws on the insights of one of the authors (TH), who played a role in the reform process. RESULTS: Historical circumstances and the Israeli public's longstanding lack of interest in changing the existing model as well as interest groups that preferred the dominance of the private sector in the dental healthcare system kept that area out of the services supplied, universally, under the National Health Insurance Law. This situation changed significantly following the publication in 2007 of a policy analysis that contributed to shifts in the motivations and balance of power within the policy network, which in turn prepared the ground for a policy change. In this environment a determined policy entrepreneur, who identified a window of opportunity, took the lead and instituted an innovative and far-reaching reform. CONCLUSIONS: A policy entrepreneur can leverage external factors as well as the previous activities of a policy network that has already matured to create a policy change. Such entrepreneurial activity includes maneuvering around opponents and overcoming resistance from various stakeholders.

Tradução, adaptação transcultural e validação da versão brasileira do "Impact of Fixed Appliances Measure" (B-IFAM) / Translation, cross-cultural adaptation and validation of the questionnaire "Impact of Fixed Appliances Measure" to the Brazilian Portuguese language

Introdução: O objetivo deste estudo foi traduzir e adaptar transculturalmente o instrumento condição-específico "Impact of Fixed Appliances Measure" (IFAM) para o idioma português do Brasil, avaliando a sua validade e confiabilidade para uso em crianças/adolescentes brasileiros. Métodos: O instrumento foi traduzido do idioma inglês para o português de forma independente por dois tradutores bilíngues. Em seguida, as duas versões traduzidas foram submetidas ao comitê de revisão, originando uma única versão, que foi retro-traduzida por outro tradutor bilíngue. Essa primeira versão do instrumento em português foi pré-testada em uma amostra de 15 crianças/adolescentes, produzindo a versão brasileira do IFAM (B-IFAM). O B-IFAM foi aplicado em 161 crianças/adolescentes, entre 10 a 18 anos de idade, que estavam em tratamento ortodôntico na clínica de Especialização em Ortodontia da Faculdade de Odontologia da Universidade Federal de Minas Gerais. A consistência interna foi avaliada por meio do teste Cronbach alfa (α) e a confiabilidade teste-reteste pelo coeficiente de correlação intraclasse (CCI). A validade de constructo e a validade convergente foram mensuradas através da correlação de Pearson. Para a validade convergente, observou-se a correlação entre o B-IFAM e a versão brasileira do "Child Oral Impact on Daily Performance" (Child-OIDP). A validade discriminante foi avaliada através da comparação das médias e desvio padrão do B-IFAM em relação ao gênero e classificação de Angle das crianças/adolescentes usando teste t de Student. Resultados: A consistência interna foi de 0,89 para a pontuação total do B-IFAM e 0,55-0,86 para as subescalas. A confiabilidade teste-reteste demonstrou um CCI de 0,81 para a pontuação total do B-IFAM, e variou entre 0,55 e 0,78, para a subescalas. A correlação de Pearson entre a pontuação total do B-IFAM e o Child-OIDP foi de r=0,28 (p<0,01). O B-IFAM demonstrou validade de constructo aceitável, com a maioria das correlações apresentando p<0,05. A validade discriminante demonstrou diferença estatisticamente significativa entre crianças/adolescentes com Classe I e Classes II/III de Angle nas subescalas Estética e Limitação Funcional (p<0,05). Conclusões: O B-IFAM demonstrou propriedades psicométricas adequadas em relação à confiabilidade e validade. O estudo apresentou um instrumento condição-específico viável para mensurar o impacto do tratamento ortodôntico na qualidade de vida de crianças/adolescentes brasileiros

