Changes in dental visits and oral health for children by race and ethnicity during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic created new barriers to oral health care, which may worsen oral health and exacerbate disparities. The authors quantified changes in children's dental care receipt and oral health outcomes during the pandemic and examined differences among racial and ethnic groups. METHODS: Using the National Survey of Children's Health (163,948 child observations from 2017-2021), the authors used weighted modified Poisson models to examine caregiver-reported receipt of a dental visit (for any reason and for preventive care) and adverse oral health outcomes (teeth in fair or poor condition; difficulty with toothaches, cavities, or bleeding gums) from 2017 through 2019 (prepandemic) compared with 2020 and 2021. The authors examined outcomes within and across racial and ethnic groups. RESULTS: Children from all racial and ethnic groups experienced declines in receipt of dental visits, but there were limited changes in adverse oral health outcomes during 2020 and 2021. Prepandemic disparities in receipt of dental visits persisted for Black children and Asian children compared with White children. Hispanic children experienced larger increases in risk of experiencing both adverse oral health outcomes compared with White children in 2020 and in having teeth in fair or poor condition in 2021. CONCLUSIONS: The pandemic did not create new disparities in receipt of dental visits or oral health outcomes, but disparities in care persisted, and the oral health of Hispanic children was affected differentially. PRACTICAL IMPLICATIONS: Continued monitoring of dental visits and adverse oral health outcomes by race and ethnicity is critical to ensuring all children have access to oral health care. This information can help develop targeted interventions to improve children's oral health, including for minoritized racial and ethnic groups.

Barriers and Strategies Used to Continue School-Based Health Services During the COVID-19 Pandemic.

OBJECTIVE: To examine perceived barriers and strategies adopted to continue the delivery of school-based health services when schools reopened in Fall of 2021 during the COVID-19 pandemic and to assess whether these barriers and strategies varied by locality. METHODS: We developed and subsequently conducted an online survey of school nurses who worked at the 1178 public elementary schools in Virginia in May 2021 to describe the impact of the COVID-19 pandemic on the delivery of school-based health services. We compared perceived barriers, strategies adopted and the effectiveness of strategies to continue the delivery of school-based health services by geographic locality (city vs. rural; suburban vs. rural and city vs. suburban). RESULTS: More than half of schools located in cities expected nine of ten potential barriers to affect the delivery of school-based health services during Fall 2021. More than 50% of responding schools located in urban, suburban and rural area indicated that external barriers outside of their control, including insufficient funding and families not able to bring students to school, were likely to be barriers to delivering care. Strategies identified as "very effective" did not vary by locality. Across all localities, more schools reported virtual strategies were less effective than in-person strategies. CONCLUSIONS FOR PRACTICE: Lessons from the early stages of the COVID-19 pandemic provide critical information for natural disaster and public health emergency preparedness. School locality should be considered in the development of plans to continue the delivery of school-based health services after natural disasters or during public health emergencies.

The Patient Protection and Affordable Care Act and Pediatric Medical Clinicians' Application of Fluoride Varnish.

Importance: Fluoride varnish reduces children's tooth decay, yet few clinicians provide it. Most state Medicaid programs have covered this service during medical visits for children aged 1 to 5 years, but private insurers began covering it only in 2015 due to the Patient Protection and Affordable Care Act (ACA) mandate that they cover a set of recommended preventive services without cost-sharing. Evidence on clinicians' behavior change postmandate is limited. Objective: To examine monthly changes in fluoride varnish applications among pediatric clinicians following the ACA mandate. Design, Setting, and Participants: Using all-payer claims data from Massachusetts, this cohort study applied an interrupted time-series approach with linear regression models comparing changes in monthly clinician-level outcomes before and after the mandate. Participants included clinicians who billed at least 5 well-child visits for patients aged 1 to 5 years and were observed at least once premandate. Adjusted for clinician fixed effects, models were assessed overall and separately for clinicians categorized by their monthly share of well-child visits paid by private insurers before the mandate: mostly private (>66% of visits paid by private insurers), mostly public (<33% of visits paid by private insurers), or mixed (33%-66% of visits paid by private insurers) insurance types. Analysis was performed from June 1, 2022, to July 31, 2023. Exposure: Preenactment and postenactment of the ACA mandate for private insurers to cover fluoride varnish applications without cost-sharing. Main Outcomes and Measures: Clinician-month measures of whether fluoride varnish was provided during at least 1 well-child visit and the share of such visits, analyzed separately for clinicians who did and did not apply fluoride varnish premandate. Results: The sample included 2405 clinicians, with 107 841 clinician-months. Premandate, 10.48% of the visits included fluoride varnish applications. Two years postmandate, the likelihood of ever applying fluoride varnish was 13.64 (95% CI, 10.97-16.32) percentage points higher. For clinicians providing fluoride varnish premandate, the share of visits with fluoride varnish increased by 9.22 (95% CI, 5.41-13.02) percentage points. This increase was observed in clinicians who treated children with insurance that was mostly mixed and mostly private; no substantial change was observed among those treating children with mostly public insurance. Conclusions and Relevance: In this cohort study of pediatric primary care clinicians, an association between the ACA mandate and an increase in fluoride varnish application was observed, especially among clinicians primarily treating privately insured patients and those applying it premandate. However, application remains infrequent, suggesting persistent barriers.

