Ryan White CARE Act Title I Dental Impact Evaluation and

Cost Effectiveness

Julia Hidalgo, ScD, MSW, MPH

Amanda Benedict, MAPositive Outcomes, Inc.

Carol M. Stewart, DDS, MSDepartment of Oral and Maxillofacial

Surgery and Diagnostic Sciences

University of Florida College of Dentistry

Stephen Abel, Julia Ali-John, Lidia Alonso, Curtis Barnes, Debbie

Cochrane, Susan Dunmore, William Green, Marlinda Quintana-Jefferson, Sharanda Richardson, James Riley, Sharon Rohoman, Michele Rosiere,

Rita Volpita, Deloris Williams, Perminder Wadhwa, Marisol Hidalgo

Acknowledgements

No Broward County

patients’ or dental

providers’ images were used in this presentation

Project Goals and Objectives Determine the cost effectiveness of Broward County EMA

CARE Act Title I dental servicesCompare Broward Title I with other EMAs to measure dental expenditures, procedures covered, reimbursement rates, and average costs of routine and specialty careDetermine cost and utilization by analyzing FY 2004-2005 claims data

Evaluate the impact of dental services on HIV+ Broward County residents

Use chart review to measure the extent to which standards and outcomes were achievedUse surveys and focus groups to determine client perceived barriers to access and retention in dental careDetermine client perceived barriers accessing general and special dental care

Determine overall effectiveness, as measured by client impact, of dental services

Determine the relationship of cost effectiveness and client outcomes in the EMA

Project Tasks

Identify CARE Act grantees that fund HIV oral health servicesObtain information about their cost-effectiveness studies Identify their best practices regarding delivering and financing HIV oral health

Measure the cost and utilization associated with Broward County Title I-funded HIV clinics

Conduct chart review at Title I-funded HIV clinics to assess the extent to which standards and outcomes were achieved

Determine the relationship between cost-effectiveness and client outcomes associated with Title-I funded HIV clinics

Assess HIV+ Broward County residents’ perceptions of barriers to access and retention in HIV primary and specialty oral health care

Update literature review Cost-effectiveness of HIV oral healthBest practices in delivering and financing HIV oral health services

What are the benefits of oral health treatment for

HIV+ patients?

Importance of HIV Oral Health Care

Conditions such as aphthous ulceration and candidiasis indicate acute seroconversion illness Conditions such as candidiasis, hairy leukoplakia, KS, and necrotizing and ulcerative gingivitis suggest HIV infection in undiagnosed individualsFor those individuals in advancing stages of HIV infection, candidiasis and hairy leukoplakia indicate clinical disease progression and predict development of AIDS Immune suppression in HIV+ individuals is associated with candidiasis, necrotizing periodontal disease, long-standing herpes infection, and major aphthous ulcersPerinatally infected children have a greater rate of caries than their siblings, particularly with advancing HIV disease

Due to the association between HIV infection and oral conditions, CDC and other staging systems for HIV disease progression include oral conditions

Oral conditions are important markers in the clinical spectrum of HIV infection

Importance of HIV Oral Health Care

Oral care early in the course of HIV infection can help to prevent or slow wasting

Access to oral care is important in aiding proper nutrition for HIV+ individuals

With the advent of HAART, the ability to sustain proper nutrition and to swallow medication is critical in achieving the optimal benefit of HAART and adherence to medication regimens

Among the almost oral conditions that can occur in HIV+ individualsAll of the conditions may be seen or palpated during physical examination and produce subjective symptoms that are noticeableMedication is effective in treating many of these conditions

HAART treatment failure can be detected through dental exam HAB considers dental care to be so beneficial to HIV+ individuals that it is

considered a “core service”

Early recognition and management of oral conditions associated with HIV infection are important in sustaining the health and quality of life of HIV+ individuals

Access to HIV Oral Health Services is a National Problem

Oral infections, mouth ulcers, and other severe dental conditions associated with HIV infection are more than twice as likely to go untreated as other HIV-related health problems

Less than one-half (42%) of respondents had seen a dental health professional in the preceding six months

