The Patient-Centered Dental Home: A Framework for Quality Measurement, Improvement, and Integration

OBJECTIVE

This study completed the development of a standardized patient-centered dental home (PCDH) framework to align and integrate with the patient-centered medical home. This study identified measure concepts and specific measures and standards to complete the 4-level measurement framework to implement and evaluate a PCDH. This study built on prior model development, which identified the PCDH definition and characteristics and the components nested within those characteristics.

METHODS

An environmental scan identified existing oral health care quality measure concepts, measures, and standards for rating by the project's National Advisory Committee (NAC). A modified Delphi process, adapted from the RAND appropriateness method, was used to obtain structured feedback from the NAC. NAC members rated measure concepts on importance and, subsequently, specific measures and standards on feasibility, validity, and actionability using a 1 to 9 rating scale. Criteria for model inclusion were based on median ratings and rating dispersion. Open-ended comments were elicited to inform model inclusion as well as identify additional concepts.

RESULTS

We identified more than 500 existing oral health care measures and standards. A structured process was used to identify a subset that best aligned with a PCDH for rating by the NAC. Four Delphi rounds were completed, with 2 rounds to rate measure concepts and 2 rounds to rate measures and standards. NAC quantitative ratings and qualitative comments resulted in a total of 61 measure concepts and 47 measures and standards retained for inclusion in the framework.

CONCLUSIONS

The NAC ratings of measure concepts, and specific measures and standards nested within those concepts, completed the 4-level PCDH measurement framework. The resulting framework allows for the development and implementation of core measure sets to identify and evaluate a PCDH, facilitating quality improvement and dental-medical integration.

KNOWLEDGE TRANSFER STATEMENT

Clinicians, payers, health care systems, and policy makers can use the results of this study to guide and assess implementation of the various components of a patient-centered dental home and to support dental-medical integration.

The Effects of Medical Well Baby Visits in Promoting Earlier First Dental Visits for Children

The objective of the study was to assess the effects of medical well baby visits in promoting earlier first dental visits. We analyzed Iowa Medicaid claims data (2000-2013). The sample included 4 cohorts of children born in 2000, 2003, 2007, or 2010 and enrolled in Medicaid from birth (N = 38,211). Children were followed for 3 y. The independent variables were cohort year and medical well baby visit frequency during 3 time periods (birth to age 10 mo, ages 11-19 mo, ages 20-36 mo). We used survival analyses to estimate first dental visit rates. First dental visit rates improved significantly from 2000 to 2013, with children in latter cohorts having significantly earlier first dental visits. Children with more medical well baby visits before age 11 mo had significantly delayed first dental visit rates than children with fewer medical well baby visits. The opposite was observed for children with more medical well baby visits between ages 11 to 19 mo and ages 20 to 36 mo. First dental visit rates for Medicaid-enrolled children have improved, but there continues to be a need for early interventions to improve age 1 dental visits and other preventive oral health behaviors. Knowledge Transfer Statement: The results of this study can be used by policy makers when developing strategies to improve access to dental care for young children in Medicaid. With consideration to promoting earlier preventive dental visits for publicly insured children, this study could lead to early interventions and improved health outcomes.

The Timing of Subsequent Treatment for Teeth Restored with Large Amalgams and Crowns: Factors Related to the Need for Subsequent Treatment

Crowns and large amalgams protect structurally compromised teeth to various degrees in different situations. The aim of this investigation was to evaluate the survival of teeth with these two types of restorations and the factors associated with better outcomes. Retrospective administrative and chart data were used. Survival was defined and modeled as: (1) receipt of no treatment and (2) receipt of no catastrophic treatment over five- and 10-year periods. Analyses included: Kaplan-Meier survival curves, Log-Rank tests, and Cox proportional hazards regression modeling. Crowns survived longer with no treatment and with no catastrophic treatment; however, mandibular large amalgams were least likely to have survived with no treatment, and maxillary large amalgams were least likely to have survived with no catastrophic treatment. Having no adjacent teeth also decreased survival. Crowns survived longer than large amalgams, but factors such as arch type and the presence of adjacent teeth contributed to the survival of large amalgams.

