Participation in the CARES Act Provider Relief Fund policy by dentists in South Carolina's safety net.

OBJECTIVES: The Coronavirus Aid, Relief, and Economic Security (CARES) Act appropriated $100 billion to the Provider Relief Fund, allowing for direct payments to health care providers due to COVID-19. Few studies have evaluated participation in the Provider Relief Fund (PRF), and none have specifically looked at dental providers in the safety net. METHODS: We conducted a retrospective, secondary data analysis using a quasi-experimental cohort design of South Carolina dentists who received PRF payments, comparing those who did and did not participate in the safety net. Safety net practice was operationalized as those participating in Medicaid, and whether they provided care in dental health professional shortage areas, or rural communities. RESULTS: Of the 628 dental providers in South Carolina who received PRF payments, 34% were identified as Medicaid providers while 66% did not participate in Medicaid; we found no statistical difference between payments to Medicaid versus non-Medicaid dental providers. Of PRF payments to dental providers participating in South Carolina's Medicaid program, we found no difference between payments to rural and urban providers but did find that practices offering services in dental care shortage areas received less than providers practicing in counties not designated as a shortage area. CONCLUSIONS: The PRF achieved its goal of distributing financial support to providers affected by the COVID-19 pandemic. But without policy imperatives linked to need-based allocations or incentives for PRF recipients to serve safety net populations, we may later learn this was a missed opportunity for PRF.

A Technical Assistance Curriculum for Expanding Sustainable School-Based Oral Health Programs in the Carolinas' Dental Safety Net.

PURPOSE: School-based oral health programs (SBOHPs) provide opportunities to address oral health inequities by providing convenient access points for care. No published guidelines on SBOHP implementation existed. Our work describes how philanthropic, public, and academic organizations partnered to support dental safety net providers with designing comprehensive SBOHPs in North and South Carolina. DESCRIPTION: A multi-sector leadership team was established to manage a new SBOHP philanthropic-funded grant program organized into two phases, Readiness and Implementation, with the former a 6-month planning period in preparation of the latter. Readiness included technical assistance (TA) delivered through coaching and 15 online learning modules organized in four domains: operations, finance, enabling services, and impact. Organizations could apply for implementation grants after successful TA completion. Process evaluation was used including a Readiness Stoplight Report for tracking progression. ASSESSMENT: Ten Readiness grantees completed the TA. A variety of models resulted, including mobile, portable and fixed clinics. Descriptive analysis was conducted on the readiness stoplight reports. Components of the operation and finance domains required were the most time-intensive, specifically the development of policy manuals, production goals, and financial performance tracking. CONCLUSION: The program's structure resulted in (a) a two-state learning community, (b) SBOHP practice and policy alignment, and (c) coordinated program distribution. TA improvements are planned to account for COVID-19 threats, including school closures, space limitations, and transmission fears. Telehealth, non-aerosolizing procedures, and improved scheduling and communication can address concerns. Organizations considering SBOHPs should explore similar recommendations to navigate adverse circumstances.

Normally functioning quadricuspid aortic valve mistaken for bicuspid valve in a septuagenarian.

A 70-year-old male underwent transthoracic (TTE) and transesophageal (TEE) echocardiography for a stroke. A bicuspid aortic valve was suspected by TTE, but TEE revealed a normally functioning quadricuspid aortic valve. A quadricuspid aortic valve may be more common than generally thought, as it may not be readily diagnosed by TTE, and may remain functionally normal.

Untreated Dental Caries May be Associated with Subsequent Mortality among Working-Age Adults: Evidence from NHANES III.

OBJECTIVES: Poor oral health has been shown to be associated with selected adverse health outcomes. This study assessed the association between untreated dental caries and mortality and examined whether having dental insurance mitigates the risk of mortality among working-age US adults with dental caries. METHODS: Analysis used the publicly available linked mortality file for NHANES III, an observational study conducted in 1988-1994, with follow-up through December 2015. Propensity score matching was conducted to create similar populations of insured and uninsured adults, resulting in a sample of 4420 matched observations. The Cox proportional hazard model was used to investigate the effect of untreated dental caries and that of dental insurance on risk of all-cause mortality. The descriptive and final outcome statistical analyses were adjusted for complex sampling technique using weights, strata and cluster variables. RESULTS: Adults with untreated dental caries had a higher risk of mortality (HR: 1.33; 95% CI: 1.06-1.68) than those with no dental caries. Having dental insurance was associated with a lower risk of mortality (HR: 0.73; 95% CI: 0.59-0.92). An interaction between caries treatment status and dental insurance was not statistically significant. CONCLUSIONS: Adults with untreated dental caries have a higher risk of mortality, even in the presence of dental insurance. Untreated caries may be an indicator for multiple risk factors, including personal attitudes regarding health and healthcare-seeking behaviour.

