EARLY HEAD START AND COORDINATION OF PREVENTIVE DENTAL SERVICES BY - - PowerPoint PPT Presentation
EARLY HEAD START AND COORDINATION OF PREVENTIVE DENTAL SERVICES BY MEDICAL AND DENTAL PROVIDERS Jacqueline M. Burgette, DMD, PhD 2018 AcademyHealth ARM Dental Public Health Seattle, WA Pediatric Dentistry Health Policy & Management
Jacqueline M. Burgette, DMD, PhD Dental Public Health Pediatric Dentistry Health Policy & Management University of Pittsburgh
2018 AcademyHealth ARM Seattle, WA June 24, 2018
Early Head Start (Explanatory, x) Preventive Oral Health Services from Dental and Medical Providers (Outcome, y)
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Determine the effectiveness of EHS in increasing caregiver- reported child use of POHS from dental and medical providers
Hypothesis: EHS children will have a greater odds of receiving POHS compared to Medicaid-matched children, particularly from dental providers, because EHS coordinates dental referrals.
Tooth decay affects children EARLY High prevalence in American preschoolers ages two to five EHS serves low-income families with children ages birth to three In 2017: 1,398 programs, serving over 154,000 children Performance standards include oral health oral health education oral health exam by a dental professional within 90 days referral to dentist if a child has treatment needs
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Poor Oral Health
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EHS
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Improved oral health outcomes
36% of children who enter kindergarten in NC have experienced dental caries Effective early education program Increases social and cognitive development Improves some health outcomes Preventive Oral Health Services from Dental and Medical Providers
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Preventive Oral Health Services (POHS) were available to both the EHS & non- EHS Groups by Medical Providers Medical providers in North Carolina received a bundled fee from Medicaid and CHIP for delivering the following POHS to children under age 3.5
Oral health education Fluoride varnish Screening and Risk Assessment Referral to dentists
High adoption rates among medical providers
500+ practices
Increased access to preventive services
Wide geographic distribution
58% of well-child visits Physician visits 4 times greater than dentists
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Rozier et al. J Dent Educ 2003;67:876-85. Close et al. Pediatrics. 2008;122:1387-94. Rozier et al. Health Affairs. 2010;29:2278-85.
EHS vs. non-EHS (Medicaid-matched controls) non-randomized, pretest-posttest nested cohort control group cluster trial
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EHS Programs EHS Families Medicaid- matched families
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EHS Non-EHS
Approximately 24 months
60% 25% 75% 9% 75% 25%
Recruited through NC EHS Programs n=1,458 Recruited through NC Medicaid files
(matched on residential code, age of child and English or Spanish language)
n=11,795 Enrolled at Baseline n=634 Enrolled at Baseline n=927 Followed up n=479 Loss to Follow-up n=155 Loss to Follow-up n=228 Followed up n=699 Eligible for Enrollment N=1,054 Eligible for Enrollment n=9,967
Figure 1. Data Collection for the Zero Out Early Childhood Caries Study by EHS Group. INTERVIEW INTERVIEW
85% 72%
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Four POHS Outcome Variables (Cumulative over Lifetime):
1. Preventive oral health assessment by medical provider 2. Preventive oral health assessment by dental provider 3. Fluoride application by medical provider 4. Fluoride application by dental provider
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ONE multivariate logistic regression model
Spanish and English (SAHL-S&E)
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Table 1. Baseline Child Characteristics of the ZOE Study Population, by Early Head Start (EHS) and non- Early Head Start (Non-EHS) Groups Characteristic EHS (n=479) Non-EHS (n=699) p-value† Age (months) [mean, SD (range)] 10.6, 4.8 (0-19) 10.4, 4.6 (1-19) 0.351 Male 54.17% 50.4% 0.226 Race and ethnicity <0.001 Non-Hispanic White 17.5% 36.8% Non-Hispanic Black 37.8% 19.5% Non-Hispanic Native American 2.4% 1.2% Non-Hispanic Other, Single R/E 0.0% 1.0% Non-Hispanic Other, Multiple R/E 7.5% 10.9% Hispanic 34.2% 30.4% Missing 0.6% 0.3% Enrolled in public health insurance 98.3% 98.8% 0.441 Physical, learning, or mental health limitations 4.5% 2.9% 0.160 Ever been homeless 4.7% 1.6% 0.002
N=number of subjects in stratum, SD=standard deviation.
