oral health (dental) pg - homepage for harris county, … oral health.pdforal health (dental) pg ......

J:\Committees\Quality Assurance\FY16 How To Best\Workgroups\Workgroup 2\TOC - WG2.doc

Oral Health (Dental) Pg

Service Category Definition - Part B Untargeted 1

Service Category Definition - Part A Targeted to Rural (North)

5

Oral Health Care Chart Review - The Resource Group, 2014 8

Dental Care Chart Review - RWGA, December 2014 15

Retention of People Living with HIV/AIDS in Oral Health Care - Public Health Reports, 2012 Supplement 2, Volume 127

23

Increasing Access to Oral Health Care for People Living with HIV/AIDS in the U.S.: Baseline Evaluation Results of the Innovations in Oral Health Care Initiative - Public Health Reports, 2012 Supplement 2, Volume 127

33

Local Service Category: Oral Health Care Amount Available: To be determined Unit Cost: Budget Requirements or Restrictions (TRG Only):

Maximum of 10% of budget for Administrative Costs

Local Service Category Definition: Restorative dental services, oral surgery, root canal therapy, fixed and removable prosthodontics; periodontal services includes subgingival scaling, gingival curettage, osseous surgery, gingivectomy, provisional splinting, laser procedures and maintenance. Oral medication (including pain control) for HIV patients 15 years old or older must be based on a comprehensive individual treatment plan. Prosthodontics services to HIV infected individuals including but not limited to examinations and diagnosis of need for dentures, crowns, bridgework and implants, diagnostic measurements, laboratory services, tooth extraction, relines and denture repairs. Emergency procedures will be treated on a walk-in basis as availability and funding allows. Funded Oral Health Care providers are permitted to provide necessary emergency care regardless of a client’s annual benefit balance. If a provider cannot provide adequate services for emergency care, the patient should be referred to a hospital emergency room.

Target Population (age, gender, geographic, race, ethnicity, etc.):

HIV/AIDS infected individuals residing within the Houston HIV Service Delivery Area (HSDA).

Services to be Provided: Services must include, but are not limited to: individual comprehensive treatment plan; diagnosis and treatment of HIV-related oral pathology, including oral Kaposi’s Sarcoma, CMV ulceration, hairy leukoplakia, xerostomia, lichen planus, aphthous ulcers and herpetic lesions; diffuse infiltrative lymphocytosis; standard preventive procedures, including oral hygiene instruction, diet counseling and home care program; oral prophylaxis; restorative care; oral surgery including dental implants; root canal therapy; fixed and removable prosthodontics including crowns and bridges; periodontal services, including subgingival scaling, gingival curettage, osseous surgery, gingivectomy, provisional splinting, laser procedures and maintenance. Proposer must have mechanism in place to provide oral pain medication as prescribed for clients by the dentist. Limitations: • Cosmetic dentistry for cosmetic purposes only is prohibited. • Maximum amount that may be funded by Ryan White/State Services per

patient is $3,000/year. • In cases of emergency, the maximum amount may exceed the above

cap • In cases where there is extensive care needed once the procedure has

begun, the maximum amount may exceed the above cap. • Dental providers must document via approved waiver the reason for

exceeding the yearly maximum amount. Service Unit Definition(s) (TRG Only):

General Dentistry: A unit of service is defined as one (1) dental visit which includes restorative dental services, oral surgery, root canal therapy, fixed and removable prosthodontics; periodontal services includes subgingival scaling, gingival curettage, osseous surgery, gingivectomy, provisional splinting, laser procedures and maintenance. Oral medication (including pain control) for HIV patients 15 years old or older must be based on a comprehensive individual treatment plan.

Page 1 of 44

Prosthodontics: A unit of services is defined as one (1) Prosthodontics visit.

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Financial Eligibility: Income at or below 300% Federal Poverty Guidelines. Maximum amount that

may be funded by Ryan White/State Services per patient is $3,000/year. Client Eligibility: HIV positive; Adult resident of Houston HSDA Agency Requirements (TRG Only): To ensure that Ryan White is payer of last resort, Agency and/or dental

providers (clinicians) must be Medicaid certified and enrolled in all Dental Plans offered to Texas STAR+PLUS eligible clients in the Houston EMA/HSDA. Agency/providers must ensure Medicaid certification and billing capability for STAR+PLUS eligible patients remains current throughout the contract term. Agency must document that the primary patient care dentist has 2 years prior experience treating HIV disease and/or on-going HIV educational programs that are documented in personnel files and updated regularly. Dental facility and appropriate dental staff must maintain Texas licensure/certification and follow all applicable OSHA requirements for patient management and laboratory protocol.

Staff Requirements: State of Texas dental license; licensed dental hygienist and state radiology certification for dental assistants.

Special Requirements (TRG Only): Must comply with the Houston EMA/HSDA Standards of Care. Must Comply with applicable DSHS Standards of Care.

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FY 2016 RWPC “How to Best Meet the Need” Decision Process

Step in Process: Council Date: 06/11/2015

Recommendations: Approved: Y:_____ No: ______ Approved With Changes:______

If approved with changes list changes below:

1.

2.

3.

Step in Process: Steering Committee Date: 06/07/2015



1.

2.

3.

Step in Process: Quality Assurance Committee Date: 05/21/2015



1.

2.

3.

Step in Process: HTBMTN Workgroup #2 Date: 04/14/2015

Recommendations: Financial Eligibility:

1.

2.

3.

Page 4 of 44

FY 2015 Houston EMA/HSDA Ryan White Part A/MAI Service Definition Oral Health/Rural

(Revision Date: 06/03/14) HRSA Service Category Title: RWGA Only

Oral Health

Local Service Category Title:

Oral Health – Rural (North)

Budget Type: RWGA Only

Unit Cost

Budget Requirements or Restrictions: RWGA Only

Not Applicable

HRSA Service Category Definition: RWGA Only

Oral health care includes diagnostic, preventive, and therapeutic services provided by general dental practitioners, dental specialists, dental hygienists and auxiliaries, and other trained primary care providers.

Local Service Category Definition:

Restorative dental services, oral surgery, root canal therapy, fixed and removable prosthodontics; periodontal services includes subgingival scaling, gingival curettage, osseous surgery, gingivectomy, provisional splinting, laser procedures and maintenance. Oral medication (including pain control) for HIV patients 15 years old or older must be based on a comprehensive individual treatment plan. Prosthodontics services to HIV-infected individuals including, but not limited to examinations and diagnosis of need for dentures, diagnostic measurements, laboratory services, tooth extractions, relines and denture repairs.

Target Population (age, gender, geographic, race, ethnicity, etc.):

HIV/AIDS infected individuals residing in Houston Eligible Metropolitan Area (EMA) or Health Service Delivery Area (HSDA) counties other than Harris County. Comprehensive Oral Health services targeted to individuals residing in the northern counties of the EMA/HSDA, including Waller, Walker, Montgomery, Austin, Chambers and Liberty Counties.

Services to be Provided: Services must include, but are not limited to: individual comprehensive treatment plan; diagnosis and treatment of HIV-related oral pathology, including oral Kaposi’s Sarcoma, CMV ulceration, hairy leukoplakia, xerostomia, lichen planus, aphthous ulcers and herpetic lesions; diffuse infiltrative lymphocytosis; standard preventive procedures, including oral hygiene instruction, diet counseling and home care program; oral prophylaxis; restorative care; oral surgery including dental implants; root canal therapy; fixed and removable prosthodontics including crowns, bridges and implants; periodontal services, including subgingival scaling, gingival curettage, osseous surgery, gingivectomy, provisional splinting, laser procedures and maintenance. Proposer must have mechanism in place to provide oral pain medication as prescribed for clients by the dentist.

Service Unit Definition(s): RWGA Only

General Dentistry: A unit of service is defined as one (1) dental visit which includes restorative dental services, oral surgery, root

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canal therapy, fixed and removable prosthodontics; periodontal services includes subgingival scaling, gingival curettage, osseous surgery, gingivectomy, provisional splinting, laser procedures and maintenance. Oral medication (including pain control) for HIV patients 15 years old or older must be based on a comprehensive individual treatment plan. Prosthodontics: A unit of services is defined as one (1) Prosthodontics visit.

Financial Eligibility: Refer to the RWPC’s approved Financial Eligibility for Houston EMA/HSDA Services.

Client Eligibility: HIV-infected adults residing in the rural area of Houston EMA/HSDA meeting financial eligibility criteria.

Agency Requirements:

Agency must document that the primary patient care dentist has 2 years prior experience treating HIV disease and/or on-going HIV educational programs that are documented in personnel files and updated regularly. Service delivery site must be located in one of the northern counties of the EMA/HSDA area: Waller, Walker, Montgomery, Austin, Chambers or Liberty Counties

Staff Requirements: State of Texas dental license; licensed dental hygienist and state radiology certification for dental assistants.

Special Requirements: RWGA Only

Agency and/or dental providers (clinicians) must be Medicaid certified and enrolled in all Dental Plans offered to Texas STAR+PLUS eligible clients in the Houston EMA/HSDA. Agency/providers must ensure Medicaid certification and billing capability for STAR+PLUS eligible patients remains current throughout the contract term. Must comply with the joint Part A/B standards of care where applicable.

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FY 2016 RWPC “How to Best Meet the Need” Decision Process Step in Process: Council

Date: 06/11/2015 Recommendations: Approved: Y:_____ No: ______

Approved With Changes:______ If approved with changes list changes below:

1.

2.

3.

Step in Process: Steering Committee Date: 06/07/2015



1.

2.

3.

Step in Process: Quality Assurance Committee Date: 05/21/2015



1.

2.

3.

Step in Process: HTBMTN Workgroup Date: 04/14/2015

Recommendations: Financial Eligibility:

1.

2.

3.

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ORAL HEALTH CARE SERVICES

2014 CHART REVIEW

Page 8 of 44

2014 SERVICE CATEGORY OVERVIEW

Oral Health Care Services

2014 data shows a continuation of excellent overall oral healthcare. Six (6) data elements reviewed

were 100%. Health history and updates were appropriate and timely. Allergies and medication

sensitivities were well documented. Clinical oral care was excellent; vital signs, medication review,

intraoral exams, and tooth chart documentation was completed on all charts reviewed.

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PREFACE

DSHS Monitoring Requirements

The Texas Department of State Health Services (DSHS) contracts with The Houston Regional

HIV/AIDS Resource Group, Inc. (TRG) to ensure that Ryan White Part B and State of Texas

HIV Services funding is utilized to provide in accordance to negotiated Priorities and Allocations

for the designated Health Service Delivery Area (HSDA). In Houston, the HDSA is a ten-county

area including the following counties: Austin, Chambers, Colorado, Fort Bend, Harris, Liberty,

Montgomery, Walker, Waller, and Wharton. As part of its General Provisions for Grant

Agreements, DSHS also requires that TRG ensures that all Subgrantees comply with statutes and

rules, perform client financial assessments, and delivery service in a manner consistent with

established protocols and standards.

As part of those requirements, TRG is required to perform annual quality compliance reviews on

all Subgrantees. Quality Compliance Reviews focus on issues of administrative, clinical,

consumer involvement, data management, fiscal, programmatic and quality management nature.

Administrative review examines Subgrantee operating systems including, but not limited to, non-

discrimination, personnel management and Board of Directors. Clinical review includes review

of clinical service provision in the framework of established protocols, procedures, standards and

guidelines. Consumer involvement review examines the Subgrantee’s frame work for gather

client feedback and resolving client problems. Data management review examines the

Subgrantee’s collection of required data elements, service encounter data, and supporting

documentation. Fiscal review examines the documentation to support billed units as well as the

Subgrantee’s fiscal management and control systems. Programmatic review examines non-

clinical service provision in the framework of established protocols, procedures, standards and

guidelines. Quality management review ensures that each Subgrantee has systems in place to

address the mandate for a continuous quality management program.