The role of dental insurance in mitigating mortality among working-age U.S. adults with periodontitis.

AIM: To assess the relationship of dental insurance with all-cause mortality and mortality due to cardiovascular diseases (CVD), diabetes mellitus (DM), and cerebrovascular diseases (CBD) among those with periodontitis. MATERIALS AND METHODS: NHANES III and its associated mortality data set were used in this study. The outcome variables were "all-cause mortality" and "combined mortality" due to CVD, DM, and CBD. The independent variable was dental insurance stratified over periodontitis status. Unweighted frequencies with weighted column percentages were used for descriptive statistics, and chi-square test was applied for significance. Cox proportional hazard models were used for stratified multivariable analyses. All analyses were performed in SAS v9.4 accounting for survey data complexities. Significance level was kept at 5%. RESULTS: The mortality was 14.58% for all-cause mortality and 4.06% for combined mortality among those with periodontitis in this study. Dental insurance significantly reduced the hazard of all-cause mortality among those with periodontitis (HR: 0.75; 95% CI: 0.61 - 0.93), adjusted for covariates. However, no association of dental insurance with combined mortality was observed among periodontitis group. CONCLUSIONS: Dental insurance reduces hazard of all-cause mortality among those with periodontitis. Dental insurance ensures access to dentists and improves oral and dental health. Longitudinal study is needed to establish causality.

Should dental school faculty be measured and compensated using academic productivity models? Two viewpoints.

Operationalizing faculty contributions in ways that align with organizational mission can be difficult, particularly when monetizing effort. Conventional compensation methods may result in faculty effort going undefined, resulting in more subjectivity in recognition and compensation. Inequities lead to faculty marginalization, fragmentation, decreased motivation, and attrition. Dental faculty retirements are expected to increase, as 81% of men and 19% of women faculty aged 60 years and older in 2015-2016. We present opposing perspectives on the use of educational value units (EVUs) in academic dentistry. The first viewpoint articulates that such models improve recruitment and retention by objectifying (a) faculty performance measurement, (b) academic productivity improvements, and (c) compensation determination. The counterpoint suggests EVUs are deterrents to faculty retention due to challenges with objectively quantifying performance measures, a potential inherent bias linked to gender, and the undervaluing of teaching quality or collaborative practices.

An alternative early childhood caries risk surveillance methodology for public policy and practice advancements.

OBJECTIVES: Early childhood caries (ECC) negatively impacts many child health outcomes and can lead to greater costs for medical and dental care as well as negatively impact future oral health wellness. ECC risk factors are rooted in many social determinants of health. Addressing ECC at the population-level is a national public health priority. The purpose of this study was to identify the South Carolina counties with the greatest risk for ECC. As policy-makers seek to address inequities stemming from early childhood caries, documenting its prevalence is essential. METHODS: Since no county level ECC rates were published for South Carolina, we identified an opportunity to strengthen ECC surveillance through public use data, so as to properly equip policy-makers and pediatric providers with an evidence based understanding of the scope of the problem. As a result we sought to develop an overall county level prevalence measure for ECC risk through an ecological analysis of public use data. RESULTS: Ten counties with the greatest overall risk for ECC were all rural as hypothesized. Additionally, seven of the 10 highest risk counties fell into what is often referred to as the "Corridor of Shame." CONCLUSIONS: We have found an affordable way of measuring county level risk for ECC that allows pediatric advocates and policy-makers to develop population level interventions to reduce and measure risk with public-use data.

Elevating Oral Health Interprofessional Practice Among Pediatricians Through a Statewide Quality Improvement Learning Collaborative.