Understanding Pediatric Dentists' Dental Caries Management Treatment Decisions: A Conjoint Experiment

When traditional ranking and rating surveys are used to assess dentists' treatment decisions, the patient's source of payment appears to be of little importance. Therefore, this study used the marketing research tool conjoint analysis to investigate the relative impact of source of payment along with the child's age and cooperativeness on pediatric dentists' willingness to use Atraumatic Restorative Treatment (ART) to restore posterior primary teeth. A conjoint survey was completed by 707 pediatric dentists. Three factors (age of the child, cooperativeness, type of insurance) were varied across 3 levels to create 9 patient scenarios. The relative weights that dentists placed on these factors in the restorative treatment decision process were determined by conjoint analysis. "Cooperativeness" (52%) was the most important factor, "age of the child" (26%) the second-most important factor, followed by "insurance status of the child" (22%). For the third factor, insurance, pediatric dentists were least willing to use ART with publicly insured children (-0.082), and this was significantly different from their willingness to use ART with uninsured children (0.010) but not significantly different than their willingness to use ART for children with private insurance (0.073). Unlike traditional ranking and rating tools, conjoint analysis found that the insurance status of the patient appeared to be an important factor in dentists' decisions about different restorative treatment options. When pediatric dentists were forced to make tradeoffs among different patients' factors, they were most willing to use ART technique with young, uncooperative patients when they had no insurance. Knowledge Transfer Statement: The present study suggests the feasibility of using techniques borrowed from marketing research, such as conjoint analysis, to understand dentists' restorative treatment decisions. Results of this study demonstrate pediatric dentists' willingness to use a particular restorative treatment option (Atraumatic Restorative Treatment in this application) when forced to make tradeoffs in a "conjoined," or holistic, context among different factors presented in real-life patient scenarios. A deeper understanding of dentists' treatment decisions is vital to develop valid practice guidelines and interventions that encourage the use of appropriate restorative treatment modalities.

Perceived dental needs of children enrolled in Iowa's Medicaid Supplemental Security Income (SSI) health plan

The purpose of this study was to determine parental perception of the oral health needs of children with disabilities and whether or not they had difficulty obtaining dental care. A survey of parents of children enrolled in the Medicaid Supplemental Security Income (SSI) health plan in Iowa showed that 68 percent of children had dental needs during the previous year. Of these children, parents reported that 9.4 percent had a 'big problem' getting that care, 8.1 percent had a 'small problem' getting care and 82.5 percent stated that getting dental care was 'not a problem.' There were significantly more dental needs reported in children in the older age groups (> or = 5 years) and those with more years of experience in the program (p < 0.01). Further study is necessary to determine the types of barriers faced by those in the SSI program seeking dental care.

The question of cost: reimbursement and remuneration

Dentists and the dental team have been encouraged to become an important part of the effort to curb tobacco use. Many health insurance policies, however, do not cover tobacco cessation programs, especially by dentists. The generosity of insurance for tobacco cessation has been found to influence the use of these programs. The dental profession can help by: 1) training more dental students, dental hygienists, and dental practitioners to provide tobacco cessation counseling; 2) increasing the number of practices routinely monitoring tobacco use and providing tobacco cessation programs; 3) increasing the utilization of the available procedure codes for tobacco cessation, whether it is a covered service or not; and 4) stimulating demand for more tobacco cessation coverage by employees.

Are general dentists' practice patterns and attitudes about treating Medicaid-enrolled preschool age children related to dental school training?

PURPOSE

The purpose of this study were to investigate the willingness of general practitioners to provide dental care for preschool-aged children, and to explore the relationship between dental school experiences and practitioners' attitudes about treating Medicaid-enrolled children 3 years of age and younger.

METHODS

A survey was mailed to 3,559 randomly selected general dentists in Texas. Respondents were asked to answer questions about their willingness to provide specified dental procedures for children of different ages, their dental school experiences with pediatric dentistry and whether these experiences were hands-on, lecture or no training, and their attitudes concerning treating Medicaid-enrolled children 3 years of age or younger. Associations between attitudes about treating Medicaid-enrolled children and dental school experiences were determined.

RESULTS

The response rate was 26%. Almost all respondents were willing to provide routine procedures such as an examination (95%) and prophylaxis (94%) for children 5 years or younger. However, as children became younger and procedures more difficult, the number of general dentists willing to provide treatment decreased. The level of dental school training was significantly associated with the attitudes of general dentists about providing dental care for Medicaid-enrolled preschool-aged children (P < or = 0.05).