QM Component of Monitoring

As a result of quality compliance reviews, the Subgrantee receives a list of findings that must be

address. The Subgrantee is required to submit an improvement plan to bring the area of the

finding into compliance. This plan is monitored as part of the Subgrantee’s overall quality

management monitoring. Additional follow-up reviews may occur (depending on the nature of

the finding) to ensure that the improvement plan is being effectively implemented.

Scope of Funding

TRG contracts with two Subgrantees to provide oral health care services in the Houston HSDA.

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INTRODUCTION

Description of Service

Prosthodontics services to HIV infected individuals including but not limited to examinations

and diagnosis of need for dentures, crowns, bridgework and implants, diagnostic measurements,

laboratory services, tooth extraction, relines and denture repairs.

Tool Development

The TRG Oral Healthcare Review tool is based upon the established local and DSHS standards

of care.

Chart Review Process

All charts were reviewed by Bachelors-degree registered nurse experienced in treatment,

management, and clinical operations in HIV of over 10 years. The collected data for each site

was recorded directly into a preformatted computerized database. The data collected during this

process is to be used for service improvement.

File Sample Selection Process

File sample was selected from a provider population of 3,246 who accessed oral healthcare

services in the measurement year. The records of 301 clients were reviewed, representing 9% of

the unduplicated population. The demographic makeup of the provider was used as a key to file

sample pull.

Report Structure

A categorical reporting structure was used. The report is as follows:

Health History

Allergies and Drug Sensitivities

Vital signs assessment and documentation

Medication Review

PCP Contact Information

Up to Date Clinical Tooth Chart

Intraoral Exam and Progress Notes

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RESULTS OF REVIEW

HEALTH HISTORY

Percentage of HIV-positive client records that had client initial health history

Yes No N/A

Number of client records that showed

evidence of a client initial health history.

300 1 -

Number of HIV-infected clients in oral

health services that were reviewed.

301 301 -

Rate 100.0% 0.0% -

HEALTH HISTORY UPDATE

Percentage of HIV-positive client records that had client health history updated in the past 12

months.

Yes No N/A


evidence of a client health history updated

every 6 months.

279 2 -


health services that were reviewed that had

over 6 months of oral care.

281 281 -

Rate 99.3% .7% -

ALLERGIES AND DRUG SENSATIVITIES

Percentage of HIV-positive client records that had allergies and drug sensitivities documented.

Yes No N/A


evidence of a client’s allergies and drug

sensitivities.

301 0 -



301 301 -

Rate 100.0% 0.0% -

VITAL SIGNS ASSESSMENT

Percentage of HIV-positive client records that showed vital signs assessed at every visit

Yes No N/A


evidence of vital signs assessment at every

visit.

301 0 -



301 301 -

Rate 100.0% 0.0% -

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MEDICATION REVIEW

Percentage of HIV-positive client records that had HIV and NON-HIV medication documented

Yes No N/A


evidence of client medication

documentation.

301 0 -



301 301 -

Rate 100.0% 0.0% -

PCP CONTACT INFORMATION

Percentage of HIV-positive client records that had client PCP contact information

Yes No N/A


evidence of client PCP contact information.

301 0 -



301 301 -

Rate 100.0% 0.0% -

CLINICAL TOOTH CHART

Percentage of HIV-positive client records that had a clinical tooth chart marked and up to date

Yes No N/A


evidence of a client clinical tooth chart

marked and up to date.

301 0 -



301 301 -

Rate 100.0% 0.0% -

HARD AND SOFT TISSUE EXAM

Percentage of HIV-positive client records that had a hard and soft tissue exam in the last 12

months

Yes No N/A


evidence of an intraoral exam.

297 4 -



301 301 -

Rate 98.0% 2.0% -

ORAL HEALTH EDUCATION Percentage of HIV-positive clients who have received oral health education within the past 12

months

Yes No N/A


evidence of an intraoral exam.

296 5 -

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301 301 -

Rate 98% 2% -

CONCLUSION

2014 data shows a continuation of excellent overall oral healthcare. Six (6) data elements

reviewed were 100%. Health history and updates were appropriate and timely. Allergies and

medication sensitivities were well documented. Clinical oral care was excellent; vital signs,

medication review, intraoral exams, and tooth chart documentation was completed on all charts

reviewed.

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1

Ryan White Part A Quality Management Program–Houston EMA

Oral Health Care-Rural Target Chart Review

FY 2013

Prepared by Harris County Public Health & Environmental Services – Ryan White Grant Administration

December 2014

CONTACT: Heather Keizman Project Coordinator–Clinical Quality Improvement Harris County Public Health & Environmental Services Ryan White Grant Administration 2223 West Loop South, RM 431 Houston, TX 77027 713-439-6037 [email protected]

Page 15 of 44

mailto:[email protected]

2

Introduction Part A funds of the Ryan White Care Act are administered in the Houston Eligible Metropolitan Area (EMA) by the Ryan White Grant Administration Section of Harris County Public Health & Environmental Services. During FY 13, a comprehensive review of client dental records was conducted for services provided between 3/1/13 to 2/28/14. This review included one provider of Adult Oral Health Care that received Part A funding for rural-targeted Oral Health Care in the Houston EMA. The primary purpose of this annual review process is to assess Part A oral health care provided to persons living with HIV in the Houston EMA. Unlike primary care, there are no federal guidelines published by the U.S Health and Human Services Department for oral health care targeting individuals with HIV/AIDS. Therefore, Ryan White Grant Administration has adopted general guidelines from peer-reviewed literature that address oral health care for the HIV/AIDS population, as well as literature published by national dental organizations such as the American Dental Association and the Academy of General Dentistry, to measure the quality of Part A funded oral health care. The Ryan White Grant Administration Project Coordinator for Clinical Quality Improvement (PC/CQI) performed the chart review. Scope of This Report This report provides background on the project, supplemental information on the design of the data collection tool, and presents the pertinent findings of the FY 13 oral health care chart review. Any additional data analysis of items or information not included in this report can likely be provided after a request is submitted to Ryan White Grant Administration. The Data Collection Tool The data collection tool employed in the review was developed through a period of in-depth research and a series of working meetings between Ryan White Grant Administration. By studying the processes of previous dental record reviews and researching the most recent HIV-related and general oral health practice guidelines, a listing of potential data collection items was developed. Further research provided for the editing of this list to yield what is believed to represent the most pertinent data elements for oral health care in the Houston EMA. Topics covered by the data collection tool include, but are not limited to the following: basic client information, completeness of the health history, hard & soft tissue examinations, disease prevention, and periodontal examinations.

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3

The Chart Review Process All charts were reviewed by the PC/CQI, a Master’s-level registered nurse experienced in identifying documentation issues and assessing adherence to published guidelines. The collected data for each site was recorded directly into a preformatted database. Once all data collection was completed, the database was queried for analysis. The data collected during this process is intended to be used for the purpose of service improvement. The specific parameters established for the data collection process were developed from HIV-related and general oral health care guidelines available in peer-reviewed literature, and the professional experience of the reviewer on standard record documentation practices. Table 1 summarizes the various documentation criteria employed during the review.

Table 1. Data Collection Parameters

Review Area Documentation Criteria Health History Completeness of Initial Health History: includes but not limited to

past medical history, medications, allergies, substance use, HIV MD/primary care status, physician contact info, etc.; Completed updates to the initial health history

Hard/Soft Tissue Exam Findings—abnormal or normal, diagnoses, treatment plan, treatment plan updates

Disease Prevention Prophylaxis, oral hygiene instructions Periodontal screening Completeness

The Sample Selection Process The sample population was selected from a pool of 212 unduplicated clients who accessed Part A oral health care between 3/1/13 and 2/28/14. The medical charts of 75 of these clients were used in the review, representing 35.4% of the pool of unduplicated clients. In an effort to make the sample population as representative of the actual Part A oral health care population as possible, the EMA’s Centralized Patient Care Data Management System (CPCDMS) was used to generate a list of client codes to be reviewed. The demographic make-up (race/ethnicity, gender, age) of clients accessing oral health services between 3/1/13 and 2/28/14 was determined by CPCDMS, which in turn allowed Ryan White Grant Administration to generate a sample of specified size that closely mirrors that same demographic make-up.

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4

Characteristics of the Sample Population The review sample population was generally comparable to the Part A population receiving rural-targeted oral health care in terms of race/ethnicity, gender, and age. It is important to note that the chart review findings in this report apply only to those who received rural-targeted oral health care from a Part A provider and cannot be generalized to all Ryan White clients or to the broader population of persons with HIV or AIDS. Table 2 compares the review sample population with the Ryan White Part A rural-targeted oral health care population as a whole. Table 2. Demographic Characteristics of FY 13 Houston EMA Ryan White Part A Oral Health Care

Clients Sample Ryan White Part A EMA Race/Ethnicity Number Percent Number Percent African American 23 30.7% 74 34.9% White 51 68% 136 64.2% Asian 1 1.3% 2 2.7% Native Hawaiian/Pacific Islander 0 0% 0 0% American Indian/Alaska Native 0 0% 0 0% Multi-Race 0 0% 75 100% 212 100% Hispanic Status Hispanic 17 22.7% 46 21.7% Non-Hispanic 58 77.3% 166 78.3% 75 212 100% Gender Male 53 70.7% 143 67.5% Female 22 29.3% 69 32.5% Transgender 0 0% 0 0% 75 100% 212 100% Age 18 – 24 4 5.3% 18 8.5% 25 – 34 13 17.3% 38 17.9% 35 – 44 20 26.7% 59 27.8% 45 – 54 27 36% 70 33% 55 – 64 9 12% 24 11.3% 65+ 1 1.3% 3 1.4% 75 100% 212 100%

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5

Findings Clinic Visits Information gathered during the 2014 chart review included the number of visits during the study period. The average number of oral health visits per patient in the sample population was eight.

Health History

A complete and thorough assessment of a patient’s medical history is essential among individuals infected with HIV or anyone who is medically compromised. Such information, such as current medication or any history of alcoholism for example, offers oral health care providers key information that may determine the appropriateness of prescriptions, oral health treatments and procedures. The form that is used by the agency to assess patient’s health history captures a wide range of information; however, for the purposes of this review, this report will focus on the assessment of information that is of particular importance among HIV/AIDS patients compared to patients in the general population.

Assessment of Medical History 2013 Primary Care Provider

79%

Dental Health History*

73%

Medical Health History*

72%

Medical History 6 month Update

57%

Medication Review

85%

Allergies Recorded

87%

Documentation of HIV Status

92%

Documentation of Opportunistic Infection Status

71% Tobacco Use

88%

Substance Abuse

87%

*HIV/AIDS Bureau (HAB) Performance Measures

Page 19 of 44

6

Health Assessments

2013 Vital Signs

99%

CBC documented

80%

Screening for Antibiotic Prophylaxis

91%

Prevention and Detection of Oral Disease Maintaining good oral health is vital to the overall quality of life for individuals living with HIV/AIDS because the condition of one’s oral health often plays a major role in how well patients are able manage their HIV disease. Poor oral health due to a lack of dental care may lead to the onset and progression of oral manifestations of HIV disease, which makes maintaining proper diet and nutrition or adherence to antiretroviral therapy very difficult to achieve. Furthermore, poor oral health places additional burden on an already compromised immune system.

2013 Oral Health Education*

85%

Clinical Tooth Chart

99%

Intraoral Exam

95%

Extraoral Exam

95%

Periodontal screening*

91%

X-rays present

95%

Treatment plan*

93%

*HIV/AIDS Bureau (HAB) Performance Measures Nine clients presented with oral pathology, including salivary stones, candidiasis, denture stomatitis, oral Herpes Simplex Virus, leukoplakia, and possible squamous cell carcinoma. Six clients were treated appropriately, one did not require treatment, and two were referred to a specialist.