CONTEXT: Because of persistent effects of early childhood caries and impacts of dental health professional shortages areas, the integration of oral health in primary care settings is a public health priority. In this study, we explored oral health interprofessional practice (OHIP) as an integrative pathway to reduce oral health disparities. OHIP can include performing oral health risk assessments, describing the importance of fluoride in the drinking water, implementing fluoride varnish application, and referring patients to a dental home. OBJECTIVE: To conduct a formative evaluation of how 15 pediatric primary care practices implemented the adoption of OHIP in their clinical settings. DESIGN: Using an ecological framework, we conducted a qualitative process evaluation to measure the factors that inhibited and facilitated OHIP adoption into pediatric settings. Document review analysis and qualitative interviews were conducted with pediatric practices to contextualize challenges and facilitators to OHIP adoption. SETTING AND PARTICIPANTS: A total of 15 Children's Health Insurance Program Reauthorization Act pediatric practices located in 13 South Carolina counties participated in this study. MAIN OUTCOME MEASURES: Outcomes of interest were the facilitators and challenges of OHIP adoption into pediatric primary care practices. RESULTS: Thematic analysis revealed challenges for OHIP adoption including limited resources and capacity, role delineation for clinical and administrative staff, communication, and family receptiveness. OHIP training for clinical practitioners and staff and responsiveness from clinical staff and local dentists were facilitators of OHIP adoption. Twelve key recommendations emerged on the basis of participant experiences within OHIP, with developing an active dental referral network and encouraging buy-in from clinical staff for OHIP adoption as primary recommendations. CONCLUSION: We demonstrated the effectiveness of a learning collaborative meeting among pediatric primary care providers to adopt OHIPs. This work reveals an actionable pathway to support oral health equity advancement for children through an additional access point of preventive oral care, reinforcement of positive oral health behaviors, and interaction between parent and child for overall health and wellness of the family.

An Assessment of Participant-Described Interprofessional Oral Health Referral Systems Across Rurality.

PURPOSE: As a means to identify and quantify oral health interprofessional collaborative practice (IPP), we examined participant-described medical-to-dental (M2D) referral networks and how they function across rurality. METHODS: We conducted a cross-sectional survey on the appraisal of IPP referral systems in 2016. Secondarily, we examined if rural health clinics (RHCs) have different experiences with M2D referrals compared to other practice types. Independent variables included geographic and organizational indicators, referral system attributes, and respondent characteristics. Data were coded by Census region and state Medicaid expansion status. Bivariable and multivariable analyses were conducted using SAS. FINDINGS: A convenience cohort (n = 559) from 44 states was examined. Nearly, half (48.7%) reported dependable M2D referral systems. In bivariate analysis, all independent variables were significant except for state Medicaid expansion status. In multivariable analysis, Census region retained significance (P = .0093). Organization type and practice issues with no shows/missed appointments continued to have significance (P < .001 and .002, respectively). Accountable care organizations were over 5 times (5.72, P = .001) more likely than RHCs to report dependable M2D referral systems. Federally qualified health clinics were slightly over 3 times more likely than RHCs to report dependable M2D referral (3.04, P < .001). No differences between RHCs and other private practices were observed. CONCLUSIONS: The importance of IPP continues to be promoted in the current health care environment. Our study demonstrates that, in this motivated study population, M2D referrals can work well, even in rural areas. Organization type, directionality of referral, broken appointment rates, and electronic health information management were all found to significantly impact the respondents' rating on the dependability of an M2D referral process.

Diagnostic and Demographic Differences Between Incarcerated and Nonincarcerated Youth (Ages 6-15) With ADHD in South Carolina.

OBJECTIVE: Analyze diagnostic and demographic factors to identify predictors of delinquency resulting in incarceration within a group of children/adolescents diagnosed with ADHD. METHOD: The study followed a cohort of 15,472 Medicaid covered children/adolescents with ADHD, ages 6 to 15 inclusive, between January 1, 2003, and December 31, 2006. The Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev. [ DSM-IV-TR]), 2000 Codes were used for qualifying diagnosis codes. Available demographic characteristics included race, sex, and residence. The outcome was incarceration at the South Carolina Department of Juvenile Justice during 2005-2006. RESULTS: Among youth with ADHD, incarceration was more likely among black, male, and urban youth. Children/adolescents with comorbid ODD and/or CD were at greater risk compared with those with ADHD alone. CONCLUSION: Within ADHD-diagnosed youth, comorbid conditions and demographic characteristics increase the risk of incarceration. Intervention and treatment strategies that address behavior among youth with these characteristics are needed to reduce incarceration.

Feasibility assessment for using telehealth technology to improve access to dental care for rural and underserved populations.