†The p-values are for chi-square tests or t-tests comparing EHS and non-EHS groups.
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Table 1. Baseline Child Characteristics of the ZOE Study Population, by Early Head Start (EHS) and non- Early Head Start (Non-EHS) Groups Characteristic EHS (n=479) Non-EHS (n=699) p-value† Age (months) [mean, SD (range)] 10.6, 4.8 (0-19) 10.4, 4.6 (1-19) 0.351 Male 54.17% 50.4% 0.226 Race and ethnicity <0.001 Non-Hispanic White 17.5% 36.8% Non-Hispanic Black 37.8% 19.5% Non-Hispanic Native American 2.4% 1.2% Non-Hispanic Other, Single R/E 0.0% 1.0% Non-Hispanic Other, Multiple R/E 7.5% 10.9% Hispanic 34.2% 30.4% Missing 0.6% 0.3% Enrolled in public health insurance 98.3% 98.8% 0.441 Physical, learning, or mental health limitations 4.5% 2.9% 0.160 Ever been homeless 4.7% 1.6% 0.002
N=number of subjects in stratum, SD=standard deviation.
†The p-values are for chi-square tests or t-tests comparing EHS and non-EHS groups.
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Table 1. Baseline Child Characteristics of the ZOE Study Population, by Early Head Start (EHS) and non- Early Head Start (Non-EHS) Groups Characteristic EHS (n=479) Non-EHS (n=699) p-value† Age (months) [mean, SD (range)] 10.6, 4.8 (0-19) 10.4, 4.6 (1-19) 0.351 Male 54.17% 50.4% 0.226 Race and ethnicity <0.001 Non-Hispanic White 17.5% 36.8% Non-Hispanic Black 37.8% 19.5% Non-Hispanic Native American 2.4% 1.2% Non-Hispanic Other, Single R/E 0.0% 1.0% Non-Hispanic Other, Multiple R/E 7.5% 10.9% Hispanic 34.2% 30.4% Missing 0.6% 0.3% Enrolled in public health insurance 98.3% 98.8% 0.441 Physical, learning, or mental health limitations 4.5% 2.9% 0.160 Ever been homeless 4.7% 1.6% 0.002
N=number of subjects in stratum, SD=standard deviation.
†The p-values are for chi-square tests or t-tests comparing EHS and non-EHS groups.
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76 58 89 55 69 82 54 54 76 45 70 81 10 20 30 40 50 60 70 80 90 100 DENTAL MEDICAL‡ EITHER DENTAL MEDICAL EITHER PERCENTAGE OF PARENT-CHILD DYADS
EHS (n=479) Non-EHS (n=699)
ASSESSMENT FLUORIDE
* * *
Figure 1. Bar Chart on the Receipt of Preventive Oral Health Services by a Medical‡ Provider and Preventive Dental Services by a Dental Provider in the First Three Years of Life, by Early Head Start (EHS) or Non-Early Head Start (Non-EHS) Group.
‡Medical providers delivered preventive oral health assessments and fluoride varnish through the Into the
Mouth of Babes program. *P≤0.001
Table 2. Estimated Odds Ratios for Early Head Start (EHS) versus Non-Early Head Start (Non-EHS) for the Receipt of Preventive Oral Health Services by a Medical‡ Provider and Preventive Dental Services by a Dental Provider using Alternating Logistic Regression† (N=1,178) OR (95% CI) Dental Assessment 2.33** (1.74, 3.13) Dental Fluoride 1.53** (1.16, 2.03) Medical‡ Assessment 0.93 (0.70, 1.22) Medical Fluoride 0.73* (0.54, 0.99) *P<0.05, ** P<0.01, OR=odds ratio, CI=confidence interval
‡Medical providers delivered preventive oral health assessments and fluoride
varnish through the Into the Mouth of Babes program.
†The adjusted marginal logistic regression model controlled for parent health
literacy, parent overall health, survey language and a generalized boosted model propensity score.
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EHS children had 2.3 times the
an oral health assessment by a dental provider compared to non- EHS children. EHS children had 1.5 times the
fluoride applied by a dental provider compared to non- EHS children.
