Aug. 1, 1998
Dental Wellness Index helps practices predictably measure treatment outcomes and assure that quality levels remain high

Dental Wellness Index helps practices predictably measure treatment outcomes and assure that quality levels remain high

Lawrence J. Singer, DDS

Social planners are actively engaged in attempting to force dentistry into medicine`s mold and profile. Developers of medical managed-care programs seek to place dentists under the same controls that have been so burdensome to our medical colleagues. In the developer`s view, costs are of paramount importance, and it makes little difference whether the provider of care has a dental or medical degree. Human resource directors - the people responsible for choosing the type of health-care plan for their personnel - have been told that "the practice patterns of dentists are as suspect as are those of their medical counterparts, and therefore just as `adjustable` where cost of services is a problem." Further, "Many of the services that are provided by dentists are either unnecessary or inappropriate for the patient being treated."

Until recently, dentists have been unable to refute and disprove any of these allegations. Today, methods and programs exist that measure the individual`s level of dental health. They also can trace the efficiency and efficacy of treatments provided. These methods are based on a diagnostic protocol that is prioritized on degree of disease status and treatment-sequencing. Treatment-outcome measurement now is available in dentistry.

Medical managed-care plans are rated and measured by means of a "report card." The medical plan is evaluated in terms of types of services that are available to insured participants and accessibility. These measures are done on a "plan level" using gross population calculations. Treatment-outcome measures in dentistry are performed on the "patient level" and the provider level (one on one).

In this article, we`ll discuss the genesis and design of a Dental Wellness Index. We also will examine the many applications that the Dental Wellness Index makes possible through its use in dental-treatment outcomes measurement and quality assessment.

The issue of quality, as it applies to health-care services, has become more difficult to assess. This difficulty is not due to any misunderstanding of society`s appreciation for the concept, but rather because of the proliferation of definitions of the word. Health-care providers possess one or more definitions of the word as it is applied to their practices, while government and/or the insurance industry suggest their own definitions. Even members of the Trial Lawyers Association of America have their own understanding of the concept of quality in the health-care delivery system. At issue here, however, is usually the perception of a lack of quality care that has contributed to an untoward treatment outcome. As long as the definition of quality remained subjective, existing in one`s mind, each and every definition of the term was valid. Once it became objective, pertaining to a material object rather than a mental concept, the variations narrowed dramatically. The term has become objective and quality now is a measurable and statistically valid material object.

In July 1990, Dr. John Burns, then vice president of Health Management for Honeywell Inc., summarized the status of dental-health care during his keynote address to the American Dental Association`s Council on Dental Care Programs.

Dr. Burns said: "Although our manufacturing industries have finally begun to adopt the total-quality concept, by and large the health professional has totally ignored it. The purchaser and the beneficiary are focused almost entirely on access. Now, guaranteed access is bad, but the real question is access to what? Unless the purchaser and the beneficiary are willing and capable of defining the health-care product in terms of necessity and appropriateness, there will be neither cost management nor quality control.

"The fundamental requirement for quality in health care - as in any other industry - is that the product conforms to the specifications (specs). In health care, particularly in the area of benefits, no one has defined the products.

"My request is that you (dentists) focus your attention on the definition of the dental-care product that will result in maximum oral health at a reasonable cost. What is it that we should be paying for? Define it as maximal oral health, not the disease model or the "fix-when-broken" model.

"The dental health-care product must be defined in specifics. The contract for the product should facilitate an audit of the system for conformity to the standards and should reward efficiency. Only after the standards of quality are defined, the product specified, and the cost of providing the necessary care have been decided is a discussion of financial participation with insurers appropriate."

Wellness Index

In 1987, Oral Health International, OHI, in collaboration with the Center For Health Systems and Analysis at the University of Wisconsin, Madison, developed the Dental Wellness Index™, DWI. The DWI is an oral-health, status-assessment tool and outcome-measurement device. The DWI device consists of four parts: 1) a data-collection instrument (the DWI form) used to collect oral-health information about a patient, 2) the attributes of the DWI (issues, components, weights, measures, and utilities), 3) a series of algorithms that interprets the data collected, and 4) a custom software program.

The DWI shows the oral-health status - or level of dental wellness - of an individual at any point in time. The DWI has a range of possible values between 0 and 100. A DWI score of 100 signifies perfect oral health. The lower the DWI score, the lower the oral-health status or wellness of the individual. The difference between the two DWI scores is a direct measure of the difference of an individual`s oral health between one measurement and the next. The DWI assesses the appropriateness of treatments, prioritizes treatment in order of merit, assesses treatment outcomes, and monitors cost-effectiveness and cost-efficiency.

