Measuring quality: caries-related emergency department visits and follow-up among children

Spatial Patterns of Emergency Dental Care Utilization: Assessing the Influence of Social Vulnerability and Dental Provider Availability

AIM

Our aim was to examine the association between emergency dental care use and dental providers' availability and ZIP code social vulnerability index.

METHODS

This cross-sectional observational study mapped variations in emergency dental care and analyzed their association with social vulnerability using generalized spatial two-stage least-squares to address spatial correlation. To perform spatial autoregressive modeling to examine how dental provider capacity and social vulnerability influence emergency care use across neighboring counties, accounting for ZIP Code Tabulation Area (ZCTA) spillover effects, we used secondary data from the Maryland Health Services Cost Review Commission, InfoUSA, and the US Census American Community Survey. We focused on emergency dental care usage in ZIP Code Tabulation Areas, using emergency department visits and inpatient stays per 1000 residents for dental conditions, as the dependent variable.

RESULTS

Highly vulnerable ZCTAs saw 5.9× more non-traumatic dental condition (NTDC) ED visits, 5.3× more chronic dental ED visits, 3.3× more NTDC inpatient stays, and 1.3× more chronic dental inpatient stays than less vulnerable areas. For all four measures of emergency dental care use, increased dental provider availability was associated with reductions in use of emergency dental care (ED), while higher social vulnerability was associated with increased use. For example, an increase of one dental provider per 1000 residents was associated with a reduction of 28.2 non-traumatic dental ED visits, while a high social vulnerability index was associated with an increase of 88.6 non-traumatic dental ED visits.

CONCLUSIONS

There was an association among dental provider availability, social vulnerability, and the use of emergency dental care.

Testing dental quality measures: Emergency department visits for nontraumatic dental conditions and subsequent follow-up dental visits

BACKGROUND

The goal of this study was to test the feasibility, reliability, and validity of the Dental Quality Alliance's adult dental quality measures for system-level implementation for ambulatory care sensitive (ACS) emergency department (ED) visits for nontraumatic dental conditions (NTDCs) in adults and follow-up after ED visits for NTDCs in adults.

METHODS

Medicaid enrollment and claims data from Oregon and Iowa were used for measure testing. Testing included validation of diagnosis codes in claims data through patient record reviews of ED visits and calculations of κ statistic, sensitivity, and specificity.

RESULTS

Adult Medicaid enrollees' ACS NTDC ED visits ranged from 209 through 310 per 100,000 member-months. In both states, patients in the age category 25 through 34 years and non-Hispanic Black patients had the highest rates of ACS ED visits for NTDCs. Only one-third of all ED visits were associated with a follow-up dental visit within 30 days, decreasing to approximately one-fifth with a 7-day follow-up. The agreement between the claims data and patient records for identification of ACS ED visits for NTDCs was 93%, κ statistic was 0.85, sensitivity was 92%, and specificity was 94%.

CONCLUSIONS

Testing revealed the feasibility, reliability, and validity of 2 DQA quality measures. Most beneficiaries did not have a follow-up with a dentist within 30 days of an ED visit.

PRACTICAL IMPLICATIONS

Adoption of quality measures by state Medicaid programs and other integrated care systems will enable active tracking of beneficiaries with ED visits for NTDCs and develop strategies to connect them to dental homes.

Patient centered dental home: Building a framework for dental quality measurement and improvement

INTRODUCTION

This article presents results of the second phase of a project to develop a patient-centered dental home (PCDH) model. Aims of PCDH model development include broadening the scope of prior dental home definitions to include populations across the lifespan, developing a quality measurement framework to facilitate quality assessment and improvement, and promoting opportunities for medical-dental integration through alignment with existing PCMH models. This phase determined the components, or conceptual subdivisions, associated with a previously developed PCDH definition and characteristics.

METHODS

We used a modified Delphi process to obtain structured feedback and gain consensus among the project national advisory committee (NAC). The process included a web-based survey that asked NAC members to rank the importance of each potential component on a scale of 1-9. Criteria for consensus on component inclusion/exclusion combined a median rating and measure of disagreement. Respondents were also encouraged to provide open-ended feedback regarding rationale for component ratings and additional suggested components.

RESULTS

A total of 47 out of 51 members completed the survey. All 34 components met the quantitative criteria for inclusion in the PCDH model. Changes were made to components based on open-ended feedback.

CONCLUSIONS

This project phase further developed a PCDH measurement framework that aims to guide practice transformation, quality measurement and improvement in dental care delivery, as well as integration between medicine and dentistry. Using a Delphi approach with a broad group of stakeholders ensured that components had face validity and were conceptually aligned with the PCDH definition and characteristics.

Quality measures for dental care: A systematic review

Objectives

This systematic review aimed to (a) provide an overview of existing quality measures in the field of oral health care, and to (b) evaluate the scientific soundness and applicability of these quality measures.

