Evaluation of Relationship between Quality and Performance Measures Concepts of Pediatric Oral Health: A Cross-sectional Study.

BACKGROUND: The dental quality alliance of the American Dental Association developed quality and performance measure concepts (QMCs) for pediatric dentistry to identify variations in care and to improve quality of care.
OBJECTIVES: This study evaluated the relationship between the proposed QMCs and oral health, measured as caries status.
METHODOLOGY: Parents/guardians of new patients presenting to the Nationwide Children's Hospital Dental Clinic for a nonurgent hygiene appointment were asked to complete a 10-question survey that reflected the QMCs. An oral examination was completed on each patient to determine his/her caries status.
RESULTS: For the majority of the QMCs evaluated in the study, there was no statistically significant difference in caries status between patients who had attended care according to the QMCs and those who had not.
CONCLUSIONS: From the findings, attending care as outlined by the QMCs may be no better than counting procedures as a measure of quality oral health-care outcomes. Copyright:

INTRODUCTION

In 2008, the American Dental Association established the dental quality alliance (DQA) to develop quality and performance measures.[1] The QMCs include utilization of services, usual source of services, care continuity/regular source of care, evaluation, prevention, and treatment. By evaluating these aspects of care, disparities in care can be identified and used to improve the quality of care.[23]

The Centers for Medicare and Medicaid Services projects spending on oral care to nearly double between 2005 and 2020, from $86.8 billion in 2005 to $167.9 billion in 2020.[4] Dental caries remains the most common chronic childhood disease[5] and is not improving for all children. Tooth decay in primary teeth in children aged 2–5 years increased from 24% to 28% between 1988–1994 and 1999–2004 according to the Centers for Disease Control and Prevention (CDC).[6] The purpose of this cross-sectional study was to evaluate and compare pediatric patients between the ages of 3 and 5 years seeking dental care at Nationwide Children's Hospital Dental Clinic (NCH-DC) using the QMCs outlined by the DQA.[7] This age group was selected based on the CDC's findings of tooth decay being on the rise in this population.

METHODOLOGY

A ten-question survey was developed incorporating the QMCs as described by the DQA.[78] The DQA quality measures were developed such that administrative data (claims/encounters) could be used to obtain information/data about each measure.

Therefore, the survey questions had to be adapted to the quality measures. The QMCs evaluated in this study include utilization of services, care continuity, usual source of services, and prevention. Other questions in the survey were related to use of emergency dental care and oral health evaluation.[9] The survey was determined to have a Flesch–Kincaid Grade Level score of 5.7 in terms of readability.

One examiner (CJ) completed an oral examination on each patient to determine the caries status. No explorer was used and radiographs were not viewed during the examination. Caries status was defined as “no caries,” if the patient had no decayed, missing due to caries, or filled teeth, and “caries,” if the patient had at least one decayed, missing due to caries, or filled tooth. The examiner assigned each patient to a treatment urgency category modeled after the Ohio Department of Health's Basic Screening Examination.[10] The kappa coefficient for interexaminer reliability for caries status was 0.8333 (95% confidence interval 0.5250–1.000). After establishing a caries status for each patient, they were grouped as either “caries” or “no caries.”

Statistical analysis

The Chi-square analysis or Fisher's exact analysis was used (P ≤ 0.05). All statistical analyses were completed using SAS 9.3 (SAS Institute Inc., Cary, NC, USA).

RESULTS

Table 1 denotes that there was no statistically significant difference in regard to caries status based on age and gender. For males and females, more patients had caries than were caries-free [Table 2].

Table 1

Distribution of study participants according to demographic characteristics (n=58)

	n (%)
Gender
Male	25 (43)
Female	33 (57)
Socioeconomic status
Upper class	29(50)
Upper middle	16 (27.5)
Middle	1 (1.7)
Lower class	12 (21)
Payment
Medicaid	48 (83)
Private insurance	8 (13.8)
No insurance	1 (1.7)
Other	1 (1.7)
Caries status
Caries	31 (53)
No caries	27 (47)

Table 2

Distribution of study participants according to the status of caries status among various age groups and gender

	Caries (%)	No caries (%)	Total
Age groups
3 years	9 (37.5)	15 (62.5)	24
4 years	12 (60.0)	8 (40.0)	20
5 years	10 (71.43)	4 (28.57)	14
Total	31	27	58
Gender
Male	13 (52)	12 (48)	25
Female	18 (54.55)	15 (45.45)	33
Total	31	27	58

Table 3 shows that there was a statistically significant difference in caries status between patients that had a prior dental visit and those without a prior visit.

Table 3

Caries status based on utilization and quality and performance measure concept of usual source of services

	Caries (%)	No caries (%)	Total
Utilization of services
Prior visit	17 (70.83)	7 (29.17)	24
No visit	14 (41.18)	20 (58.82)	34
Total	31	27	58
QMC of usual source of services
Seen by same dentist 2 consecutive years	9 (100)	0	9
Not seen by same dentist 2 years	4 (66.67)	2 (33.33)	6
Total	13	2	15

Table 4 shows no statistically significant difference in caries experience for patients who had a comprehensive/periodic examination in the 12 months preceding the study visit and those who had not had a comprehensive/periodic examination in the 12 months preceding the study visit. For patients who had a comprehensive/periodic examination, 80% had caries.

