Ryan White CARE Act Title I Dental Impact Evaluation and Cost Effectiveness

1. Ryan White CARE Act Title I Dental Impact Evaluation and Cost Effectiveness Julia Hidalgo, ScD, MSW, MPH Amanda Benedict, MA Positive Outcomes, Inc. Carol M. Stewart, DDS, MS Department of Oral and Maxillofacial Surgery and Diagnostic Sciences University of Florida College of Dentistry

2. Acknowledgements Stephen Abel, Julia Ali-John, Lidia Alonso, Curtis Barnes, Debbie Cochrane, Susan Dunmore, William Green, Marlinda Quintana-Jefferson, Sharanda Richardson, James Riley, Sharon Rohoman, Michele Rosiere, Rita Volpita, Deloris Williams, Perminder Wadhwa, Marisol Hidalgo

3. No Broward County patients’ or dental providers’ images were used in this presentation

4. Project Goals and Objectives • Determine the cost effectiveness of Broward County EMA CARE Act Title I dental services • Compare Broward Title I with other EMAs to measure dental expenditures, procedures covered, reimbursement rates, and average costs of routine and specialty care • Determine cost and utilization by analyzing FY 2004-2005 claims data • Evaluate the impact of dental services on HIV+ Broward County residents • Use chart review to measure the extent to which standards and outcomes were achieved • Use surveys and focus groups to determine client perceived barriers to access and retention in dental care • Determine client perceived barriers accessing general and special dental care • Determine overall effectiveness, as measured by client impact, of dental services • Determine the relationship of cost effectiveness and client outcomes in the EMA

5. Project Tasks • Update literature review • Cost-effectiveness of HIV oral health • Best practices in delivering and financing HIV oral health services • Identify CARE Act grantees that fund HIV oral health services • Obtain information about their cost-effectiveness studies • Identify their best practices regarding delivering and financing HIV oral health • Measure the cost and utilization associated with Broward County Title I-funded HIV clinics • Conduct chart review at Title I-funded HIV clinics to assess the extent to which standards and outcomes were achieved • Determine the relationship between cost-effectiveness and client outcomes associated with Title-I funded HIV clinics • Assess HIV+ Broward County residents’ perceptions of barriers to access and retention in HIV primary and specialty oral health care

6. What are the benefits of oral health treatment for HIV+ patients?

7. Importance of HIV Oral Health Care • Oral conditions are important markers in the clinical spectrum of HIV infection • Conditions such as aphthous ulceration and candidiasis indicate acute seroconversion illness • Conditions such as candidiasis, hairy leukoplakia, KS, and necrotizing and ulcerative gingivitis suggest HIV infection in undiagnosed individuals • For those individuals in advancing stages of HIV infection, candidiasis and hairy leukoplakia indicate clinical disease progression and predict development of AIDS • Immune suppression in HIV+ individuals is associated with candidiasis, necrotizing periodontal disease, long-standing herpes infection, and major aphthous ulcers • Perinatally infected children have a greater rate of caries than their siblings, particularly with advancing HIV disease • Due to the association between HIV infection and oral conditions, CDC and other staging systems for HIV disease progression include oral conditions

8. Importance of HIV Oral Health Care • Early recognition and management of oral conditions associated with HIV infection are important in sustaining the health and quality of life of HIV+ individuals • Oral care early in the course of HIV infection can help to prevent or slow wasting • Access to oral care is important in aiding proper nutrition for HIV+ individuals • With the advent of HAART, the ability to sustain proper nutrition and to swallow medication is critical in achieving the optimal benefit of HAART and adherence to medication regimens • Among the almost oral conditions that can occur in HIV+ individuals • All of the conditions may be seen or palpated during physical examination and produce subjective symptoms that are noticeable • Medication is effective in treating many of these conditions • HAART treatment failure can be detected through dental exam • HAB considers dental care to be so beneficial to HIV+ individuals that it is considered a “core service”

9. Access to HIV Oral Health Services is a National Problem • Despite the importance of access to quality oral care, large numbers of PLWH have an unmet need for HIV oral health care • Data from the longitudinal Health Care Services Utilization Study (HCSUS) initiated in 1996 assessed barriers to accessing dental services • Oral infections, mouth ulcers, and other severe dental conditions associated with HIV infection are more than twice as likely to go untreated as other HIV-related health problems • Less than one-half (42%) of respondents had seen a dental health professional in the preceding six months • African-Americans, individuals whose exposure to HIV was caused by hemophilia or blood transfusions, persons with less education, and employed individuals were less likely to use dental care than their counterparts • 19% of HIV-infected medical patients had perceived unmet need for dental care in the last six months