Introduction: The aim of this study was translate and cross-culturally adapt the condition-specific instrument Impact of Fixed Appliances Measure (IFAM), to Brazilian Portuguese , assessing its validity and reliability for use among Brazilian children/adolescents. Methods: The instrument was translated from English to Portuguese independently by two bilingual translators. Then, the two translated versions were submitted to the committee review, resulting in a single version, which was backtranslated by another bilingual translator. This first version of the instrument in Portuguese was pretested on a sample of 15 children/adolescents, resulting in the Brazilian version of IFAM (B-IFAM). The B-IFAM was tested on 161 children/adolescents, between 10 to 18 year old, who were undergoing orthodontic treatment at the Orthodontic Clinic, School of Dentistry, Federal University of Minas Gerais. Internal consistency was assessed using Cronbach's alpha (α) and test-retest reliability by intraclass correlation coefficients (ICC). The construct validity and convergent validity were assessed by Pearson's correlation. Convergent validity was conducted among the B-IFAM and the Brazilian version of Child Oral Impact on Daily Performance (Child-OIDP). Discriminant validity was evaluated by comparisons of BIFAM's means and SD with gender and children's/adolescents' Angle's classification using Student's t-test. Results: Internal consistency was 0.89 for overall score and 0.55 to 0.86 for subscales. ICC for test-retest reliability for B-IFAM's overall score was 0.81 and for subscales, ranged from 0.55 to 0.78. Pearson's correlation between overall score of B-IFAM and Child-OIDP was r=0.28 (p<0.01). The B-IFAM demonstrated acceptable construct validity, which most correlations presenting p<0.05. Discriminant validity demonstrated statistically significant difference between children/adolescents classified as Class I and Class II/III malocclusion in Aesthetic and Functional Limitation subscales (p <0.05). Conclusions: The B-IFAM demonstrated adequate psychometric properties regarding reliability and validity. The study achieved a specific-condition instrument feasible to measure the impact of orthodontic treatment on quality of life of Brazilians children/adolescent

The incidence and nature of complaints against dentists for the treatment of children in Israel from 1992-2011.

OBJECTIVES: Medical literature lacks information about complaints against dentists who treat children. The present study aimed to evaluate the reports filed to Medical Consultant International (MCI) regarding paediatric dentistry in 1992-2011. BASIC RESEARCH DESIGN: Most dentists in Israel (85%) are obliged by their professional liability insurance policy to report adverse events to MCI. Reports were analysed using a structured form that included demographic details of the treating dentist, patients and parents, type of treatment, the result and the dentist's attitude. MCI dental consultants' decisions were evaluated by two specialists in paediatric dentistry. RESULTS: The number of complaints per year is increasing. Complaints involved maltreatment (33%), case mismanagement (25%) and complications that required additional treatment (26%). Communication was problematic in 60% of cases. Only 16.7% of complaints developed into an actual lawsuit. Most complaints were against female general practitioners and against dentists who worked in community dental clinics located in peripheral areas. Treating permanent teeth increased to 3.6 times the probability of developing into a lawsuit. 59% of event records had missing data. Seventy-five percent of the cases rose from elective treatments while 25% concerned emergency treatments. One third of the cases required additional treatment in a hospital i.e. abscess drainage, foreign body swallowing or other physical damages. CONCLUSIONS: Better case selection and documentation, better training of dentists who treat children and more appropriate attitude toward patients and parents, are likely to reduce the number of complaints.

The evolution of behavior guidance: a history of professional, practice, corporate and societal influences.

Behavior guidance in pediatric dentistry is a composite of influences including expert opinion, historical precedent, scientific studies, and social factors including the law and the media. The early icons of pediatric dentistry injected their personal views on child management, and those often reflected the child-rearing norms of the times. The business of pediatric dentistry with its efficiency and quality orientations also shaped approaches to behavior management. Scientific studies contributed minimally. A major influence on behavior guidelines in recent years has been external scrutiny of techniques prompted by media and other exposure of both private practice and corporate management of children. Changing parenting and reaction of society to authority have also had significant impact on behavior. This paper describes in more detail the evolution of behavior guidance and the subsequent codification of practices into professionally derived guidelines.

State regulations governing oral sedation in dental practice.

PURPOSE: The purpose of this study was to survey 50 state dental boards concerning their regulations governing the practice of moderate sedation administered by the oral route. METHODS: An online search was conducted to review each state's dental practice act. When interpretation of the information provided online was difficult, clarification was achieved by contacting that state board directly by telephone interview. To assist in further interpretation, the ADA's Statutory Guidelines for Conscious Sedation Permit were reviewed for comparison with the data collected. RESULTS: Forty-one states required a permit to administer moderate sedation by the oral route. Every state except Kansas required minimum didactic educational requirements for permit issuance. Every state required monitoring of the patient throughout the procedure and during recovery until discharge. In addition, all states expected the practitioner and clinical staff to be adequately trained to manage a sedation-related emergency. CONCLUSIONS: State dental boards have significantly increased regulation of oral sedation over the past 10 years, but vary widely in their permit requirements for issuance. This dis-harmony among the states should foster the national desire to develop a more unified approach in regulating oral sedation.

