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Goff SL, Gilson CF, DeCou E, Dick AW, Geissler KH, Dalal M, Kranz AM. Barriers and Facilitators to Optimal Fluoride Varnish Application. Acad Pediatr 2024; 24:755-764. [PMID: 37802248 PMCID: PMC10995105 DOI: 10.1016/j.acap.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 09/21/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVE National guidelines recommend that all children under age six receive fluoride varnish (FV) in medical settings. However, application rates remain low. This study aimed to update understanding of barriers and facilitators to guideline concordant FV application. METHODS We conducted virtual semi-structured interviews with a purposive sample (eg, FV application rates, geographic location, practice size and type) of pediatric primary care clinicians and medical assistants in Massachusetts between February 1 and June 30, 2022. The Consolidated Framework for Implementation Research (CFIR) served as the study's theoretical framework and data were analyzed using a modified grounded theory approach. RESULTS Of the 31 participants, 90% identified as White and 81% as female. Major themes, which linked to four CFIR domains, included: variation in perceived adequacy of reimbursement; differences in FV application across practice types; variation in processes, protocols, and priorities; external accountability for quality of care; and potential levers for change. Important subthemes included challenges for small practices; role of quality measures in delivering guideline-concordant preventive oral health care; and desire for preventive care coordination with dentists. CONCLUSIONS This study suggests that potential barriers and facilitators to guideline concordant FV application exist at multiple levels that may warrant further study. Examples include testing the effectiveness of quality measures for FV application and testing strategies for implementing consistent processes and protocols for improving FV application rates.
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Affiliation(s)
- Sarah L Goff
- University of Massachusetts Amherst School of Public Health and Health Sciences (SL Goff, CF Gilson, and E DeCou), Health Promotion and Policy, Amherst, Mass.
| | - Charlotte F Gilson
- University of Massachusetts Amherst School of Public Health and Health Sciences (SL Goff, CF Gilson, and E DeCou), Health Promotion and Policy, Amherst, Mass
| | - Erin DeCou
- University of Massachusetts Amherst School of Public Health and Health Sciences (SL Goff, CF Gilson, and E DeCou), Health Promotion and Policy, Amherst, Mass
| | | | - Kimberley H Geissler
- UMass Chan Medical School-Baystate (KH Geissler), Department of Healthcare Delivery and Population Sciences, Springfield, Mass
| | - Michelle Dalal
- Boston Office, Reliant Medical Group (M Dalal), Milford, Mass
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Lienhart G, Elsa M, Farge P, Schott AM, Thivichon-Prince B, Chanelière M. Factors perceived by health professionals to be barriers or facilitators to caries prevention in children: a systematic review. BMC Oral Health 2023; 23:767. [PMID: 37853400 PMCID: PMC10585780 DOI: 10.1186/s12903-023-03458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 09/26/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Considered the most prevalent noncommunicable disease in childhood, dental caries is both an individual and a collective burden. While international guidelines highlight prevention as a major strategy for caries management in children, health professionals still struggle to implement prevention into their clinical practice. Further research is needed to understand the gap between the theoretical significance of dental prevention and its lack of implementation in the clinical setting. This systematic review aims to identify and classify factors perceived by health professionals to be barriers or facilitators to caries prevention in children. METHOD A systematic literature search was conducted in three electronic databases (Medline, Web of Science and Cairn). Two researchers independently screened titles, abstracts and texts. To be selected, studies had to focus on barriers or facilitators to caries prevention in children and include health professionals as study participants. Qualitative and quantitative studies were selected. The factors influencing caries prevention in children were sorted into 3 main categories (clinician-related factors, patient-related factors, and organizational-related factors) and then classified according to the 14 domains of the theoretical domains framework (TDF). RESULTS A total of 1771 references were found by combining manual and database searches. Among them, 26 studies met the inclusion criteria, of which half were qualitative and half were quantitative studies. Dentists (n = 12), pediatricians (n = 11), nurses (n = 9), and physicians (n = 5) were the most frequently interviewed health professionals in our analysis. Barriers and facilitators to caries prevention in children were categorized into 12 TDF domains. The most frequently reported domains were Environmental Context and Resources, Knowledge and Professional Role and Identity. CONCLUSION This systematic review found that a wide range of factors influence caries prevention in children. Our analysis showed that barriers to pediatric oral health promotion affect all stages of the health care system. By highlighting the incompatibility between the health care system's organization and the implementation of caries prevention, this study aims to help researchers and policy-makers design new interventions to improve children's access to caries prevention. TRIAL REGISTRATION PROSPERO CRD42022304545.