Methods

A systematic search was conducted in three electronic databases MEDLINE (via PubMed), EMBASE (via OVID) and LILACS (via BIREME). The search was restricted to articles published between 2002 and 2018. Publications reporting on the development process or clinimetric properties of oral health care quality measures for outpatient oral health care in dental practices were included. The identified publications reporting on oral health care quality measures were critically appraised with the Appraisal of Indicators through Research and Evaluation 2.0 (AIRE 2.0) instrument to evaluate the soundness and applicability of the measures.

Results

The search strategy resulted in 2541 unique and potentially relevant articles. In total, 24 publications were included yielding 215 quality measures. The critical appraisal showed a large variation in the quality of the included publications (AIRE scores ranging from 38 to 78 out of 80 possible points). The majority of measures (n = 71) referred to treatment and preventive services. Comparably, few measures referred to the domain patient safety (n = 3). The development process of measures often exhibited a lack of involvement of patients and dental professionals. Few projects reported on the validity (n = 2) and reliability (n = 3) of the measures. Four projects piloted the measures for implementation in practice.

Conclusions

This systematic review provides an overview of the status quo with respect to existing quality measures in oral health care. Potential opportunities include the piloting and testing of quality measures and the establishment of suitable information systems that allow the provision of transparent routine feedback on the quality of oral health care.

Pediatric Adapted Liking Survey: A Novel, Feasible and Reliable Dietary Screening in Clinical Practice

PURPOSE

Rapid yet useful methods are needed to screen for dietary behaviors in clinical settings. We tested the feasibility and reliability of a pediatric adapted liking survey (PALS) to screen for dietary behaviors and suggest tailored caries and obesity prevention messages.

METHODS

In an observational study, children admitted to a pediatric emergency department (PED) for nonurgent care were approached to complete the PALS (33 foods, 4 nonfoods including brushing teeth). Measured height/weight were used for body mass index (BMI) percentile determination. Feasibility was assessed by response rate and PALS completion time. Reliability was assessed by internal consistency of food groups and test-retest reliability for PED-home reported PALS.

RESULTS

PALS was completed by 144 children (96% of approached) - 54% male (average age = 11 ± 3 years) with diversity in family income (43% publicly insured), race/ethnicity (15% African American, 33% Hispanic, 44% Caucasian) and adiposity (3% underweight, 50% normal, 31% overweight, 17% obese, 8% extremely obese). The average completion time was 3: 52 min, and conceptual food groups had reasonable internal reliability. From 57% (n = 82) with PED-home completion, PALS had a good/excellent test-retest reliability. Relative preferences for sweets versus brushing teeth identified unique groups of children for tailored prevention messages (high sweet/brushing preference, sweets > brushing, brushing > sweets). Females with higher adiposity reported significantly greater preference for sweet/high-fat foods, independently of demographic variables; the relationship was nonsignificant in males and with the other food groups.

CONCLUSION

The PALS appears to be a fast, feasible and reliable dietary screener in a clinical setting to assist in forming tailored diet-related messages for dental caries and obesity prevention.

The Association of Health Literacy With Preventable Emergency Department Visits: A Cross-sectional Study

BACKGROUND

Policymakers argue that emergency department (ED) visits for conditions preventable with high-quality outpatient care contribute to waste in the healthcare system. However, access to ambulatory care is uneven, especially for vulnerable populations like minorities, the poor, and those with limited health literacy. The impact of limited health literacy on ED visits that are preventable with timely, high-quality ambulatory care is unknown.

OBJECTIVE

The objective was to determine the association of health literacy with preventable ED visits.

METHODS

We conducted an observational cross-sectional study of potentially preventable ED visits (outcome) among adults (≥18 years old) in an ED serving an urban community. We assessed health literacy (predictor) through structured interviews with the Rapid Estimate of Adult Literacy in Medicine (REALM). We recorded age, sex, race, employment, payer, marital and health status, and number of comorbidities through structured interviews or electronic record review. We identified potentially preventable ED visits in the 2 years before the index ED visit by applying Agency for Healthcare Research and Quality technical specifications to identify ambulatory care sensitive conditions using ED discharge diagnoses in hospital administrative data. We used Poisson regression to evaluate the number of preventable ED visits among patients with limited (REALM < 61) versus adequate (REALM ≥ 61) health literacy after adjusting for covariates.

RESULTS

Of 1,201 participants, 709 (59%) were female, 370 (31%) were African American, mean age was 41.6 years, and 394 (33%) had limited health literacy. Of 4,444 total ED visits, 423 (9.5%) were potentially preventable. Of these, 260 (61%) resulted in hospital admission and 163 (39%) were treat and release. After covariates were adjusted for, patients with limited literacy had 2.3 (95% confidence interval [CI] = 1.7-3.1) times the number of potentially preventable ED visits resulting in hospital admission compared to individuals with adequate health literacy, 1.4 (95% CI = 1.0-2.0) times the number of treat-and-release visits, and 1.9 (95% CI = 1.5-2.4) times the number of total preventable ED visits.

CONCLUSIONS

Our results suggest that the ED may be an important site to deploy universal literacy-sensitive precautions and to test literacy-sensitive interventions with the goal of reducing the burden of potentially preventable ED visits on patients and the healthcare system.