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IAA 06-217 – HSR&D Study

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IAA 06-217
Improving Dental Decision Making for Root Canal Therapy
Nancy R. Kressin PhD
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
Boston, MA
Funding Period: September 2010 - November 2015

BACKGROUND/RATIONALE:
Tooth preservation is the ultimate goal of modern dental care, yet many veterans using VA care have partial or total tooth loss. Root canal therapy is an available, efficacious therapeutic strategy to retain teeth; however, VA's rates of this therapy are low, and there are variations in such treatment. We examined the use of root canal therapy versus tooth extraction, and racial variations in this outcome, finding that racial disparities continue to exist in VA dental care in FY 2011.

OBJECTIVE(S):
Original objectives are listed below. However, we were not able to evaluate the effects of the intervention due to insufficient study enrollment/primary data collection from participating patients. Thus, the only objective that our study was able to address is #4.That manuscript is now in press at Medical Care.

Original objectives:
1. Determine whether the intervention increases the proportion of root canal therapy provided among the sample. While improving outcomes, we expect to change the process of care and patient/provider attitudes.
2. Examine the effects of the intervention on the process of care, namely the degree to which the intervention affects the amount, type, and equitable provision of counseling given to patients about the benefits of root canal therapy, and whether these vary by socio-demographics.
3) Assess the effects of the intervention on patient and provider attitudes and explore which of these factors are most strongly associated with the therapy provided. We will a) determine the intervention's effects on provider or patient attitudes about root canal therapy, and whether this varies by patient socio-demographics; and b) identify the interpersonal and attitudinal factors (of patient and dentist) associated with the therapy provided, and examine whether these vary by patient background.
4) Examine whether previously identified disparities in care remained in FY11.

METHODS:
We implemented a communication skills training intervention for dental providers at five VA dental clinics, to improve tooth retention by increasing the proportion of root canal procedures versus tooth extraction, among patients for whom such care is clinically appropriate. We obtained baseline data from the prior year to determine root canal and tooth extraction procedures performed, and collected medical and dental information associated with these procedures. Similar data to assess the effect of the intervention was drawn prospectively from electronic records.
At two of the study sites, we queried patients who received either of these procedures to determine patients' attitudes about oral health, preferences for care, and other factors that may impact their decision-making. We also collected data from the treating dentists, to determine their assessment of the patient's clinical situation and rationale for the care recommended. Due to numerous administrative problems at the study sites, we did not collect a sufficient amount of data from either patients or providers for analysis.
However, we were able to examine administrative data to evaluate whether previously-identified disparities in dental care continued until FY2011.

FINDINGS/RESULTS:
Background: Racial disparities in dental care have previously been shown in the Veterans Health Administration (VA) -- a controlled access setting valuing equitable, high quality care.
Objectives: To examine current disparities in dental care by focusing on the receipt of root canal therapy versus tooth extraction, using administrative data.
Research Design: This is a retrospective analysis of administrative data contained in the VA's electronic health records. We performed logistic regressions on the independent measures along with a facility-specific random effect, using dependent binary variables that distinguished root canal from tooth extraction procedures.
Subjects: VA outpatients who had at least one tooth extraction or root canal visit in the VA in fiscal year 2011.
Measures: A dependent binary measure of tooth extraction or root canal therapy. Other measures are medical record data on medical comorbidities, dental disease severity, and demographic characteristics.
Results: The overall rate of preferred tooth-preserving root canal therapy was 18.1% during the study period. Black and Asian patients were most dissimilar with respect to dental severity, types and overall quantity of dental, medical and psychological disorders, and Black patients had the least amount of eligibility for comprehensive dental care. After adjustment for known confounding factors of root canal therapy, Black patients had the lowest root canal therapy rates (77% of the odds for Whites), while Asians had the highest rates (49% higher than the odds for Whites).
Conclusions: Current quality improvement efforts and a value to improve the equity of care are not sufficient to address racial/ethnic disparities in VA dental care; rather more targeted efforts will be needed to improve the equity for all.

IMPACT:
Study results suggest that racial/ethnic disparities in VA dental care continue, despite establishment of the VA Office of Health Equity and the organization's value on providing equitable care for all veterans.

PUBLICATIONS:

Journal Articles

  1. Boehmer U, Glickman M, Jones JA, Orner MB, Wheler C, Berlowitz DR, Kressin NR. Dental Care in an Equal Access System Valuing Equity: Are There Racial Disparities? Medical care. 2016 Nov 1; 54(11):998-1004.


DRA: Aging, Older Veterans' Health and Care, Health Systems, Other Conditions
DRE: Treatment - Observational, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Disparities, Patient-centered Care, Patient-Provider Interaction, Attitudes/Beliefs, Communication -- doctor-patient, Decision-Making
MeSH Terms: none

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