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Washington State Dental Association

I am…disappointed · Editorial by Dr. Mary Jennings

    I have been irritated with the Kellogg Foundation since this whole DHAT thing in Alaska started. Why would a foundation worth eight billion dollars originally seeded with money from sugary cereal be interested in changing the dental workforce? Because the “W.K. Kellogg Foundation supports children, families, and communities as they strengthen and create conditions that propel vulnerable children to achieve success as individuals and as contributors to the larger community and society.”
    Wise people have advised me to remain impartial and patiently wait for the Kellogg Foundation’s Final Report. The report was released on October 25, 2010 and is titled “Evaluation of the Dental Health Aide Therapist Workforce Model in Alaska.” Before I read it, I really put effort into clearing my prejudices and reading it in a properly respectful frame of mind. I rarely sum up my thoughts in one word. I am…disappointed.
    The evaluation was done by RTI International and funded by the Kellogg Foundation, the Rasmuson Foundation and the Bethel Community Services Foundation. Not coincidentally, they also sponsored the DHAT pilot program.
    I took experimental design to get my Psychology degree but I still have a difficult time with this report. On one hand, it says they completed a 2.5 year detailed report. On the other, they refer to it as a “snapshot.” They seemingly would have preferred a long term study with baselines, but due to lack of comparable sites and studies, settled for a case study of five unique villages. I had a spasm when they discussed that they had such a small sample size that they had to study it as a “convenience sample.” The bottom line is that they studied five clinics employing five Dental Health Aide Therapists. It is difficult to determine how many patients were involved as they evidently did not study the same population for each parameter. The best I can figure is between 61 and 300 patients were involved. The website says 400.
    Kellogg et al focused on five topics: patient satisfaction and perceived access to care; oral health status; clinical technical performance and performance measures; record-based process measures and evaluation of clinics; and implementation of community based preventive plans and programs. Some of the research was blinded and seemingly followed established research protocol. On site visits and phone interviews were “semi-structured interviews using interview guides.” While they were at it, they also evaluated some quality assurance performance standards per the request of ANTHC, the tribal consortium.
    The five clinics studied varied in geography, length of employment of the DHAT, program goals and philosophies, program design, how the DHAT was integrated into the program, back log of unmet need and the socioeconomic status of the patient population.
    I began to feel a bit sorry for the team that had to sort all this out. With all the variables and small sample size how could they possibly provide meaningful data to evaluate the effectiveness of the DHAT in solving the access to care problem? They didn’t. On pages 1-4, the researchers state that they “were not tasked with developing policy recommendations for wider implementation of this or some other allied or midlevel workforce model.” It says we are to formulate our own inferences.
    After knowing the good, bad and ugly business of this report why does the Kellogg Foundation’s Website brag about its two-year intensive evaluation and proudly claim resounding success for the DHAT? Where did all the caveats they wrote about go? I understand that they have contacted a DC area media company to help them spread the good news.
    To me, this is sugar coating of the highest level and it is dangerous. Without a doubt, most people will not read the full report and will rely only on the glowing summaries provided by this highly respected, deep pocketed, objective third party.
    It is a good time to access the WSDA website. We have listed talking points that are far more lucid than my visceral response. With legislation being actively developed by others in our state, it is time to join our Grassroots Program and tell your legislators exactly how difficult it is to drill at 430,000 rpm mere inches from their brains. Offsite general supervision is not acceptable in a state where open roads lead directly to our offices.
    If Kellogg et al had run an impeccable study and found the DHATs were the best thing that could happen for our patients, I would have been the first person to (reluctantly) acknowledge their success. Instead, they have produced a sloppy study that will further muddy the waters as we try to resolve access to care and workforce issues.
    I am disappointed.

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