Barriers and Facilitators to Optimal Fluoride Varnish Application.

OBJECTIVE: National guidelines recommend that all children under age six receive fluoride varnish (FV) in medical settings. However, application rates remain low. This study aimed to update understanding of barriers and facilitators to guideline concordant FV application. METHODS: We conducted virtual semi-structured interviews with a purposive sample (eg, FV application rates, geographic location, practice size and type) of pediatric primary care clinicians and medical assistants in Massachusetts between February 1 and June 30, 2022. The Consolidated Framework for Implementation Research (CFIR) served as the study's theoretical framework and data were analyzed using a modified grounded theory approach. RESULTS: Of the 31 participants, 90% identified as White and 81% as female. Major themes, which linked to four CFIR domains, included: variation in perceived adequacy of reimbursement; differences in FV application across practice types; variation in processes, protocols, and priorities; external accountability for quality of care; and potential levers for change. Important subthemes included challenges for small practices; role of quality measures in delivering guideline-concordant preventive oral health care; and desire for preventive care coordination with dentists. CONCLUSIONS: This study suggests that potential barriers and facilitators to guideline concordant FV application exist at multiple levels that may warrant further study. Examples include testing the effectiveness of quality measures for FV application and testing strategies for implementing consistent processes and protocols for improving FV application rates.

Association Between Insurance Type and Fluoride Varnish Application During Well-Child Visits in Massachusetts.

OBJECTIVE: To compare rates of fluoride varnish (FV) applications during well-child visits for children covered by Medicaid and private medical insurance in Massachusetts. METHODS: This cross-sectional study analyzed well-child visits for children aged 1 to 5 years paid by Medicaid and private insurance during 2016.Çô18 in Massachusetts. Multivariate regression models, with all covariates interacting with insurance type, were used to calculate odds ratios and adjusted predicted probabilities of fluoride varnish during well-child visits by calendar year and age. RESULTS: Across 957,551 well-child visits, 40.0% were paid by private insurers. Unadjusted rates of fluoride varnish were significantly lower among well-child visits paid by private insurers (6.6%) than visits paid by Medicaid (14.2%). In the fully interacted regression model, the odds of a visit including fluoride varnish were significantly lower for older children than for children aged 1 for visits paid by both insurance types. Adjusted rates of fluoride varnish increased significantly from 2016 to 2018 for both insurance types. Moreover, rates were higher among visits for children covered under Medicaid than privately insured children in all years, and the differences by insurance type declined over time (2016: 8.0% points, 95% confidence interval.á=.á.êÆ8.7 to .êÆ7.3, 2018: 5.3% points, 95% confidence interval.á=.á.êÆ6.6 to .êÆ3.9). CONCLUSIONS: Rates of fluoride varnish applications during well-child visits were low for both Medicaid and private insurance despite growth from 2016 to 2018 in Massachusetts. Low rates are concerning because this is a recommended service with the potential to help address racial, geographic, and income-based disparities in access and oral health outcomes.

The U.S. Equity-First Vaccination Initiative: Impacts and Lessons Learned.