Page 20 of 44

7

Conclusions Overall, oral health care services continues its trend of high quality care. Ninety-five percent (95%) of clients received both an intraoral and extraoral exam and 91% received periodontal screening. When oral disease was identified, it was treated or referred to a specialist as needed. Measures that would benefit from quality improvement initiatives include documentation of the dental and medical history. RWGA will continue to conduct annual oral health chart reviews and we anticipate continued high levels of care for Houston EMA patients in future.

Page 21 of 44

8

Appendix A – Resources Dental Alliance for AIDS/HIV Care. (2000). Principles of Oral Health Management for the HIV/AIDS Patient. Retreived from: http://aidsetc.org/sites/default/files/resources_files/Princ_Oral_Health_HIV.pdf. HIV/AIDS Bureau. (2013). HIV Performance Measures. Retrieved from: http://hab.hrsa.gov/deliverhivaidscare/habperformmeasures.html. Mountain Plains AIDS Education and Training Center. (2013). Oral Health Care for the HIV-infected Patient. Retrieved from: http://aidsetc.org/resource/oral-health-care-hiv-infected-patient.

New York State Department of Health AIDS Institute. (2004). Promoting Oral Health Care for People with HIV Infection. Retrieved from: http://www.hivdent.org/_dentaltreatment_/pdf/oralh-bp.pdf.

U.S. Department of Health and Human Services Health Resources and Services Administration. (2014). Guide for HIV/AIDS Clinical Care. Retrieved from: http://hab.hrsa.gov/deliverhivaidscare/2014guide.pdf. U.S. Department of Health and Human Services Health Resources and Services Administration, HIV/AIDS Bureau Special Projects of National Significance Program. (2013). Training Manual: Creating Innovative Oral Health Care Programs. Retrieved from: http://hab.hrsa.gov/deliverhivaidscare/2014guide.pdf.

Page 22 of 44

http://aidsetc.org/sites/default/files/resources_files/Princ_Oral_Health_HIV.pdf

http://hab.hrsa.gov/deliverhivaidscare/habperformmeasures.html

http://aidsetc.org/resource/oral-health-care-hiv-infected-patient

http://aidsetc.org/resource/oral-health-care-hiv-infected-patient

http://www.hivdent.org/_dentaltreatment_/pdf/oralh-bp.pdf

http://hab.hrsa.gov/deliverhivaidscare/2014guide.pdf

http://hab.hrsa.gov/deliverhivaidscare/2014guide.pdf

Research Articles

Public Health Reports / 2012 Supplement 2 / Volume 127 45

Retention of People Living with HIV/AIDS in Oral Health Care

Carol R. Tobias, MMHSa

Jane E. Fox, MPHa

Angela W. Walter, MSW, MPH, MAa,b

Celeste A. Lemay, RN, MPHc

Stephen N. Abel, DDS, MSDd

aBoston University School of Public Health, Health & Disability Working Group, Boston, MA bBrandeis University, The Heller School for Social Policy and Management, Waltham, MAcUniversity of Massachusetts Medical School, Worcester, MA dNova Southeastern University, College of Dental Medicine, Fort Lauderdale-Davie, FL

Address correspondence to: Carol R. Tobias, MMHS, Boston University School of Public Health, 715 Albany St., 2W, Boston, MA 02118; tel. 617-638-1932; fax 617-638-1931; e-mail <[email protected]>.

©2012 Association of Schools of Public Health

ABSTRACT

Objective. We identified factors associated with retention in oral health care for people living with HIV/AIDS (PLWHA) and the impact of care retention on oral health-related outcomes.

Methods. We collected interview, laboratory value, clinic visit, and service utilization data from 1,237 HIV-positive patients entering dental care from May 2007 to August 2009, with at least an 18-month observation period. Retention in care was defined as two or more dental visits at least 12 months apart. We conducted multivariate regression using generalized estimating equations to explore factors associated with retention in care.

Results. In multivariate analysis, patients who received oral health education were 5.91 times as likely (95% confidence interval 3.73, 9.39) as those who did not receive this education to be retained in oral health care. Other factors associated with care retention included older age, taking antiretroviral medica-tions, better physical health status, and having had a dental visit in the past two years. Patients retained in care were more likely to complete their treat-ment plans and attend a recall visit. Those retained in care experienced fewer oral health symptoms and less pain, and better overall health of teeth and gums.

Conclusions. Retention in oral health care was associated with positive oral health outcomes for this sample of PLWHA. The strongest predictor of reten-tion was the receipt of oral health education, suggesting that training in oral health education is an important factor when considering competencies for new dental professionals, and that patient education is central to the develop-ment of dental homes, which are designed to engage and retain people in oral health care over the long term.

Page 23 of 44

46 Research Articles

Public Health Reports / 2012 Supplement 2 / Volume 127

The connection between oral health and systemic health is widely acknowledged by public health profes-sionals and is particularly important for people with chronic diseases, including people living with human immunodeficiency virus (HIV) and acquired immu-nodeficiency syndrome (AIDS) (PLWHA).1,2 PLWHA are at increased risk for caries, periodontal disease, oral lesions, and xerostomia (dry mouth).3–6 Affected individuals may have difficulty taking medications or maintaining appropriate nutrition, further impacting their physical health.7–9

The receipt of oral health care can improve oral health, reduce the risk of oral disease, and prevent the progression of existing disease.1,10,11 Studies have found that retention in care and the receipt of regular dental examinations are associated with fewer caries,12 better periodontal health,13 and increased retention of existing teeth.14,15 Retention in care also reduces the severity of dental pain and discomfort while improv-ing the ability to eat, speak, and socialize.16 Individuals who are retained in care receive more diagnostic and preventive services, which can arrest the progression of disease and result in lower costs per visit.17,18

However, access to and retention in dental care is problematic for many PLWHA. Lack of dental insur-ance or the means to pay for care are the main barri-ers to dental care.2,19 Patient experiences at the dental office, particularly patient-provider interactions, also impact care retention. When patients are dissatisfied or do not trust their dental providers, they are less likely to return for care.20,21 Other barriers to care reported in the literature include fear of dentists, stigma, and limited oral health literacy.9,22–26

One of the challenges of promoting retention in oral health care for PLWHA is the lack of strong evidence about the appropriate recall intervals for maintaining oral health. In HIV primary care, clinical evidence sup-ports the receipt of clinical monitoring and laboratory tests every three to six months, depending on stage of HIV illness.27 Therefore, it is possible to test and evaluate interventions that promote retention in HIV primary care. Both federal health agencies and private foundations have sponsored demonstration projects to test strategies that promote engagement and retention in HIV primary care, but none of these projects has explicitly embraced retention in oral health care as part of its model.28,29 At the same time, it is difficult to test and evaluate retention strategies in oral health if there is inconsistent evidence about the appropriate definition or measurement of retention.30 While the standard of care in many dental practices is six months between recall appointments,12,31 systematic reviews of the research literature have found no evidence to

support this visit frequency, and many argue that recall intervals should be based on the individual’s age and risk for dental disease.30,32–34

In 2006, the Health Resources and Services Adminis-tration HIV/AIDS Bureau’s Special Projects of National Significance program funded the Innovations in Oral Health Care Initiative, a five-year project to improve access to oral health care for PLWHA. This article describes the results of a study exploring the factors associated with retention in oral health care and the impact of retention on service utilization, the elimina-tion of active disease, and oral health outcomes. The results of this analysis will contribute to a better under-standing of the benefits of retention in oral health care for PLWHA and inform strategies to promote retention.

METHODS

Study sample and data collectionFourteen dental programs across the United States enrolled 2,178 PLWHA in dental care and a longi-tudinal study from May 2007 to August 2009. Details about the study sites and program models are described elsewhere.35 To be eligible for the study, individuals had to be HIV-positive and 18 years of age or older. They could not have received any dental care, other than for an emergency, in the 12 months prior to study enroll-ment, and they had to receive at least one dental visit within 45 days of their baseline interview.

To analyze retention, we restricted the sample to individuals with an observation period of at least 18 months before the end of data collection in August 2010 (n51,466) to maximize the opportunity to have two dental visits at least 12 months apart. We further restricted the sample to delineate two distinctly differ-ent groups of service users—those who were retained in care for more than 12 months and those who dropped out of care within six months of study enrollment, yielding a final sample of 1,237 individuals.

We collected four types of data for this longitudi-nal study: (1) interviews conducted at baseline, six months, and 12 months in English or Spanish; (2) laboratory values for CD4 cell counts (cells/cubic mil-limeter [mm3]) and viral load, collected from patient charts or laboratory slips every six months; (3) clinic data collected at each dental visit, including the visit date and whether or not a phase 1 treatment plan was completed at that visit; and (4) dental service uti-lization data, collected at each dental visit, including the 2006–2007 Current Dental Terminology (CDT) procedure codes for each service provided.36 All data were entered into a password-protected, Web-based database and housed at the Boston University School of

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Retaining People with HIV/AIDS in Oral Health Care 47


Public Health (BUSPH), which served as the multisite evaluation center.

Interviewers at each site were trained in both Span-ish and English by the multisite evaluation center. BUSPH provided technical assistance to each site in the collection of clinic visit and service utilization data. All utilization data were audited by the lead dentist at each site and verified by chart audits conducted by the site and the oral health consultants at the multisite evalu-ation center at least three times during the course of the study to ensure consistency and completeness in coding and data entry across sites. All study sites and the multisite evaluation center received approval from their respective Institutional Review Boards.

Variables The dependent variable, retention, was created using the clinic visit data. There are multiple definitions of retention or regular users in the oral health litera-ture. Some retention studies examine visit intervals of six months,10,37 while others examine intervals of 24 months or a range of intervals.11,16,17,29 The most common visit interval used in retention studies is 12 months, or a visit at least once per year.12–14,38,39 For this study, we defined retention in care as a minimum of two visits at least 12 months apart. Non-retention was defined as less than six months of care. Thus, an individual might attend several dental appointments, but if they all occurred within the first six months, the person was considered not retained in care.

Independent variables were selected based on a review of the oral health-care access and retention lit-erature and guided by the Institute of Medicine model on access to health services.40 The model posits that access to health-care services is influenced by structural factors, financial factors, and personal/cultural factors. These factors can be mediated by the appropriateness and efficacy of treatment. Structural factors included receipt of care in a mobile van or in a stationary clinic setting, having an HIV case manager, and the amount of time it took the patient to travel to the dentist. We did not include a dental insurance variable because dental services were provided at no cost to study participants. Personal factors included gender, age, race/ethnicity, housing, employment, education, income, and expo-sure to HIV through injection drug use (IDU). Health measures included years since the participant tested HIV-positive; the SF-8™ Health Survey, a standardized instrument that measures mental and physical health-related quality of life;41 laboratory values for viral load dichotomized as detectable or undetectable, and CD4 cell counts dichotomized as 200 cells/mm3 or 200 cells/mm3; and whether the participant was taking

antiretroviral medications. Oral health characteristics included the number of dental symptoms at initial study assessment, the length of time since the last dental visit, prior unmet need for dental care, the main reason for an unmet need, the reasons for seeking care at intake (i.e., for an examination/cleaning or to resolve a problem), and the overall health of teeth and gums.

Eleven dental symptoms—toothache, bad breath, growths/bumps, tooth decay, bleeding gums, problem with appearance, pain in jaw joints, sensitivity, sores, loose teeth, and other symptoms not listed—were summed and measured as a continuous variable. Twenty potential reasons for unmet need were col-lapsed into four categories: (1) financial (lack of insur-ance or funds to pay for care); (2) logistical (did not know where to go, could not get to the dentist); (3) stigma or fear (afraid the dentist would not be HIV friendly, fear of the dentist); and (4) other. The “other” category included 10 different reasons, including illness and addiction. The most frequent “other” response indicated that dental care was neither important nor a priority. A single mediating variable, the receipt of any oral health education during a dental visit, was included to reflect the appropriateness of treatment. Oral health education was defined as the presence of any CDT code of 1310 (nutritional counseling), 1320 (tobacco cessation counseling), or 1330 (oral hygiene instructions).

