The intervention had a strong effect, a 10% increase, on practice behavior related to delivery of advice to quit tobacco among tobacco users. Our study is the first to demonstrate that a multimodal, Internet-delivered intervention designed to promote and support tobacco control in dental practices can be effective. As with most Internet-delivered interventions, the website required a considerable start-up effort in terms of content development (intellectual content), web programming, and usability testing to ensure consistent navigation. However, the marginal server demands to disseminate the intervention to each additional practice were low.
For some online interventions directed at changing provider behavior, the evaluations have ended at changes in knowledge and attitudes [17
]. Our goal was to directly assess changes in provider behavior as measured by patients. When provider performance outcomes have been assessed, results of Internet-delivered interventions for providers have been mixed [15
]. In some of these interventions, baseline rates of provider behavior have been higher than anticipated, reducing the ability to affect change [16
]. Our intervention clearly benefited from the fact that there was clear room for improvement in targeted behaviors.
Baseline rates of ASK in our sample were less than 30%, and ADVISE was 42% in control and 44% in intervention. In prior studies, rates of ADVISE in dental practices varied from 30% to 50%, depending on the setting, sample, and respondent (patient or provider) [6,7,31,43-45]. In a randomized trial, Andrews et al reported that patient-reported control group rates of dental provider advice to quit were 42.4%, which is similar to our findings [43
We were successful in engaging 80% of the intervention practices in the website activities, and among those practices that did participate, a high proportion of dentists and hygienists logged on. Low rates of participation have been sighted as a reason for limited success in some Internet-delivered interventions targeting providers [41
]. Of note, our intent-to-treat analysis demonstrated an impact of the intervention even though 20% of the intervention practices did not use the website cases and supportive tools. Among those practices that did participate, we were moderately successful in sustaining activity over 8 months. Previous research in online professional development suggests that a “spaced education” approach, where content is distributed, repeated, and reinforced over time, has a stronger impact on knowledge and subsequent behavior than a one-time education [46
]. We used automated reminders and frequent content updates that served as hooks to encourage repeated participation over the 8 months.
Our study has several limitations. As noted, we recruited our 190 dental practices from a large pool of practices. We required a run-in phase and enrolled the first 190 practices who completed the baseline data collection. Although not uncommon in randomized trials, the low enrollment to recruitment ratio suggests that our practices may be somewhat different than the average dental practice. Specifically, these practices may be more computer-oriented and more Internet-savvy than the average practice. Attrition was also a limitation. In terms of the outcome of interest, a direct measurement of provider behavior, such as audiotapes of visits or direct observation, was not accomplished nor was it feasible in a study of this size. We demonstrated that distribution and collection of exit cards from patients was feasible, and that the office staff was willing to support the study with a small incentive for data collection. As discussed above, we validated the results of the exit cards with patient phone calls in a subset.
In our study, rates of advice to quit smoking increased 10% in intervention practices with only marginal increases in patient reports of being asked about tobacco use by a provider. Tobacco control guidelines emphasize the need for systematic screening as a first step in tobacco control that leads to increasing advice [4
]. Some studies in medical practice suggest that screening increases advice [47
]. In preliminary nominal group technique meetings, dentists reported that they could often “tell” that patients were tobacco users without asking. It may be that through the oral exam and having a working space that is close to the patient's face, dental providers are able to more accurately diagnose tobacco use in the absence of screening than medical providers [49
]. The oral exam itself may provide a strong cue to delivering quit tobacco advice. If active screening had been implemented by the dental providers, we may have seen an even greater increase in cessation advice.
We chose to assess provider performance based on patient reports collected immediately after the visit. Assessments of provider delivery of tobacco control services are increasing [50
]. Patient reports of provider behavior have been used for outcome assessments such as ours [51
]. Compared to the gold standard of audio-tapes of doctor-patient encounters, immediate surveys of patients are more accurate than provider reports or chart abstraction [51
]. The Health Plan Employer Data and Information Set (HEDIS), a set of standardized performance measures collected by the National Committee for Quality Assurance, adopted patient-report of provider tobacco cessation advice as a national standard [59
In conclusion, the intervention was successful, but success was somewhat limited by initial participation in the intervention and waning activity over time. Future intervention activities should include additional marketing and persuasive techniques to encourage and sustain participation. We interpret the results of this study to suggest that dental practices are settings where low-intensity interventions to support tobacco control can be effective. The Internet-delivered intervention in this study was more successful than some prior interventions in medical practice, also supporting the potential of the Internet for outreach in dentistry.