The one-year U.S. Equity-First Vaccination Initiative (EVI), launched in April 2021, aimed to reduce racial inequities in coronavirus disease 2019 (COVID-19) vaccination across five demonstration cities (Baltimore, Chicago, Houston, Newark, and Oakland) and over the longer term strengthen the United States' public health system to achieve more-equitable outcomes. This initiative comprised nearly 100 community-based organizations (CBOs), who led hyper-local work to increase vaccination access and confidence in communities of individuals who identify as Black, Indigenous, and People of Color. In this study, the second of two on the initiative, the authors examine the results of the EVI. They look at the initiative's activities, effects, and challenges, and provide recommendations for how to support and sustain this hyper-local community-led approach and strengthen the public health system in the United States.

The Impact of Nurse Practitioner-Led Primary Care on Quality and Cost for Medicaid-Enrolled Patients in States With Pay Parity.

Studies have established that nurse practitioners (NPs) deliver primary care comparable to physicians in quality and cost, but most focus on Medicare, a program that reimburses NPs less than physicians. In this retrospective cohort study, we evaluated the quality and cost implications of receiving primary care from NPs compared to physicians in 14 states that reimburse NPs at the Medicaid fee-for-service (FFS) physician rate (i.e., pay parity). We linked national provider and practice data with Medicaid data for adults with diabetes and children with asthma (2012-2013). We attributed patients to primary care NPs and physicians based on 2012 evaluation & management claims. Using 2013 data, we constructed claims-based primary care quality measures and condition-specific costs of care for FFS enrollees. We estimated the effect of NP-led care on quality and costs using: (1) weighting to balance observable confounders and (2) an instrumental variable (IV) analysis using differential distance from patients' residences to primary care practices. Adults with diabetes received comparable quality of care from NPs and physicians at similar cost. Weighted results showed no differences between NP- and physician-attributed patients in receipt of recommended care or diabetes-related hospitalizations. For children with asthma, costs of NP-led care were lower but quality findings were mixed: NP-led care was associated with lower use of appropriate medications and higher rates of asthma-related emergency department visits but similar rates of asthma-related hospitalization. IV analyses revealed no evidence of differences in quality between NP- and physician-led care. Our findings suggest that in states with Medicaid pay parity, NP-led care is comparable to physician-led care for adults with diabetes, while associations between NP-led care and quality were mixed for children with asthma. Increased use of NP-led primary care may be cost-neutral or cost-saving, even under pay parity.

Pediatric oral health services in Medicaid managed care and fee for service.

OBJECTIVES: In 2008, Florida's Medicaid program began reimbursing medical providers for preventive oral health services (POHS) delivered to children aged 6 months to 42 months. We examine whether Medicaid comprehensive managed care (CMC) and fee for service (FFS) had different rates of POHS during pediatric medical visits. STUDY DESIGN: Observational study using claims data (2009-2012). METHODS: Using repeated cross-sections of 2009-2012 Florida Medicaid data for children 3.5 years or younger, we examined pediatric medical visits. We estimated a weighted logistic regression model to compare POHS rates among visits reimbursed by CMC and FFS Medicaid. The model controlled for FFS (vs CMC), years Florida had a policy allowing POHS in medical settings, an interaction between these 2 variables, and additional child- and county-level characteristics. Results are presented as regression-adjusted predictions. RESULTS: Among 1,765,365 weighted well-child medical visits in Florida, POHS were included in 8.33% of CMC-reimbursed visits and 9.67% of FFS-reimbursed visits. Compared with FFS, CMC-reimbursed visits had a nonsignificant 1.29-percentage-point lower adjusted probability of including POHS (P = .25). When examining differences over time, although the POHS rate was 2.72 percentage points lower for CMC-reimbursed visits after 3 years of policy enactment (P = .03), rates were similar overall and increased over time. CONCLUSIONS: POHS rates among pediatric medical visits in Florida were similar for visits paid via FFS and CMC, with low rates that increased modestly over time. Our findings are important because more children continue to be enrolled in Medicaid CMC.

Claims-Based Reporting of Post-Operative Visits for Procedures with 10- or 90-Day Global Periods: Updated Results Using Calendar Year 2018 Data.

