Utilization and Validity of the Dental Diagnostic System over Time in Academic and Private Practice

Development of quality measures to assess tooth decay outcomes from electronic health record data

OBJECTIVES

To develop outcomes of care quality measures derived from the dental electronic health record (EHR) to assess the occurrence and timely treatment of tooth decay.

METHODS

Quality measures were developed to assess whether decay was treated within 6 months and if new decay occurred in patients seen. Using EHR-derived data of the state of each tooth surface, algorithms compared the patient's teeth at different dates to determine if decay was treated or new decay had occurred. Manual chart reviews were conducted at three sites to validate the measures. The measures were implemented and scores were calculated for three sites over four calendar years, 2016 through 2019.

RESULTS

About 954 charts were manually reviewed for the timely treatment of tooth decay measure, with measure performance of sensitivity 97%, specificity 85%, positive predictive value (PPV) 91%, negative predictive value (NPV) 95%. About 739 charts were reviewed for new decay measure, with sensitivity 94%, specificity 99%, PPV 99%, and NPV 94%. Across all sites and years, 52.8% of patients with decay were fully treated within 6 months of diagnosis (n = 247,959). A total of 23.8% of patients experienced new decay, measured at an annual exam (n = 640,004).

CONCLUSION

Methods were developed and validated for assessing timely treatment of decay and occurrence of new decay derived from EHR data, creating effective outcome measures. These EHR-based quality measures produce accurate and reliable results that support efforts and advancement in quality assessment, quality improvement, patient care and research.

Preventive dental care is associated with improved health care outcomes and reduced costs for Medicaid members with diabetes

Introduction

Preventive dental services have been associated with improved health outcomes. This study expands on previous observations by examining the relationship between oral health care and health care outcomes and costs in a publicly insured population with diabetes.

Methods

Utilization of dental services, health care outcomes and costs were evaluated for New York State Medicaid members with a diagnosis of diabetes mellitus (DM), ages 42 to 64, who were continuously enrolled between July 1, 2012 and June 30, 2015. Utilization of dental services focused on preventive dental care (PDC), and extractions and endodontic treatment (both indicative of advanced dental infection). Data were analyzed using regression models with propensity score weighting to control for potential confounding.

Results

Receipt of PDC was associated with lower utilization rates and costs compared to members who did not access dental services. The most pronounced average cost difference was observed for inpatient admissions at $823 per year for members who had at least one PDC without extraction or endodontic treatment. Each additional PDC visit received was associated with an 11% lower rate of inpatient admissions and lower average inpatient costs by $407 per member. The need for a dental extraction or endodontic therapy was associated with relatively higher rates and costs.

Conclusions

These findings demonstrate an association between PDC and improved health care outcome rates and lower average costs among members with DM and suggest a general health benefit associated with provision of preventive dental care for persons with DM.

Current state of dental informatics in the field of health information systems: a scoping review

Background

Over the past 50 years, dental informatics has developed significantly in the field of health information systems. Accordingly, several studies have been conducted on standardized clinical coding systems, data capture, and clinical data reuse in dentistry.

Methods

Based on the definition of health information systems, the literature search was divided into three specific sub-searches: “standardized clinical coding systems,” “data capture,” and “reuse of routine patient care data.” PubMed and Web of Science were searched for peer-reviewed articles. The review was conducted following the PRISMA-ScR protocol.

Results

A total of 44 articles were identified for inclusion in the review. Of these, 15 were related to “standardized clinical coding systems,” 15 to “data capture,” and 14 to “reuse of routine patient care data.” Articles related to standardized clinical coding systems focused on the design and/or development of proposed systems, on their evaluation and validation, on their adoption in academic settings, and on user perception. Articles related to data capture addressed the issue of data completeness, evaluated user interfaces and workflow integration, and proposed technical solutions. Finally, articles related to reuse of routine patient care data focused on clinical decision support systems centered on patient care, institutional or population-based health monitoring support systems, and clinical research.

Conclusions

While the development of health information systems, and especially standardized clinical coding systems, has led to significant progress in research and quality measures, most reviewed articles were published in the US. Clinical decision support systems that reuse EDR data have been little studied. Likewise, few studies have examined the working environment of dental practitioners or the pedagogical value of using health information systems in dentistry.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02163-9.

Structure, function, and productivity from the National Dental Practice-Based Research Network

Introduction:

Following inception in 2005 as a multiregional practice-based research network (PBRN), the “National Dental PBRN” expanded nationwide in 2012, and in 2019 implemented additional organizational changes. The objectives are to: (1) describe the new structure and function of the network; and (2) quantify its scientific productivity since 2005.

Methods:

A national Administrative and Resource Center is based in Alabama; regional and specialty nodes are based in Alabama, Florida, Illinois, Minnesota, Oregon, New York, and Texas. A Network Coordinating Center is based in Oregon. Studies are funded via investigator-initiated grants. Scientific productivity is assessed using specific metrics, including the Relative Citation Ratio.