OBJECTIVE: South Carolina Dental Association members were surveyed on telehealth knowledge, need, and interest in using it for access to care improvements. METHODS: Dependent variables were Medicaid patient population size (less than or greater than 10%), career stage (early to middle and advanced), and National Health Service Corps participation (yes or no). Practice and provider characteristics were screener questions. Data were collected electronically and analyzed with SAS. Descriptive and bivariate analyses were conducted. RESULTS: Most (69.3%) reported some or no teledentistry knowledge. Distribution of needing consults was: endodontics (40.2%), oral-maxillofacial surgery (37.9%), orthodontia (30.7%), periodontics (28.4%), and pediatrics (12.5%). Consultations for diagnosis (72.9%), emergencies (56.7%), and continuing education (53.3%) were most frequently identified telehealth uses. Medicaid patient population size was the only dependent measure with statistical significance. Compared to <10% Medicaid, >10% was more likely to (1) frequently need consults for orthodontics (25.5% vs 43.4%, P = .0043) and pediatrics (5.9% vs 29.0%, P < .0001); (2) use telehealth for children with special health care needs (44.1% vs 65.8%, P = .0017), complex health conditions (54.3% vs 78.1%, P = .0004), conditions exacerbated by unmet dental needs (44.6% vs 65.8%, P = .0022); and (3) use telehealth for extending practice to underserved populations (14.6% vs 33.8%, P = .0004). CONCLUSIONS: Despite need for telehealth knowledge improvement, sufficient interest exists. Further study will determine if demand for teledentistry is in balance with consultant availability. It has been suggested that access to care improvements require capacity expansions in private practices. States will need to engage dental communities determine if teledentistry is an effective solution.

Impact of South Carolina's Medicaid fluoride varnish reimbursement policy on children's receipt of fluoride varnish in medical and dental settings.

OBJECTIVE: We estimated the effect of South Carolina's (SC) Medicaid fluoride varnish (FV) reimbursement policy on children's receipt of fluoride varnish in medical (MFV) and dental (DFV) settings. METHODS: We obtained data from SC Medicaid enrollment and claims files for children ≤ 47 months of age across State Fiscal Years (SFY) 2008-2013 and created a panel dataset of 52,841 children representing 126,464 child-years of observation. Pooled multivariate logistic regression models were estimated to identify factors associated with a higher likelihood of a child receiving one or more MFV or DFV treatments. RESULTS: The FV rates per child-year were 1 percent for physicians and 23 percent for dentists, respectively. The child-year rate for receipt of FV from both a physician and a dentist was less than one-third of one percent. CONCLUSIONS: A policy designed to increase access to FV treatments from physicians and dentists for children up to forty-seven months of age was not successful for physicians; however, the positive findings for dentists were promising.

Analysis of hospital-based emergency department visits for dental caries in the United States in 2008.

OBJECTIVES: Using nationally representative data, we examined differences in dental care utilization in emergency departments (EDs) among working age adults associated with rural residence and lack of health insurance. METHODS: We used data from the 2008 Nationwide Emergency Department Sample, restricted to working age adults (ages 19-64; 16,928,424 observations). The dependent variable was a principal diagnosis of dental caries. The primary independent variable was patient's area of residence, rural versus urban. The control variables were payer, age, gender, median income, region, and admission timing. Logistic regression analysis was performed to determine the association with residence, payer, and other covariates. Multivariate logistic regression models were estimated. RESULTS: In 2008, there were an estimated 74 million ED visits among working adults ages 19-64 in the United States. Dental caries accounted for between 0.2 percent and 1.0 percent of all visits, depending on patient characteristics. Rural patients were significantly more likely than urban patients to have dental visits. Dental visits were more prevalent among patient with government insurance or self -pay relative to the privately insured. CONCLUSIONS: The Affordable Care Act may reduce the proportion of self-pay visits for dental care. Medicaid expansion may not result in improved dental use among Medicaid patients unless dental services are covered and dental practitioners appropriately engaged.

Maternal obesity and gestational weight gain in rural versus urban dwelling women in South Carolina.

PURPOSE: An unhealthy prepregnancy weight and/or gaining an inappropriate amount of weight during pregnancy increase the risk for poor pregnancy and birth outcomes. To our knowledge, no studies to date have examined differences in prepregnancy body mass index (BMI) and gestational weight gain (GWG) patterns by rurality. METHODS: The 2004-2006 South Carolina birth certificate data (n = 132,795) were used. Rurality of residence was determined using Rural-Urban Commuting Area (RUCA) codes. Mothers were categorized as underweight (<18.5 kg/m(2)), normal weight (18.5-24.9), overweight (25.0-29.9), and obese (≥30.0) using their prepregnancy BMI and as having inadequate, adequate, or excessive GWG according to the Institute of Medicine's 2009 GWG guidelines. Chi-square tests and adjusted multinomial logistic regression were used in analysis. FINDINGS: Rural women had higher odds of being overweight and obese compared to urban women. This relationship was found to be partially explained by the higher proportion of minorities living in rural areas. The relationship between GWG and residence type varied by BMI category. Specifically, among normal weight women, rural women had increased odds of inadequate GWG. Among overweight women, rural women had decreased odds of excessive GWG. In obese women, rural women had decreased odds of both inadequate and excessive GWG. CONCLUSIONS: Rural women were more likely to have an unhealthy prepregnancy weight than urban women. However, rural residence was found to be protective against unhealthy GWG in overweight and obese women. Future research exploring reasons for these findings and confirmation of these results in other populations is necessary.

