A Resident-Led QI Project to Improve Dental Health at a Primary Care Pediatric Practice

Dental caries are the most common chronic condition of childhood.¹  In addition to increased risk of hospitalization, caries have been associated with poor growth, irritability, poor school performance, and school absences.^2,3  Fluoride varnish (FV) has been well studied as a means to reduce dental caries, with reduction rates as high as 25% to 45%.⁴  The American Academy of Pediatrics (AAP) and the United States Preventive Services Task Force recommend that primary care physicians (PCPs) apply FV every 3 to 6 months from tooth emergence through age 5.^5,6  Since almost 90% of infants and toddlers are up-to-date with the pediatrician, compared with only 1.5% with the dentist, PCPs can have an early impact on dental health and health care savings through application of FV.^7,8 

Practice-based learning and improvement is a core competency for residents, recommended by the Accreditation Council for Graduate Medical Education (ACGME). Many residency programs have incorporated quality improvement (QI) curricula to meet this competency in various forms, but experiential learning has been shown to be most effective in improving knowledge and effecting practice change.^9–16  For our resident-led QI initiative, we chose to implement FV application at our primary care clinic.

Based on resident experience and consensus, our primary aim was to increase FV application from 3.6% to 50% of patients ages 1 through 5 over the 2017–2018 academic year. Additionally, we aimed to increase the percentage of patients who had seen a dentist in the preceding 6 months from 30% to 50%, and to increase the percentage of dental referrals for patients who were overdue from 17% to 60%.

This study took place at the New York Presbyterian (NYP) Broadway Practice, 1 of 4 resident-led continuity clinics in Columbia University's Ambulatory Care Network (ACN), during the 2017–2018 academic year. In addition to weekly continuity clinic, all residents participate in a month-long ambulatory rotation. During this rotation, residents provide patient care in addition to leading the clinic's QI project.

As part of our resident-led QI curriculum, residents vote on an annual improvement project for their clinic site and participate in planning, implementation of plan-do-study-act cycles, data collection, and sustainability efforts. The senior resident on the ambulatory rotation leads the QI team, which includes residents, the clinic's designated QI attending, and the ambulatory director. At the end of the month, the residents report their efforts to the entire practice team, and the next month's team resumes the next phase of the QI process.

The NYP Broadway Practice is a community-based clinic in the Inwood neighborhood of Manhattan. We see an ethnically diverse patient population with a total of 4804 pediatric patients and 1866 patients ages 4 and under. The clinic sees approximately 13 000 patients yearly.

Patients were included in this study if they were ages 1 through 5, eligible for FV, and had a well care or follow-up appointment. Sick visits were excluded. Patients were eligible for FV if they had not visited a dentist in the preceding 6 months and did not have FV applied by another provider within the past month.

As part of standard QI methodology, we collected baseline data via chart review from May through August 2017. Included in our electronic health record are dental screening questions to identify children due for a dental appointment. We added features to document whether patients were referred to a dentist and whether FV was indicated and given at the visit. Each month we analyzed all eligible patient charts over the course of 1 week.

During this 4-month period, only 29% of patients (47 of 163) were up-to-date with dental appointments. Of those patients due for a dental appointment, only 17% (27 of 163) had a dental referral made and only 4% (4 of 112) had FV applied.

We utilized the Model for Improvement to implement changes aimed at improving our rates of FV application. The first QI team determined the aims of the project, ascertained the key drivers, or factors that contribute directly to achieving those aims, and suggested interventions that might improve those factors (figure 1). The interventions were focused on the following key drivers that are summarized in the table.

Columbia University dental residents provided face-to-face lectures using the AAP oral health curriculum to all the clinic's preceptors who then led sessions for the residents during continuity clinic.¹⁷ 

We surveyed providers to identify obstacles that prohibited their ability or desire to apply FV, notably insufficient time, workflow concerns, patient or family refusal, and uncertainty regarding how to educate and counsel families. By engaging physicians in this exercise and beginning to address these barriers, buy-in significantly improved. We sent monthly email updates about the project and placed reminder cards on all the computer desktops. We also distributed report cards informing each provider of their personal rates of FV application.