Table 2. Estimated Odds Ratios for Early Head Start (EHS) versus Non-Early Head Start (Non-EHS) for the Receipt of Preventive Oral Health Services by a Medical‡ Provider and Preventive Dental Services by a Dental Provider using Alternating Logistic Regression† (N=1,178) OR (95% CI) Dental Assessment 2.33** (1.74, 3.13) Dental Fluoride 1.53** (1.16, 2.03) Medical‡ Assessment 0.93 (0.70, 1.22) Medical Fluoride 0.73* (0.54, 0.99) *P<0.05, ** P<0.01, OR=odds ratio, CI=confidence interval
‡Medical providers delivered preventive oral health assessments and fluoride
varnish through the Into the Mouth of Babes program.
†The adjusted marginal logistic regression model controlled for parent health
literacy, parent overall health, survey language and a generalized boosted model propensity score.
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EHS children had decreased odds
fluoride from a medical provider compared to children not enrolled in EHS.
Odds of receiving preventive oral health services for children enrolled in EHS compared to Non-enrolled children:
1. Preventive oral health assessment by medical provider 2. Preventive oral health assessment by dental provider 3. Fluoride application by medical provider 4. Fluoride application by dental provider
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National estimates for young children have much lower rates of POHS 17
Prevalence of dental visit and receipt of preventive services (topical fluoride, sealant, or both) among children — Medical Expenditure Panel Survey, United States, 2009. Age group (years) Dental Visits Overall Preventive Services n % (95% CI) % (95% CI) 0–2 1,599 7.6 (6.0–9.7) 1.7 (1.1–2.5) 3–5 1,768 43.7 (40.2–47.1) 17.5 (15.0–20.3)
Griffin et al., 2014
providers compared to children not enrolled in EHS
Re-affirmation that EHS increases dental use compared to Non-EHS group
Medical providers may equalize the exposure to fluoride for young children Non-EHS gets significantly more fluoride from medical providers Medical providers fill the gap at a local level for both EHS and Non-EHS parents who may not be able to get their child to the dentist
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Not generalizable to states that do not have a strong Medicaid program where medical providers receive training and reimbursement for preventive oral health services
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Positive impact from the combined availability of POHS by medical and dental providers (professional integration)
Early Head Start Into the Mouth of Babes (POHS is integrated in primary medical care)
Depicts positive implications for access to preventive services though early education programs like EHS
Evidence of effectiveness and guidance for the inclusion of oral health promotion in early childhood education policies and programs Disadvantaged children and families benefit from enrollment in comprehensive early education programs
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National Institute of Dental and Craniofacial Research Prevention of Dental Caries in Early Head Start Children #R01 DE018236 Richard Gary Rozier Health Policy and Management Gillings School of Global Public Health University of North Carolina at Chapel Hill John Preisser Biostatistics Gillings School of Global Public Health University of North Carolina at Chapel Hill
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Department of Health and Human Services. About Early Head Start. http://eclkc.ohs.acf.hhs.gov/hslc/tta- system/ehsnrc/about-ehs/about.html#about. Updated 2016. Accessed March 10, 2016.
Department of Health and Human Services. Early Head Start program facts for fiscal year 2012. http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/ehsnrc/about-ehs/about.html. Updated 2014. Accessed October 5, 2014.
In: Haskins R, Barnett WS, eds. Investing in young children: New directions in federal preschool and early childhood policy. Brookings and NIEER; 2010:29-37.
developmental context. Monogr Soc Res Child Dev. 2013;78(1):vii-viii, 1-173.
http://www2.ncdhhs.gov/dph/oralhealth/stats/MeasuringOralHealth.htm
NJ: National Institute for Early Education Research; 2013.
Health Dent. 2016;76(1):17-29.
applied to longitudinal data. Am J Epidemiol. 2003 Sep 1;158(5):495-501.
Children Younger Than 3 Years. Am J Public Health 2017;107(4):614-20.
dental care and effective preventive services in preventing tooth decay among U.S. Children and adolescents--Medical Expenditure Panel Survey, United States, 2003-2009 and National Health and Nutrition Examination Survey, United States, 2005-2010. MMWR Suppl. 2014 Sep 12;63(2):54-60.