African-Americans, individuals whose exposure to HIV was caused by hemophilia or blood transfusions, persons with less education, and employed individuals were less likely to use dental care than their counterparts

19% of HIV-infected medical patients had perceived unmet need for dental care in the last six months

Despite the importance of access to quality oral care, large numbers of PLWH have an unmet need for HIV oral health care

Data from the longitudinal Health Care Services Utilization Study (HCSUS) initiated in 1996 assessed barriers to accessing dental services

Access to HIV Oral Health Services is a National Problem

65% of respondents with a usual source of dental care had used that service in the preceding six months

Use of dental care was reported to be greatest among patients obtaining dental care from an AIDS clinic (74%) and lowest among individuals with no usual source of dental care (12%)

Medicaid enrollees report significantly more unmet dental need compared with privately insured patients

14% of HIV patients had unmet dental needs in the six months, compared to 9% of the general population

Individuals most likely to have unmet dental needs included Medicaid beneficiaries in states without dental benefits, individuals with no dental insurance, the very poor, and individuals with less than a high school education

What is the HIV oral health funding experience of other CARE Act grantees?

Broward EMA ranks 11th among Title I EMAs in planned FY 2004 total direct service funds allocated to dental services

EMA Total FY 2004Dental $

% Total FY 2004 Direct Service $ to Dental

MAI FY 2004Dental $

% Total FY 2004 MAI $ to Dental

Miami $1,286,359 5.6% $0 0.0%

Washington, DC $1,144,437 5.1% $39,300 3.4%

Chicago $1,040,943 4.5% $0 0.0%

Houston $884,175 5.2% $0 0.0%

Baltimore $858,455 5.1% $0 0.0%

Los Angeles $841,290 2.7% $39,002 4.6%

Atlanta $824,882 4.8% $0 0.0%

New York $802,298 0.8% $222,872 27.8%

San Francisco $726,007 2.6% $0 0.0%

Dallas $700,482 6.0% $0 0.0%

Ft. Lauderdale $658,734 5.2% $0 0.0%

Philadelphia $653,156 3.0% $0 0.0%

San Diego $650,795 7.3% $0 0.0%

Boston $556,619 4.1% $0 0.0%

Phoenix $530,000 8.9% $0 0.0%

Learning From Other CARE Act Grantees

POI contacted by telephone Title I and Title II grantees spending over $500 K in direct service funds for HIV dental services

Asked if they had assessed dental cost-effectiveness, the methods used to pay for dental services, and how services were organized

Similarly, Dental Reimbursement Programs (DRPs) were contacted by email

Published articles and reports were searched HAB dental expert also queried

Learning From Other CARE Act Grantees

No grantees contacted reported conducting cost-effectiveness or cost-benefit studies related to the HIV oral health services they purchased

Several approaches taken by Title I and Title II to purchase dental services

University or community-based dental providers were funded; grantees tend to have a small number of contractorsTend to pay for general dental services, several also purchase special dental servicesStandard dental fee schedule, Medicaid payment rates (with slightly higher payments), negotiated rates, “cost-based” reimbursement, fund FTEsFee schedules variably updated

What is the utilization

experience of Title I-funded HIV

oral health services and

related expenditures?

Title I Funded HIV Dental Clinics

Nova Southeastern University College of Dental Medicine, S University Drive, Ft Lauderdale

Paul Hughes Health Center Dental Clinic, NW 6th Ave, Pompano Beach

Northwest Health Center Dental Clinic, NW 15th Way, Ft Lauderdale

Children’s Diagnostic and Treatment Center Dental Clinic, S Federal Hwy, Ft Lauderdale

South Regional Health Center Dental Clinic, Pembroke Rd, Hollywood

Accessibility of Title I Funded HIV Dental ClinicsGeneral dental clinic

services are geographically accessible

Distributed throughout Broward CountyFor the most part, they are located near major freeways and bus lines