Table 4

Caries continuity and measure of prevention

Past 12 months	Caries (%)	No caries (%)	Total
Care continuity
Preventive visit	12 (80)	3 (20)	15
No preventive visit	5 (55.56)	4 (44.44)	9
Total	17	7	24
Measure of prevention
Fluoride application	5 (62.5)	3 (37.5)	8
No fluoride application	22 (48.89)	23 (51.11)	45
Total	27	26	53

Table 5 represents parent/guardian evaluation of child's oral health based on caries status. There was a statistically significant difference of evaluation of the child's oral health based on caries status. Parents/guardians of patients with caries were more likely to choose fair, poor, or don't know compared to parents/guardians of caries-free patients.

Table 5

Represents parent/guardian evaluation of child’s oral health based on caries status

	Excellent (%)	Very good (%)	Good (%)	Fair (%)	Poor (%)	Don’t know (%)	Total
Caries	2 (6.45)	7 (22.58)	9 (29.03)	6 (19.35)	6 (19.35)	1 (3.23)	31
No caries	8 (29.63)	11 (40.7)	8 (29.63)	0	0	0	27
Total	10	18	17	6	6	1	58
Fisher’s exact test
Table probability (P)	1.326E-06
Two-sided Pr≤P	0.0014

DISCUSSION

For the majority of the QMCs evaluated in this study, the caries experience was not statistically different between patients who had attended care according to the QMC and those who had not. The utilization of services was the only QMC that revealed a statistically significant difference between patients with caries and caries-free patients. However, of the patients with no prior dental visit, 59% were caries-free compared to only 29% of patients with a prior dental visit.

For our survey question, an affirmative answer to being seen by a dentist before the study visit could represent the patient being seen formally in a dental office for a comprehensive examination and/or treatment, or it could represent a limited examination in a school-based or community setting. Another consideration is that for patients with a prior visit, they may have had a prior visit because of a known dental problem either identified by the parent/guardian or a health-care professional. The variability of the definition of accessing any dental service could explain the findings in regard to caries status for this QMC.[12]

In our study, we only assessed the topical fluoride application due to the age restriction of our study. As can be seen in the results, very few patients had a fluoride application as reported by the parent/guardian in the previous year. Despite the impact of underreporting, this QMC is limited in nature too because it focuses on the annual application of fluoride.[10] Our results show that the distribution of caries versus caries-free subjects for those without a fluoride application in the previous 12 months was nearly equal. For those with a fluoride application in the previous 12 months, 62.5% had a positive caries status.

One of the QMCs not analyzed in this study was treatment. Previous studies[1314] have evaluated the recurrence of dental caries among children who received comprehensive dental treatment for either early childhood caries (ECC) or severe ECC (S-ECC) under general anesthesia. Nagarkar et al.[15] reported on a disease management (DM) approach to ECC in patients younger than 60 months through a quality improvement project. The DM protocol had in-office and at-home component. With this approach, positive outcomes were achieved, but the authors highlight the difficulty in implementing an ECC DM protocol. This is due to the lack of reimbursement for frequent visits, education, and counseling.

This study also evaluated the use of emergency dental appointments and the emergency department for dental pain. The majority of patients had never been seen in the emergency department for dental pain nor had to attend an emergency dental appointment for dental pain. Sheller et al.[16] studied caries-related dental emergencies that were either seen in the emergency room or in the dental clinic at a children's hospital during a 3-year period. Three hundred and sixty-two patients were seen for caries-related dental emergencies. For 27% of the patients seen, the emergency visit was the patient's first contact with a dentist. For patients 3.5 years and younger, the emergency visit was the first dental visit for 52% of these patients. It is likely similar findings were not observed in this study because of the study population. The convenience sample was drawn from patients scheduled for nonurgent hygiene appointments.

The findings of this study and other studies in dentistry and medicine indicate that there are multiple approaches and methods to developing, validating, and implementing quality measures in health care. Quality measures for health care are not “one-size-fits-all” owing to the complex nature of health care. This study adds to the scant literature presently available on evidence-based quality measures for pediatric dentistry.

This study had several limitations. The convenience sample included only patients and parents/guardians that were seeking care. The parents/guardians may have been advised before the study appointment to have their child seen by a dentist due to known dental caries. Therefore, the caries prevalence in the study population may be higher than the true caries prevalence of the general population. Furthermore, the sample size for this pilot study was small. All data obtained from parents/guardians were self-reported, and it is possible parents/guardians underreported or overreported prior dental care which could have also skewed the results. NCH-DC is a safety-net dental clinic and a large proportion of patients are from a low socioeconomic status background which lends to these patients being classified as high risk for caries.[11] The prevalence of caries in our sample population could be skewed and not reflect the true prevalence of caries within the pediatric population age 3–5 years. Even with these limitations, the framework of this study can be built upon to further the evidence base on quality measures in pediatric dentistry.

CONCLUSIONS

The study showed that attending care according to the QMCs was not correlated with improved oral health compared to not attending care according to the QMCs. More research is needed on dental treatment recommendations and outcomes for pediatric patients before quality measures can be developed and endorsed as a metric for quality outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.