We also examined selected service-utilization char-acteristics of the sample and health outcomes for the retained subset of the sample as descriptors. Utilization data, including the total number of services received, the receipt of patient education services, and the receipt of a recall visit after phase 1 treatment plan completion, were obtained from CDT codes. We derived the number of clinic visits from individual dates of services, and we obtained phase 1 treatment plan completion data (the elimination of active disease and restoration of function) from clinic visit forms.

AnalysisWe used measures of central tendency to describe characteristics of the study sample. Given the variation in site data, generalized estimating equations (GEEs) were used to control for site variation in the bivariate analysis. All variables significant at the p0.15 level in bivariate analysis were included in the multivariate analysis. We used multivariate regression modeling techniques, using GEEs to account for within-site correlation of the data, to explore factors associated with being retained in care. Data were analyzed using SPSS®/PASW® statistics software, version 18.0.42

Oral health outcome measures were calculated as

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the change at 12 months from baseline using t-tests to compare means. These analyses were only conducted among the retained sample because the variables were obtained from patient interviews, and more than 75% of the non-retained sample did not complete a 12-month interview. The number of oral health symp-toms at baseline (total possible n511) was subtracted from the number of oral health symptoms at 12 months to obtain the change in symptom score, with a decrease in score representing a decrease in symptoms. Oral pain was measured on a five-point Likert scale, where 0 5 “none at all,” and 4 5 “a great deal,” with a decrease in score representing a decrease in pain. Oral health status was also measured on a five-point Likert scale, where 0 5 “poor,” and 4 5 “excellent,” with an increase in score representing an improvement in overall oral health status. The one health outcome measure, change in detectable viral load, was calculated using McNemar-Bowker Chi-square tests.

RESULTS

Of the 1,237 individuals included in this analysis, 442 (36%) were not retained and 795 (64%) were retained in dental care. Table 1 shows the program structural features, sociodemographic characteristics, and health and oral health characteristics of the two groups. The delivery of services at a stationary clinic, rather than in a mobile van, was the only structural factor of significance associated with retention in care. Several sociodemographic characteristics were significantly associated with retention in dental care, including older age, non-Hispanic white race/ethnicity, living in one’s own home or apartment, being employed, and having a monthly income of more than $850. IDU risk exposure was significantly associated with non-retention. Gender and education were not associated with retention in care. Health- or oral health-related characteristics significantly associated with retention in dental care included taking antiretroviral medications, having an undetectable viral load, having better self-reported physical health status, having received dental care in the previous two years, and reporting a prior unmet need for dental care due to financial reasons. There was no significant difference in retention based on overall oral health status, number of oral health symptoms, reason for seeking care, mental health status, years since testing HIV-positive, or CD4 count.

People who were retained in oral health care received significantly more visits and services than individuals who were not retained, as shown in Table 2. Although all study participants had at least one dental visit, those who were retained were significantly more

likely than those not retained to have received patient education (68% vs. 27%). They were also significantly more likely to complete their phase 1 treatment plan (65% vs. 17%), and if that plan was completed, to have received a subsequent recall visit (87% vs. 64%).

In the multivariate model, patient education was the factor most strongly associated with retention in oral health care, as shown in Table 3. Those who received patient education were 5.91 times as likely to be retained in care as those who did not receive educa-tion. Other significant factors included age (with older adults being 3% more likely to be retained in care for every additional year of age), the taking of antiretrovi-ral medications (with those taking medications being 41% more likely to be retained than those not taking medications), and better physical health status. Indi-viduals who had not received any oral health care in the past two years or more were 33%–36% less likely to be retained in care than those who had received care, and individuals who reported “other” reasons for prior unmet dental needs were 34% less likely to be retained than those who had no trouble obtaining dental care when needed. None of the other variables entered into the model was significant at the p0.05 level.

Those who were retained in care experienced improvements in their health and oral health status during a 12-month period, as shown in Table 4. They experienced a significant decline (21.45) in overall oral health symptoms, which represented a change from 3.49 symptoms per person at baseline to 2.04 symptoms per person at 12 months. The most common symptoms included tooth decay, problems with appear-ance, and sensitivity, experienced by 55%–69% of the sample at baseline (data not shown). The decrease in symptoms was significant for each symptom, with the exception of problems with dentures or partials. The retained group also experienced a decline in oral pain and their overall oral health improved. The percentage of individuals whose viral load changed from detect-able to undetectable also increased from baseline to 12 months among the retained sample.

DISCUSSION

In this study, retention in oral health care was associ-ated with improved overall oral health status and a reduction in pain and oral health symptoms. Those retained in care reported a significant drop in problems associated with tooth decay, sensitivity, bleeding gums, bad breath, loose teeth, sores, their appearance, and several other dental concerns after 12 months in care. Individuals who were retained in care were more likely to complete their phase I treatment plans, thereby

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continued on p. 50

Table 1. Characteristics of HIV-infected individuals retained and not retained in oral health care, controlling for site (n=1,237): SPNS Oral Health Initiative, 2006–2011

Characteristic

Not retained (n5442)

Retained (n5795)

P-valueN (percent)a N (percent)a

Structural Clinical setting 0.01 Stationary clinic 333 (75) 691 (87) Mobile van 109 (25) 104 (13) Time to travel to dentist in minutes (mean [SD]) 43.4 (43.7) 44.4 (41.5) 0.73 Has an HIV case manager 0.33 No 61 (14) 132 (17) Yes 379 (86) 655 (83)

Sociodemographic Gender 0.35 Male 346 (79) 599 (76) Female 92 (21) 190 (24) Age in years (mean [SD]) 42.9 (10.2) 44.7 (9.2) 0.01 Race/ethnicity 0.03 Non-Hispanic white 134 (30) 301 (38) Non-Hispanic black or African American 187 (42) 292 (37) Hispanic/Latino 98 (22) 159 (20) Other 23 (5) 43 (5) Housing 0.01 Own home or apartment 234 (53) 494 (62) Someone else’s home or apartment 108 (25) 193 (24) Temporary or no housing 99 (22) 107 (14) Employment 0.01 Unemployed 333 (76) 546 (69) Employed full- or part-time 107 (24) 247 (31) Education in years (mean [SD]) 12.3 (2.4) 12.5 (2.6) 0.32 Monthly income 0.01 $0–$850 270 (62) 380 (48) $851 167 (38) 403 (52) IDU risk exposure 88 (20) 111 (14) 0.02

Health and oral health Years since testing HIV-positive (mean [SD]) 10.6 (7.3) 10.7 (7.0) 0.82 Taking antiretroviral medications 0.01 No 137 (31) 165 (21) Yes 300 (69) 628 (79) CD4 count category (cells/mm3) 0.11 200 93 (23) 140 (18) 200 307 (77) 636 (82) Viral load status 0.07 Undetectable 198 (50) 441 (57) Detectable 199 (50) 333 (43) SF-8™ Health Survey physical composite score (mean [SD]) 46.7 (10.5) 47.8 (10.1) 0.05 SF-8™ Health Survey mental composite score (mean [SD]) 45.8 (12.0) 46.0 (11.3) 0.76 Time since last dental visit 0.02 2 years 194 (44) 397 (50) 2–5 years 140 (32) 225 (28) 5 years 108 (24) 173 (22) Unmet need for dental care since testing positive 0.71 No 204 (47) 382 (48) Yes 234 (53) 407 (52)

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Characteristic


Retained (n5795)


Main reason for unmet dental need 0.01 Financial 104 (24) 246 (31) Logistical 30 (6) 32 (4) Fear or stigma 40 (9) 64 (8) Other 60 (14) 63 (8) Not applicableb 204 (47) 382 (48) Reason for seeking dental care now 0.95 Dental problem 256 (62) 463 (63) Dental cleaning or examination only 155 (38) 276 (37) Has removable dental appliance 0.60 No 366 (83) 645 (81) Yes 74 (17) 147 (19) Overall health of teeth and gums 0.41 Poor or fair 288 (65) 491 (62) Good, very good, or excellent 154 (35) 304 (38) Number of dental symptomsc (mean [SD]) 3.3 (2.4) 3.5 (2.5) 0.12

aTotal N may not sum to total sample due to missing data. Percentages are based on number of responses in each category, and percentages may not add to 100 due to rounding.b“Not applicable” responses are from those who reported no prior unmet need for dental care.cOut of 11 total symptoms, including toothache, bad breath, growths or bumps, tooth decay, bleeding gums, problem with appearance, pain in jaw joints, sensitivity, sores, loose teeth, and other symptoms not listed

HIV 5 human immunodeficiency virus

SPNS 5 Special Projects of National Significance

SD 5 standard deviation

IDU 5 injection drug use

mm3 5 cubic millimeter

SF-8™ 5 Short Form 8™

Table 1 (continued). Characteristics of HIV-infected individuals retained and not retained in oral health care, controlling for site (n=1,237): SPNS Oral Health Initiative, 2006–2011

Table 2. Services received by HIV-infected individuals retained and not retained in care, controlling for site (n=1,237): SPNS Oral Health Initiative, 2006–2011

Service utilization


Retained (n5795)


Number of visits (mean [SD]) 2.3 (1.8) 11.2 (7.4) 0.01Any patient education 0.01 No 324 (73) 251 (32) Yes 118 (27) 544 (68)Phase 1 treatment plan completed 0.01 No 369 (83) 276 (35) Yes 73 (17) 519 (65)Recall visit after phase 1 treatment plan completed 0.01 No 26 (36) 68 (13) Yes 47 (64) 451 (87)

aTotal N may not sum to total sample due to missing data. Percentages are based on number of responses in each category, and percentages may not add to 100 due to rounding.




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Table 3. Factors associated with retention in oral health care among a sample of HIV-positive adults, using multiple logistic regression with generalized estimating equations to control for clustering by site (n=1,131): SPNS Oral Health Initiative, 2006–2011

Independent variables ß OR (95% CI) P-value

Clinical setting Stationary clinic Ref. Ref. Ref. Mobile van 20.49 0.62 (0.27, 1.40) 0.25

Age 0.03 1.03 (1.01, 1.06) 0.01

Race/ethnicity Non-Hispanic white 0.05 1.06 (0.66, 1.68) 0.82 Non-Hispanic black or African American 0.09 1.09 (0.70, 1.70) 0.71 Hispanic/Latino 0.14 1.15 (0.64, 2.07) 0.64 Other Ref. Ref. Ref.

Housing Own home or apartment 0.29 1.34 (0.78, 2.32) 0.29 Someone else’s home or apartment 0.34 1.41 (0.72, 2.74) 0.32 Temporary or no housing Ref. Ref. Ref.

Employment Unemployed Ref. Ref. Ref. Employed full- or part-time 0.10 1.11 (0.79, 1.56) 0.55

Monthly income $0–$850 Ref. Ref. Ref. $851 0.28 1.33 (0.96, 1.84) 0.09

IDU risk exposure 20.31 0.73 (0.43, 1.25) 0.25

Taking antiretroviral medications No Ref. Ref. Ref. Yes Ref. 1.41 (1.09, 1.81) 0.01

Viral load status Undetectable 20.02 0.98 (0.77, 1.25) 0.87 Detectable Ref. Ref. Ref.

Physical health status (SF-8™ Health Survey physical composite score) 0.02 1.02 (1.00, 1.03) 0.04

Time since last dental visit 5 years 20.44 0.64 (0.45, 0.93) 0.02 2–5 years 20.40 0.67 (0.50, 0.91) 0.01 2 years Ref. Ref. Ref.

Reason for unmet dental care need Financial 0.12 1.13 (0.71, 1.79) 0.61 Othera 20.42 0.66 (0.43, 1.00) 0.05 Fear or stigma 20.17 0.84 (0.40, 1.80) 0.66 Logistical 20.37 0.69 (0.33, 1.43) 0.32 Did not have trouble getting dental care at a time they needed it (not applicable)

Ref. Ref. Ref.

Patient education No Ref. Ref. Ref. Yes 1.78 5.91 (3.73, 9.39) 0.0001

aThe majority of “other” reasons included “dental care not important” or “low priority.”