Specialty services are available at Nova or community-based dental specialists

Two of the five clinics are co-located with medical clinics

NOVA is adding a new site co-located at Center One

Dental clinics do not have evening appointments

HIV Dental Clinic Utilization

This represents 25% of the estimated 10,748 HIV+ Broward County residents “in care”

An average of 3.7 regular visits per adult patient (median=3 visits), with total visits ranging from 1 to 31 visits

363 HIV+ Broward County residents received specialty dental services, with an average of one visit per patient

Total visits per patient ranged from 1 to 3 visits Inconsistent data coding and missing data prevented

analysis of differences in use or expenditures by age, gender, race, ethnicity, income, or HIV dental clinic

Data were not transferred from dental records

2,738 HIV+ Broward County adult residents received regular dental visits at Title I-funded BCHD clinics between December 2002 through June 2005

What are the expenditures associated with Title I-funded regular and specialty dental services?

TYPE OF SERVICE

YEAR REGULAR SPECIALTY

2002 $930

2003 $624,803 $79,612

2004 $615,753 $128,013

2005 $237,221 $90,303

Title I paid $128 per regular dental visit during the study period

An average of $526 was spent per patient during the study period (median=$408), with expenditures ranging from $128 to $4,237

An average of $791 was spent per patient (median=$800) for specialty dental services, with expenditures ranging from $42 to $8,050

Payments through June 2005

Utilization patterns among adult BCHD HIV clinics patients reflect availability of other funds to pay for dental services and the impact of expanding dental contractors

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What are HIV+ Broward County

residents’ perceptions of

barriers to access and retention in HIV

general and specialty oral health care?

Consumer feedback is being sought through two methods

A focus group will be convened on February 22nd at 6 pm at BRHPC

HIV+ consumers receiving dental service purchased by Title I, dental insurance, or other mechanisms are encouraged to participateRefreshments and compensation will be providedCall Michelle Smith to sign up for the group

A survey is being conducted via Internet, paper survey, POI interview, or case manager-assisted survey

Focus Group Questions

What barriers do HIV infected Broward County residents experience in getting dental care from community dentists? Nova Dental School? County-operated dental clinics?

To what extent does the cost of dental insurance act as a barrier to HIV infected Broward County residents?

To what extent do out of pocket payments for dental care act as a barrier to HIV infected Broward County residents?

How can access to HIV dental care in Broward County be improved? What is the perception of HIV infected Broward County residents

about the quality of dental care they receive? In what ways can the quality of HIV dental care in Broward County be

improved?

Why is dental care important to HIV infected Broward County residents?

To what extent are community dentists in Broward County willing to treat HIV infected adults? Children?

Survey Design

Flyers were posted at all Broward County HIV counseling and testing, treatment, case management, and support programs

1,000 individual postcards about the survey are being distributed at these sites

The Planning Council and Committees were notified about the survey

The Case Management Network was notified about the survey

The survey’s design is based on HCSUS, a federally-funded nationally representative survey of HIV+ adults initiated in 1996

National results are available to serve as benchmark data via special analysis being conducted by federal researchers

Surveys may be completed via Internet, by telephone, via case managers’ assistance, or by paper survey

12 surveys had been submitted by February 10th

A convenience sample of HIV+ Broward County residents is being used due to absence of systematic gathered data to identifying survey subjects

What is the quality of

dental services

provided by Broward

County Title I-funded dental

clinics?

Chart Review Process POI entered into a Business Associates

Agreement to be allowed to do chart review The dental standards were reviewed to

design the chart review form; with additional items added by Dr. Stewart, the project’s dental consultant

Study period: March 2004 – February 2005

Reviews were conducted at three of the four BCHD HIV dental clinics: Paul Hughes HC, Northwest HC, South Regional HC

Charts were not reviewed at CDTC (only 12 patients in the study period) or Nova (not contracted during the study period)

CHD staff created a data file containing records for 1,628 dental patients served in the study period

A random sample of the records was created to assist chart pull by BCHD dental records staff; the first 45 charts on each clinic’s random sample list

Chart Review Process

15 additional charts were randomly selected in case charts were unavailable or the patient was treated outside the study period

Dr. Stewart and Dr. Hidalgo reviewed 92 chartsData were entered into an entry screen from the chartSPSS was used to analyze the chart dataA draft report was prepared, with clinic-specific

findings notedThe report findings were reviewed with BCHD staff;

with Dr. Stewart providing peer TAThe final report provided summary findings, with

blinded results for the three individual clinics

A target of 30 randomly selected charts was set per clinic to ensure statistically significant, generalizable results

Chart Review Items Intake form complete?