The issues that comprise dental wellness

Dental wellness can be more precisely defined by identifying the issues it contains. An issue is defined as one area or aspect of dental care that is determined to be important (from either the clinician`s or patient`s view) and that contributes to the fulfillment of the general definition of dental wellness.

The DWI assesses eight oral health issues: periodontal status, restorative status, pain, oral pathology, temporomandibular disorder, cosmetics, occlusion, and habits. The eight issues listed above are not mutually exclusive and do not contribute equally to dental wellness.

The relative importance of the issues (e.g., the contribution of each issue to dental wellness) is quantified by weighing each issue. The weights are then expressed as a decimal or a percentage. The sum of all weights is about 1.0 or 100 percent.

The oral-health issues designated above still are too general to be measured directly. Each of the eight issues needs to be further divided into measurable units or components. A component is defined as a single, measurable item that contributes to its parent issue. Some issues contain multiple components and some issues share components.

Not to leave the process incomplete, the components then are weighted. To compare components to each other, the values of all of the components are converted to a standard measuring unit. This standard unit is called a utility unit.

To summarize, in order to quantify the oral-health status of a patient, criteria must be established against which a patient`s clinical status can be measured. For the purposes of this DWI:

- Each of the eight issues pertaining to dental wellness has measurable components within it.

- The relative importance of the issues and components is quantified by weighting.

- A measure and range of values have been established for each component.

- Component values are converted to standard measuring units called utilities (utility units).

Techo-phile`s delight

Once the data concerning a patient`s oral-health status has been collected using the DWI data-collection form, a series of algorithms (mathematical procedures) is applied to the data. This is the manner by which the individual`s DWI score is obtained.

Underlying the formulae used in the calculation of the DWI is a mathematical model called a multiattribute utility model or MAU.

Since the DWI is based on the MAU model, the DWI is a multiattribute utility index or MAUI.

All of the above calculations and measurements relate to the algorithm, which allows a wellness score to be statistically valid and free from evaluator prejudice or error.

Quality/outcomes applications

Equal in importance to the clinical applications of the DWI are its applications as a quality- and outcomes- assessment tool.

The DWI can be used as a quality-and outcomes-assessment tool in the following ways:

- Assesses the quality of care in terms of the cost-efficiency of treatment provided.

- Assesses the quality of care in terms of the cost-effectiveness of treatment provided.

- Identifies inappropriate or unnecessary treatment rendered or proposed (order of merit).

- Monitors treatment outcomes in terms of time, costs, and change in oral-health status.

- Performs statistical comparisons of patient groups, measurements of incidences, demographic analysis, and evaluations of costs.

- Provides data to document quality performance (by provider).

Cost-efficiency and cost-effectiveness are not mutually exclusive terms. Cost-efficiency is a measure of the ratio between the cost of treatment and the result of that treatment. The lower the cost and the better the result, the more cost-efficient the treatment is. Cost-effectiveness is a true measure of the outcome of treatment provided in terms of enhanced oral-health status.

Because the DWI shows the amount of utility lost in each of the components (there are 39), it is possible to identify those treatments that are inappropriate or unnecessary based on the MAUI score.

The ability to track the change in a patient`s oral-health status as a result of treatment (outcomes) is inherent in the DWI. A more complete picture of outcomes is possible when the cost of treatment rendered and the time expended in that process are compared to the DWI-documented results.

Having DWI scores on an entire patient population allows for a thorough analysis of quality and outcomes. For example, DWI scores can show the incidence of periodontal disease in a patient population, the average age at which a periodontal problem is likely to occur, the most effective periodontal treatment, and the time and cost estimates connected with achieving optimal health results.

The DWI gives the dentist a way to measure his/her own performance against objective, exacting, and statistically valid criteria. The underlying assumption is that provider excellence is indicated by helping patients achieve dental wellness and maintenance in a cost-efficient and cost-effective manner. This is most important in a "fee-for-service" environment.

Computer-based clinical record

The computer-based clinical record must be differentiated from the computer-based patient record.

The dental office-management software industry has provided dental offices with many valuable programs that make the "business" part of the practice of dentistry much more efficient. It is possible to keep track of patient appointments and provider productivity, as well as producing practice-utilization reports. Dental insurance claims can to be produced from the patient-record computer program. Many dental offices transmit these claims electronically through "clearing houses" to the appropriate carrier for reimbursement. The CBPR (computer-based patient record) keeps track of dental procedures performed and the appropriate billing information relating to those services. Some programs produce individualized "family" reports for billing and treatment history on a per family member basis.