The impact of additional dental providers in the dental labor market on the income of private practice dentists.

This study estimates the impact that the entrance of hypothetical allied dental professionals into the dental labor market may have on the earnings of currently practicing private practice dentists. A simulation model that uses the most reliable available data was constructed and finds that the introduction of hypothetical allied dental professionals into the competitive California dental labor market is likely to have relatively small effects on the earnings of the average dentist in California.

[Contributions and perspectives of the multiprofessional team to the health basket in primary care. SESPAS report 2012]. / Aportaciones y perspectivas del equipo multiprofesional a la cartera de servicios en atención primaria. Informe SESPAS 2012.

For primary health care to have an impact on health in the community, the involvement of multiple professionals is essential. The health team should include the knowledge and experience of distinct professional disciplines, with a results-oriented approach. This new approach requires the team to share key elements, such as the electronic record, the organization of care for different population groups, quality systems, and consultations among professionals in the same center. Examples of these interrelations are a woman attending an prenatal visit being referred to preventive dentistry, a smoking adult referred from dentistry to the family doctor or nurse, and a patient with low back pain referred from physiotherapy to a consultation on contraception. The present article analyzes the actions and perspectives of different disciplines in oral health care, sexual health / reproductive care and physiotherapy.

Should fear of malpractice dissuade dentists from caring for children?

PURPOSE: Little information is available on malpractice related to dentistry for children. The purpose of this report was to examine characteristics of malpractice allegations related to dentistry for children from the National Practitioner Databank (NPDB) from February 1, 2004 to November 22, 2006. METHODS: The public use file of the NPDB was obtained and transformed into a searchable database and allegations involving children were sorted and characterized by payment size, reason, practitioner type, and location. RESULTS: During the roughly 34-month study period, 571,172 total cases were evaluated. 51,691 (9%) of these involved dentists; 367 reports were identified using age-based variable reporting. The majority of cases (275; 75%) involved 10- to 19-year-old children and 92 (25%) of the cases involved 0- to 9-year-old children. One case was an infant younger than one year old. No cases were found with the provider citation of dental resident. The geographic distribution of cases was consistent with relation to practitioner (dentist) density and mean age. CONCLUSION: The allegation of malpractice related to dentistry for children is a very small portion of both dental and general health malpractice in the United States.

Legitimidade e licitude da técnica de separação acompanhante-criança durante o atendimento odontológico no contexto brasileiro / Legitimacy and legality of the technique for separating parent/caregiver and child during the dental treatment in the brazilian scenario

Introdução: A técnica da separação acompanhante-criança, durante o atendimento odontológico, merece maiores discussões e aprofundamentos à luz de referenciais jurídicos e morais que envolvem o atendimento odontológico da criança e do adolescente, pois a literatura brasileira parece não contemplar esse debate. O referencial teórico que embasa este trabalho contempla três abordagens específicas sobre o tema objeto de investigação, em suas duas vertentes, ou seja, a legitimidade e a legalidade da técnica em questão: aspectos técnicos, aspectos éticos (Deontologia e Bioética) e aspectos legais (Código Civil, Estatuto da Criança e do Adolescente, Código de Defesa do Consumidor).Objetivo: Esta pesquisa bibliográfica consiste no levantamento e análise de aspectos éticos e legais envolvidos no emprego da técnica de separação durante o manejo comportamental da criança em situação de atendimento odontológico, com a finalidade de servir de orientação para cirurgiões-dentistas e demais profissionais da área da saúde para a reflexão sobre essa relação dialética entre o profissional e seus pacientes.Conclusão: Não há evidências de que a separação da criança de seu acompanhante, visando o melhor comportamento da primeira, produza algum efeito. Os aspectos éticos e legais relacionados a essa técnica são a vulnerabilidade e a incapacidade da criança, a necessidade de se respeitar a autonomia da pessoa, a análise dos riscos e benefícios da técnica, a educação e informação dada à família quanto ao atendimento odontológico da criança e o consentimento livre e esclarecido pelo responsável legal da criança. Essa técnica pode ser considerada ilegítima e ilegal, caso a sua indicação não seja compartilhada entre cirurgião-dentista, criança e seu representante legal...

TRICARE; changes included in the National Defense Authorization Act for fiscal year 2005; TRICARE Dental Program. Interim final rule.