Name, SSN, address, birth date, gender, race/ethnicity

Primary care MD’s name and contact information complete?

HIV+ status, income, and Broward County residency documented?

Emergency contact identified? Signed consent for treatment? Patient’s Rights Statement received

and HIPAA compliance documented? Signed releases for all referrals made

and all disclosures of confidential patient information to a third party?

Progress notes are current, legible, signed, and dated?

Chart organized and orderly? Progress notes address treatment

plan goals? Treatment plan, contains measurable goals, objectives, and time frames for achievement?

Treatment plan complies with treatment guidelines?

Is patient’s medical history recorded and updated at least every six months?

Allergies, special conditions, current meds, CD4+ value, white blood cell count, platelet count, hepatitis C status, TB status, medical clearance for treatment?

Patient referred to specialist documented?

Documentation of OI exam, soft tissue exam, head and neck exam, gingival and periodontal structure, hard tissue?

Patient received preventive education on oral techniques and self-care?

If appropriate, patient received nutrition counseling and tobacco cessation counseling?

Chart Review Items Preventive fluoride program, if appropriate? Is patient’s oral hygiene level noted? Frequency of follow-up visits documented in the treatment

plan? Was the dental note written?

Within 24 hours of the visit? Within 48 hours of the visit?No documentation?

All dental notes appropriately signed? Patients with more than one visit have a dental treatment

plan recorded in the dental record? Patient will complete their initial treatment plan (Phase I)

within six months? Discharge date and discharge plan follow-up or discharge

summary? Procedures performed (surgical or routine extraction)? X-ray of diagnostic quality? Any complications?

Chart Review Findings: Considerations for Dental Record Staff

Most dental charts recorded patient identifying informationAll dental charts recorded patient name, Social Security number, address, telephone number, and birth date

Primary care MD’s contact information was recorded in 85% of charts

Documentation of income and Broward County residency was included in almost all charts

Case management referral forms tended to be the source of dental clinic referrals; these forms were not updated

Referral forms were not completed uniformly by the referring case managerCheck off items, such as receipt of a signed release of patient information, were not completed uniformlyNo updated case management referral forms were included in patient charts, including patients served for several years

12% of patients did not have emergency contact information listed in their files

Most dental charts contained all of the relevant legal forms

Chart Review Findings: Considerations for Dental Personnel

Allergy information was noted in almost all charts, special conditions were noted for 67% of patients, and current medications were listed for 82% of patients52% of dental charts included documentation of patients’ CD4+ valuesSome charts contained CD4+ counts that were obtained one to two years before the review periodOnly 11% of dental charts included documentation of Hepatitis C status; a question regarding Hepatitis C was not included on the medical history form Platelet and white blood cell count and TB infection status were in almost all charts, as was medical clearance for dental treatment

All reviewed charts documented a treatment plan with measurable goals, objectives, and a timeframe for completion

Medical history was recorded and updated at six month intervals for almost all patients

Chart Review Findings: Considerations for Dental Personnel

All treatment plans complied with published treatment guidelines

Almost all progress notes addressed the treatment plan goals

Less than one-half (44%) of all treatment plans’ progress notes met one or more of the “current, legible, signed, and dated” criteria

Almost all charts documented OI exams, soft tissue exams, head and neck exams, gingival and periodontal structure exams, and hard tissue exams

Of the 21 patients who were referred to a specialist, 71% had referral follow-ups documented in their files

Chart Review Findings: Considerations for Dental Personnel

The dental hygienist seemed very conscientious in providing debridements, appropriately recording the patient’s level of home care, and consistently recording oral hygiene instruction provided to patients

