Determining a Measure to Drive Clinical Behavior

For younger kids, clinical evidence shows that application of sealants to newly emerged permanent molars can prevent caries (cavities).   

What’s the best measure to encourage dental providers to put sealants on new molars?

An annual national measure for federally qualified community health centers (FQHCs)

Health Resources Services Administration (HRSA), the primary funder of FQHCs, has a candidate measure in its core set of required annual measures: 

 “Percentage of children, age 6-9 years, at moderate to high risk for caries who received a sealant on a first permanent molar during the annual measurement period.”

In 2015, national data for FQHCs shows that fewer than half of eligible children received one or more sealants (https://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2015&state= , accessed 4 July 2017).

Right now there’s no penalty for low performance and many health centers just take a look at the numbers once a year.

From annual to monthly measurement

An annual measure does not give fast enough feedback for a dental clinic that wants to achieve higher rates of sealants for their eligible patients. 

A year ago, I started working with 27 community health centers to improve oral health.  Our oral health collaborative revised the HRSA measure.   We developed a monthly measure to allow clinics to see the impact of changes 12 times faster than an annual measure.  

Here’s our revised definition, derived from the HRSA annual measure:

“Percentage of children, age 6–9 years, at moderate to high risk for caries who received at least one sealant on a permanent first molar within three months of an oral evaluation or assessment in the index month.”

We included the three-month interval to give health centers a chance to get the sealants done—i.e. if a provider recognized a need for sealants in January, the center would have 90 days to get that sealant applied.

For example, to calculate a monthly sealant number for April 2017, a health center needs to consider 6-9 year-old patients at moderate to high risk for caries who had an oral evaluation or assessment in January.   How many of those patients got a sealant on at least one permanent first molar within 90 days of the recognition exam in January?

The 90 day look back, intended to make it easier for the health centers to get sealants applied, actually confused people trying to calculate sealant performance.

Worse than confusion, the look-back made it difficult to detect improvements.

Consider our main change idea to improve rates of sealants:  allow and encourage hygienists to apply sealants to kids’ teeth as a standing order.  The hygienists have no need for explicit dentist approval, kid by kid.  The hygienists can apply sealants when they have a kid with sealable molars “in the chair.” 

Our measure, with the lag structure built in, doesn’t show the impact of the change in practice for three months.  Changing hygienists’ workflow in February won’t show up until May.  This delayed sensitivity to changes is a major flaw in the revised measure, especially when we’re trying to build evidence among providers and clinics that the main change idea is having the desired effect.

Measurement Version 3:  Align the measure with the change we want to see

We started work in May 2017 with a different group of FQHC dental centers eager to share performance measures.  They want to spur improvement through a benchmarking project.

Our sealant measure is now simpler:

“Percent of 6-9-year-old children who receive a sealant on all eligible permanent first molar teeth during the measurement month.”

Kids are counted if they come to the clinic for any reason and no matter what their risk profile.   Also, if a child has two, three or four eligible molars, the clinic needs to seal all the molars to count the child in the numerator of the measure.

Given the reality of clinic scheduling, the main way to drive the new measure to a high level is to apply the sealants the same day a child with sealable molars comes to the clinic.

The measure aligns perfectly with the work change we want to promote.

Furthermore, you don’t need to wait until the end of the month to calculate the numbers.

Measure version 3 can be built day by day, integrating measurement with a daily clinical huddle and daily plan-do-study-act thinking. 

In the huddle, we want each clinical team to ask and answer a few questions:  

• How many kids needed sealants yesterday? 
• How many of those kids got sealants?
• How many kids are on the schedule today who will need sealant?
• What can we do to improve our sealant work?    
• What can we do to get ready for today’s kids?   

A simple tally on a white board or piece of paper at the site of the daily huddle provides the answers to the first three questions.

Our first month of using the third measure version suggests health centers can pull the right numbers.

With our new simpler measure in hand, we now turn our attention to changing work in ways that will increase the number of kids who get eligible molars sealed.

That’s the focus of the next phase of our work starting later this summer.

Notes:  CMS Description of Federally Qualified Health Centers

FQHCs are safety net providers that primarily provide services typically furnished in an outpatient clinic. FQHCs include community health centers, migrant health centers, health care for the homeless health centers, public housing primary care centers, and health center program “lookalikes.” They also include outpatient health programs or facilities operated by a tribe or tribal organization or by an urban Indian organization.  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/fqhcfactsheet.pdf

Notes:  2016 Definition of Annual Dental Sealants measure included in the HRSA Unified Data System

Dental Sealants for Children between 6-9 Years (Line 22 of UDS report), CMS277v0

Performance Measure: Percentage of children, age 6-9 years, at moderate to high risk for caries who received a sealant on a first permanent molar during the measurement period.

This is calculated as follows:

Universe (Denominator): Children 6 through 9 years of age who had a dental visit in the measurement period who had an oral assessment or comprehensive or periodic oral evaluation visit and are at moderate to high risk for caries in the measurement period (Columns A and B)

Enter the number of patients who:

• Were born between January 1, 2007, and December 31, 2009, and
• Had a dental visit with the health center or with another dental provider through a paid referral, and
• Had at least one oral assessment or comprehensive or periodic oral evaluation visit during the measurement period, and
• Were at moderate to high risk for caries.

Exclusions: Children for whom all first permanent molars are non-sealable (i.e., molars are either decayed, filled, currently sealed, or un-erupted/ missing)

The following CDT codes will be useful in identifying the universe:

• CDT = D0602 and D0603 for caries risk assessment of moderate or high risk
• CDT = D0191 for oral assessment performed
• CDT = D0120, D0145, D0150, D0180 for comprehensive or periodic oral evaluation

Numerator: Children who received a sealant on a permanent first molar tooth during the measurement period (Column C)

(https://bphc.hrsa.gov/datareporting/reporting/2016udsreportingmanual.pdf accessed 5 May 2017, pp. 102-103)