CONCLUSION

Identification of factors associated with general dentists' willingness to see young children may improve access by increasing the number who will provide care for preschool-aged children.

Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia

OBJECTIVE

This paper examines the cost to the Iowa Medicaid program of hospitalizing young children for restorative dental care under general anesthesia, and describes the dental services received in this setting.

METHODS

Medicaid dental claims for young children receiving restorative dental care under general anesthesia during fiscal year 1994 were matched with corresponding hospital and anesthesia claims.

RESULTS

The total cost to the Medicaid program of treating a child in the hospital under general anesthesia was $2,009 per case. Less than 2 percent of Medicaid-enrolled children under 6 years of age who received any dental service accounted for 25 percent of all dollars spent on dental services for this age group, including hospital and anesthesia care. The most frequent type of procedure was stainless steel crowns (SSCs), with an average of almost six per case.

CONCLUSIONS

Early identification, prevention, and intervention are critically important to prevent the costly treatment of children with ECC in hospital operating rooms.

Unexplained symptoms in primary care: perspectives of doctors and patients

This study evaluated unexplained symptoms in primary care from the perspective of both patients and physicians. The data were obtained from two 1998 statewide surveys, one targeting Medicaid patients and the other all primary care physicians in the state. There were 439 patients who responded (45% response rate) and 280 primary care physicians who responded (33% response rate). Half of the patients and half of the physicians were in non-metropolitan counties. Half of the patients reported unexplained symptom usually or always, and 75% of whom sought help for these symptoms. Fifty-two percent of these patients believed their physician was very concerned about their unexplained symptoms. Eighty percent of them rated their physician as providing the best possible care compared to only 49% of patients whose physician did not care about their unexplained symptoms (P=.001). Among the physicians, only 14% reported very good or excellent satisfaction with managing unexplained symptoms as compared to 44% who claimed similar satisfaction in managing psychological problems. Physicians who saw themselves as more effective in dealing with somatoform symptoms were more likely to be in solo practice (P<.005), or in the same location for at least five years (P=.04). Residence in a nonmetropolitan county did not affect patient reporting of symptoms, patient perception of physician concern about symptoms, or physician satisfaction in managing these symptoms. These results indicate the prevalence and importance of unexplained symptoms in the Medicaid population and the comfort of physicians in managing these symptoms. There is an unmet need among primary care physicians to learn how to manage patients with unexplained symptoms.

Primary care physician perceptions of the nurse practitioner in the 1990s

OBJECTIVE

To evaluate factors associated with primary care physician attitudes toward nurse practitioners (NPs) providing primary care.

DESIGN

A mailed survey of primary care physicians in Iowa.

SETTING AND PARTICIPANTS

Half (N = 616) of the non-institutional-based, full-time, primary care physicians in Iowa in spring 1994. Although 360 (58.4%) responded, only physicians with complete data on all items in the model were used in these analyses (n = 259 [42.0%]).

MAIN OUTCOME MEASURES

There were 2 principal dependent measures: physician attitudes toward NPs providing primary care (an 11-item instrument) and physician experience with NPs in this role. Bivariate relationships between physician demographic and practice characteristics were evaluated by chi 2 tests, as were both dependent variables. Ordinary least-squares regression was used to determine factors related to physician attitudes toward NPs.

RESULTS

In bivariate analyses, physicians were significantly more likely to have had experience with an NP providing primary care if they were in pediatrics or obstetrics-gynecology (78.3% and 70.0%, respectively; P < .001), had been in practice for fewer than 20 years (P = .045), or were in practices with 5 or more physicians. The ordinary least-squares regression indicated that physicians with previous experience working with NPs providing primary care (P = .01), physicians practicing in urban areas with populations greater than 20,000 but far from a metropolitan area (P = .03), and general practice physicians (P = .04) had significantly more favorable attitudes toward NPs than did other primary care physicians.

CONCLUSIONS

The association between previous experience with a primary care NP and a more positive attitude toward NPs has important implications for the training of primary care physicians, particularly in community-based, multidisciplinary settings.

The impact of WIC dental screenings and referrals on utilization of dental services among low-income children

PURPOSE

This cross-sectional study examined whether referrals from nondental health professionals impacted utilization of dental services by low-income populations.

