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Applying Systems Science Methods to Risk-Based Disease Management and Population Oral Health

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Applying Systems Science Methods to Risk-Based Disease Management and Population Oral Health UCLA UCLA Electronic Theses and Dissertations Title Applying Systems Science Methods to Risk-Based Disease Management and Population Oral Health Permalink https://escholarship.org/uc/item/1649b99h Author Flint MacBride, Robin A. Publication Date 2018 Peer reviewed|Thesis/dissertation eScholarship.org Powered by the California Digital Library University of California UNIVERSITY OF CALIFORNIA Los Angeles Applying Systems Science Methods to Risk-Based Disease Management and Population Oral Health A dissertation submitted in partial satisfaction of the requirements for the degree of Doctor of Public Health by Robin Audrey Flint MacBride 2018 Ó Copyright by Robin Audrey Flint MacBride 2018 ABSTRACT OF THE DISSERTATION Applying Systems Science Methods to Risk-Based Disease Management and Population Oral Health by Robin Audrey Flint MacBride Doctor of Public Health University of California, Los Angeles, 2018 Professor Neal Halfon, Chair Policymakers and public health practitioners face many complex population and health care related problems that cannot be fully understood by simply understanding the component parts. However, the predominant approach in research, practice and policymaking is to approach complex problems with reductionist thinking and methods. Complex systems methods such as agent-based modeling (ABM), System Dynamics (SD) and discrete-event simulations are well suited to deal with the inherent complexity of populations and delivery systems and complement reductionist approaches. Early childhood caries and the dental care delivery system are good examples of complex systems at many levels. Caries is a complex multifactorial disease that is both infectious and chronic. It is one of the most prevalent chronic conditions in the U.S. and the world, and it is therefore a costly disease, not just financially, but also the impact it can have on learning, development and social engagement of children. Oral health disparities persist in vulnerable ii populations despite marked improvements in the overall oral health of the nation in the last 50 years. Developments in risk-based care and disease management in the last decades have demonstrated its ability to reduce disease and its consequences, yet it is generally not used to its full potential in dentistry. An overarching goal of this dissertation is to demonstrate the utility and feasibility of a system-science approach for analyzing interconnected population and health care problems. I draw on the system science toolkit to, first, take a holistic view of the system influences on dentists’ behaviors, and second to use a hybrid simulation model to explore the structure and dynamics of a risk based and disease management approach to dental care and population oral health. The simulation provides a demonstration of ways to harness the strengths of agent-based models, system dynamics models, and discrete event simulations to represent and learn about the structures driving the system’s behaviors and the underlying interactions at the individual level of patients and providers. Overall, the modeling process yielded much learning about the disease and dental care process, as well as about the modeling process, its techniques and the language of systems. The findings support the application of these simulation and system thinking tools to aid in learning, planning and to inform the policy making process. iii The dissertation of Robin Audrey Flint MacBride is approved. Moira Inkelas Nadereh Pourat James J. Crall Nathaniel Osgood Neal Halfon, Committee Chair University of California, Los Angeles 2018 iv Dedication To my beloved parents, Vivian and Roderick Flint. Da’, for your love of learning and creativity to make useful things out of whatever you find. Ma, your ingenuity, creativity, and persistence to make things work better, and to transform simple things into something beautiful and useful; your energy inspires me, and your laughter and joy keep me smiling. You both figured out how to make the best lemonade out of life’s lemons. You gave me light to pursue a path less travelled, do something hard but useful, to always be learning something new, and to try and make things better for those who can’t do it for themselves. Thank you for your encouragement, inspiration, love, and support. I’m glad you are both here to witness this. and To my dear and departed friend, Debra Tom Salgado. Such a smart, talented, creative, generous and loving soul. I took for granted you’d be here while I finished this; with your help it would not have taken as long (or be as long!). I wish you were here now so we could catch up on all the time we were planning to spend together when you got better and I finished, but I know you’d be proud of me (and bake me my favorite cookies). I’m grateful for all the love and time you generously gave to me, glad that the gift of your life enriched mine and so many others. v Table of Contents TABLE OF CONTENTS ...................................................................................... VI LIST OF FIGURES .............................................................................................. XI LIST OF TABLES .............................................................................................. XIII LIST OF ABBREVIATIONS & ACRONYMS ...................................................... XIV GLOSSARY ........................................................................................................ XV Glossary of Dental Terms ................................................................................. xv Glossary of Systems Science Terms ............................................................... xvi ACKNOWLEDGEMENTS .................................................................................. XIX VITA ................................................................................................................... XX CHAPTER 1: INTRODUCTION ............................................................................ 1 Dissertation Goals and Objectives .................................................................... 8 Aims & sub-aims .................................................................................................... 10 Landscape of this dissertation ............................................................................... 13 CHAPTER 2: LITERATURE REVIEW OF CARIES AND DENTAL CARE .......................................................................................... 15 Introduction to Dental Terminology ................................................................. 15 Oral Health Epidemiology ............................................................................... 18 Disparities in oral health ......................................................................................... 18 Disparities in access to dental care ....................................................................... 21 The Cost of Caries .......................................................................................... 29 Dental expenditures ............................................................................................... 30 Emergency dental care and hospitalizations .......................................................... 31 Dental care under general anesthesia ................................................................... 33 Effect on other health conditions ............................................................................ 34 Effect of disparities on military readiness ............................................................... 35 The human cost of caries ....................................................................................... 36 Effect on child development and learning .............................................................. 37 Caries Etiology ................................................................................................ 39 Disturbance of the microbial homeostasis .............................................................. 39 Disturbance of the mineral homeostasis ................................................................. 45 vi Acquisition and transmission ................................................................................. 54 Stages and progression of disease ........................................................................ 58 Risk & protective factors — oral health and personal health behaviors .................. 58 Dental Care Processes of Care ....................................................................... 59 Risk and Disease Management ...................................................................... 60 Motivational interviewing and behavior change ...................................................... 64 Effectiveness of caries risk and disease management in practice .......................... 65 Traditional one-size-fits-all approach to caries ....................................................... 67 The conflicting goals of the present-day dental-care business model .................... 70 Patient and population approaches ....................................................................... 72 Dental Care Delivery System .......................................................................... 74 Dental workforce .................................................................................................... 74 Financing of dental care ........................................................................................ 76 Dentist participation in Medicaid ...........................................................................
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