Variation in VA Dental Procedures
Judith A. Jones DDS MPH DSc
VA New England Health Care System
Bedford, MA
Funding Period: October 1999 - September 2003

BACKGROUND/RATIONALE:
VA strives to provide appropriate, accessible, high-quality, and effective health care to the nation’s veterans.

OBJECTIVE(S):
Our research seeks to understand reasons for variation in dental care in VA by addressing four specific research objectives: (1) determine variation in rates per 1000 dental care users, of dental extractions and root canal therapy in VA, and in the proportion of these two target procedures that are root canals; (2) describe patient characteristics associated with the decision to extract teeth versus those associated with root canal therapy; (3) examine whether there are important differences in the approach to dental care (rates of extractions versus root canal therapy) in VA according to provider and structural characteristics; and (4) determine whether there are variations in procedure rates after adjusting for patient, provider and structural characteristics.

METHODS:
We conducted a retrospective study in 54,423 users of outpatient VA dental care who had either root canal therapy or a tooth extraction at a VA facility in FY 1998. We examined rates of root canals [#root canals/(#root canals + #extractions)] in users of VA outpatient care. Data sources included the VA outpatient clinic file (sociodemographic data, VISN, medical dental ICD-9 codes, CPT codes) and the VA Dental Activity System (dental eligibility). The unit of the analyses was the visit. Root canal rates were calculated by VISN and emergency versus regular visits. Logistic regression modeled root canal rates, adjusting for dental care eligibility (emergency vs. regular visit), VISN, and medically appropriate factors affecting the chance of a root canal (dental diagnoses and comorbid medical diagnosis-Charlson index, schizophrenia, and alcoholism).

FINDINGS/RESULTS:
Current findings address the effects of provider and structural characteristics from objectives 3 and 4. We hypothesized that younger providers who graduated from dental school more recently, and who are specialists, i.e., endodontists are expected to prefer root canal therapy as the treatment choice. In our first model we adjusted for dental disease severity and the existence of other medical conditions that are expected to have an impact on the clinical decision to treat with root canal therapy. A high Charlson index (OR 95% CI=0.63,0.79), a diagnosis of alcohol dependence or abuse (OR 95% CI=0.57,0.66) and specific dental conditions reduces the likelihood of having a root canal. Once we introduced patient characteristics, in model 2, we found that emergency care visits (OR 95% CI=0.02,0.03), other dental eligibility (OR 95% CI=0.50,0.56), African American race(OR 95% CI=0.71,0.83), and being male decreased the likelihood of root canal therapy after dental disease severity, medical and psychiatric comorbidities had been adjusted, whereas female gender (OR 95% CI=1.3,1.6)and income (OR 95% CI=1.01,1.02) increased odds of root canal therapy. The next logistic regression model adds facility characteristics to the model. After dental, medical, and psychiatric comorbidities and patient characteristics are controlled, visits at dental teaching facilities of small (OR 95% CI=1.4,3.2), medium (OR 95% CI=1.4,3.0) or large size (OR 95% CI=1.7,4.2) are significantly associated with an increased likelihood of root canal therapy. Our final model examined whether provider characteristics are associated with the odds of obtaining root canal therapy even after all other factors have been controlled. In this adjusted model, only the proportion of endodontists is significantly associated with root canal therapy (OR 95% CI=1.0,3.0), whereas the availability of dentists, provider age, female providers, and years since graduation had no significant positive or negative impact on the provision of root canal therapy. This manuscript is under preparation.

IMPACT:
VA studies of the quality of dental care should employ risk-adjusted models. Our results suggest that there is substantial variation in quality of care between VISNs.

PUBLICATIONS:

Journal Articles

1. Jones JA, Kressin NR, Miller DR, Orner MB, Garcia RI, Spiro A. Comparison of patient-based oral health outcome measures. Quality of Life Research. 2004; 13(5): 975-85.
2. Kressin NR, Boehmer U, Berlowitz D, Christiansen CL, Pitman A, Jones JA. Racial variations in dental procedures: the case of root canal therapy versus tooth extraction. Medical Care. 2003; 41(11): 1256-61.
3. Jones JA, Orner MB, Spiro A, Kressin NR. Tooth loss and dentures: patients' perspectives. International Dental Journal. 2003; 53(5 Suppl): 327-34.
4. Jones JA, Boehmer U, Berlowitz DR, Christiansen CL, Pitman A, Kressin NR. Tooth retention as an indicator of quality dental care: development of a risk adjustment model. Medical Care. 2003; 41(8): 937-49.
5. Boehmer U, Kressin NR, Berlowitz DR, Christiansen CL, Kazis LE, Jones JA. Self-reported vs administrative race/ethnicity data and study results. American Journal of Public Health. 2002; 92(9): 1471-2.
6. Jones JA, Spiro A, Miller DR, Garcia RI, Kressin NR. Need for dental care in older veterans: assessment of patient-based measures. Journal of The American Geriatrics Society. 2002; 50(1): 163-8.

DRA: Chronic Diseases
DRE: Communication and Decision Making, Quality of Care, Resource Use and Cost
Keywords: Behavior (provider), Chronic disease (other & unspecified), Practice patterns
MeSH Terms: none