OR 5 odds ratio

CI 5 confidence interval

Ref. 5 reference category

IDU 5 injection drug use


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Table 4. Health changes in retained sample of HIV-positive adults from baseline to 12 months (n=605): SPNS Oral Health Initiative, 2006–2011

Change from baseline to 12 months Mean (SD) P-value

Change in symptomsa 21.45 (2.39) 0.01Change in oral pain experienced in past three monthsb 20.40 (1.37) 0.01Change in oral health statusc 0.69 (1.23) 0.01Change in detectable viral load (n5562) 0.01 Undetectable to detectable (N [percent]) 38 (12) Detectable to undetectable (N [percent]) 107 (45)

aOut of 11 total symptoms, including toothache, bad breath, growths/bumps, tooth decay, bleeding gums, problems with appearance, pain in jaw joints, sensitivity, sores, loose teeth, and other symptoms not listed. At baseline, the mean number of symptoms per person retained in care was 3.49.bOn a five-point scale, where 0 5 “a great deal” and 5 5 “none at all”cOn a five-point scale, where 0 5 “poor” and 5 5 “excellent”




eliminating active disease and restoring function, than those who were not retained, and they completed at least one recall visit. While these results are consistent with the results of other studies17,18 and, therefore, are not surprising, it is useful to confirm that retention in care had a positive impact on oral health and quality of life for this sample. We were surprised to find a significant change in the percentage of individuals who achieved an undetectable viral load at 12 months among the retained sample. This finding, along with the finding that taking antiretroviral medications was significantly associated with retention in multivariate analysis, may indicate that individuals who took care of their physical health were more likely to remain engaged in oral health care.

People who received oral health education, whether for nutritional counseling, tobacco cessation counsel-ing, or oral hygiene instructions, were nearly six times as likely to be retained in care as those who did not receive any education, making this the strongest factor associated with retention in care. Patient education was far more predictive of retention than a history of IDU, race/ethnicity, housing status, employment, or monthly income, none of which was significant in multivariate analysis. In this study, individuals who reported a prior unmet need for dental care for “other” reasons were significantly less likely to be retained in care than peo-ple who reported financial, logistical, or stigma/fear barriers to care. The most common “other” responses included “I did not think it was that important” and “I did not want to go.” This finding reinforces the idea that patient education is a key component of retention. Other findings from the multivariate analysis suggest that patient education should target younger adults,

individuals who are not taking antiretroviral medica-tions, people who have been out of care for more than two years, and people with poorer health status.

The Surgeon General’s “National Call to Action to Promote Oral Health” recognized the need to expand and enhance the present makeup of the oral health workforce.43 With a number of different proposed models and providers, great emphasis has been placed on the dental procedures these new practitioners will be allowed to perform. Our data suggest that, if we want to achieve improved access to and retention in care and reduce health disparities, these new prac-titioners will need to demonstrate competencies in effective oral health education, counseling, and health promotion.

Nationally, health-care policy makers and providers are engaged in important efforts to improve the health of individuals with chronic illness through strategies that promote retention in care, including chronic care self-management and the establishment of medical or health homes.44–47 The health home is a model of care that replaces “episodic care based on illnesses and [an] individual’s complaints with coordinated care for all life stages. . . .”48 Some leaders in public health dentistry have called for the establishment of dental homes49–51 to mirror the concept of medical homes for health care, but the dental field as a whole lags behind the medical field in establishing dental homes or dental care as part of the health home. Oral health is often excluded from mention in the establishment of health homes, despite the fact that oral disease is a chronic illness, one that is largely avoidable, and, if detected early, certainly treatable. As HIV disease is increasingly managed as a chronic illness, it is more

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important than ever to consider oral health as a part of the health home for PLWHA.

LimitationsSeveral important limitations to this study should be considered. We used a convenience sample of PLWHA who had not received dental care in the past year rather than a probability sample, and, thus, the results may not be generalizable to the national population of PLWHA. Also, some of the study participants were not in the study long enough to have two full years of data but may have only had 18 months of data; thus, there is a possibility that some of those who were con-sidered “not retained” might have returned for more care after the study period ended. Furthermore, we were not able to compare health and oral health status outcomes for the retained group with those of the not retained group because the majority of those who were not retained in care were not retained in the study, which was the primary source of data for outcomes. Therefore, while there were significant health and oral health status changes for those who were retained in care, we cannot be certain that those changes were caused by retention in care.

In addition, we did not have access to information about other important factors that might influence care retention, such as the length of time between follow-up appointments, appointments cancelled because a mobile van broke down or a dentist resigned, or the inability of an individual to return to care due to hospitalization, incarceration, or moving out of state. Finally, although we did collect uniform data from all sites about the delivery of patient education, we did not collect specific information about the contents or duration of that education. Given the strength of the association between patient education and care retention, this is an important area for future research.

CONCLUSION

Nearly two-thirds of this sample of 1,237 PLWHA were retained in care for more than a year, and most completed their phase 1 treatment plans and expe-rienced improvements in oral health-related quality of life. Patient education was the strongest predictor of care retention, suggesting that the training of oral health clinicians should encompass the delivery of oral health education and counseling. Retention in care is preferable to episodic emergency treatment if we want to ensure access to comprehensive, coordinated, preventive care in a dental home or health home that includes oral health care.

The authors thank Howard Cabral, MPH, PhD, Associate Professor, Biostatistics, Boston University School of Public Health, Boston, Massachusetts; and Karl Hoffman, DDS, Director of Dentistry, Center for Comprehensive Care, St. Luke’s-Roosevelt Hospital, New York, New York, for providing constructive com-ments and suggestions in the development of this article.

This study was supported by grant #H97HA07519 from the U.S. Department of Health and Human Services, Health Resources and Services Administration. This grant is funded through the HIV/AIDS Bureau’s Special Projects of National Significance program. The contents of this article are solely the responsibility of the authors and do not necessarily represent the views of the funding agencies or the U.S. government.

This research project was approved by the Institutional Review Board of the Boston University Medical Campus, 2006–2011.

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32. Gibson TJ, Nash DA. Practice patterns of board-certified pediatric dentists: frequency and method of cleaning children’s teeth. Pediatr Dent 2004;26:17-22.

33. Bader J. Risk-based recall intervals recommended. Evid Based Dent 2005;6:2-4.

34. Patel S, Bay RC, Glick M. A systematic review of dental recall intervals and incidence of dental caries. J Am Dent Assoc 2010;141:527-39.

35. Fox JE, Tobias CR, Bachman SS, Reznik DA, Rajabiun S, Verdecias N. Increasing access to oral health care for people living with HIV/AIDS in the U.S.: baseline evaluation results of the Innovations in

Oral Health Care Initiative. Public Health Rep 2012;127 Suppl 2:5-16.

36. American Dental Association. Current dental terminology (CDT-2007/2008). Chicago: ADA; 2007.

37. Gilbert GH, Duncan RP, Vogel WB. Determinants of dental care use in dentate adults: six-monthly use during a 24-month period in the Florida Dental Care Study. Soc Sci Med 1998;47:727-37.

38. Doty HE, Weech-Maldonado R. Racial/ethnic disparities in adult preventive dental care use. J Health Care Poor Underserved 2003;14:516-34.

39. Crocombe LA, Broadbent JM, Thomson WM, Brennan DS, Slade GD, Poulton R. Dental visiting trajectory patterns and their ante-cedents. J Public Health Dent 2011;71:23-31.

40. Institute of Medicine. Millman M, editor. Access to health care in America. Washington: National Academy Press; 1993.

41. Ware JE, Kosinski M, Dewey JE, Gandek B. How to score and interpret single-item health status measures: a manual for users of the SF-8™ Health Survey. Lincoln (RI): Quality Metric Inc.; 2001.

42. IBM SPSS, Inc. SPSS®/PASW®: Version 18.0. Chicago: IBM SPSS, Inc.; 2008.

43. Department of Health and Human Services (US). National call to action to promote oral health. 2003 [cited 2011 Jan 14]. Available from: URL: http://www.surgeongeneral.gov/topics/oralhealth/nationalcalltoaction.html

44. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home. February 2007 [cited 2010 Dec 8]. Available from: URL: http://www .aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.Par.0001.File.dat/022107medicalhome .pdf

45. Ginsburg PB, Maxfield M, O’Malley AS, Peikes D, Pham HH. Making medical homes work: moving from concept to practice. Health System Change Policy Analysis No. 1. Washington: Center for Studying Health System Change; 2008.

46. Stange KC, Nutting PA, Miller WL, Jaén CR, Crabtree BF, Flocke SA, et al. Defining and measuring the patient-centered medical home. J Gen Intern Med 2010;25:601-12.

47. Department of Health and Human Services (US), Agency for Healthcare Research and Quality. Patient centered medical home resource center [cited 2010 Dec 8]. Available from: URL: http://www.pcmh.ahrq.gov

48. Department of Health and Human Services (US), Centers for Medicare and Medicaid Services. Health homes for enrollees with chronic conditions. November 16, 2010 [cited 2010 Dec 1]. Avail-able from: URL: http//www.cms.gov/smdl/downloads/SMD10024 .pdf

49. Glick M. A home away from home: the patient-centered health home. J Am Dent Assoc 2009;140:140-2.

50. Nowak AJ, Casamassimo PS. The dental home: a primary care oral health concept. J Am Dent Assoc 2002;133:93-8.

51. Lee JY, Bouwens TJ, Savage MF, Vann WF Jr. Examining the cost-effectiveness of early dental visits. Pediatr Dent 2006;28:102-5.

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Research Articles

Public Health Reports / 2012 Supplement 2 / Volume 127 5

Increasing Access to Oral Health Care for People Living with HIV/AIDS in the U.S.: Baseline Evaluation Results of the Innovations in Oral Health Care Initiative

Jane E. Fox, MPHa

Carol R. Tobias, MMHSa Sara S. Bachman, PhDb

David A. Reznik, DDSc,d Serena Rajabiun, MA, MPHa

Niko Verdecias, MPHe

aBoston University School of Public Health, Health & Disability Working Group, Boston, MAbBoston University Schools of Social Work and Public Health, Boston, MAcGrady Health System, Infectious Disease Program, Atlanta, GAdEmory University School of Medicine, Atlanta, GAeAlbert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY

Address correspondence to: Jane E. Fox, MPH, Boston University School of Public Health, Health & Disability Working Group, Talbot 247W, 715 Albany St., Boston, MA 02118; tel. 617-638-1937; fax 617-638-1931; e-mail <[email protected]>.

©2012 Association of Schools of Public Health

ABSTRACT

Objectives. We provide an overview of the Health Resources and Services Administration HIV/AIDS Bureau’s Special Projects of National Significance Innovations in Oral Health Care Initiative, describe the models developed by the 15 demonstration sites and associated evaluation center, and present initial descriptive data about the characteristics of the multisite evaluation study sample.

Methods. Baseline data were collected from May 2007–August 2009 for 2,469 adults living with HIV/AIDS who had been without dental care, except for emergency care, for 12 months or longer. Variables included sociodemographic characteristics, HIV status, medical care, history of dental care and oral health symptoms, oral health practices, and physical and mental health quality of life. Descriptive statistics of baseline variables were calculated.

Results. The study sample included 2,469 adults who had been HIV-positive for a decade; most were engaged in HIV care. The majority (52.4%) of patients had not seen a dentist in more than two years; 48.2% reported an unmet oral health-care need since testing positive for HIV, and 63.2% rated the health of their teeth and gums as “fair” or “poor.”

Conclusions. This study is the largest to examine oral health care among people living with HIV/AIDS in more than a decade. The need for access to oral health care among members of this HIV-positive patient sample is greater than in the general population, following previous trends. Findings from our study reinforce the necessity for continued federal and statewide advocacy and support for oral health programs targeting people living with HIV/AIDS; findings can be extended to other vulnerable populations.