The Department is publishing this interim final rule to implement sections 711 and 715 of the Ronald W. Reagan National Defense Authorization Act for Fiscal Year 2005 (NDAA-05), Public Law 108-375. Specifically, that legislation makes young dependents of deceased Service members eligible for enrollment in the TRICARE Dental Program when the child was not previously enrolled because of age, and authorizes post-graduate dental residents in a dental treatment facility of the uniformed services under a graduate dental education program accredited by the American Dental Association to provide dental treatment to dependents who are 12 years of age or younger and who are covered by a dental plan established under 10 U.S.C. 1076a. This rule also corrects certain references in 32 CFR 199.13. The rule is being published as an interim final rule with comment period in order to comply with statutory effective dates. Public comments are invited and will be considered for possible revisions to the final rule.

Perceptions associated with dentists' decisions to report hypothetical cases of child maltreatment.

The purpose of this study was to examine case-specific perceptions associated with dentists' decisions to report hypothetical cases suggestive of child maltreatment. Surveys were mailed to 500 general dentists (GDs) in Georgia and all 200 pediatric dentists (PDs) in Georgia and Florida. The GDs were chosen from a pool of 1500 by a stratified randomization scheme. Each survey contained two brief vignettes suggestive of, but not conclusive for, child neglect and abuse. Identical questions followed each vignette that were designed to assess five perceptions of the incident and whether the respondent would be likely to report the case. Responses were received from 185 GDs (37%) and 103 PDs (51.5%), for a total of 288 (41.1%). A majority of respondents considered each vignette to be serious, but only a minority believed that they were required to report the neglect (7.3%) and the abuse (33.7%) vignettes. The percentages of likely reporters of the neglect (n = 28) and abuse (N = 103) vignettes were 9.7 and 36%, respectively. No significant differences were noted in the response patterns of GDs and PDs. Decisions to report child maltreatment described in the vignettes were associated with perceptions of 1) the seriousness of the incident, 2) the incident being defined as neglect or abuse, and 3) a requirement to report. The possibility that a maltreatment report would have a negative impact on the child was associated with a decision not to report. The perception that a report would have a negative impact on the family was common among likely reporters and nonreporters.

Demographic, educational, and experiential factors associated with dentists' decisions to report hypothetical cases of child maltreatment.

The purpose of this study was to examine demographic factors associated with dentists' decisions to report hypothetical cases suggestive of child maltreatment. Surveys were mailed to 500 general dentists (GDs) in Georgia and all 200 pediatric dentists (PDs) in Georgia and Florida. The general dentists were chosen from a pool of 1500 by a stratified randomization scheme. Each survey contained two brief vignettes suggestive of, but not conclusive for, child neglect and abuse. Respondents were asked about their likelihood of reporting each vignette. General demographic questions were asked about the population served by the dentist, the year of dental degree and speciality certificate acquisition, and gender of the respondent. Further questions were asked about the individual's exposure to continuing education in child maltreatment, knowledge of legal requirements to report and the agency to which reports should be directed, and experience with suspected and filed cases. Responses were received from 185 GDs (37%) and 103 PDs (51.5%), a total of 288 (41.4%). PDs had more practitioners in larger communities and had more female respondents. PDs were more likely to answer yes to the questions about education/experience with child maltreatment. Factors associated with likely reporting of neglect were: 1) serving communities with populations < or = 100,000; 2) PDs acquiring specialty certificates after 1980; 3) being female; 4) exposure to continuing education; 5) having suspected cases in practice; and 6) having filed a maltreatment report. Factors associated with likely reporting of abuse were: 1) PDs acquiring specialty certification after 1980 and 2) self-reported recognition of the legal obligation to report.

Dental practice considerations.

Treating young children, working through an intermediary (the parenting adult), obtaining informed consent, and reporting suspected child abuse bring extra pressures to the dentist and staff members unless the protocol for each step is established and followed precisely. Managing for fiscal soundness and making a profit are other professional responsibilities. Counterbalancing the many pressures, the dentist who treats young children enjoys an added measure of pleasure beyond that experienced by many colleagues by helping a young child cope with the stresses of treatment, leading a child into a lifetime free of dental disease, and winning the trust and approval of parents or guardians. All of these aspects make dentistry a profession that provides a lifetime of excitement, fulfillment, learning, and constant opportunities for growth.