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 June 24, 2018 University of Pittsburgh

2 THE IMPACT OF EARLY HEAD START (EHS) ON 2 PREVENTIVE ORAL HEALTH SERVICES (POHS) Preventive Oral Health Services Early Head Start from Dental and Medical Providers (Explanatory, x) (Outcome, y) • Oral health assessment • Fluoride 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.

3 3 WHY EARLY HEAD START (EHS)? 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

4 COMBATING THE EPIDEMIC OF DENTAL 4 CARIES BY PARTNERING WITH EDUCATION  36% of children who enter kindergarten in NC Poor Oral Health have experienced dental caries +  Effective early education program EHS  Increases social and cognitive development  Improves some health outcomes = Improved oral health outcomes  Preventive Oral Health Services from Dental over time and Medical Providers

5 CONTEXT: INTO THE MOUTH OF BABES (IMB) 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 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.

6 6 DESIGN: QUASI-EXPERIMENTAL EHS vs. non-EHS (Medicaid-matched controls) non-randomized, pretest-posttest nested cohort control group cluster trial Medicaid- EHS Programs EHS Families matched families

7 EHS Non-EHS Recruited through NC Medicaid files (matched on residential code, age of child Recruited through NC EHS Programs and English or Spanish language) n=1,458 n=11,795 72% 85% Eligible for Enrollment Eligible for Enrollment N=1,054 n=9,967 9% 60% Enrolled at Baseline Enrolled at Baseline INTERVIEW n=634 n=927 Loss to Loss to 25% 25% Follow-up Follow-up Approximately 24 months n=155 n=228 75% 75% Followed up Followed up INTERVIEW n=479 n=699 Figure 1. Data Collection for the Zero Out Early Childhood Caries Study by EHS Group.

8 MAIN OUTCOME VARIABLE: USE OF PREVENTIVE ORAL HEALTH SERVICE (POHS) 8 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

9 9 MODELING ONE multivariate logistic regression model • Alternating logistic regressions estimation procedure • Control Variables: • Parent health literacy: Short Assessment of Health Literacy – Spanish and English (SAHL-S&E) • Binary: low (SAHL- S&E≤14), not low (SAHL-S&E>14) • Parent overall health • Binary: excellent/very good/good/missing, fair/poor • Survey language • Binary: Spanish, English • Generalized boosted model propensity score • Continuous

10 Table 1. Baseline Child Characteristics of the ZOE Study Population, by Early Head Start (EHS) and non- Early Head Start (Non-EHS) Groups EHS Non-EHS p-value † Characteristic (n=479) (n=699) 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.

11 Table 1. Baseline Child Characteristics of the ZOE Study Population, by Early Head Start (EHS) and non- Early Head Start (Non-EHS) Groups EHS Non-EHS p-value † Characteristic (n=479) (n=699) 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.

12 Table 1. Baseline Child Characteristics of the ZOE Study Population, by Early Head Start (EHS) and non- Early Head Start (Non-EHS) Groups EHS Non-EHS p-value † Characteristic (n=479) (n=699) 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.

13 RESULTS: UNADJUSTED 100 EHS (n=479) PERCENTAGE OF PARENT-CHILD DYADS * Non-EHS (n=699) 90 80 * 70 60 * 50 89 82 81 40 76 76 70 69 30 58 55 54 54 45 20 10 0 DENTAL MEDICAL‡ EITHER DENTAL MEDICAL EITHER 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

14 RESULTS: ADJUSTED Table 2. Estimated Odds Ratios for Early Head Start (EHS) versus Non-Early EHS children had Head Start (Non-EHS) for the Receipt of Preventive Oral Health Services by a 2.3 times the Medical ‡ Provider and Preventive Dental Services by a Dental Provider using odds of having Alternating Logistic Regression † (N=1,178) an oral health assessment by a OR (95% CI) dental provider Dental Assessment 2.33** (1.74, 3.13) compared to non- Dental Fluoride 1.53** (1.16, 2.03) EHS children. Medical ‡ Assessment 0.93 (0.70, 1.22) Medical Fluoride 0.73* (0.54, 0.99) EHS children had 1.5 times the *P<0.05, ** P<0.01, OR=odds ratio, CI=confidence interval odds of having fluoride applied ‡ Medical providers delivered preventive oral health assessments and fluoride by a dental varnish through the Into the Mouth of Babes program. provider † The adjusted marginal logistic regression model controlled for parent health compared to non- literacy, parent overall health, survey language and a generalized boosted EHS children. model propensity score.

15 RESULTS: ADJUSTED 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) EHS children had Dental Fluoride 1.53** (1.16, 2.03) decreased odds Medical ‡ Assessment 0.93 (0.70, 1.22) of receiving fluoride from a Medical Fluoride 0.73* (0.54, 0.99) medical provider compared to *P<0.05, ** P<0.01, OR=odds ratio, CI=confidence interval children not ‡ Medical providers delivered preventive oral health assessments and fluoride enrolled in EHS. 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.