Prediction of unmet primary care needs for the medically vulnerable post-disaster: an interrupted time-series analysis of health system responses.

Disasters serve as shocks and precipitate unanticipated disturbances to the health care system. Public health surveillance is generally focused on monitoring latent health and environmental exposure effects, rather than health system performance in response to these local shocks. The following intervention study sought to determine the long-term effects of the 2005 chlorine spill in Graniteville, South Carolina on primary care access for vulnerable populations. We used an interrupted time-series approach to model monthly visits for Ambulatory Care Sensitive Conditions, an indicator of unmet primary care need, to quantify the impact of the disaster on unmet primary care need in Medicaid beneficiaries. The results showed Medicaid beneficiaries in the directly impacted service area experienced improved access to primary care in the 24 months post-disaster. We provide evidence that a health system serving the medically underserved can prove resilient and display improved adaptive capacity under adverse circumstances (i.e., technological disasters) to ensure access to primary care for vulnerable sub-groups. The results suggests a new application for ambulatory care sensitive conditions as a population-based metric to advance anecdotal evidence of secondary surge and evaluate pre- and post-health system surge capacity following a disaster.

Place of origin and violent disagreement among Asian American families: analysis across five States.

We examined the prevalence of and factors associated with violent and heated disagreements in the Asian American families, with an emphasis on place of birth differences between parent and child. Data were obtained from the 2003 National Survey of Children's Health, limited to five states with the highest concentration of Asian-Americans (n = 793). Multivariable analysis used generalized logistic regression models with a three-level outcome, violent and heated disagreement versus calm discussion. Violent disagreements were reported in 13.7% of Asian-American homes and 9.9% of white homes. Differential parent-child place of birth was associated with increased odds for heated disagreement in Asian-American families. Parenting stress increased the likelihood of violent disagreements in both Asian-American and white families. Asian-American families are not immune to potential family violence. Reducing parenting stress and intervening in culturally appropriate ways to reduce generation differences should be violence prevention priorities.

Relationship between presence of a reported medical home and emergency department use among children with asthma.

This study examined data from the 2005-2006 National Survey of Children with Special Health Care Needs to assess the relationship among children with asthma between a reported medical home and emergency department (ED) use. The authors used 21 questions to measure 6 medical home components: personal doctor/nurse, family-centered, compassionate, culturally effective and comprehensive care, and effective care coordination. Weighted zero-inflated Poisson regression analyses assessed the independent effects of having a medical home on annual number of child ED visits while controlling for child and parental characteristics, and the differential likelihood of securing a medical home. Nearly half (49.9%) of asthmatic children had a medical home. Receiving primary care in a medical home was associated with fewer ED visits (incidence rate ratio = 0.93; 95% confidence interval = 0.89-0.97). A medical home in which physicians and parents share responsibility for ensuring that children have access to needed services may improve child and family outcomes for children with asthma.

Patterns of engagement in care by HIV-infected adults: South Carolina, 2004-2006.

OBJECTIVE: Identify factors associated with HIV care utilization in South Carolina. DESIGN: Cross-sectional analysis of South Carolina nonpregnant HIV-infected individuals (N = 13,042) for the period 1 January 2004 to 31 December 2006. METHODS: Reporting of HIV laboratory markers is legally mandated in South Carolina. Individuals with reported viral load tests or CD4 cell counts during a calendar year were defined as 'in HIV-medical care' that year. Care utilization categories were in care, care all 3 years; not-in-care (NIC), no care received; and transitional care, during some but not all years. Multinomial logistic regression using generalized logits was used to estimate relationships between care utilization and predictor variables. RESULTS: Five thousand, two hundred and seventeen (40.0%) of South Carolina HIV-infected adults were NIC and 3300 (25.3%) were in transitional care during 2004-2006. Although a larger number of black than white HIV-infected adults were NIC, adjusted odds for NIC status were lower among blacks than whites [adjusted odds ratio (AOR), 0.82; 95% confidence interval 0.74, 0.92)]. Women had lower odds of being NIC than men (AOR, 0.66; 95% confidence interval 0.58, 0.74). Compared with individuals 55 years or older, individuals who were 25-34 years old were most likely to demonstrate both the NIC (AOR, 1.85; 95% confidence interval 1.29, 2.65) and transitional (AOR, 1.85; 95% confidence interval 1.31, 2.62) care patterns. CONCLUSION: Large proportions of the South Carolina HIV-infected adult population are not consistently accessing HIV-medical care. Targeted programs are needed to improve engagement for HIV-infected adults most likely to transition or not be in care.