The combination of the DWI computer-based clinical record with the computer-based patient record provides an ex-tremely accurate record of a patient`s dental health and treatment history.

The data de-rived from the DWI process, combined with that of the individual provider`s patient-record program, allows for the most complete assessment of quality and treatment outcome at the "micro" level.

Please note that the DWI process does not mandate that a computer program be integrated with it. The DWI processes may be performed manually and "hard copy" transmitted via conventional land services.

Clinical applications of DWI

The DWI provides the clinician with detailed information about a patient`s oral-health status. The DWI has a value far beyond its strictly clinical applications. The data that the DWI generates also can be used to analyze and assess what in broad terms may be called "quality of care" and "outcomes."

The DWI can be used by the "dental team" in the following ways:

- Document the exact oral-health status (degree of dental utility) of any patient at any given time.

- Document the exact degree of dental unwellness (loss of dental utility) of any patient at any given time.

- Document the exact reasons a patient has lost dental utility.

- Determine the appropriate treatment necessary to bring a patient to optimal oral health (total dental utility).

- Create a treatment plan prioritized in order of merit.

- Document the change in a patient`s oral-health status as a result of care rendered.

- Monitor a patient`s oral-health status over time.

An assumption is made that "total dental wellness means total dental utility." Therefore, the DWI does more than provide an exact clinical picture of a patient`s oral condition. It provides or generates a score (e.g., 84.5) that compares a patient`s degree of dental utility at that particular time to the optimum dental utility score of 100. The DWI also may illustrate the degree of lost utility that has beset a patient at any given time by demonstrating the patient`s degree of dental unwellness. For example, a utility score of 75.2 would indicate the patient`s loss of utility of 24.8.

In terms of determining the cause or reason for a patient`s loss of dental utility, the DWI returns to the issues that comprise dental wellness. The examiner reviews the manner by which issues have been refined into components and then weighted according to each component`s importance to the issue as a whole. The examiner then can define exactly where the patient has lost utility and why.

This enables the clinician to identify exactly the reason where and why a patient has lost utility and permits the him/her to generate a treatment plan. This plan is designed to bring the patient toward the goal of total dental wellness.

Since the goal of any treatment plan is to restore dental utility, the best plan is one that treats the areas of most lost utility before it treats the areas of least lost utility. The DWI directs the treatment plan based on order of merit. Therefore, dental treatment that is planned out of sequence (i.e., ignoring the order of merit) would be identified as not contributing to the patient`s most expeditious return to optimal dental utility. The DWI is capable of identifying "order- of-merit" treatment conflicts immediately.

By administering a DWI before treatment and again after treatment, a clinician can track change in a patient`s oral-health status. For example, if a patient`s initial DWI score is 48 and the next score is 85, the patient has enjoyed a gain of 37 utility points. This is also an "outcome" application. The DWI can be used to monitor the patient`s oral-health status on a long-term basis. An effective use of the DWI for this purpose would be to administer a DWI once or twice a year during a patient`s annual or biannual checkup.

Custom software applications

The Custom Software Program that the DWI is structured about is able to produce important reports based on data that are collected throughout the patient evaluation and treatment process. Some of the reports are:

- Patient summary. Notes the degree of oral-health status change for individuals and given populations. It reports on dollars expended for individuals and given populations. It computes the cost per patient on average to generate X amount of status change. It also projects the wellness points possible for individuals and given populations, and can project the future cost to recover lost utility.

- Gain vs. loss of utility. Can compute the percentages of patients with a gain versus loss of utility who have had two or more indexes completed.

- Maintenance status. Compiles costs and outcomes for patients above versus below maintenance. Tracks the length of time necessary to move each patient to maintenance status.

- Procedure analysis. Analyzes the effectiveness and efficiencies of procedures aimed at returning the patient to optimal oral health in a cost-efficient manner.

- Procedures analysis. Can illustrate the cost-effectiveness and cost- efficiency of specific procedures performed on patients involved in a DWI program.

- DWI components. Can determine the dental components associated with frequency of treatment and the amount of lost utility for any given individual or population.

- Optimum codes for patients not achieving maintenance. Can determine plan costs associated with utilizing optimum treatment-plan protocols for patients not having attained a maintenance level of oral-health status.

These and many other reports made possible through the DWI Custom Software Program provide invaluable insight into the oral-health status of any given individual or population. It allows for the identification of current and future costs associated with recognized and documented utility loss in any group, and assesses the appropriateness and correct sequencing of treatment for utility loss.

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