Medicare payments for most surgical procedures cover both procedures and post-operative visits occurring within a global period of either ten or 90 days following procedures. There have been concerns that fewer post-operative visits are provided than the number of post-operative visits considered when the procedure was valued. To help inform accurate valuation of procedures with global periods, the Centers for Medicare & Medicaid Services (CMS) required select practitioners to report on post-operative visits after select procedures with 10- or 90-day global periods. The authors of this article summarize patterns of post-operative visits for procedures furnished during calendar year 2018, building on prior research that analyzed data for procedures with July 1, 2017, through June 30, 2018, service dates. During calendar year 2018, 96.5 percent of procedures with 10-day global periods did not have an associated post-operative visit. Approximately two-thirds of procedures with 90-day global periods had an associated post-operative visit; however, the ratio of observed to expected post-operative visits provided for 90-day global period procedures was only 0.38. Underreporting of post-operative visits might be driving these low rates. However, in sensitivity analyses limited to practitioners who were actively reporting their post-operative visits, post-operative patterns were largely similar to the main analysis. Collectively, these findings suggest that a large share of expected post-operative visits are not delivered, and that underreporting is unlikely to fully explain the low ratio of expected post-operative visits provided.

Claims-Based Reporting of Post-Operative Visits for Procedures with 10- or 90-Day Global Periods: Updated Results Using Calendar Year 2019 Data.

Medicare payments for most surgical procedures cover both procedures and post-operative visits occurring within a global period of either 10 or 90 days following procedures. There have been concerns that fewer post-operative visits are provided than the number of post-operative visits considered when the procedure was valued. To help inform accurate valuation of procedures with global periods, the Centers for Medicare & Medicaid Services (CMS) required select practitioners to report on post-operative visits after select procedures with 10- or 90-day global periods. The authors of this article summarize patterns of post-operative visits for procedures furnished during calendar year 2019, building on prior research that analyzed data for procedures furnished from July 1, 2017, through June 30, 2018, and for the entire 2018 calendar year. During calendar year 2019, 96.5 percent of procedures with 10-day global periods did not have an associated post-operative visit. Approximately two-thirds of procedures with 90-day global periods had an associated post-operative visit; however, the ratio of observed to expected post-operative visits provided for 90-day global period procedures was only 0.38. Underreporting of post-operative visits might be driving these low rates. However, in sensitivity analyses limited to practitioners who were actively reporting their post-operative visits, post-operative patterns were largely similar to the main analysis. Collectively, these findings suggest that many expected post-operative visits are not delivered and that underreporting is unlikely to fully explain the low ratio of expected post-operative visits provided.

Racial/Ethnic Differences in Receipt of Dental Cleanings During Pregnancy.

INTRODUCTION: We aimed to examine racial/ethnic differences in receipt of dental cleanings during pregnancy, overall and by health insurance type, using 2016-2018 Pregnancy Risk Assessment Monitoring System survey data from 39 states and New York City. METHODS: We used a weighted linear probability model to estimate receipt of a dental cleaning during pregnancy. Key explanatory variables included race/ethnicity (Hispanic, White, Black, Asian and Pacific Islander (API), and other racial groups) and health insurance type (Medicaid, private, and other). RESULTS: Among a weighted sample of 5,301,753 individuals, 45.9% received a dental cleaning during pregnancy. Regression-adjusted predicted rates of dental cleanings were significantly higher among White than non-White individuals, with the lowest rates observed among Black (43.2%; 95% confidence interval [CI], 40.6%-45.9%) and API individuals (30.6%; 95% CI, 28.5%-32.7%). When comparing rates by health insurance type, adjusted rates were highest among privately insured White individuals (57.4%; 95% CI, 56.1%-58.7%) and lowest among Medicaid-enrolled API individuals (25.4%; 95% CI, 21.5%-29.2%). CONCLUSIONS: Fewer than one-half of pregnant individuals received dental cleanings, with the lowest rates observed for non-White individuals and Medicaid-enrolled individuals. Efforts are needed to increase dental visits among publicly insured, Black, Hispanic, and API pregnant individuals.

Racial And Ethnic Disparities In COVID-19 Booster Uptake.