The treatment plan contained documentation of the frequency of follow-up visits for almost all patients

Dental notes were written and included in all dental charts, and were written within 24 hours of the visit

However, complete signatures were not present on all dental notes; 78% of dental notes were only initialed

Almost all patients had more than one visit and had a treatment plan noted in their dental records

77% of patients will have completed their initial treatment plan (Phase I) within six months

Nearly two-thirds (65%) of patients’ care ceased without formal discharge from care

Patients tended to fail to return for care and no follow-up inquiry was apparent

The level of oral hygiene was noted for most patients

X-rays of diagnostic quality were present in 84% of dental charts No treatment-related complications were reported for any of the

charts reviewed Preventive education on oral techniques and self-care was

administered to 91% of patientsInquiry about tobacco use was not included on the medical history form; very low percentages of patients received tobacco cessation counseling (7%) Nutrition counseling did not appear to be a standard practice and was not noted for any patients

Chart Review Findings: Considerations for Dental Personnel

Extractions were noted in more than one-third (35%) of charts, with 31% of these patients (10 patients) having surgical extractions and 75% having routine extractions performed

How do the chart review findings compared to Title I standards?

Category Outcome Indicator Chart Review Finding

Morbidity Patients receive preventive care

90% of patients are assessed for opportunistic infections

98.9%

90% of patients receive soft tissue exam, including perioral tissue and oral mucosa

98.9%

90% of patients receive exam of the gingival and periodontal structures

96.7%

90% of patients receive preventive education on oral techniques and self care

91.1%

Treatment adherence

Patients complete treatment

90% of patients with more than one visit will have a dental treatment plan recorded in the dental record

95.7%

70% of patients examined will have completed their initial treatment plan within six months

77.2%

How do the chart review findings compared to Title I standards?

Category Indicator Chart Review Finding

Provider completes a medical/dental history form in initial visit

100% of patient charts show complete medical/dental history

95.7%(medical)

Treatment plan is developed based on the initial comprehensive exam

100% of patients’ chart have a treatment plan

100%

Patient treatment plan is reviewed and updated as necessary by the dental provider

100% of patients’ charts show review, as needed

96.7%

Patients are referred to specialty care in accordance with the patients’ needs and treatment plan

100% of patients’ charts show referral to specialty care for clients needing this service

100%

Patients referred to specialty services are followed-up

100% of patients’ charts have documentation of referral follow-up

71.4%

Recommendations

Blood pressure readings should be a part of the baseline medical history and should be added to the intake process

The accepted standard of care in dentistry is to take the patient’s blood pressure at the initial appointment and at subsequent appointmentsThis procedure can be done by a trained auxiliaryIt is especially important before any procedures that utilize local anesthetic, such as restorative, surgical, and some periodontal procedures

Tobacco cessation and nutritional counselingThe medical history should be modified to include those items

The medical clearance form should include CD4+ count, along with blood values for platelets, white blood cell count, and TB

Revise the patient intake form The conceptual approach to the treatment plan

and progress notes should be revised to better capture temporal flow

Record current or a past history of hepatitis C and current or past history of hepatitis B infection

Recommendations

Although the charts reviewed documented that a gingival and periodontal exam were completed, evidence of the results of that exam was difficult to confirm

Infrequently a periodontal screening exam (PSR), or a periodontal charting was found regarding attachment loss or periodontal pockets, bleeding upon probing, or tooth mobilityA periodontal diagnosis determined by the dentist, needed to support the periodontal therapy provided, was not found readily in the charts

A review of the medical history immediately before a dental extraction is important to help avoid undesirable outcomes such as drug interactions, prolonged bleeding, delayed healing, or infections Such a review was recorded infrequently in

the treatment or progress notes associated with dental extractions

Recommendations

Consequently, it is very important for the dental team to suggest ways to improve oral comfort through strategies to improve salivary flow such as sugar free gums, lozenges, and fluids

Efforts to minimize the patient’s susceptibility to dental decay are also important

The dental team should encourage patients to use a fluoride regimen appropriate for the particular individualThis might include an over-the-counter alcohol-free fluoride rinse, fluoride home treatments, or prescription fluoride gels

Documentation of these issues was absent from most charts. If these concerns were discussed with patients, a chart entry would be appropriate

The majority of HIV seropositive patients report discomfort from xerostomia (i.e., “dry mouth”)

This is a condition makes chewing, swallowing, and speaking more difficult, putting HIV seropositive patients at much higher risk for dental decay

Are dental services

purchased with Broward

County Title I funds cost-effective?