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20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 180,000
2000 2002 2004 2006 2008 2010 2012 2014 2016
Source: North Carolina Division of Medical Assistance
Number of Visits
Figure 2. Number of Visits With Preventive Oral Health Services in North Carolina Medical Offices, 2000-2016.
Special type of generalized estimating equation (GEE) The estimation algorithm alternates between solving the GEE for the model for the four outcomes and a log odds ratio model for the within-child association among the four outcomes with a second logistic regression estimation, hence the name ALR ALR does two things simultaneously 1. Estimate the marginal effects of EHS on each of the four types of POHS use (dental assessment, dental fluoride, medical assessment, and medical fluoride) 2. Evaluate the associations between pairs of POHS outcomes
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Carey VC, Zeger SL, Diggle PJ. Modelling multivariate binary data with alternating logistic regressions. Biometrika 1993; 80(3):517-26. Ananth CV, Preisser JS. Bivariate logistic regression: modelling the association of small for gestational age births in twin gestations. Stat Med. 1999 Aug 15;18(15):2011-23. Preisser JS, Arcury TA, Quandt SA. Detecting patterns of occupational illness clustering with alternating logistic regressions applied to longitudinal data. Am J Epidemiol. 2003 Sep 1;158(5):495-501.
Multiple BINARY outcomes that you want to compare
Examples:
Compare inappropriate opioid prescribing to inappropriate antibiotic prescribing Compare the odds of receiving a measles vaccine to the odds of receiving a flu vaccine Compare the odds of receiving preventive health services to emergency services Compare the odds of being a victim of nonviolent and violent crime
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Appendix A. Alternating Logistic Regression on the Effect of Early Head Start (EHS) on the Receipt of Preventive Oral Health Services by a Medical Provider and Preventive Dental Services by a Dental Provider (N=1,178) Estimate Standard Error 95% Confidence Interval p-value Intercept 0.67 0.20 0.29, 1.06 0.0007 EHS 0.43 0.14 0.15, 0.71 0.0025 Propensity Score
0.37
0.60 Outcome Medical‡ Assessment
0.24
0.006 Medical Fluoride 0.16 0.27
0.57 Dental Assessment
0.16
0.066 Dental Fluoride Referent Referent Referent Referent Low Parent Health Literacy†
0.11
0.99 English-speaking Parent∞
0.10
<0.0001 Good Parent Overall Health§
0.16
0.014 EHS*Outcome Medical Assessment
0.19
0.0069 Medical Fluoride
0.19
<.0001 Dental Assessment 0.42 0.14 0.14, 0.70 0.003 Dental Fluoride Referent Referent Referent Referent Propensity Score*Outcome Medical Assessment 1.42 0.48 0.47, 2.37 0.0032 Medical Fluoride 1.42 0.49 0.46, 2.39 0.0038 Dental Assessment 0.85 0.33 0.20, 1.51 0.011 Dental Fluoride Referent Referent Referent Referent Good Parent Health*Outcome Medical Assessment 0.68 0.19 0.30, 1.05 0.0004 Medical Fluoride 0.54 0.21 0.12, 0.96 0.011 Dental Assessment 0.47 0.13 0.21, 0.73 0.0004 Dental Fluoride Referent Referent Referent Referent
‡Medical providers delivered preventive oral health assessments and fluoride varnish through the Into the Mouth of Babes program. †Low Parent Health Literacy at baseline was defined as a score of 14 and under using the Short Assessment of Health Literacy (SAHL ≤14). ∞Parent surveys were obtained using an English- (n=888) or Spanish-speaking (n=290) interviewer. §Parent health was categorized as ‘good’ if the parent self-report of their overall health at baseline was ‘very good,’ ‘excellent’ or ‘good’ (n=938). Alternatively, parent health was notcategorized as ‘good’ if the parent self-report of their overall health was ‘fair’ or ‘poor’ (n=240). Note: We removed the non-significant interactions between the covariates, Low Parent Health Literacy and English-speaking Parent, with the outcome, EHS.