10. Access to HIV Oral Health Services is a National Problem • Individuals most likely to have unmet dental needs included Medicaid beneficiaries in states without dental benefits, individuals with no dental insurance, the very poor, and individuals with less than a high school education • 65% of respondents with a usual source of dental care had used that service in the preceding six months • Use of dental care was reported to be greatest among patients obtaining dental care from an AIDS clinic (74%) and lowest among individuals with no usual source of dental care (12%) • Medicaid enrollees report significantly more unmet dental need compared with privately insured patients • 14% of HIV patients had unmet dental needs in the six months, compared to 9% of the general population

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

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

13. Learning From Other CARE Act Grantees • POI contacted by telephone Title I and Title II grantees spending over $500 K in direct service funds for HIV dental services • Asked if they had assessed dental cost-effectiveness, the methods used to pay for dental services, and how services were organized • Similarly, Dental Reimbursement Programs (DRPs) were contacted by email • Published articles and reports were searched • HAB dental expert also queried

14. Learning From Other CARE Act Grantees • No grantees contacted reported conducting cost-effectiveness or cost-benefit studies related to the HIV oral health services they purchased • Several approaches taken by Title I and Title II to purchase dental services • University or community-based dental providers were funded; grantees tend to have a small number of contractors • Tend to pay for general dental services, several also purchase special dental services • Standard dental fee schedule, Medicaid payment rates (with slightly higher payments), negotiated rates, “cost-based” reimbursement, fund FTEs • Fee schedules variably updated

15. What is the utilization experience of Title I-funded HIV oral health services and related expenditures?

16. Title I Funded HIV Dental Clinics Nova Southeastern University College of Dental Medicine, S University Drive, Ft Lauderdale Paul Hughes Health Center Dental Clinic,NW 6th Ave, Pompano Beach Northwest Health Center Dental Clinic, NW 15th Way, Ft Lauderdale Children’s Diagnostic and Treatment Center Dental Clinic, S Federal Hwy, Ft Lauderdale South Regional Health Center Dental Clinic, Pembroke Rd, Hollywood

17. Accessibility of Title I Funded HIV Dental Clinics General dental clinic services are geographically accessible Distributed throughout Broward County For the most part, they are located near major freeways and bus lines Specialty services are available at Nova or community-based dental specialists Two of the five clinics are co-located with medical clinics NOVA is adding a new site co-located at Center One Dental clinics do not have evening appointments

18. HIV Dental Clinic Utilization • 2,738 HIV+ Broward County adult residents received regular dental visits at Title I-funded BCHD clinics between December 2002 through June 2005 • This represents 25% of the estimated 10,748 HIV+ Broward County residents “in care” • An average of 3.7 regular visits per adult patient (median=3 visits), with total visits ranging from 1 to 31 visits • 363 HIV+ Broward County residents received specialty dental services, with an average of one visit per patient • Total visits per patient ranged from 1 to 3 visits • Inconsistent data coding and missing data prevented analysis of differences in use or expenditures by age, gender, race, ethnicity, income, or HIV dental clinic • Data were not transferred from dental records

19. What are the expenditures associated with Title I-funded regular and specialty dental services? Payments through June 2005 • Title I paid $128 per regular dental visit during the study period • An average of $526 was spent per patient during the study period (median=$408), with expenditures ranging from $128 to $4,237 • An average of $791 was spent per patient (median=$800) for specialty dental services, with expenditures ranging from $42 to $8,050

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

21. What are HIV+ Broward County residents’ perceptions of barriers to access and retention in HIV general and specialty oral health care?

22. Consumer feedback is being sought through two methods • A focus group will be convened on February 22nd at 6 pm at BRHPC • HIV+ consumers receiving dental service purchased by Title I, dental insurance, or other mechanisms are encouraged to participate • Refreshments and compensation will be provided • Call Michelle Smith to sign up for the group • A survey is being conducted via Internet, paper survey, POI interview, or case manager-assisted survey

23. Focus Group Questions • Why is dental care important to HIV infected Broward County residents? • To what extent are community dentists in Broward County willing to treat HIV infected adults? Children? • What barriers do HIV infected Broward County residents experience in getting dental care from community dentists? Nova Dental School? County-operated dental clinics? • To what extent does the cost of dental insurance act as a barrier to HIV infected Broward County residents? • To what extent do out of pocket payments for dental care act as a barrier to HIV infected Broward County residents? • How can access to HIV dental care in Broward County be improved? • What is the perception of HIV infected Broward County residents about the quality of dental care they receive? • In what ways can the quality of HIV dental care in Broward County be improved?

