Quality Controls in Dentistry

A few years after I started my practice I was asked to serve on the Medical Executive Committee of our local hospital. I think it was just because I drew the short straw during a Dental Department meeting. At that time, the hospital was implementing quality checks and measures to be in compliance with new standards that Medicare was implementing. I saw the headache that it was causing the administration and the toll that it took on clinicians who had to jump through additional hoops in order to get a good evaluation. The quality assurance measures were put in place as a way to improve patient outcomes and identify and rate physicians based on their “quality of care.” The debate continues whether these burdensome evaluations are effective.

Dentistry is currently facing a similar dilemma. The Dental Quality Alliance (DQA) is an organization whose goal is “improving oral health through measurement.” They want to accomplish this objective through the evaluation of the quality of dental care provided by dentists. Here is their stated purpose…

“The mission of the DQA is to advance performance measurement as a means to improve oral health, patient care, and safety through a consensus-building process.

Objectives

1. To identify and develop evidence-based oral health care performance measures and measurement resources.

2. To advance the effectiveness and scientific basis of clinical performance measurement and improvement.

3. To foster and support professional accountability, transparency, and value in oral health care through the development, implementation and evaluation of performance measurement. Quality of Care: The degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

The ADA is trying to get ahead of the game by utilizing the DQA as a way to dictate what quality assurance measures will be used to evaluate dentists in the future. If the ADA sets the standards for these performance measures, the thought is that the federal government or other outside entities (ie. dental insurances) cannot dictate how dentists should be evaluated. The Council of Government Affairs (CGA), along with other ADA councils, were recently asked to evaluate some of these metrics proposed by a DentaQual whitepaper. The evaluation was composed of a list of 40+ performance measures, including… ● Percentage of restored teeth developing subsequent caries ● Percentage of treated teeth subsequently extracted ● Percentage of fillings requiring replacement [within 36 months] of initial placement ● Percentage of Total Crowns requiring extraction of the tooth subsequent to placement ● Percentage of high risk patients ages 6 to 9 that received sealants on a first permanent molar tooth ● Percentage of patients that leave and go to another provider of the same specialty

Along with several other ways to evaluate Endodontists, General Dentists, Oral and Maxillofacial Surgeons, Pediatric Dentists, and Prosthodontists.

After reading the DQA whitepaper and evaluating the quality measures, the CGA was in agreement with the other councils that there are several factors that could influence the outcomes of dental work performed by providers. Some of the concerns of the CGA with this method of evaluation include…

“A number of social factors may influence treatment outcomes and cannot be controlled by the treating dentist. Examples may include patient education and assumed patient responsibility for proper oral health care, medical and environmental factors, financial ability, and perception of the need for dental insurance or the assistance afforded by dental insurance. The risk stratification of a patient can also be used to measure quality and can factor into a quality metric if defined and analyzed properly to showcase provider skillsets through treatment outcomes.”

Another concern of the CGA is how this data will be used and publicized…

“What is the purpose of this data? If these metrics and rating systems are made public, we could see a backlash in the dental world. If this data is to be used for social safety net programs such as Medicaid, CHIP, and possibly future Medicare programs it could deter dentists from accepting government subsidized programs, thus further limiting access to care for populations who desperately need increased access to dental services. If dentists know that they will be scrutinized by the quality of their care to certain populations, they may avoid treating those populations. This could be detrimental to elderly, special needs, and other patients with untoward medical conditions.”

These delicate issues are at the forefront of the ADA today. I personally hope that the ADA stays engaged in this arena and will somehow find a solution to this problem that could cause a huge dilemma to the future of dentistry. The insurance industry is already using these metrics to evaluate dentists on their panels; the ADA should be making every effort to make sure this data isn’t published and made public. Without the ADA’s help on this matter, dentistry could be burdened by quality measures that are meant to improve the quality of care to the public.

For more information on the Dental Quality Alliance visit: http://ada.org/dqa

Darren Chamberlain, DDS ADA Council on Government Affairs