We investigated racial and ethnic disparities in COVID-19 vaccine uptake, using data from the Centers for Disease Control and Prevention. As of March 29, 2022, uptake of the first dose was higher among Hispanic and Asian people than among White and Black people. In contrast, uptake rates of the booster were higher among Asian and White people than among Black and Hispanic people.

Assessing Health and Human Services Needs to Support an Integrated Health in All Policies Plan for Prince George's County, Maryland.

With evolving demographics and a changing health system landscape, the Prince George's County Council, acting as the County Board of Health, is considering its future policy approaches and resource allocations related to health and well-being. To inform this path forward, the authors of this study used primary and secondary data to describe both the health needs of county residents and drivers of health within the county, inclusive of the social, economic, built, natural, and health service environments. This study integrates these findings, an analysis of budget documents, and a review of promising practices from other communities to situate recommendations in a Health in All Policies framework to foster aligned and integrated planning and budgeting across the county to promote health and well-being. Findings from the assessment indicate a shared interest among leaders and residents to embrace a holistic strategy for health and well-being in the county. Inefficient uses of the health care system are identified, highlighting a need to rebalance investments in health care use and drivers of health. Additionally, challenges in navigating health and human services and inequities in drivers of health across communities are noted, signaling broader concerns related to residents' access to health and human services that influence health and well-being outcomes. Recommendations are provided for several paths forward for the county to pursue a more integrated policy approach to influence health and well-being outcomes.

Variation in prices for an evidence-based pediatric preventive service.

OBJECTIVE: To examine variation in prices paid by private medical insurers for fluoride varnish applications in medical settings, a newly reimbursed service that few children receive. DATA SOURCES: Private-insurance medical claims from Connecticut, Maine, New Hampshire, and Rhode Island (2016-2018). STUDY DESIGN: We examined prices paid for fluoride varnish by private insurers and compared these to prices paid by Medicaid. DATA COLLECTION/EXTRACTION METHODS: Private claims for fluoride varnish during medical visits for children aged 1-5 years. State Medicaid rates for fluoride varnish were obtained from the American Academy of Pediatrics. PRINCIPAL FINDINGS: Prices paid for fluoride varnish by private insurers varied within and across states, ranging from less than $5 to $50. Median prices closely followed Medicaid rates in three of the four states. In states covering a package of fluoride varnish plus additional preventive oral health services during medical visits, combined Medicaid rates were nearly double the median price paid by private insurers. CONCLUSIONS: Fluoride varnish is a recommended service, but few children receive it. Price variation may contribute to the low uptake of this service. Ensuring sufficient Medicaid and private insurance rates could increase fluoride varnish applications in medical settings and improve oral health.

A comparison of approaches to identify live births using the medicaid analytic extract.

Medicaid claims are an important, but underutilized source of data for neonatal health services research in the United States. However, identifying live births in Medicaid claims data is challenging due to variation in coding practices by state and year. Methods of identifying live births in Medicaid claims data have not been validated, and it is not known which methods are most appropriate for different research questions. The objective of this study is to describe and validate five approaches to identifying births using Medicaid Analytic eXtract (MAX) from 45 states (2006-2014). We calculated total number of MAX births by state-year using five definitions: (1) any claim within 30 days of birth date listed in personal summary (PS) file, (2) any claim within 7 days of PS birth date, (3) live birth ICD-9 in inpatient or other therapies file, (4) live birth ICD-9 code in inpatient file, (5) live birth ICD-9 in inpatient file with matching PS birth date. We then compared the number of MAX births by state and year to expected counts using outside data sources. Definition 1 identified the most births (14,189,870) and was closest to total expected count (98.3%). Each definition produced over- and underestimates compared to expected counts for given state-years. Findings suggest that the broadest definition of live births (Definition 1) was closest to expected counts, but that the most appropriate definition depends on research question and state-years of interest.

Delivery of fluoride varnish during pediatric medical visits by rurality.

