Article Title: A performance Measurement Plan for Pediatric Dentists: Using Accuracy of Caries Diagnosis from Intraoral Radiographs
Author: Hanry O. Ohiomoba, BDS, MPH, Linda P. Nelson, DMD, MScD
Journal/Date: Pediatric Dentistry, Vol. 35 No. 1 Jan/Feb 2013
Major Topic: Performance Measurements
Main Purpose: Develop a metric to measure: 1) an individual pediatric dentist’s performance against peer performance and 2) aggregate group performance; using accuracy of caries diagnosis
Introduction: In 2007, Boston Children’s Hospital asked all surgical department heads to evaluate their individual providers against a group of their peers by utilizing a performance metric. This is provides information for credentialing, data for third party payers, and as a way to assess quality improvements. The medical field has many of these assessment tools in place and we find dentistry less so. Diagnostic accuracy was chosen due to the literature showing that there is a wide variation in diagnosis of caries from intraoral radiographs among dentists.
Methods: Standard was set that interproximal caries was defined as a lesion that was half way through the dental enamel and occlusal caries was any lesion that was visible from the occlusal surface on the radiograph. Conventional (non-digital) bitewing radiographs were used, all taken on a patient 6 y/o or younger.
3,985 surfaces were used; data was collected from all operating room procedures performed between October 2007 and December 2010.
9 pediatric (4 full-time, 5 part-time) attendings were calibrated. Scorecard was developed for data collection, which contained a matrix of teeth #A-T, surfaces were mesial, large occlusal, distal. Response choices were yes or no. Three pediatric attendings rated the surfaces. 1 provider and 2 randomly selected peer pediatric dental attendings (reviewers). 3 scorecards were collected for each patient. Data was entered into an Access 2003 database and was analyzed by SAS 9.2 software.
Results: Total tooth surfaces assessed per provider varied due to number of patients treated. Per provider acceptable diagnosis was between 89%-96% and overall for the department it was 95%. Using the 95% confidence interval the department acceptable diagnosis ranged from approximately 94-95%. There was secondary analysis completed with the criteria that all three reviewers had to agree. No significant change was assessed. The caveat was that 436 cases were thrown out when the two reviews didn’t agree. It was also not able to look at the surfaces that were in agreement, meaning that much to the agreement was upon non-carious surfaces.
Additional interesting findings:
· Years in practice tend to influence the attending tendency to over or under-treat. 4 attendings with average of 8 years of practice experience 1.52 times more likely to overdiagnose compared to 5 attending with an aver of 27 years of practice experience.
· Gender predilections: males were 1.2 times more likely to overdiagnose then females, but whenever an unacceptable diagnosis was made is was more likely to be overdiagnosis and there was no gender difference.
Most treatment rendered due to high caries risk of patient was a stainless steal crown (SSC) per the American Academy of Pediatric Dentistry guidelines.
Conclusion: Accuracy of caries diagnosis from intraoral radiographs is a useful metric. Calibration and periodic reporting of diagnostic accuracy is important to achieve high level of quality care. Use of SSC’s helps with issues that might arise from underdiagnosis in a high-risk population that are treated in the operating room.
Discussion: Interesting article. I originally wanted to blame the calibration for the good out come but in the results section there was mention of the differences between attending. Having equal number of tooth surfaces assessed may have changed the results. It shows us that continual assessment of our radiographic diagnosis is important in providing appropriate care.