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6 Research Articles


The Centers for Disease Control and Prevention (CDC) estimates that more than 1.1 million people are living with human immunodeficiency virus (HIV) infection in the U.S.,1 and the incidence rate for new U.S. HIV infections continues at approximately 50,000 cases annually.2 Over the past 30 years, efforts to prolong and improve the quality of patients’ lives through medical care, pharmaceutical interventions such as combi-nation antiretroviral therapy (cART), and support services have been successful. More people with HIV and acquired immunodeficiency syndrome (AIDS) are living longer productive lives.3 Amid all the advances in HIV/AIDS care and treatment, however, access to oral health care continues to be frequently cited by state and regional HIV/AIDS consumer needs assessments as the primary unmet need.4,5

The importance of oral health for people living with HIV has been documented. In the 2000 Surgeon Gen-eral’s report Oral Health in America, Surgeon General David Satcher described the mouth as the gateway to the body. It signals nutritional deficiencies and serves as an early warning system for diseases such as HIV/AIDS and other infections related to the immune sys-tem.5 Oral health problems can have a great impact on a patient’s overall health, especially if that person has a compromised immune system and is thus more vulnerable to infection.6 In the early 1990s, studies estimated that up to 90% of HIV-positive patients would have at least one oral manifestation during the course of their disease.7,8 Due to the success of cART, the incidence of oral manifestations has decreased; however, the type of oral manifestations encountered by oral health providers is shifting.8 According to recent estimates, HIV-related oral conditions may occur at least once over the course of the disease in as few as 30% of HIV patients.9,10 Although the incidence of certain oral manifestations such as oral candidiasis and Kaposi’s sarcoma has decreased,11 the rate of HIV salivary gland disease has increased. HIV salivary gland disease results in xerostomia (dry mouth), which is also frequently cited as a side effect of some HIV medications. This reduction in the volume of saliva, as well as chemical changes that lower the antimicrobial properties of saliva, can result in an increase in dental problems such as tooth decay and periodontal disease.12 The observance of an increase in certain oral mani-festations such as oral warts11 and HIV salivary gland disease, coupled with a longer patient life expectancy after HIV diagnosis, strongly indicates the need for access to continuous oral health care for people living with HIV and AIDS (PLWHA).

Studies conducted in the last two decades suggest, however, that PLWHA have limited access to oral

health care. The Surgeon General reported that 11% (16.7 million) of Americans needed oral health care but were not able to access it for a number of reasons, most commonly the cost of care.5 The HIV Cost and Services Utilization Study (HCSUS), conducted in 1996–1997 by the Agency for Healthcare Research and Quality and the RAND Corporation, included detailed oral health questions in a survey of PLWHA in the U.S. who were engaged in medical care. Based on this nationally representative study, researchers estimated that 40% of PLWHA needed oral health care in the past six months but did not get it.13 Other studies have reported an unmet need for oral health care among PLWHA ranging from 5% to 52% in the pre-cART era; the inability to pay for dental care was the primary reason for not receiving care.13–18 More than a decade since the HCSUS, barriers to dental care for PLWHA persist, in part due to lack of coverage through private insurance and the dwindling benefits provided by state Medicaid programs, as well as patients’ inability to pay for dental services out-of-pocket. Other barriers to care include the inability to find an HIV-friendly dentist, fear of going to the dentist, and concerns about confidentiality.5

In 2006, the HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA) funded an initiative under its Special Projects of National Significance (SPNS) program to address these issues and expand access to dental services for PLWHA. The Innovations in Oral Health Care Initiative (hereafter, Oral Health Initiative) comprised 15 sites across the U.S. serving both urban and rural populations, and a multisite evaluation and technical assistance center. The goals of the initiative were to (1) develop innova-tive models of comprehensive oral health-care services for PLWHA; (2) expand oral health services to new communities and populations; (3) implement mod-els to maximize payment of services from all sources, including Medicaid and other community resources, and develop financing methods to sustain dental ser-vices; (4) establish linkages and referrals to HIV medi-cal care and support services to ensure a continuum of care; and (5) provide appropriate training and support for clinical and other staff in developing the expertise to manage oral health care for PLWHA, and provide ongoing education in HIV care management.19

In addition to sponsoring sites to provide oral health care, the SPNS program established the Evaluation Center on HIV and Oral Health (ECHO). ECHO, convened by the Boston University School of Public Health, comprised a team of experts, including den-tists, dental hygienists, policy analysts, and researchers. ECHO’s goals were to (1) provide technical assistance

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Increasing Access to Oral Health Care for People with HIV/AIDS 7


to help oral health providers and programs improve access and adherence to high quality oral health care for underserved populations; (2) implement a mixed-methods multisite evaluation of the demonstration projects; (3) assist grantees in implementing both the multisite evaluation and their local evaluations; and (4) disseminate findings to a broad range of audiences including oral health-care providers, medi-cal care providers, consumers, and policy makers. In collaboration with the demonstration grantees, ECHO implemented a longitudinal quantitative evaluation using patient survey and dental utilization data at all sites and a qualitative study involving two in-depth interviews with a small sample of patients at six sites. ECHO also provided clinical and programmatic techni-cal assistance to all the sites.

The purpose of this initial article in the supplement is to provide an overview of the Oral Health Initiative, including information about the models developed by the 15 demonstration sites. We also discuss the approach developed to evaluate the demonstration sites and present baseline descriptive data of the char-acteristics of the 2,469 adult PLWHA who accessed dental care after not receiving any care in the prior 12 months other than for an emergency.

METHODS

Theoretical model The design of the Oral Health Initiative evaluation was based on the Institute of Medicine’s (IOM’s) conceptual model of access to personal health-care services.20 The IOM model suggests that access to care is shaped by structural barriers, such as availability of services or transportation; financial barriers, such as a lack of health insurance coverage or inability to pay; and personal barriers, such as culture, language, and education. Use of services is further mediated by efficacy of treatment, quality of providers, and patient adherence to health-care treatment, leading to improvements in patient outcomes such as health status and reductions in patients’ unmet needs. Using a participatory approach with sites, ECHO designed the evaluation and operationalized measures to reflect the IOM model domains.

Study design and recruitment Fifteen oral health programs in 12 states and one U.S. territory participated in the study. The sites were located in San Francisco, California; Eugene, Oregon; Tyler, Texas; New Orleans, Lousiana; Green Bay, Wis-consin; Miami, Florida; Jefferson, South Carolina; Cha-pel Hill, North Carolina; Chester, Pennsylvania; New

York, New York; Norwalk, Connecticut; Provincetown, Massachusetts; and St. Croix, U.S. Virgin Islands. The oral health programs were located at universities, hos-pitals, Community Health Centers, and AIDS service organizations. The sites recruited HIV-positive patients for the study through direct outreach to patients, col-laboration with social-service organization and HIV case managers, and referrals from HIV clinics.

Staff at the Oral Health Initiative sites gathered quantitative baseline and follow-up data through structured interviews. Researchers developed survey instruments through a participatory process with staff at all sites, drawing from existing tools whenever pos-sible. The baseline interview, guided by this survey, was conducted in person when a patient enrolled in the study. Follow-up interviews were conducted at six, 12, 18, and 24 months via phone or in person. Baseline interview data included sociodemographic characteristics, mode of HIV transmission, and access-to-care barriers as defined by the IOM model. Variables related to structural barriers included the patient’s regular place for dental care, unmet dental need since testing positive for HIV, the last time the patient saw a dentist, and how long it took the patient to get to the first study-related dental appointment. Variables related to financial barriers included health insurance and dental insurance coverage. Variables to measure personal barriers included income, education level, language, patient hygiene practices, and risk behav-iors such as past and current substance, tobacco, and alcohol use, which could impact oral health outcomes. The interview also included items from validated and reliable standardized measures including the SF-8™ Health Survey to measure health-related quality of life21 and a brief oral quality-of-life scale.22 Research-ers pretested the baseline instrument at the sites and made slight modifications to items that needed more clarity. Follow-up interviews collected the same data except for sociodemographic characteristics that were not expected to change (e.g., age and race/ethnicity).

Data collection Study eligibility criteria included (1) self-reported HIV infection, (2) 18 years of age or older, (3) no routine or preventive dental care within the past 12 months, and (4) an initial study-related oral health visit within 45 days after completing the baseline interview. Baseline data collection occurred from May 1, 2007, through August 31, 2009. Interviewers at each site participated in a standard training program conducted by ECHO. Interviews were repeated every six months for up to two years and were conducted in both English and Spanish. All participants gave informed consent to participate.

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8 Research Articles


Each time an interview was conducted, staff collected patient clinical data, including the participant’s most recent CD4 cell count (measured in cells per cubic millimeter [cells/mm3]) and viral load from laboratory reports or medical charts, as well as detailed clinic visit data, dental utilization data, and information about oral health-related referrals. At each patient visit, sites reported whether or not the Phase I treatment plan was completed. Phase I treatment was defined as prevention, maintenance, and/or elimination of oral pathology that results from dental caries or periodon-tal disease.23 All follow-up interview, clinic visit, and utilization data collection ended on August 31, 2010. Data from all 15 sites were entered into a Web-based database hosted by ECHO. ECHO then cleaned and merged the data into a single multisite database.

AnalysisWe calculated descriptive statistics using SPSS® version 16.0.24 The results are categorized in the following manner: sociodemographics; description of HIV status and medical care and services; history of dental care and oral health symptoms; oral health practices; and physical, mental, and oral health status. Qualitative data collected about the program models were analyzed using case study methods.25

RESULTS

Program modelsThe Figure describes the program models, target popu-lations served, level of oral health care provided, and number of patients enrolled in the multisite evaluation at each site. Five programs (33%) were AIDS service organizations or community-based organizations, and six programs (40%) were hospital-based programs. The remaining four programs were Community Health Centers. Six programs (40%) were located in major metropolitan cities, four programs (27%) served both urban and rural populations, and five programs served rural communities. To increase access to oral health-care services, four programs (27%) incorporated a mobile dental unit and nine programs (60%) employed a dental care coordinator or dental case manager as part of their model.26 All programs served patients living with HIV, with a majority of programs targeting low-income populations and communities of color.

Sites provided a range of dental services that were categorized into four levels for the purpose of this study. Level I includes diagnostic and preventive services, such as oral exams, radiographs, dental prophylaxis (clean-ing), and fluoride therapies. Level II is inclusive of all treatment in Level I as well as restorative procedures

(fillings), simple extractions, nonsurgical periodontal care, night guards, management of common oral lesions associated with HIV disease, emergency care, and chair-side denture reline/repair. Level III is inclu-sive of Level II and adds removable prosthetics (com-plete and partial dentures), single-unit crowns, end-odontic therapy (anterior and premolar root canals), cast post and core build-ups, and laboratory denture repair/reline. Level IV includes all procedures of the previous level with the addition of fixed bridge work, periodontal surgery, biopsy of suspect lesions, molar endodontics, complex surgical extractions, implants, apicoectomy, and specialty care that is often referred to other providers. The total number of patients enrolled in the multisite evaluation study was 2,469.

Sociodemographics of the ECHO sample at baselineTable 1 describes the baseline demographic character-istics of the study sample at the time of enrollment. Participants ranged in age from 18 to 81 years with a mean age of 43.6 years. People who identified as black comprised 40.6% of the sample, followed by those who identified as white (33.2%). The majority of the sample was male (75.0%). Most study participants were born in the U.S. (81.8%) and reported English as their primary language (85.4%). The majority of patients (59.8%) reported living in their own home or apartment and had completed high school (33.4%) or schooling beyond high school (43.0%). More than half of the study participants reported either being unem-ployed (35.3%) or having a disability that prevented employment (32.8%). Most reported a monthly income of #$850 (55.7%); $850 per month was the federal poverty level for one person when this study began in 2006. When asked about current smoking status, 52.1% reported being current smokers. Regarding drug use, 39.9% reported having ever used crack/cocaine, while 3.3% reported using it in the past 30 days. In addition, 20.3% reported past use of crystal methamphetamine, with 2.7% reporting using it in the past 30 days. A minority (17.0%) of patients reported having some type of removable denture appliance at baseline.

