Periodic Reporting for period 3 - ADVOCATE (Added Value for Oral Care) Reporting period: 2018-05-01 to 2019-04-30 Summary of the context and overall objectives of the project In 2012, EU spending on oral health care was close to €79 billion per annum. Globally, 3.9 billion people suffer from the common oral diseases all of which are preventable. Dental caries and periodontitis (severe gum disease), leading to tooth loss, are the first and the sixth most prevalent health conditions worldwide, affecting 35% and 11% of the global population, respectively. This poses major challenges to public health and society. Socioeconomic and lifestyle factors contribute to the pervasive nature of these conditions, while their impact on individual quality of life and well-being, and the collective burden they place on society are very substantial. The current restoration and conservation paradigm in oral health care originated in an era when the caries level in the population was of epidemic proportion. However, while still the most common chronic disease, in developed countries the incidence of caries has been greatly reduced and rather than being epidemic it is now endemic and preventable. In contrast, health payment systems such as provider payment do not mirror the prevention paradigm, for example, with fee-for-service remaining the predominant reimbursement mechanism. Such characteristics encourage under-utilisation of oral care in high risk groups and over-utilisation in low risk groups. The multidisciplinary ADVOCATE consortium came together with the shared vision of achieving a step change in oral health care systems design and performance. Its intention was to shift the focus away from the predominant surgery and treatment model towards one which is patient centred, prevention-orientated and sustainable, and delivers safe and effective care. Work performed from the beginning of the project to the end of the period covered by the report and main results achieved so far The project accessed longitudinal data from a range of public and private insurance schemes in the ADVOCATE partner countries: Denmark, Germany, Hungary, Ireland, Netherlands and the UK. Along with a series of stakeholder engagements and patient and public interactions, these data were analysed, using novel advanced data science techniques, to determine the historical trajectories of oral health care patterns and to judge the effectiveness of financial incentives and economic strategies on the promotion of prevention-orientated care. Barriers and facilitators to change were also considered through stakeholder interactions, and a Patient Engagement App was developed, together with an Oral Health Care Dashboard, so that patients can provide feedback on their perceptions of treatment. The degree of success of the Patient App and Dashboard in promoting prevention-orientated oral health care was evaluated by field studies with dentists.ADVOCATE recognised the value of data and proposed a data driven learning oral health care system which relied on patient centred extrinsic and intrinsic motivational approaches to develop a prevention-orientated oral health care system. The power to shape practitioner behaviour through extrinsic motivation delivered through the remuneration system has been demonstrated. The potential to change dentists’ behaviour via intrinsic motivational and peer learning approaches was confirmed through patient feedback and subsequent reflection and discussion of comparative performance in an academic detailing system.Through an extensive series of focus groups, interviews and questionnaires, ADVOCATE identified the barriers and facilitators to prevention from the perspective of the patient, the practitioner and the policy maker. This new knowledge is available to inform oral health care system design that addresses the objectives of a patient centred prevention-orientated oral health care system.The multifaceted system described as Health Care Model 2020 is a learning health care system informed by evidence from the outcome of system redesign and patient feedback and driven by quality improvement groups. ADVOCATE also demonstrated the usefulness of an operational paradigm in the relatively straightforward context of oral disease, which has the potential to translate into more complex areas of health care. Progress beyond the state of the art and expected potential impact (including the socio-economic impact and the wider societal implications of the project so far) According to a global study of diseases by WHO, oral diseases remain the most common chronic diseases known to man. Of 291 diseases studied world wide untreated decay of the permanent teeth tops the charts and gum disease is in 6th place. The good news is that both diseases can be prevented with the support of dental professionals who provide preventive care and help to establish good habits and effective customised oral hygiene regimes. Dental professionals also play an important role in the early identification and treatment of disease when it is still reversible.The identification of best practice in system design will be offered to policy makers and insurers as evidence based recommendations for system planning and development to promote preventionThe design and application of the patient focused App and the dashboard for dentists and insurers which are designed to motivate prevention of dental disease will be offered as a new tried and tested approach.The overall aim of ADVOCATE is to reorientate dental services from a primarily restorative focus to primarily disease prevention. A successful outcome will lead to a gradual decrease in the need for invasive treatments and result in less pain and distress for patients of all ages, and possibly less expense in the long term.Crucially, ADVOCATE has the potential to demonstrate the usefulness of this approach not only for oral healthcare but for general health, with healthcare providers adapting the model for their own areas of practice. The public engagement App. Dutch version.