Appendix B. Estimated Log Odds Ratios on the Effect of Provider Type on the Receipt of Preventive Oral Health Services from Dental versus Medical Providers within both the Early Head Start (EHS) and Non-Early Head Start (Non-EHS) Groups using Alternating Logistic Regression† (N=1,178) Dental Versus Medical Provider
EHS (n=479) Non-EHS (n=699)
OR (95% CI) OR (95% CI) Assessment 3.65** (1.84, 7.24) 1.45 (0.86, 2.43) Fluoride 1.79 (0.94, 3.42) 0.86 (0.50, 1.46) ** P<0.01, OR=odds ratio, CI=confidence interval
‡Medical providers delivered preventive oral health assessments and fluoride varnish through
the Into the Mouth of Babes program.
†The adjusted marginal logistic regression model controlled for parent health literacy, parent
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Within the EHS group, children had a greater odds of receiving an oral health assessment from a dental provider compared to a medical provider compared to children not enrolled in EHS.
Appendix C. Estimated Pairwise Odds Ratios on the Comparative Receipt of Preventive Oral Health Services by Medical and Dental Providers using Alternating Logistic Regression† (N=1,178) Pairwise Odds Ratio 95% Confidence Interval p-value Dental Assessment, Dental Fluoride 29.11 19.62, 43.19 <0.0001 Dental Assessment, Medical‡ Assessment 1.33 1.04, 1.71 0.025 Dental Assessment, Medical‡ Fluoride 0.94 0.72, 1.23 0.65 Dental Fluoride, Medical‡ Assessment 1.68 1.32, 2.13 <0.0001 Dental Fluoride, Medical‡ Fluoride 1.74 1.34, 2.25 <0.0001 Medical‡ Assessment, Medical‡ Fluoride 3.06 2.35, 3.98 <0.0001
‡Medical providers delivered preventive oral health assessments and fluoride varnish through the Into the Mouth of Babes
program.
†The adjusted marginal logistic regression model controlled for parent health literacy, parent overall health, survey
language and a generalized boosted model propensity score.
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A child who received dental assessment had 29 times the odds of also receiving dental fluoride compared to a child who did not receive a dental assessment.
Concerned about systematic differences between children in EHS and children not in EHS (Medicaid-matched controls) Lack of randomization could lead us to over- or under-estimate effect of EHS intervention
e.g., children in EHS have caregivers with lower average education→ Underestimate EHS treatment effect
Adjust for 2 sources of selection bias:
1. Program enrollment criteria 2. Family selection (child characteristics, caregiver and family characteristics)
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Instrumental variable analysis Multiple regression without propensity scores Multiple regression with propensity scores
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Appendix D. Descriptive Statistics on the Receipt of Preventive Oral Health Services by a Medical Provider and Preventive Dental Services by a Dental Provider, by Early Head Start (EHS) or Non-Early Head Start (Non-EHS) Group EHS (n=479) Non-EHS (n=699) Dental and Medical Visits Combined Any Assessment** 89% 76% Any Fluoride 82% 81% Dental Visits Baseline Dental Visits** 10% 2% Follow-up Assessment∞** 76% 54% Fluoride∞** 55% 45%
EHS=Early Head Start ∞Outcome variable for the analytic model on the impact of EHS.
*P<0.05 for chi-square test comparing the prevalence of ≥1 impacts between the EHS and
non-EHS groups.
**P<0.01 for chi-square test comparing the prevalence of ≥1 impacts between the EHS and
non-EHS groups.
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Appendix D (cont). Descriptive Statistics on the Receipt of Preventive Oral Health Services by a Medical Provider and Preventive Dental Services by a Dental Provider, by Early Head Start (EHS) or Non-Early Head Start (Non-EHS) Group EHS (n=479) Non-EHS (n=699) Medical Visits‡ Baseline Assessment** 33% 22% Fluoride* 36% 30% Follow-up Assessment∞ 58% 54% Fluoride∞ 69% 70%
EHS=Early Head Start
‡Medical providers delivered preventive oral health assessments and fluoride varnish through
the Into the Mouth of Babes program. ∞Outcome variable for the analytic model on the impact of EHS.
*P<0.05 for chi-square test comparing the prevalence of ≥1 impacts between the EHS and
non-EHS groups.
**P<0.01 for chi-square test comparing the prevalence of ≥1 impacts between the EHS and
non-EHS groups.
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