What are HAB’s expectations regarding cost-effectiveness?

Title I grantees should be able to compare the relative costs of providing a specific service among different providers

This necessitates having service standards, service units, and unit costs for each serviceQuality of service is also a factor in determining cost effectiveness and needs to be considered both in selecting providers and in monitoring Quality Management programs

Planning councils need cost-effectiveness data to determine how to prioritize services and allocate funds

This is closely tied to outcomes evaluation in that services with better outcomes may be more costly but nonetheless more cost effective when outcomes are consideredAlso important to consider is the way services are provided

For example, bus passes may be cheaper but not as effective in assuring access and maintenance in care as taxi vouchers

Ryan White CARE Act Title I Manual

What are outcomes?Outcomes are benefits or results

(positive or negative) for clients that may occur during or after program participation

Outcomes can be classified as initial, intermediate, and longer-term based on how soon they occur after program participation begins

Ryan White CARE Act Title I Manual

Using HAB’s framework, what is known and unknown about the cost-effectiveness of Title I- funded HIV oral health services?

TASK* RESULTDefine and describe the service to be assessed

Regular dental visit defined by Oral Health Service Delivery Model: Diagnostic, prophylactic, and therapeutic services rendered by dentists, dental hygienists, and similar professional practitioners

Agree on the standards of care or benchmarks related to service outcomes

Standards of care defined by Oral Health Service Delivery Model

Determine the unit or per-client costs of these services

The cost of a dental visit is set as $128 per general dental visit

Determine the outcomes of the service Short-term outcomes associated directly with Broward Title-I funded dental services have been achieved.

Describe the cost effectiveness of the service in terms of a ratio of cost to attain a specific outcome (e.g., it costs an average of $846 in case management funds to ensure that a client has obtained access to specified core services)

It costs $128 in Title I oral health funds to ensure that a patient receives preventive oral health care and completes treatment

** Ryan White CARE Act Title I Manual

What is cost-effectiveness analysis (CEA)?CEA compares the relative value of current versus

new strategiesCommonly in CEA, a new strategy is compared with

current practice (the "low-cost alternative") to calculate a math term, the cost-effectiveness (CE) ratio:

The result is the "price" of the additional outcome purchased by switching from current practice to the new strategy (e.g., $10,000 per life year). If the price is low enough, the new strategy is considered "cost-effective"

How should we interpret the results of cost-effectiveness analysis (CEA)?

CEA is only relevant to certain decisionsCEA is relevant only if a new strategy is both more effective and more costly (or both less effective and less costly)

If a strategy is cost-effective, the new strategy is a good value.

It does not mean that the strategy saves money

Just because a strategy saves money does not mean that it is cost-effective

The concept of cost-effective requires a value judgment—what you think is a good price for an additional outcome, someone else may not

Applying CEA to the Broward County Title I deliberations regarding purchasing of dental services

From a CEA perspective, POI considered whether the general and specialty dental services are effective versus other dental services

No other dental treatment modalities can be substituted for the service now provided (i.e., there is no “new” service to substitute for current dental practice)

This is similarly the case for the specialty services purchased

Alternatively, non-dental services might be substituted instead to address other clinical and psychosocial service needs of patients

These services cannot address the oral health needs of Broward County HIV+ indigent residents

Are dental services

purchased with Broward County Title I funds cost-

beneficial?