24. Survey Design • A convenience sample of HIV+ Broward County residents is being used due to absence of systematic gathered data to identifying survey subjects • Flyers were posted at all Broward County HIV counseling and testing, treatment, case management, and support programs • 1,000 individual postcards about the survey are being distributed at these sites • The Planning Council and Committees were notified about the survey • The Case Management Network was notified about the survey • The survey’s design is based on HCSUS, a federally-funded nationally representative survey of HIV+ adults initiated in 1996 • National results are available to serve as benchmark data via special analysis being conducted by federal researchers • Surveys may be completed via Internet, by telephone, via case managers’ assistance, or by paper survey • 12 surveys had been submitted by February 10th

25. What is the quality of dental services provided by Broward County Title I-funded dental clinics?

26. Chart Review Process • POI entered into a Business Associates Agreement to be allowed to do chart review • The dental standards were reviewed to design the chart review form; with additional items added by Dr. Stewart, the project’s dental consultant • Study period: March 2004 – February 2005 • Reviews were conducted at three of the four BCHD HIV dental clinics: Paul Hughes HC, Northwest HC, South Regional HC • Charts were not reviewed at CDTC (only 12 patients in the study period) or Nova (not contracted during the study period) • CHD staff created a data file containing records for 1,628 dental patients served in the study period • A random sample of the records was created to assist chart pull by BCHD dental records staff; the first 45 charts on each clinic’s random sample list

27. Chart Review Process • A target of 30 randomly selected charts was set per clinic to ensure statistically significant, generalizable results • 15 additional charts were randomly selected in case charts were unavailable or the patient was treated outside the study period • Dr. Stewart and Dr. Hidalgo reviewed 92 charts • Data were entered into an entry screen from the chart • SPSS was used to analyze the chart data • A draft report was prepared, with clinic-specific findings noted • The report findings were reviewed with BCHD staff; with Dr. Stewart providing peer TA • The final report provided summary findings, with blinded results for the three individual clinics

28. Intake form complete? Name, SSN, address, birth date, gender, race/ethnicity Primary care MD’s name and contact information complete? HIV+ status, income, and Broward County residency documented? Emergency contact identified? Signed consent for treatment? Patient’s Rights Statement received and HIPAA compliance documented? Signed releases for all referrals made and all disclosures of confidential patient information to a third party? Progress notes are current, legible, signed, and dated? Chart organized and orderly? Progress notes address treatment plan goals? Treatment plan, contains measurable goals, objectives, and time frames for achievement? Treatment plan complies with treatment guidelines? Is patient’s medical history recorded and updated at least every six months? Allergies, special conditions, current meds, CD4+ value, white blood cell count, platelet count, hepatitis C status, TB status, medical clearance for treatment? Patient referred to specialist documented? Documentation of OI exam, soft tissue exam, head and neck exam, gingival and periodontal structure, hard tissue? Patient received preventive education on oral techniques and self-care? If appropriate, patient received nutrition counseling and tobacco cessation counseling? Chart Review Items

29. Chart Review Items • Preventive fluoride program, if appropriate? • Is patient’s oral hygiene level noted? • Frequency of follow-up visits documented in the treatment plan? • Was the dental note written? • Within 24 hours of the visit? Within 48 hours of the visit? • No documentation? • All dental notes appropriately signed? • Patients with more than one visit have a dental treatment plan recorded in the dental record? • Patient will complete their initial treatment plan (Phase I) within six months? • Discharge date and discharge plan follow-up or discharge summary? • Procedures performed (surgical or routine extraction)? • X-ray of diagnostic quality? • Any complications?

