The prevalence of chronic non-communicable diseases [NCDs] is increasing and their impact on the global disease burden and healthcare economy is substantial. Evidence in 2015 suggested that 92% of older adults have at least one NCD and 77% have two NCDs . The reason for the increasing prevalence of NCDs is, in part, the result of an ageing population, and also due to an increase in the prevalence of risk-factors common amongst most NCDs such as sedentary lifestyles, refined diets and overweight/obesity. In addition to the substantial health burden, risk-factors for NCDs also contribute a significant economic burden, accounting for over 45% of total NHS costs in the UK in 2006–2007, at approximately £43-billion .
Allied healthcare professionals in the UK access large proportions of the population who frequently do not access general medical practice [GP] services . Given the growing NCD burden, this study aimed to determine patient acceptability and potential barriers to utilising allied healthcare professionals such as dentists and pharmacists in order to assist GPs with the NCD epidemic, through targeted risk-based assessment and early detection.
Rationale for risk directed early NCD detection in dental practice and community pharmacy settings
Members of the public usually only attend their GP when they are unwell, whereas, many people routinely visit their dentists on a regular (6–12 monthly) basis, thus facilitating prevention and lifestyle interventions . Evidence from the USA suggests that, in 2008, 24% of people did not have contact with a general healthcare provider, yet 23% of those accessed a dentist during that time . This was also reported for a UK population, where 12% of patients who reported seeing a dentist biannually reported they had not had contact with a GP in the same 12-month period . Furthermore, 48% of those who reported being regular dental attenders advised having never had a health check at their GP surgery . With approximately 60% of the UK population registered with a dentist , this places dental teams, with access to patients who would not necessarily attend their GP regularly, in an ideal position to target patients for risk assessments.
The 2011 Pharmaceutical Group of the European Union survey reported that 98% of European patients can reach their nearest community pharmacy within 30 min, while 58% indicated that their closest community pharmacy was within 5 min of their home. This may render pharmacy settings ideal for early identification of NCDs and provision of preventative advice for large population groups, who may not routinely have access to other healthcare professionals. In addition, over the past four decades there has been a move in pharmacy practice away from the traditional focus on dispensing towards a more patient-centred clinical role . United Kingdom [UK] policy and pharmacists’ professional organisations have stressed the potential of community pharmacists to extend their roles in patient care services to include screening for NCDs. This has been emphasised in policy papers calling for a wider use of community pharmacists in primary patient care [8,9,10].
The development of government policies and guidelines advocating the role of allied healthcare professionals in risk-assessment, prevention programs and risk identification for NCDs, suggests that a collaborative approach to tackle the growing NCD burden is required . It is currently common for dentists to liaise with GPs in relation to medications a patient may be taking, especially where these may have an impact on oral health, such as calcium channel blockers which may result in gingival overgrowth. Dentists also work closely with a patient’s medical team when the dentist suspects underlying conditions based on the oral manifestations of systemic diseases. One such example is poorly controlled type 2 diabetes [T2DM]. T2DM may present with oral signs and symptoms including multiple lateral periodontal abscesses. Recently the International Diabetes Federation and European Federation of Periodontology produced joint guidelines for medical and dental professionals for the effective management of patients with periodontitis and, or T2DM in recognition of the strong associations between oral and systemic health .
Community pharmacists play an important role in delivering public health services for example vaccinations, health checks, smoking cessation and weight management to complement GP roles. In addition to pharmacist role in optimising the use of medicines in liaison with GPs, providing advice about safe and effective use of medicines when dispensing to patients with prescriptions for the treatment of diabetes, heart disease and hypertension and thus relieving the pressure on the GP practices and A&E. Furthermore, pharmacists work directly in general practice as part of the multi-disciplinary team, in patient facing roles when managing conditions such as diabetes and hypertension . A recent systematic review and meta-analysis which included 21 RCTs (8933 patients) showed that pharmacists-led interventions, as part of a team in general practice, can significantly reduce medical risk factors of CVD events when managing patients with hypertension, diabetes and dyslipidaemia .
Risk-assessment strategies need to ideally provide high sensitivity and specificity so we can discriminate between those who truly do and do not have the condition, be acceptable to patients undergoing assessment, acceptable to the professional delivering the assessment and also demonstrate cost-effectiveness. Venous blood samples are often considered the “gold-standard” testing method for diagnosing many NCDs. The feasibility of primary care dental teams and community pharmacies undertaking venous blood sampling to assess for NCDs is low – as this is not within their routine scope of practice, in addition to the time and resources required to test in this way. Alternative methods for undertaking risk-assessments were considered in this study including the use of validated risk-assessment questionnaires and point-of-care testing [POCT] devices.
Validated questionnaires may be effective ways of stratifying the population into risk groups to allow more invasive and costly tests to be targeted to those in the population most in need. Though, the identification of “at risk” individuals with risk-assessment questionnaires are often satisfactory they often have lower sensitivity and specificity than conventional testing methods. But this has to be weighed up against the advantages of ease of testing, patient acceptability and relatively low associated costs. Given that the aims of risk-assessment in primary care dental and pharmacy settings are not to formally diagnose but to indicate those who may be at elevated risk, the reduction in accuracy may be acceptable given the aforementioned advantages.
POCT remains controversial due to the historical challenges associated with a wide range of devices available, each with their own advantages, disadvantages and varying levels of accuracy [15, 16]. However, the improved quality of POCT devices for capillary blood sampling has resulted more recently in NICE and other national bodies recommending their use for diagnosis of certain NCDs [15, 17,18,19,20]. Given that we are not proposing primary care dental teams and community pharmacists formally diagnose, but instead identify those who may be at risk and require further management, they may be ideal for the purpose of risk-assessment in primary care and community settings. The relative ease of use, the near immediate results and the reported patient satisfaction related to POCT are also advantageous. However, it is important that practitioners are aware of the limitations associated with their specific device and the cost associated with these devices may be higher than conventional testing methods.
Patient acceptability of undertaking targeted risk-based detection for NCDs in UK dental and pharmacy settings is currently unknown and requires further investigation. Therefore, an exploratory study was undertaken within one dental practice and one community pharmacy within the West-Midlands, UK, to determine patient acceptability of risk-assessment for NCDs in these settings.
Aims and objectives
The overarching aim of this study was to assess patient acceptability of screening for NCDs in a primary dental care and a community pharmacy setting. Further objectives of the study included:
To identify whether testing for NCDs in a high street dental practice and a community pharmacy setting was feasible in terms of logistics, environment and process. Including feasibility of participant recruitment and barriers to recruitment.
To determine whether there is benefit to the finger prick HbA1C test to identify diabetes risk compared to a validated screening questionnaire alone.
To ascertain changes needed in the study protocol and barriers to a larger scale study.
To determine whether any patients potentially at high-risk of NCDs could be identified where disease status was previously unknown.