Description of HIV status and medical care and services Among study participants, the mean number of years since testing HIV-positive was 10 years (Table 2). A small percentage of patients (10.9%) were newly diagnosed with HIV in the 12 months prior to their baseline interview. The majority of the study sample was engaged in HIV medical care at a health center or clinic (62.4%), a hospital or outpatient clinic (21.4%), or a private physician or group practice (13.7%), and

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Figure. Health Resources and Services Administration HIV/AIDS Bureau’s Special Projects of National Significance Oral Health Initiative: program models, May 2007–August 2010

Program name and location Program modelTarget population

served

Level of oral health care provideda

Number of patients

enrolled

AIDS Care Group, Chester, PA

ASO with a new satellite dental clinic in Coatesville, PA

PLWHA from communities of color in rural PA

Level IV 206

AIDS Resource Center of Wisconsin,Green Bay, WI

Milwaukee-based ASO with new dental clinic in Green Bay, WI

Uninsured and underinsured PLWHA in Green Bay and rural WI

Level IV 55

Community Health Center of Connecticut,Middletown, CT

CHC with new dental clinic in Norwalk, CT

PLWHA in Norwalk, CT, and surrounding areas

Level III 208

Harbor Health,Dorchester, MA

CHC expanding dental services at existing sites and creating a new clinic

PLWHA in the mid- and outer-Cape Cod areas

Level IV 74

HIV Alliance,Eugene, OR

ASO/dental hygiene school collaboration to treat HIV-positive patients and create rural dental satellite clinics

A diverse population of PLWHA in 15 counties in southern Oregon

Level IV 205

Louisiana State University,New Orleans, LA

University-based dental program incorporating an MDU

Underserved at-risk and HIV-positive patients of color in New Orleans

Level II 291

Lutheran Medical Center,New York, NY

University-based dental training program creating a satellite clinic in the U.S. Virgin Islands

PLWHA in the U.S. Virgin Islands Level IV 90

Montefiore Medical Center, Bronx, NY

University hospital-based dental program incorporating an MDU

PLWHA currently receiving medical care through Montefiore Medical Center’s CHCs

Level II 58

Native American Health Center, San Francisco, CA

Federally Qualified Health Center medical and dental program enhancing existing dental care with specialty care

PLWHA of color in the San Francisco Bay area

Level IV 99

Sandhills Medical Foundation,Jefferson, SC

CHC incorporating an MDU PLWHA in rural South Carolina at seven rural CHC locations

Level III 140

Special Health Resources of Texas, Longview, TX

ASO expanding oral health care at main site and two rural satellite clinics

PLWHA in rural east Texas Level IV 187

St. Luke’s-Roosevelt Hospital Center New York, NY

Hospital-based HIV medical and dental center expanding to satellite neighborhood clinics

PLWHA in New York City not enrolled in a hospital-based medical or dental program

Level IV 289

continued on p. 10

95.0% reported seeing their HIV clinician in the past six months. Values collected from laboratory reports or medical records indicated that 52.8% of the study sample had an undetectable viral load and 77.2% had a CD4 count of $200 cells/mm3. The range for a healthy CD4 count is 500–1,000 cells/mm3. A CD4 count of ,200 cells/mm3 is an indicator of an AIDS diagnosis.27 In addition, 77.9% of the study participants reported taking HIV antiretroviral medications. A majority of the study sample had an HIV case manager (85.2%); of those patients, 74.0% had been referred to dental care by their HIV case manager. Health insurance

coverage of this population varied. In total, 69.0% of participants reported having some sort of health-care coverage, either public (Medicaid or Medicare) or private. Medicaid was the primary insurance for 23.5% of the study sample (data not shown).

History of dental care and oral health symptomsTable 3 shows the baseline responses to questions related to the participant’s last dental visit, usual place for dental care, dental insurance, reasons for not getting dental care, oral health symptoms in the past 12 months, and presenting complaint at their

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Program name and location Program modelTarget population

served

Level of oral health care provideda

Number of patients

enrolled

Tenderloin Health Center,San Francisco, CA

Community-based organization working in collaboration with the San Francisco Department of Health to create a new dental clinic at the Tenderloin Health Center

PLWHA in San Francisco’s Tenderloin neighborhood, where there is a high rate of homelessness, substance use, and mental illness

Level IV 173

University of Miami,Miami, FL

University hospital-based program incorporating an MDU into an existing dental program

PLWHA in the Miami area Level II 265

University of North Carolina,Chapel Hill, NC

University hospital-based dental clinic expanding its services

Newly diagnosed HIV-positive patients in the Chapel Hill area

Level IV 129

aLevel I includes diagnostic and preventive services, such as oral exams, radiographs, dental prophylaxis (cleaning), and fluoride therapies. Level II is inclusive of all treatment in Level I as well as restorative procedures (fillings), simple extractions, nonsurgical periodontal care, night guards, management of common oral lesions associated with HIV disease, emergency care, and chair-side denture reline/repair. Level III is inclusive of Level II and adds removable prosthetics (complete and partial dentures), single-unit crowns, endodontic therapy (anterior and premolar root canals), cast post and core build-ups, and laboratory denture repair/reline. Level IV is inclusive of all procedures of Level III with the addition of fixed bridge work, periodontal surgery, biopsy of suspect lesions, molar endodontics, complex surgical extractions, implants, apicoectomy, and specialty care that is often referred to other providers.


AIDS 5 acquired immunodeficiency syndrome

ASO 5 AIDS Service Organization

PLWHA 5 people living with HIV/AIDS

CHC 5 Community Health Center

MDU 5 mobile dental unit

Figure (continued). Health Resources and Services Administration HIV/AIDS Bureau’s Special Projects of National Significance Oral Health Initiative: program models, May 2007–August 2010

first study-related oral health visit. Slightly more than half (52.4%) of the study participants reported being without oral health care for two or more years, and more than a third (38.6%) reported not having a regular place for dental care. Another third (31.0%) reported their usual place for dental care was a private dentist. When asked if there had been a time since testing HIV-positive during which they needed oral health care but were unable to get it, 48.2% responded “yes,” citing an inability to pay as the primary reason for not getting the oral health care (53.8% of those responding “yes”). Most participants (65.0%) had no dental coverage and 27.7% listed Medicaid as their dental coverage; dental coverage by Medicaid in some states is limited or does not exist.28

Participants were also queried about their oral health symptoms in the past 12 months. About half of the sample reported cavities/tooth decay (51.4%), sensitivity in their teeth/gums (49.9%), and dissatis-faction with the appearance of their teeth (49.5%). Toothache (43.1%), bleeding gums (35.4%), and bad breath (27.5%) were also frequently reported. Conversely, when asked at their first oral health visit

about their reason for the appointment, 66.4% cited a cleaning/checkup as opposed to a specific problem.

Quality of life and oral health practices The SF-8™ Health Survey (which stands for Medical Outcomes Study Short Form 8) measures two domains: physical health (four items) and mental health (four items). It is a reliable and valid measure of health-related quality of life. The SF-8 items were included in the baseline patient interview. As part of the SF-8 survey, participants were asked to rate their overall health in the past four weeks.21 As shown in Table 4, slightly more than half of participants (52.5%) rated their overall health as “good or fair,” and an additional 41.7% rated their overall health as “excellent or very good.” The physical health score is derived from the patient’s perception of his or her overall health, limitations due to physical health issues, difficulty with daily work due to physical health issues, and bodily pain in the prior four weeks. The mental health score is derived from the patient’s perception of personal energy, the impact of physical or emotional problems on social activity, the extent of being bothered by emotional problems, and

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the impact of emotional problems on daily life activi-ties. The mean physical and mental health scores for the SF-8 were 48.2 and 45.8, respectively. These scores were below the average score of 50.0 for each of the domains for the general population not living with a chronic illness.21

Questions related to patient perception of their oral health were also included in the baseline survey using a brief measure of oral health quality of life designed by Kressin et al.22 This model includes six domains: (1) physical function, (2) impairment and disease, (3) role functioning, (4) distress, (5) worry, and (6) denture use. In this study, we used an adapted measure that excluded the worry item. Patients were asked to use a four- or five-point scale to define their experience in the five domains. Two-thirds of the sample reported the health of their teeth and gums as “fair” (30.9%) or poor (32.3%). A third of participants (33.7%) reported they occasionally or fairly often avoided eating food in the past three months and 31.1% occasionally or fairly often found it difficult to relax due to the condition of their teeth and gums. When asked about distress related to teeth/gum pain, 43.7% reported a little or some distress and an additional 19.9% reported quite a bit or a great deal of distress. The majority of participants (76.8%) reported that problems with their teeth and gums did not impact their ability to take any medications, while an additional 20.3% reported not taking any medications (Table 2).

When asked about practices that affect oral health, 82.1% reported brushing daily in the past 30 days, 18.7% reported flossing daily in the past 30 days, 28.1% ate sugary candy or chewed gum with sugar 15 or more times in the past 30 days, and 41.9% drank soda with sugar 15 or more times in the past 30 days (data not shown).

DISCUSSION

The Oral Health Initiative provides valuable data about access to oral health care from the largest sample of PLWHA since the HCSUS. In relation to the IOM theoretical model used to design this evaluation study, these baseline results highlight several of the structural, financial, and personal barriers encountered by the individuals in our sample of HIV-positive patients, as well as their oral health status in the post-cART era. Of the 2,469 study participants, many of whom had been HIV-positive for at least a decade, 48.2% reported a time since testing positive in which they needed den-tal care but could not get it, with the majority citing inability to pay for oral health care as the main reason they did not get care. In addition, more than a third

Table 1. Descriptive characteristics for the ECHO study sample (n=2,469): SPNS Oral Health Initiative, 15 U.S. sites, May 2007–August 2009

Characteristic N Percent

Age in years (range: 18–81 years) (mean [SD]) 2,469 43.6 (9.8)Gender Male 1,853 75.0 Female 589 23.9 Transgender 27 1.1Race/ethnicity Black 1,003 40.6 White 819 33.2 Hispanic/Latino 524 21.2 Multiracial 68 2.8 Other 55 2.2Country of birth U.S. or U.S. territory 2,014 81.8 Other 448 18.2Primary language English 2,106 85.4 Spanish 317 12.8 Other 44 1.8Education No school 3 0.1 <High school diploma 569 23.5 High school diploma 808 33.4 .High school diploma 1,040 43.0Housing Lives in own home or apartment 1,474 59.8 Lives in someone else’s home or apartment

635 25.8

Temporary housing or homeless 354 14.4Employment Working full- or part-time 752 30.6 Unemployed 867 35.3 Disabled, not working 807 32.8 Other 32 1.3Income (monthly) #$850 1,347 55.7 $851–$1,700 827 34.3 .$1,700 241 10.0Substance use Alcohol use in the past week 793 32.1 Smoked in the past 30 days 1,277 52.1 Ever used marijuana 1,620 66.0 Marijuana use in the past 30 days 429 17.4 Ever used crack/cocaine 981 39.9 Crack/cocaine use in the past 30 days 81 3.3 Ever used crystal meth 497 20.3 Crystal meth use in the past 30 days 66 2.7Have removable denture appliances 419 17.0

ECHO 5 Evaluation Center on HIV and Oral Health



meth 5 methamphetamine

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Table 2. Description of HIV status and medical care and services for the ECHO study sample (n=2,469): SPNS Oral Health Initiative, 15 U.S. sites, May 2007–August 2009

Description of HIV status/care/service N Percent

Years HIV-positive (range: 0–29 years) (mean [SD]) 2,469 10.07 (7.2) Newly diagnosed (in the past 12 months) 270 10.9Usual place for HIV care Health center or clinic 1,537 62.4 Hospital outpatient center or clinic 527 21.4 Private physician or group practice 338 13.7 Other 36 1.5 No regular place for care 24 1.0Last time seen HIV care provider #6 months ago 2,285 95.0 .6 months ago 119 5.0Health insurance None 756 30.6 Any (including Medicaid/Medicare) 1,683 69.0Has an HIV case manager 2,086 85.2 HIV case manager referred for dental care 1,532 74.0Currently taking HIV antiretroviral medications 1,916 77.9Most recent CD4 count from patient charta