30. Chart Review Findings: Considerations for Dental Record Staff • Most dental charts recorded patient identifying information • All dental charts recorded patient name, Social Security number, address, telephone number, and birth date • Primary care MD’s contact information was recorded in 85% of charts • Documentation of income and Broward County residency was included in almost all charts • Case management referral forms tended to be the source of dental clinic referrals; these forms were not updated • Referral forms were not completed uniformly by the referring case manager • Check off items, such as receipt of a signed release of patient information, were not completed uniformly • No updated case management referral forms were included in patient charts, including patients served for several years • 12% of patients did not have emergency contact information listed in their files • Most dental charts contained all of the relevant legal forms

31. Chart Review Findings: Considerations for Dental Personnel • All reviewed charts documented a treatment plan with measurable goals, objectives, and a timeframe for completion • Medical history was recorded and updated at six month intervals for almost all patients • Allergy information was noted in almost all charts, special conditions were noted for 67% of patients, and current medications were listed for 82% of patients • 52% of dental charts included documentation of patients’ CD4+ values • Some charts contained CD4+ counts that were obtained one to two years before the review period • Only 11% of dental charts included documentation of Hepatitis C status; a question regarding Hepatitis C was not included on the medical history form • Platelet and white blood cell count and TB infection status were in almost all charts, as was medical clearance for dental treatment

32. Chart Review Findings: Considerations for Dental Personnel • All treatment plans complied with published treatment guidelines • Almost all progress notes addressed the treatment plan goals • Less than one-half (44%) of all treatment plans’ progress notes met one or more of the “current, legible, signed, and dated” criteria • Almost all charts documented OI exams, soft tissue exams, head and neck exams, gingival and periodontal structure exams, and hard tissue exams • Of the 21 patients who were referred to a specialist, 71% had referral follow-ups documented in their files

33. Chart Review Findings: Considerations for Dental Personnel • The level of oral hygiene was noted for most patients • The dental hygienist seemed very conscientious in providing debridements, appropriately recording the patient’s level of home care, and consistently recording oral hygiene instruction provided to patients • The treatment plan contained documentation of the frequency of follow-up visits for almost all patients • Dental notes were written and included in all dental charts, and were written within 24 hours of the visit • However, complete signatures were not present on all dental notes; 78% of dental notes were only initialed • Almost all patients had more than one visit and had a treatment plan noted in their dental records • 77% of patients will have completed their initial treatment plan (Phase I) within six months • Nearly two-thirds (65%) of patients’ care ceased without formal discharge from care • Patients tended to fail to return for care and no follow-up inquiry was apparent

34. Chart Review Findings: Considerations for Dental Personnel • Extractions were noted in more than one-third (35%) of charts, with 31% of these patients (10 patients) having surgical extractions and 75% having routine extractions performed • X-rays of diagnostic quality were present in 84% of dental charts • No treatment-related complications were reported for any of the charts reviewed • Preventive education on oral techniques and self-care was administered to 91% of patients • Inquiry about tobacco use was not included on the medical history form; very low percentages of patients received tobacco cessation counseling (7%) • Nutrition counseling did not appear to be a standard practice and was not noted for any patients

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

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

37. Recommendations • Revise the patient intake form • The conceptual approach to the treatment plan and progress notes should be revised to better capture temporal flow • Record current or a past history of hepatitis C and current or past history of hepatitis B infection • Blood pressure readings should be a part of the baseline medical history and should be added to the intake process • The accepted standard of care in dentistry is to take the patient’s blood pressure at the initial appointment and at subsequent appointments • This procedure can be done by a trained auxiliary • It is especially important before any procedures that utilize local anesthetic, such as restorative, surgical, and some periodontal procedures • Tobacco cessation and nutritional counseling • The medical history should be modified to include those items • The medical clearance form should include CD4+ count, along with blood values for platelets, white blood cell count, and TB

38. Recommendations • A review of the medical history immediately before a dental extraction is important to help avoid undesirable outcomes such as drug interactions, prolonged bleeding, delayed healing, or infections • Such a review was recorded infrequently in the treatment or progress notes associated with dental extractions • Although the charts reviewed documented that a gingival and periodontal exam were completed, evidence of the results of that exam was difficult to confirm • Infrequently a periodontal screening exam (PSR), or a periodontal charting was found regarding attachment loss or periodontal pockets, bleeding upon probing, or tooth mobility • A periodontal diagnosis determined by the dentist, needed to support the periodontal therapy provided, was not found readily in the charts