Results:

To date, 58 studies have been completed or are in data collection or development. These studies have investigated a broad range of topics using a wide variety of study designs. Of the studies that have completed enrollment, 70,665 patients were enrolled, as were 19,827 practitioners (some participated in multiple studies), plus electronic records for 790,493 patients in two data-only studies. To date, these studies have led to 193 peer-reviewed scientific publications in 62 different journals. The mean (1.40) Relative Citation Ratio of Network publications connotes a greater-than-average influence in their fields.

Conclusions:

These metrics demonstrate that the PBRN research context can successfully engage practitioners and patients from diverse settings nationally with a high and sustained level of scientific productivity. This infrastructure has enabled clinical scientists in oral health and nonoral health topics and provided additional recruitment venues outside of the typical academic health center research context.

Caries Risk Documentation And Prevention: eMeasures For Dental Electronic Health Records

BACKGROUND

Longitudinal patient level data available in the electronic health record (EHR) allows for the development, implementation, and validations of dental quality measures (eMeasures).

OBJECTIVE

We report the feasibility and validity of implementing two eMeasures. The eMeasures determined the proportion of patients receiving a caries risk assessment (eCRA) and corresponding appropriate risk-based preventative treatments for patients at elevated risk of caries (appropriateness of care [eAoC]) in two academic institutions and one accountable care organization, in the 2019 reporting year.

METHODS

Both eMeasures define the numerator and denominator beginning at the patient level, populations' specifications, and validated the automated queries. For eCRA, patients who completed a comprehensive or periodic oral evaluation formed the denominator, and patients of any age who received a CRA formed the numerator. The eAoC evaluated the proportion of patients at elevated caries risk who received the corresponding appropriate risk-based preventative treatments.

RESULTS

EHR automated queries identified in three sites 269,536 patients who met the inclusion criteria for receiving a CRA. The overall proportion of patients who received a CRA was 94.4% (eCRA). In eAoC, patients at elevated caries risk levels (moderate, high, or extreme) received fluoride preventive treatment ranging from 56 to 93.8%. For patients at high and extreme risk, antimicrobials were prescribed more frequently site 3 (80.6%) than sites 2 (16.7%) and 1 (2.9%).

CONCLUSION

Patient-level data available in the EHRs can be used to implement process-of-care dental eCRA and AoC, eAoC measures identify gaps in clinical practice. EHR-based measures can be useful in improving delivery of evidence-based preventative treatments to reduce risk, prevent tooth decay, and improve oral health.

Assessing the completeness of periodontal disease documentation in the EHR: a first step in measuring the quality of care

Background

Our objective was to measure the proportion of patients for which comprehensive periodontal charting, periodontal disease risk factors (diabetes status, tobacco use, and oral home care compliance), and periodontal diagnoses were documented in the electronic health record (EHR). We developed an EHR-based quality measure to assess how well four dental institutions documented periodontal disease-related information. An automated database script was developed and implemented in the EHR at each institution. The measure was validated by comparing the findings from the measure with a manual review of charts.

Results

The overall measure scores varied significantly across the four institutions (institution 1 = 20.47%, institution 2 = 0.97%, institution 3 = 22.27% institution 4 = 99.49%, p-value < 0.0001). The largest gaps in documentation were related to periodontal diagnoses and capturing oral homecare compliance. A random sample of 1224 charts were manually reviewed and showed excellent validity when compared with the data generated from the EHR-based measure (Sensitivity, Specificity, PPV, and NPV > 80%).

Conclusion

Our results demonstrate the feasibility of developing automated data extraction scripts using structured data from EHRs, and successfully implementing these to identify and measure the periodontal documentation completeness within and across different dental institutions.

Tracking oral health in a standardized, evidence-based, prevention-focused dental care system

OBJECTIVES

Learning health-care systems are foundational for measuring and achieving value in oral health care. This article describes the components of a preventive dental care program and the quality of care in a large dental accountable care organization.

METHODS

A retrospective study design describes and evaluates the cross-sectional measures of process of care (PoC), appropriateness of care (AoC), and outcomes of care (OoC) extracted from the electronic health record (EHR), between 2014 and 2019. Annual and composite measures are derived from EHR-based clinical decision support for risk determination, diagnostic and treatment terminology, and decayed-missing-filled-teeth (DMFT) measures.

RESULTS

Annually, 253,515 ± 27,850 patients were cared for with 618,084 ± 80,559 visits, 209,366 ± 22,300 exams, and 2,072,844 ± 300,363 clinical procedures. PoC metrics included provider adherence (98.3 percent) in completing caries risk assessments and patient receipt (96.9 percent) of a proactive dental care plan. AoC metrics included patients receiving prevention according to the risk-based protocol. The percent of patients at risk for caries receiving fluoride varnish was 95.4 ± 0.4 percent. OoC metrics included untreated decay and new decay. The 6-year average prevalence of untreated decay was 11.3 ± 0.3 percent, and average incidence of new decay was 13.6 ± 0.5 percent, increasing with risk level: low = 7.5 percent, medium = 18.8 percent, high = 29.4 percent, and extreme = 28.1 percent.

CONCLUSIONS

The preventive dental care system demonstrates excellent provider adherence to the evidence-based prevention protocol, with measurably better dental outcomes by patient risk compared to national estimates. These achievements are enabled by a value-centric, accountable model of care and incentivized by a compensation model aligned with performance measures.