OBJECTIVES: To examine variation in the delivery of fluoride varnish during pediatric medical visits by rurality. METHODS: This observational study used private health insurance claims (2016-2018) for children aged 1-5 years from Connecticut, Maine, New Hampshire, and Rhode Island linked to the county-level Rural-Urban Continuum codes. County-level Rural-Urban Continuum codes were categorized into three groups: metropolitan, rural, and remote rural. Logistic regression models were used to estimate the odds of a well-child medical visit including fluoride varnish by county rurality, adjusting for other individual and county characteristics. RESULTS: Among 328,661 pediatric well-child visits paid by private insurance, fluoride varnish was included in 4.3% of visits in metropolitan counties, 6.2% of visits in rural counties, and 10.3% of visits in remote rural counties. There were significantly higher odds of a visit including fluoride varnish in rural remote counties (odds ratio [OR] = 3.5, 95% confidence interval [CI] = 2.3-5.3, p < 0.001) and in rural counties (OR = 2.4, 95% CI = 1.4-4.0, p < 0.001) compared to metropolitan counties. Rates of fluoride varnish during well-child visits increased since 2016 in metropolitan counties and remained stable in rural counties. CONCLUSIONS: All young children are recommended to receive fluoride varnish applications in medical settings, yet overall rates were low. For privately insured young children, pediatric well-child medical visits were more likely to include fluoride varnish in rural and rural remote counties than metropolitan counties.

Variation in Current Guidelines for Fluoride Varnish Application for Young Children in Medical Settings in the United States.

Background: The United States Preventive Services Task Force recommends that medical providers apply fluoride varnish (FV) to the teeth of all children under 6 years of age, but fewer than 10% of eligible children receive FV as recommended. Prior studies suggest that variation in clinical guidelines is associated with low uptake of other evidence-based health-related interventions, but consistency of national guidelines for the delivery of FV in medical settings is unknown. Methods: Eligible guidelines for application of FV in medical settings for children under 6 years of age were published in the past 10 years by national pediatric or dental professional organizations or by national public health entities. Guidelines were identified using the search terms fluoride varnish + [application; guidelines, or recommendations; children or pediatric; American Academy of Pediatrics (AAP); American Academy of Pediatric Dentistry] and a search of Guideline Central. Details of the guidelines were extracted and compared. Results: Ten guidelines met inclusion criteria. Guidelines differed in terms of periodicity recommendations and whether FV was indicated for children with a dental home or level of risk of dental caries. Conclusion: Numerous recommendations about FV delivery in medical settings are available to pediatric medical providers. Further study is warranted to determine whether the variation across current guidelines detected in this study may contribute to low FV application rates in medical settings.

School-Based Health Services in Virginia and the COVID-19 Pandemic.

BACKGROUND: Schools have a long history of delivering health services, but it is unclear how the COVID-19 pandemic may have disrupted this. This study examined changes in school-based health services and student needs before and during the pandemic and the factors important for delivering school-based health services. METHODS: A web-based survey regarding the impact of the pandemic on school-based health services was distributed via email to all 1178 Virginia public elementary schools during May 2021. RESULTS: Responding schools (N = 767, response rate = 65%) reported providing fewer school-based health services during the 2020-2021 school year than before the pandemic, with the largest declines reported for dental screenings (51% vs 15%) and dental services (40% vs 12%). Reports show that mental health was a top concern for students increased from 15% before the pandemic to 27% (P < .001). Support from families and school staff were identified by most respondents (86% and 83%, respectively) as very important for the delivery of school-based health services. CONCLUSIONS: Schools reported delivering fewer health services to students during the 2020-2021 school year and heightened concern about students' mental health. Understanding what schools need to deliver health services can assist state and local education and health officials and promote child health.

Medicaid Payment and Fluoride Varnish Application During Pediatric Medical Visits.

All Medicaid programs pay for fluoride varnish applications during medical visits for infants and toddlers, but receipt of care varies considerably across states. Using 2006-2014 Medicaid data from 22 states, this study examined the association between Medicaid payment and receipt of fluoride varnish during pediatric medical visits. Among 3,393,638 medical visits, fewer than one in 10 visits included fluoride varnish. Higher Medicaid payment was positively associated with receipt of fluoride varnish during pediatric medical visits. As policymakers consider strategies for increasing young children's access to preventive oral health services, as well as consider strategies for balancing budgets, attention should be paid to the effects of provider payment on access to pediatric oral health services.