39. Recommendations • The majority of HIV seropositive patients report discomfort from xerostomia (i.e., “dry mouth”) • This is a condition makes chewing, swallowing, and speaking more difficult, putting HIV seropositive patients at much higher risk for dental decay • Consequently, it is very important for the dental team to suggest ways to improve oral comfort through strategies to improve salivary flow such as sugar free gums, lozenges, and fluids • Efforts to minimize the patient’s susceptibility to dental decay are also important • The dental team should encourage patients to use a fluoride regimen appropriate for the particular individual • This might include an over-the-counter alcohol-free fluoride rinse, fluoride home treatments, or prescription fluoride gels • Documentation of these issues was absent from most charts. If these concerns were discussed with patients, a chart entry would be appropriate

40. Are dental services purchased with Broward County Title I funds cost-effective?

41. What are HAB’s expectations regarding cost-effectiveness? • Title I grantees should be able to compare the relative costs of providing a specific service among different providers • This necessitates having service standards, service units, and unit costs for each service • Quality of service is also a factor in determining cost effectiveness and needs to be considered both in selecting providers and in monitoring Quality Management programs • Planning councils need cost-effectiveness data to determine how to prioritize services and allocate funds • This is closely tied to outcomes evaluation in that services with better outcomes may be more costly but nonetheless more cost effective when outcomes are considered • Also important to consider is the way services are provided • For example, bus passes may be cheaper but not as effective in assuring access and maintenance in care as taxi vouchers Ryan White CARE Act Title I Manual

42. Outcomes are benefits or results (positive or negative) for clients that may occur during or after program participation Outcomes can be classified as initial, intermediate, and longer-term based on how soon they occur after program participation begins What are outcomes? Ryan White CARE Act Title I Manual

43. Using HAB’s framework, what is known and unknown about the cost-effectiveness of Title I- funded HIV oral health services? *Ryan White CARE Act Title I Manual

44. What is cost-effectiveness analysis (CEA)? • CEA compares the relative value of current versus new strategies • Commonly in CEA, a new strategy is compared with current practice (the "low-cost alternative") to calculate a math term, the cost-effectiveness (CE) ratio: • The result is the "price" of the additional outcome purchased by switching from current practice to the new strategy (e.g., $10,000 per life year). If the price is low enough, the new strategy is considered "cost-effective"

45. How should we interpret the results of cost-effectiveness analysis (CEA)? • CEA is only relevant to certain decisions • CEA is relevant only if a new strategy is both more effective and more costly (or both less effective and less costly) • If a strategy is cost-effective, the new strategy is a good value. • It does not mean that the strategy saves money • Just because a strategy saves money does not mean that it is cost-effective • The concept of cost-effective requires a value judgment—what you think is a good price for an additional outcome, someone else may not

46. Applying CEA to the Broward County Title I deliberations regarding purchasing of dental services • From a CEA perspective, POI considered whether the general and specialty dental services are effective versus other dental services • No other dental treatment modalities can be substituted for the service now provided (i.e., there is no “new” service to substitute for current dental practice) • This is similarly the case for the specialty services purchased • Alternatively, non-dental services might be substituted instead to address other clinical and psychosocial service needs of patients • These services cannot address the oral health needs of Broward County HIV+ indigent residents

47. Are dental services purchased with Broward County Title I funds cost-beneficial?

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

49. Cost-Benefit Assessment: Key Concepts • Costs • Direct costs: expenses associated with paying for a service (e.g., regular dental visits) • Indirect costs: the cost not directly attributable to the manufacturing of a product • Opportunity costs: the cost of passing up the next best choice when making a decision (e.g., the cost of purchasing dental services versus another service category • Benefits • The directly measured dollar value of the tangible benefits of goods or services • Indirectly measured dollar value of the tangible benefits of good or services • Indirect benefits for which dollar value are not directly measurable

50. Detection of HIV infection associated with HIV infection Reduce the presence of bacteria, thus reducing strain on the immune system Dental exams can assist HIV medical management Detection of oral OIs and other conditions may point to HIV disease progression HIV dental exams can be used to detection OIs associated with failure of HAART or lack of adherence to HAART Reduction of systemic infections patient Identification of salivary gland disease and oral warts associated with HIV infection Treat dry mouth associated with antiretrovirals Treat conditions that exacerbate wasting Ensure that medication can be swallowed Treat conditions that inhibit swallowing, chewing of food, and speaking Reduction or elimination of head and neck pain Reduce or delay disability Improve quality of life Indirect benefits of oral health services