Original Contributions
Sealants
Feasibility and usability of measuring receipt of sealants in 2 states

https://doi.org/10.1016/j.adaj.2019.05.022Get rights and content

Abstract

Background

The authors examined the reliability and validity of the Dental Quality Alliance childhood sealant measure under actual use conditions in Texas and Florida. The 2 states provide care for almost 20% of children in Medicaid nationally.

Methods

The authors used dental claims data to examine the reliability of the caries risk assessment component of the measure. They examined validity using a 3-year look-back period to identify children who were inaccurately included in the measure denominator as sealant eligible when they were not owing to already sealed, missing, or restored teeth.

Results

The children identified at elevated risk varied between the states, with 85% at elevated risk in Texas and 39% in Florida in 2017. Different methods can be used to calculate risk, raising questions about reliability. In Texas, 31% of children included in the denominator were not eligible to receive sealants owing to already sealed, missing, or restored teeth. The magnitude of the underestimation increased with age, so by the time children were 9 years old, 40% were not measure eligible yet included in the denominator. Similar results were observed for Florida.

Conclusions

The authors propose eliminating the caries risk assessment requirement and incorporating a 3-year look-back period to identify already sealed, missing, or restored molars.

Practical Implications

The reliability and validity of the sealant measure needs to be enhanced. Measure misspecification in which children are not correctly identified as needing sealants can contribute to inaccurate development of quality improvement goals, performance improvement projects, or pay-for-quality programs.

Section snippets

Measure specification

We used the CMS core measure set technical specification to calculate the SEAL measure.

Data sources

We used child-level Texas and Florida Medicaid enrollment and dental claims data from calendar years 2014 through 2017.

Assessing reliability, validity, and feasibility

To assess reliability, we focused on the CRA component of the measure. We examined the difference in the numbers of children identified as “at risk” in Texas and Florida and the extent to which the results would differ if a 3-year look-back period was used in both states.

To assess validity,

Reliability

The SEAL technical specifications for CRA allow for different approaches when calculating risk. We observed variability between Texas and Florida in the proportion of children ages 6 through 9 years identified at elevated risk for years 2014 through 2017, with 72% through 85% at elevated risk in Texas and 32% through 39% in Florida, depending on the year (Table). The 2 states use different approaches to calculate caries risk. Texas uses CRA codes D0602 and D0603 and CDT codes, as defined in the

Discussion

Our study raises questions about the reliability, validity, and usability of the SEAL measure. We found variability between the 2 states in the approaches used to calculate caries risk, with 1 state using procedures from claims data combined with a 3-year look-back period and the other state using risk codes. These 2 calculation methods lead to differing results, with Florida showing a smaller percentage of children with elevated caries risk than Texas. Relying on prior procedures and a 3-year

Conclusions

Our study supports enhancing validity and feasibility of calculating the SEAL measure using claims data. We propose eliminating the CRA requirement given the limited predictive accuracy of current CRA measures and concerns about access to care when relying on treatment history. However, it is also possible to standardize the approach to reporting caries risk so that states and dental plans can work with their practitioners to ensure caries risk is appropriately assessed, documented, and

Dr. Shenkman is a professor, Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 2004 Mowry Road, Gainesville, FL 32608.

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Dr. Shenkman is a professor, Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 2004 Mowry Road, Gainesville, FL 32608.

Dr. Tomar is a professor, Department of Community Dentistry and Behavioral Science, College of Dentistry, University of Florida, Gainesville, FL.

Dr. Manning is the executive director, client services, DentaQuest, Boston, MA.

Ms. Davis is vice president, dental management and quality improvement, MCNA Dental, Fort Lauderdale, FL.

Ms. Sun is a data management analyst, Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL.

Dr. Amundson is a physician, Physical Medicine and Rehabilitation, Health Partners Central Minnesota Clinic, Sartell, MN.

Dr. Mistry is the director, Division of Priority Populations Research, and the senior advisor, Child Health and Quality Improvement, Office of Extramural Research, Agency for Healthcare Research and Quality, Rockville, MD.

Disclosure. Dr. Manning reports that DentaQuest has a financial interest as a managed care organization that administers Medicaid programs in various states including Texas and Florida. None of the other authors reported any disclosures.

This study was supported by grant 1U18HS025298-03 from the Agency for Healthcare Research and Quality.

Research reported in this publication was also partially supported by the University of Florida Clinical and Translational Science Institute, which is supported in part by award UL1TR001427 by the NIH National Center for Advancing Translational Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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