Objective . To describe changes in oral health behaviors following implementation of a nursing intervention targeting children at risk for early childhood caries at an urban 2-site primary care practice. Methods . Nurses used a proprietary Nursing Caries Assessment Tool (N-CAT) to identify behaviors associated with early childhood caries risk, then provided brief focused dental education, fluoride varnish applications, and dental referrals to children without a dental home. We used generalized estimating equation logistic regression models, adjusted for age at visit, to analyze changes in oral health behaviors over time including the following: (1) tooth brushing frequency, (2) use of fluoride toothpaste, and (3) adult help with brushing among children younger than 5 years of age who had at least 2 N-CATs documented during well care visits between April 2013 and June 2015. We also evaluated dietary habits including going to bed with a bottle or sippy cup and sugar-sweetened beverage consumption, as secondary study outcomes during the same time frame. Results. A total of 2097 children with a mean age of 15.8 (SD 7.6) months at the initial visit were included in the analysis; 51% were boys; 28% were black, 36% Hispanic/Latino, 5% white, 2% Asian, and 19% other; 75% were publicly insured. During the study period, significant ( P < .05) improvements were noted across the 3 oral health behaviors studied among children younger than 18 months. Conclusion. Nursing interventions show promise for promoting preventive dental care in primary care settings and deserve further study.
BackgroundImprovement initiatives rely on measures to assess their impact. When outcomes are expressed as percentages, unanticipated changes to the denominator due to complexities and interactions among processes, population and contextual factors can result in measures that fail to register real improvements. For example a pediatric oral health collaborative focused on the incidence of new dental caries as a key measure. Despite uptake of process changes, a prevalence measure failed to register associated improvement in appointment rates (fig 1). Data exploration suggested the measure was confounded with exposure to process changes and recruitment of new patients.ObjectivesTo assess whether applying Monte-Carlo simulation can help project designers test the performance of outcome measures under an array of anticipated conditions.MethodsData were obtained via a database application installed at each practice which calculated monthly collaborative measures using standard definitions, and produced a file that was uploaded to the collaborative team.A template with a Monte-Carlo simulation platform was constructed to model a typical practice panel. Random variables modeled patient appointment intervals based on hypothetical subpopulations with varying appointment compliance.ResultsThe model tested two alternative definitions of caries incidence, and suggested that a modified definition would more accurately reflect improvements in caries incidence (fig 2).Based on predictions, the application was modified to incorporate two alternative operational definitions, which were then applied retrospectively by selected practices.Data using the revised definitions more closely conformed to simulated predictions (fig 3).ConclusionsMonte Carlo simulation enables advance testing of alternative operational definitions to optimize measure performance.Figure 1Original measure.Figure 2Simulation results: alternative definitions.Figure 3Results: individual team data.
Background28% of US children aged 2 to 5 years old have early childhood caries (ECC), a disease that is largely preventable if children receive early and consistent oral health interventions. Yet, strategies ensuring timely delivery of these services remain unclear.ObjectivesTo describe efforts in two primary care centers to increase rates of oral health education (OHE) and fluoride varnish (FV) applications during well-child visits.MethodsIn accordance with American Academy of Pediatrics Guidelines (released September 2015), we implemented universal OHE and FV applications in children under 5 years of age. Nurses entered patient caries risk assessment responses into electronic medical records (EMR). The frequency of FV applications and billing were assessed through monthly automated EMR data extraction. Key PDSA intervention cycles included implementation of nursing-driven protocols to allow independent abbreviated OHE and FV applications, daily automated data reports on completed and eligible OHE and FV, reminder signage and email newsletters, in-person communications, and redesign of the billing sheet layout.ResultsOver a 20 month period, in Center 1, FV orders increased from 57% to 80% and FV billing increased from 10% to 70%, while OHE was largely maintained above the target of 80%. In Center 2, FV orders and billing increased from 42% to 67% and 10% to 36% respectively, while OHE currently averages 59%.ConclusionsRevision of processes and protocols contributed to increased rates of FV orders, FV billing and OHE completed. We anticipate continued improvement leading to reduced dental caries rates among our patient populations.Figure 1Oral health education completed during well child visits in Center 1.Figure 2Oral health education completed during well child visits in Center 2.Figure 3Fluoride varnish orders completed during well child visits in Center 1.Figure 4Fluoride varnish orders completed during well child visits in Center 2.Figure 5Well child visits with fluoride varnish billed in Center 1.Figure 6Well child visits with fluoride varnish billed in Center 2.
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