One major barrier was that providers had to leave the patient room to collect FV before applying it. Based on chart reviews of patients' dental homes, we learned that only 33% (14 of 42) of our patients ages 1 to 3 had been to a dentist in the past 6 months, compared to 64% (25 of 39) of patients ages 3 to 6. Because of this discrepancy, we decided to prioritize our efforts on the younger population. We recruited medical assistants (MAs) to supply FV to providers prior to all visits for patients ages 1 to 3, serving as a reminder for providers to apply FV while making the process more efficient.

One of our secondary aims was to improve referral rates so our patients could establish a dental home. Despite our low baseline rate of 17% of referrals made, 85% (17 of 20) of providers believed it was important to refer to the dentist. We learned it was difficult to make referrals within the institution due to lack of appointment availability, so we partnered with the Section of Population Oral Health at Columbia to ensure there would be twice-weekly availability for urgent referrals. Our electronic health record was updated to triage referrals based on the time window in which the patient needed to be seen. We developed a bilingual community dental referral sheet, and support staff stocked these in every patient room.

Parents were unaware of the dental health recommendations for young children. Bilingual educational signs were placed in the waiting and patient care rooms. We included FV application instructions in after-care summaries and on the back of the referral sheets.

Quality issues with the FV temporarily limited our clinic supply, which led to decreased application rates. Within approximately 1 month, a new formulation of FV was restocked in the clinics.

Our primary outcome was the application of FV and our secondary outcome was the percentage of patients up-to-date with dental appointments. Our process measure was the percentage of dental referrals made for patients overdue for an appointment. Balancing measures included time taken away from other clinical priorities as well as reimbursement rates; however, they were not tracked during this initiative.

This study was approved by the Columbia University Human Research Protection Office Institutional Review Board.

During this study 323 eligible patients were included with an average of 27 patients per month. The run chart documents plan-do-study-act cycles and their relation to FV application (figure 2). By April 2018, we improved our primary outcome (FV application) from 3.6% to 44% with a peak of 54%. The percentage of patients under 6 years who had seen a dentist in the preceding 6 months increased from 30% to 47%, and the percentage of dental referrals increased from 17% to 33%.

Improvements in FV application were seen with each intervention, though some had greater effects than others. The improvement seen after the educational sessions gave an initial increase to 35% but was found to be short-lived. A decline in rates occurred when the quality of FV made it unusable, and during the holidays when fewer residents were present in clinic, as they were the early adopters and more likely to apply FV than attendings. The interventions with the greatest impact were providing performance feedback report cards to providers and recruiting MAs to supply FV for patients ages 1 to 3. These 2 interventions increased FV application from 21% to 54%. As a result of this study, all continuity clinics within our ACN were stocked with FV, and FV application became part of routine patient care.

After 12 months of QI interventions, we improved our rates of FV application from 3.6% to a peak of 54%. Resident-led QI initiatives can lead to significant change in primary care practices and improved resident knowledge in QI methodology, which has been well documented in the literature.^10,11,13,14  Through this longitudinal QI curriculum, our residents have been engaged and enthusiastic about QI, particularly when applying evidence-based medicine and guidelines such as the AAP's recommendation for PCPs to apply FV. By providing residents with the tools and support to develop and implement a QI project such as this one, they can improve their knowledge and skills through experiential learning and impart meaningful clinical change.

One of the interventions with the greatest impact on FV application was recruiting MAs because it improved efficiency and overall staff buy-in for the project. We hypothesize that expanding this initiative to have MAs or nurses apply FV rather than physicians may further increase rates of application, but laws dictating which providers can apply FV vary by state. Additional lessons learned from each intervention can be found in the table.

One of our balancing measures is reimbursement, and we found that applying FV in the primary care setting can be cost-effective. Each FV applicator cost approximately $1, and Medicaid reimbursement rates range from about $15 to $40 per application.¹⁸  Additionally, preventing hospitalization for severe dental caries can have significant cost savings for the family, the hospital system, and state health care programs.⁸ 

We do not have data on this project's sustainability past the 1-year time frame, though we have attempted to ensure its acculturation by stocking FV in all our ACN clinics and training interns in FV practices. We also use the process measure of making a dental referral in place of clinical outcome data. Future efforts should determine whether these interventions result in biannual routine dental care and reduction in dental caries.

This resident-led QI project increased rates of FV application, dental referrals, and dental visits while meeting ACGME guidelines for experiential learning in QI. Medical assistants supplying fluoride to providers for patients ages 1 to 3 was the most effective intervention. By applying FV and increasing the percentage of young children who have established a dental home, PCPs can have a meaningful impact on their patients' dental health.