METHODS

A sample of 309 mothers enrolled in the Women, Infant, and Children (WIC) clinic in Jackson County, Missouri, completed a self-administered, 32-item questionnaire to assess the mother and child's oral health behavior and past use of dental services. Dental utilization, the primary dependent variable, was defined as whether or not the child had ever been to a dentist.

RESULTS

Findings showed 27% of the children in the sample had been referred for dental care. Bivariate analysis indicated that a dental referral, age of the child, age of the mother, mother's perceived dental need for the child, household size, number of children in the household, and dental insurance for the child were associated with a child having a dental visit. Logistic regression, however, indicated that only age was significantly related to utilization.

CONCLUSION

The results showed a strong effect of increasing age being related to dental utilization, while additional research is needed to clarify the importance of WIC referrals.

An in vitro evaluation of the integrity of stainless steel crown margins cemented with different luting agents

The elderly population is retaining more teeth which require extensive restorations. The purpose of this study was to identify a luting agent which had the least marginal breakdown when used with stainless steel crowns. Thirty-six caries-free molars were selected, prepared for stainless steel crowns, and embedded in acrylic to support the crown and tooth. The crowns (Unitek/3M) were cemented with 4 different luting agents: (A) Fleck's Cement, (B) Ketac-Cem, (C) All-Bond C & B Cement, and (D) Panavia EX Cement. All the restored teeth were thermocycled and divided into 3 experimental groups. Twelve teeth were stained. The remaining teeth were occlusally loaded and stained. The remaining 12 teeth were thermocycled and stained again. The stainless steel crowns were then sectioned and photographed at 7.5x mag. The dye penetration was evaluated by measurement of the percentage of dye penetration from the crown margin to the cusp tip on each side. Statistical analysis found that the least dye penetration was with All-Bond C & B Cement (p = 0.0001). The most extensive penetration was observed in Ketac-Cem Occlusal loading was a significant factor (p = 0.0001) increasing the dye penetration, but the crown-tooth gap was not.

Factors affecting primary care physician participation in Medicare

OBJECTIVES

This study investigates the levels of participation and the relative association of economic and noneconomic factors on primary care physician participation in the Medicare program.

METHODS

Demographic information, participation in Medicare, and attitudes toward both the Medicare program and Medicare patients were collected in a written survey mailed to half the primary care physicians in Iowa. Ordinary least squares and logistic regression analyses were conducted to determine factors associated with the percentage of Medicare patients in a practice and the acceptance of all new Medicare patients, respectively.

RESULTS

Two thirds of physicians were accepting all new Medicare patients, whereas 16% were accepting no new Medicare patients. Factors associated with having a higher percentage of Medicare patients in a practice were as follows: (1) a larger proportion of Medicare recipients in the county, (2) practice as a general internal medicine physician, (3) more years in practice at the current location, (4) greater enjoyment treating elderly patients, (5) less concern about having too many Medicare patients, and (6) a stronger belief that the Medicare program respects their professional judgment. Physicians less concerned about having too many Medicare patients in their practice and physicians in counties with a higher percentage of Medicare patients were significantly more likely to accept all new Medicare patients.

CONCLUSIONS

These results suggest that as Medicare reforms are discussed, careful consideration of the impact of these reforms on noneconomic issues is important to ensure adequate physician participation and access for elderly patients through the Medicare program.

Utilization of dental services by Iowa Medicaid-enrolled children younger than 6 years old

All Medicaid-enrolled children are eligible to receive dental care through the Early and Periodic Screening, Diagnostic and Treatment Program (EPSDT). As part of an evaluation of the effectiveness of the EPSDT program in Iowa, Medicaid enrollment and claims files from fiscal year (FY) 1994 were used to evaluate the utilization of dental services by Medicaid-enrolled children younger than age 6 during FY 1994. During FY 1994, 23% of Medicaid-enrolled children younger than age 6 received at least one dental service while enrolled in the Medicaid program. The total Medicaid-allowed charges for all dental services provided to this population while enrolled in Medicaid during FY 1994 was $1.53 million (the amount Medicaid would pay for the service, prior to calculating any copayments or other insurance charges). Although the EPSDT program in Iowa requires a referral of all Medicaid-enrolled children to a dentist at 1 year of age, fewer than 4% of enrolled children in this age group received any dental services. The percent of enrolled children receiving a dental exam during FY 1994, by age, was as follows: younger than 1 year, 0.2%; age 1, 3%; age 2, 10%; age 3, 27%; age 4, 46%; age 5, 54%. Utilization rates of dental services by Medicaid-enrolled children in Iowa fall far short of federal regulations, which currently require that 80% of enrollees receive EPSDT screenings, referrals, and treatment by age 3.