What is cost-benefit analysis? A systematic quantitative method of

assessing the desirability of programs or policies when it is important to take a long view of future effects and a broad view of possible side effects

Used to assess the costs versus the benefits of a specific service or set of servicesA systematic quantitative method of assessing the desirability of programs or policies when it is important to take a long view of future effects and a broad view of possible side effectsUsed to assess the costs versus the benefits of a specific service or set of servicesAllows policymakers and other stakeholders to weigh the benefits versus the costs of various policy alternatives and identify the trade-offs involved in funding one policy versus anotherMay express the point of view of a health care consumer, purchaser of services (e.g., employer, health insurance plan, BCHSD SAHCSD), service provider, or societyMay be helpful to gaining an understanding of the personal, fiscal, health care system, and societal impact of purchasing new services or redistributing funds from existing services

Cost-Benefit Assessment: Key Concepts

CostsDirect costs: expenses associated with paying for a service (e.g., regular dental visits)Indirect costs: the cost not directly attributable to the manufacturing of a product Opportunity costs: the cost of passing up the next best choice when making a decision (e.g., the cost of purchasing dental services versus another service category

Benefits The directly measured dollar value of the tangible benefits of goods or servicesIndirectly measured dollar value of the tangible benefits of good or servicesIndirect benefits for which dollar value are not directly measurable

Indirect benefits of oral health services Detection of HIV infection

associated with HIV infection Reduce the presence of bacteria,

thus reducing strain on the immune system

Dental exams can assist HIV medical management

Detection of oral OIs and other conditions may point to HIV disease progression HIV dental exams can be used to detection OIs associated with failure of HAART or lack of adherence to HAARTReduction of systemic infectionspatientIdentification of salivary gland disease and oral warts associated with HIV infection Treat dry mouth associated with antiretrovirals

Treat conditions that exacerbate wasting

Ensure that medication can be swallowed

Treat conditions that inhibit swallowing, chewing of food, and speaking

Reduction or elimination of head and neck pain

Reduce or delay disability Improve quality of life

What are the outcomes

associated with dental services purchased with Broward County

Title I funds?

Measuring HIV Oral Health Outcomes in Broward County

Improved quality of lifeClients are made aware of the benefits of

participating in care by an oral health providerReduced incidence of oral opportunistic

infectionsSlow periodontal disease progressionHealthier teeth and gums

Outcome measures to be implemented in March 2006

Challenges Likely to be Encountered in Measuring HIV Oral Health Outcomes in Broward County

How will changes in quality of life be assessed, particularly those changes directly associated with oral health treatment? There is no systematic assessment of the baseline rates of oral OIs, periodontal disease, or the health or teeth or gums

among HIV+ individuals treated in the Title-I funded systemImprovement relative to what?

Inability to measure dental services outside of Title I-funded system that may contribute to positive or negative outcomes Must accurately measure inpatient stays and count ambulatory care visits for which oral health care was provided There is significant missing data regarding demographic, clinical, smoking history, economic, health insurance, and other

characteristics associated with oral health outcomes Are you measuring actual outcomes or the quality of charting by dental and other clinical personnel?

Outcomes measurement requires planning for detailed baseline and longitudinal data collection

No baseline assessment of quality of life undertaken at initiation of dental treatment

Challenges Likely to be Encountered in Measuring HIV Oral Health Outcomes in Broward County

How will the contribution of individual dental providers treating a patient over time be taken into consideration in assessing long term outcomes?

For example, how will differences in HIV training or supervision be accounted for? Will the role of medical providers in treating oral OIs and educating patients about the

importance of dental care be assessed? How will the contribution of patients to their self care be assessed at baseline and over

time?What about factors such as attitudes towards dental care, pain phobia, health literacy, and beliefs about the benefits of dental preventive services be taken into consideration?

In measuring pediatric oral health outcomes, how will the role of parents or guardians be taken into consideration?

It is unclear if longitudinal clinical data can be gathered routinely, inexpensively, and accurately (e.g., PCIS)?

If not, chart review may add additional expense

Final Report A summary of the focus

group discussion will be provided

A summary of the results of the survey will be included

The final report recommends additional approaches to organizing and financing HIV oral health services in Broward County