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Affiliation(s)
- Guillemette Lienhart
- Service d'Odontologie, Hospices Civils de Lyon, 6/8 Place Deperet, 69007, Lyon, France.
| | - Masson Elsa
- Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Bron, France
| | - Pierre Farge
- Research On Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Domaine Rockefeller, 8 Avenue Rockefeller, 69373, Lyon 8, France
| | - Anne-Marie Schott
- Research On Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Domaine Rockefeller, 8 Avenue Rockefeller, 69373, Lyon 8, France
| | | | - Marc Chanelière
- Research On Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Domaine Rockefeller, 8 Avenue Rockefeller, 69373, Lyon 8, France
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Chen AYA, Opper IM, Dick AW, Stein BD, Kranz AM. Pediatric oral health services in Medicaid managed care and fee for service. THE AMERICAN JOURNAL OF MANAGED CARE 2023; 29:104-108. [PMID: 36811985 PMCID: PMC10100644 DOI: 10.37765/ajmc.2023.89319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVES In 2008, Florida's Medicaid program began reimbursing medical providers for preventive oral health services (POHS) delivered to children aged 6 months to 42 months. We examine whether Medicaid comprehensive managed care (CMC) and fee for service (FFS) had different rates of POHS during pediatric medical visits. STUDY DESIGN Observational study using claims data (2009-2012). METHODS Using repeated cross-sections of 2009-2012 Florida Medicaid data for children 3.5 years or younger, we examined pediatric medical visits. We estimated a weighted logistic regression model to compare POHS rates among visits reimbursed by CMC and FFS Medicaid. The model controlled for FFS (vs CMC), years Florida had a policy allowing POHS in medical settings, an interaction between these 2 variables, and additional child- and county-level characteristics. Results are presented as regression-adjusted predictions. RESULTS Among 1,765,365 weighted well-child medical visits in Florida, POHS were included in 8.33% of CMC-reimbursed visits and 9.67% of FFS-reimbursed visits. Compared with FFS, CMC-reimbursed visits had a nonsignificant 1.29-percentage-point lower adjusted probability of including POHS (P = .25). When examining differences over time, although the POHS rate was 2.72 percentage points lower for CMC-reimbursed visits after 3 years of policy enactment (P = .03), rates were similar overall and increased over time. CONCLUSIONS POHS rates among pediatric medical visits in Florida were similar for visits paid via FFS and CMC, with low rates that increased modestly over time. Our findings are important because more children continue to be enrolled in Medicaid CMC.
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Affiliation(s)
- Annie Yu-An Chen
- RAND Corporation, 20 Park Plaza, 9th Floor, Ste 920, Boston, MA 02116.
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Kranz AM, Opper IM, Stein BD, Ruder T, Gahlon G, Sorbero M, Dick AW. Medicaid Payment and Fluoride Varnish Application During Pediatric Medical Visits. Med Care Res Rev 2022; 79:834-843. [PMID: 35130771 PMCID: PMC9357861 DOI: 10.1177/10775587221074766] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
All Medicaid programs pay for fluoride varnish applications during medical visits for infants and toddlers, but receipt of care varies considerably across states. Using 2006-2014 Medicaid data from 22 states, this study examined the association between Medicaid payment and receipt of fluoride varnish during pediatric medical visits. Among 3,393,638 medical visits, fewer than one in 10 visits included fluoride varnish. Higher Medicaid payment was positively associated with receipt of fluoride varnish during pediatric medical visits. As policymakers consider strategies for increasing young children's access to preventive oral health services, as well as consider strategies for balancing budgets, attention should be paid to the effects of provider payment on access to pediatric oral health services.