A profile of patients in six dental school clinics and implications for the future

Surveys were conducted of patients receiving care at six dental school clinics in the United States during a one-week period in the fall of 1993. Survey data were analyzed to determine who was using services provided by these dental schools, the types of services being provided, and why people chose to receive their care at these dental schools. Eighty-one percent of the patients indicated that low cost was an important reason for seeking care at a dental school; the patients receiving care at these dental schools tended to be low income. Seventy-six percent paid for some or all of their care out of pocket. As dental schools reevaluate their mission regarding patient care issues and assess the impact of their decisions, information about dental school clinics, particularly who seeks care there and why, should be an important consideration.

Health care system reform and public health. Protecting the safety net

The most difficult to reach underserved populations are not likely to disappear even with universal insurance coverage. Universal coverage does offer all educated and motivated individuals, including those lacking financial resources, the opportunity to seek improved health through prevention services and treatment for illness. But, it would not guarantee that uneducated and unmotivated people, substance abusers, the chronically mentally ill, people with geographic or cultural barriers to access, or other traditionally underserved populations will use or be able to use a new system more wisely. These last groups, who, for various reasons, may underuse prevention services or delay contact until disease is transmitted or illness is advanced, will continue to add costs to a reformed health care system. Care must therefore be exercised in health care system reform to provide incentives for private-sector outreach to these problem populations. Even with incentives, however, history suggests that the private sector will either avoid or have difficulty incorporating the large groups of disadvantaged patients who in the past have relied on public health services and public hospitals for their health care. The public health sector will need to maintain the capacity to provide for the health care of many disadvantaged groups with historically poor access. It becomes critical in the budgetary trade-offs inherent in health care system reform that the infrastructure of the public health system not be damaged.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessing quality in dentistry: dental boards, peer review vary on disciplinary actions

Reported inconsistencies in entry level exams and variations in available disciplinary mechanisms suggest the need for modifications to improve these processes. A quality assurance system combining education with some sanctions is likely to engender dentist support and improve quality of care.

Clinical board examinations: variation found in pass rates

This study found significant variation in pass rates within and among state and regional dental board clinical examinations during 1979-1988. This suggests that factors other than the abilities of the candidates influence exam outcomes. As long as individual states can argue that there is currently no definitive system to assure the quality of dental care, states may remain reluctant to relax their restrictions on dentists' freedom of movement.

Expanding health insurance coverage and the implications for dentistry

Numerous proposals have been suggested for expanding health insurance coverage to the over 30 million Americans without health insurance. These proposals range from establishing a program of national health insurance modeled after the Canadian system to establishing statewide risk pools. Many of these proposals could have an impact on financial access to dental care for the approximately 120 million people without dental insurance. Dental insurance coverage has been shown to increase access to dental services and improve oral health status. Oral health professionals could facilitate discussions concerning health insurance expansion by informing policymakers about important preventive benefits to be gained by improving access to dental services. Dental public health professionals can serve as a bridge between organized dentistry and health policymakers by providing information to help formulate the priorities and characteristics of a dental health insurance program. This visibility and influence in the health policy arena would be beneficial to dentistry and could ultimately result in greater access to dental services and improved oral health for the uninsured.

Factors affecting dentist participation in a state Medicaid program

Provider participation is one factor affecting access to care for Medicaid recipients. There is evidence that providers are increasingly limiting their acceptance of Medicaid patients. Reasons cited for physicians and dentists not participating in Medicaid include low reimbursement rates, excessive paperwork, denial of reimbursement, and bureaucratic complexities. Telephone interviews were conducted with 92 dentists in California to determine factors affecting their decisions to participate in the California Medicaid (Medi-Cal) program. Low fees, denial of payment, and broken appointments by patients were identified as the three most important problems with the program. Non-participating dentists were more concerned about broken appointments, and complicated paperwork while less likely to believe the complexity of the program had recently decreased. Participating dentists were more concerned about the lack of services covered by Medi-Cal. The fact that participating and non-participating dentist have similar concerns about most aspects of the program may indicate that dentists who currently participate in Medi-Cal may become non-participants if problems with the program are not addressed.