,200 cells/mm3 471 19.1 $200 cells/mm3 1,906 77.2Most recent viral load value from patient chart Undetectable 1,249 52.8 Detectable 1,116 47.2

aThe range for a healthy CD4 count is 500–1,000 cells/mm3. A CD4 count of ,200 cells/mm3 is an indicator of an AIDS diagnosis. Source: Department of Health and Human Services (US). AIDS.gov: understand your test results: CD4 count [cited 2010 Dec 13]. Available from: URL: http://aids.gov/hiv-aids-basics/diagnosed-with-hiv-aids/understand-your-test-results/cd4-count





mm3 5 cubic millimeter

AIDS 5 acquired immunodeficiency syndrome

of the sample reported not having a regular place for dental care and more than half reported their last den-tal visit occurred two or more years ago. These results are not so different from those reported by the HCSUS in which 35% of patients reported no usual source of dental care and 40% of the sample needed dental care but was unable to access it in the past six months. One difference is that only 24% of the HCSUS sample had not had a dental visit in two or more years.13,29

For a variety of reasons, PLWHA continue to face limited access to oral health care. Context for these findings can be provided by the 2009 National Health Interview Survey data, which show that 44% of U.S. adults had contact with a dentist in the past six months and an additional 17% in the past 12 months. Only 26% of the adult general population had not seen a dentist in two or more years.30 The two most influen-tial factors limiting access to care in the current study

appear to be a lack of dental coverage through either private insurance or public funding and the inability to pay for oral health care. A majority of the sample lives in poverty and is unemployed. Findings indicate that the majority of patients had no dental coverage and of those with dental coverage, 27.7% reported cover-age through Medicaid, although adult dental coverage through Medicaid varies by state. For those patients who reported Medicaid as dental coverage, 20.9% resided in a state that had no adult dental Medicaid coverage or only provided emergency dental services through Medicaid.

The 2,469 HIV-positive adults enrolled in the study were largely engaged in medical care and taking anti-retroviral medications, and the majority reported a visit with their HIV provider in the six months prior to their initial study interview. Almost two-thirds rated their oral health as “fair” or “poor” while rating their

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Table 3. History of dental care and oral health symptoms for the ECHO study sample (n=2,469): SPNS Oral Health Initiative, 15 U.S. sites, May 2007–August 2009

Dental care history/oral health symptom N Percent

Last dental visit ,1 year agoa 308 12.5 .1–2 years ago 868 35.2 .2–5 years ago 715 29.0 .5 years ago 510 20.6 Never 68 2.8

Usual place for dental care No regular place 933 38.6 Private dentist 751 31.0 Community Health Center 440 18.2 Dental school 132 5.5 Other 164 6.8

Dental insurance None 1,604 65.0 Medicaid 685 27.7 Private 117 4.7 Medicare 8 0.3 Other/don’t know 55 2.2

Since testing HIV-positive, have needed dental care but could not get it 1,189 48.2 Top reasons for not getting dental care Could not afford it 638 53.8 Could not find HIV-friendly dentist 102 8.6 Could not get an appointment or an appointment at a time I could make 69 5.8 Fear of pain, dentist, or finding out something was wrong 68 5.7 Did not want to go/had other/family responsibilities 63 5.3

Oral health symptoms in the past 12 months Cavities/tooth decay 1,270 51.4 Sensitivity in teeth/gums 1,233 49.9 Dissatisfied with appearance of teeth 1,221 49.5 Toothache 1,065 43.1 Bleeding gums 874 35.4 Bad breath 678 27.5

Reason for dental visit Cleaning/checkup 1,640 66.4 Teeth filled or replaced 632 25.6 Relief of pain 464 18.8 Denture work 333 13.5

aPatients had received only emergency oral health services in the past year.




overall health as “good” or “excellent” (94.2%). It is interesting to note that some study patients appeared to discount their oral health status when rating their overall health. There is clearly a disconnect between how patients view their oral health status in relation to their overall health. Past oral health symptoms such as tooth decay and sensitivity were reported by half of the sample. This is a vulnerable patient population, yet these individuals had not accessed oral health care in the past year or longer.

Through the Oral Health Initiative, two primary reported barriers to care for PLWHA—lack of dental coverage and the inability to pay for oral health care—were mitigated as a result of the HRSA SPNS funding. The Oral Health Initiative enabled sites to enroll PLWHA into their programs to receive free oral health care. However, minimizing that barrier did not create an instant demand for oral health care. The funded sites had to rely on their innovative programs and staff to actively recruit PLWHA into care. These efforts

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Table 4. Quality of life and oral health practices for the ECHO study sample (n=2,469): SPNS Oral Health Initiative, 15 U.S. sites, May 2007–August 2009

Evaluation/practice N Percent or mean (SD)

SF-8TM Health Surveya

Mental health score (MCS) 2,466b 45.8 (11.7)c

Physical health score (PCS) 2,466b 48.2 (10.1)c

Overall health in the past four weeks Excellent or very good 1,029 41.7 Good or fair 1,298 52.5 Poor or very poor 142 5.8

Oral health quality of lifed N Percent

Health of teeth and gums (self-rated) Excellent or very good 330 13.4 Good 579 23.4 Fair 763 30.9 Poor 797 32.3Avoided eating food in past three months due to condition of teeth/gums Never or hardly ever 1,638 66.3 Occasionally 491 19.9 Fairly often 340 13.8Found it difficult to relax in the past three months due to condition of teeth/gums Never or hardly ever 1,700 68.9 Occasionally 471 19.1 Fairly often 296 12.0Avoided going out in the past three months due to condition of teeth/gums Never or hardly ever 1,985 80.5 Occasionally 275 11.1 Fairly often 207 8.4Distress from teeth/gum pain in past three months None at all 899 36.4 A little bit or some 1,079 43.7 Quite a bit or a great deal 491 19.9Difficult to take medications because of problems with teeth/mouth Do not take medications 502 20.3 Not at all 1,894 76.8 Sometimes 61 2.5 Much of the time or always 9 0.4

aThe physical health score is derived from the patient’s perception of his or her overall health, limitations due to physical health issues, difficulty with daily work due to physical health issues, and bodily pain in the prior four weeks. The mental health score is derived from the patient’s perception of personal energy, the impact of physical or emotional problems on social activity, the extent of being bothered by emotional problems, and the impact of emotional problems on daily life activities. Source: Ware JE, Kosinski M, Dewey JE, Gandek B. How to score and interpret single-item health status measures: a manual for users of the SF-8 Health Survey. Lincoln (RI): Quality Metric Inc.; 2001.bThree patients from the ECHO study sample did not complete the SF-8 Health Survey.cThese scores were below the average score of 50 for each of the domains for the general population not living with a chronic illness. Source: Ware JE, Kosinski M, Dewey JE, Gandek B. How to score and interpret single-item health status measures: a manual for users of the SF-8 Health Survey. Lincoln (RI): Quality Metric Inc.; 2001.dSource: Kressin NR, Jones JA, Orner MB, Spiro A 3rd. A new brief measure of oral quality of life. Prev Chronic Dis 2008;5:A43.




MCS 5 Mental Component Summary

PCS 5 Physical Component Summary


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included the incorporation of dental case managers at several sites to engage patients in care and provide personalized support to get patients to appointments. Four sites used mobile dental units to take oral health-care services to locations more convenient to PLWHA. And all sites reported building relationships with staff, clinicians, and case managers at local infectious disease clinics, Community Health Centers, and AIDS service organizations to assist them in educating and informing patients about the importance of oral health care in relation to HIV infection, as well as to make referrals into the oral health-care programs.

LimitationsSeveral study limitations should be noted. This was a cross-sectional study of data collected from a conve-nience sample of HIV-positive patients enrolling in oral health care at 15 HIV dental clinics. Sites varied by geographic location, type of dental program, level of dental care provided, and patient recruitment methods. Although the results of this study are not generalizable to HIV-positive individuals nationally, the geographic diversity of this sizable sample affirms the utility of results. An additional limitation was that the sample comprised people who had not seen a dentist in the preceding year; thus, the results may be more relevant to those who have delayed or never accessed care compared with those who have been receiving oral health care. These data were collected using an interview instrument that was created through a par-ticipatory process. Elements of the survey, such as the SF-8 and the oral health quality-of-life measures, have been tested for reliability and validity; however, such testing was not the case for the entire survey. Finally, these data were based on self-report rather than dental examination. Sites did not collect a clinical assessment of symptoms, dentition, and the patient treatment plan.

CONCLUSIONS

Having a usual source of oral health care or “dental home” is an important predictor of use of dental ser-vices.31 Many HCSUS authors argued that the findings of the HCSUS research, conducted more than 10 years prior to the beginning of this study, would inform the public health, HIV, community health, and oral health professions to better respond to the oral health needs of the HIV population and improve access to services. The baseline results of this study identify a persistent unmet need for oral health care among this sample of PLWHA, a group that had not been engaged in dental care in the previous 12 months or longer. In the face of Medicaid cuts, particularly to adult dental services,32,33

and uncertainty about funding for comprehensive HIV care in relation to health-care reform, it stands to reason that this unmet need for oral health care will continue to grow if left untended.

The availability of health care, inclusive of oral health care, is fundamental for the attainment of gen-eral health; for vulnerable populations such as PLWHA, this care is especially a priority.34 It is the collective responsibility of HIV care providers and the research community, as well as the public health dental com-munity, to continue to support innovative models for increasing access to oral health care for HIV-positive patients—models that not only offer high-quality comprehensive oral health care, but also address the barriers to accessing oral health care identified in this article and in past studies. Comprehensive adult oral health care is a core component of quality HIV care and requires continued attention and funding from state and federal governments through Medicaid, the Ryan White HIV/AIDS Program,35 and Community Health Center programming.

The results presented in this article are from data collected at baseline interviews. This study was part of a larger longitudinal study, which also included col-lection of follow-up interview data and patient dental utilization data. Additional analyses will focus on find-ings related to the other domains of the IOM model, such as patient longitudinal changes and outcomes, as well as the types of oral health services provided. Future results will provide new insights into the implications for providing access to comprehensive oral health care to HIV patients as well as other vulnerable populations.

This study was supported by grant #H97HA07519 from the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA). This grant is funded through the HRSA HIV/AIDS Bureau’s Special Projects of National Significance program. The contents of this article are solely the responsibility of the authors and do not necessarily rep-resent the views of the funding agencies or the U.S. government.

This multisite research project was approved by the Institu-tional Review Board (IRB) of the Boston University Medical Campus 2006–2011. The study was also approved by the following participating sites’ IRBs: AIDS Care Group—Western IRB; AIDS Resource Center of Wisconsin—Human Research Review Committee with the Medical College of Wisconsin; Community Health Center, Inc.—Chesapeake Research Review, Inc.; Harbor Health—University of Massachusetts Medical School Commit-tee for the Protection of Human Subjects in Research; HIV Alliance—Western IRB; Louisiana State University—Louisiana State University Health Sciences Center IRB; Lutheran Medical Center—Lutheran Medical Center Health System IRB; Monte-fiore Medical Center—Montefiore Medical Center IRB; Native American Health Center—Independent Review Consulting Inc.; Sandhills Medical Center—University of South Carolina IRB; Special Health Resources for Texas—Liberty IRB, Inc.; St. Luke’s-Roosevelt Hospital Center—St. Luke’s-Roosevelt Hospital

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Center, Institute for Health Sciences IRB; Tenderloin Health Center—Independent Review Consulting, Inc.; University of Miami—University of Miami, Social and Behavioral IRB; and University of North Carolina—University of North Carolina at Chapel Hill Biomedical IRB.

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