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Kranz AM, Gahlon G, Dick AW, Goff SL, Whaley C, Geissler KH. Variation in prices for an evidence-based pediatric preventive service. Health Serv Res 2022; 57:1175-1181. [PMID: 35467008 PMCID: PMC9441288 DOI: 10.1111/1475-6773.13995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To examine variation in prices paid by private medical insurers for fluoride varnish applications in medical settings, a newly reimbursed service that few children receive. DATA SOURCES Private-insurance medical claims from Connecticut, Maine, New Hampshire, and Rhode Island (2016-2018). STUDY DESIGN We examined prices paid for fluoride varnish by private insurers and compared these to prices paid by Medicaid. DATA COLLECTION/EXTRACTION METHODS Private claims for fluoride varnish during medical visits for children aged 1-5 years. State Medicaid rates for fluoride varnish were obtained from the American Academy of Pediatrics. PRINCIPAL FINDINGS Prices paid for fluoride varnish by private insurers varied within and across states, ranging from less than $5 to $50. Median prices closely followed Medicaid rates in three of the four states. In states covering a package of fluoride varnish plus additional preventive oral health services during medical visits, combined Medicaid rates were nearly double the median price paid by private insurers. CONCLUSIONS Fluoride varnish is a recommended service, but few children receive it. Price variation may contribute to the low uptake of this service. Ensuring sufficient Medicaid and private insurance rates could increase fluoride varnish applications in medical settings and improve oral health.
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Affiliation(s)
| | | | | | - Sarah L. Goff
- School of Public Health & Health SciencesUniversity of Massachusetts AmherstAmherstMassachusettsUSA
| | | | - Kimberley H. Geissler
- School of Public Health & Health SciencesUniversity of Massachusetts AmherstAmherstMassachusettsUSA
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Kranz AM, Goff SL, Dick AW, Whaley C, Geissler KH. Delivery of fluoride varnish during pediatric medical visits by rurality. J Public Health Dent 2022; 82:271-279. [DOI: 10.1111/jphd.12518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/04/2022] [Accepted: 03/22/2022] [Indexed: 12/01/2022]
Affiliation(s)
| | - Sarah L. Goff
- Department of Health Promotion and Policy School of Public Health and Health Sciences, University of Massachusetts Amherst Amherst Massachusetts USA
| | | | | | - Kimberley H. Geissler
- Department of Health Promotion and Policy School of Public Health and Health Sciences, University of Massachusetts Amherst Amherst Massachusetts USA
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Goldstein EV, Xu WY, Seiber EE. Impact of the Affordable Care Act Medicaid expansion on oral surgery delivery at community health centers: an observational study. BMC Oral Health 2021; 21:540. [PMID: 34670549 PMCID: PMC8529833 DOI: 10.1186/s12903-021-01895-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Unmet oral health needs routinely affect low-income communities. Lower-income adults suffer a disproportionate share of dental disease and often cannot access necessary oral surgery services. The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) to provide mission-relevant services in low-income areas. However, little is understood in the literature about how the ACA Medicaid expansion impacted oral surgery delivery at CHCs. Using a large sample of CHCs, we examined whether the ACA Medicaid expansion increased the likelihood of oral surgery delivery at expansion-state CHCs compared to non-expansion-state CHCs. METHODS Exploiting a natural experiment, we estimated Poisson regression models examining the effects of the Medicaid expansion on the likelihood of oral surgery delivery at expansion-state CHCs relative to non-expansion-state CHCs. We merged data from multiple sources spanning 2012-2017. The analytic sample included 2054 CHC-year observations. RESULTS Compared to the year prior to expansion, expansion-state CHCs were 13.5% less likely than non-expansion-state CHCs to provide additional oral surgery services in 2016 (IRR = 0.865; P = 0.06) and 14.7% less likely in 2017 (IRR = 0.853; P = 0.02). All else equal, and relative to non-expansion-state CHCs, expansion-state CHCs included in the analytic sample were 8.7% less likely to provide oral surgery services in all post-expansion years pooled together (IRR = 0.913; P = 0.01). CONCLUSIONS Medicaid expansions can provide CHCs with opportunities to expand their patient revenue and services. However, whether because of known dental treatment capacity limitations, new competition, or coordination with other providers, expansion-state CHCs in our study sample were less likely to provide oral surgery services on the margin relative to non-expansion-state CHCs following Medicaid expansion.
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Affiliation(s)
- Evan V Goldstein
- Department of Population Health Sciences, School of Medicine, University of Utah, Salt Lake City, UT, 84108, USA.
| | - Wendy Yi Xu
- Division of Health Services Management and Policy, College of Public Health, Ohio State University, Columbus, OH, 43210, USA
| | - Eric E Seiber
- Division of Health Services Management and Policy, College of Public Health, Ohio State University, Columbus, OH, 43210, USA
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