Dental hospitalisation of Victorian children – distribution, determinants, impacts and policy implications John Rogers September 2016

Impact of oral disease

Outline of presentation Background Research questions, conceptual model & methodology Results Fit with social determinants model Key messages

1. Background Dental general anaesthetic (DGA) care Potentially Preventable Dental Hospitalisations (PPDHs)

Rate of dental hospitalisations (DGA) per 1,000 population by age group in Australia, 2013-14

Rate of PPDHs per 1,000 population by age group in Australia, 2013-14

Rates of potentially preventable hospitalisations in Victoria, 2013-14

Relevance PPDHs highest cause of all PPHs in under 25yr olds Costly to families and the health system with some risk PPDHs rate used as an indicator of health system performance Policy and practice implications

2. Research questions 1. What is the extent of dental hospitalisation of Victorians? What was the distribution by frequency, rates, diagnosis and treatment patterns in 2013-14? What were the trends from 2001-02 to 2013-14? What are the determinants (contributing factors)?

Research questions 2. What are the impacts on Victorian children? What are the risks and complications – mortality and morbidity? What are the costs – financial impacts? 3. What are the policy implications?

  Child intermediary factors Age Gender Dental treatment needs Behaviour and ability Socioeconomic and cultural context of family Family income, parents’ education, concession card status Food availability Health insurance Country of birth Child’s Aboriginal background Language spoken at home Dental Hospitalisation Environmental structural factors Public health policy Access to fluoridation Dental care system Access to dental services Dental provider factors Health care system Access to primary care/geographic remoteness Family function Access to general anaesthetic facilities General parent factors     Conceptual social determinants model for dental hospitalisation of young children

How impact on PPDH measured and data sources Methodology DGA factors How impact on PPDH measured and data sources Dental system 1. Access to primary dental services Public dental data Dental provider: population ratios AHPRA and ABS data linked to Victorian Admitted Episode Dataset (VAED) 2. Dental provider factors Literature review Qualitative research with dental providers Health system 3. Access to ph care – remoteness Remoteness category; Parents perception VAED, ABS, 2009 Victorian Child Health and Welfare Survey (VCHWS) 4. Access to GA facilities Policy makers DH & DHS policy documents Public health policy 5. Access to community water fluoridation Fluoridation status linked to VAED

How impact on PPDHs measured DGA factors How impact on PPDHs measured 6. Families socioeconomic status Income; Education level; Concession card status; IRSID; Public or private admission 7. Aboriginal or Torres Strait Islander background VAED; VCHWS 8. Cultural background Country of birth Language other than English 9. Dental treatment needs Emergency treatment data Literature 10. Age. 11. Gender 12. Anxiety/disability VCHWS 13. Aboriginal or Torres Strait Islander background of child 14. Cultural background

Qualitative research In-depth semi-structured interviews Purposive & snowballing sampling Thematic analysis Data saturation Open approach

3. Results

PPDHs by proportion of principal diagnosis by age group, 2013-14

Rate of PPDHs by age group from 2001-02 to 2013-14

Rate of PPDHs for 0-4 year olds living in metropolitan and rural areas from 2001-02 to 2013-14

Standardised PPDH admission rate ratios comparison by SES quintile (IRSED) for 0-4 year olds, Victoria, 2013-14

Descriptive statistics of 0–4 year olds admitted for PPDHs by postcode in Victoria in 2012–13   Postcodes n=344 No. (%) PPDHs n = 1,297 Weighted PPDH rate:1,000 Access to DHPs Lowest 113 (32.8) 252 (19.4) 6.4 Medium 114 (33.1) 602 (46.4) 3.6 Highest 117 (34.0) 443 (34.2) 3.3 Fluoridation status Fluoridated 210 (61.0) 907 (69.9) 3.2 Not fluoridated 134 (39.0) 390 (30.1) 6.2 SES status Q1 51 (14.8) 302 (23.3) 5.9 Q2 61 (17.7) 227 (17.5) 4.3 Q3 53 (15.4) 242 (18.7) 4.0 Q4 88 (22.6) 281 (21.7) 3.0 Q5 91 (26.5) 245 (18.9) 2.9

Poisson regression between PPDHs, access to DPHs and water fluoridation, and SES for 0–4 year old children by postcode, Victoria, 2012–13   Unadjusted Model 1 Model 2 IRR/p Access to DHPs Lowest Medium Highest 1.96**** 1.08 1.00 1.47**** Access to fluoridation Yes No 1.92**** 1.59**** 1.75**** SES status Q1 2.04**** 1.70**** Q2 1.48**** 1.28* 1.37** Q3 1.39**** 1.23* 1.22* Q4 1.02 0.95 0.96* Q5

Variables statistically significantly associated with child DGA, VCHWS 2009 Multivariate analysis 1-8 years old 9-12 years 1-12 years Rural dweller ✔ High dental treatment needs Behavioural difficulties Parent not university trained Bivariate analysis Child is restless and overactive; parent with a health card; family with low level of income and with low level of food security; parent who perceives that the family does not have good access to primary health care.

Qualitative results - Dental provider factors Paediatric dentists model of care – lower threshold for DGA supply Dentists reluctance to treat children Dental therapists specialists in child management

Qualitative results - Parent and child factors Increase in child focus Behavioural/disability Parent Convenience of DGA Oral health literacy Guilt

Impact of DGA Mortality and morbidity Qualitative findings NCIS - one DGA death in Australia between 2000 and 2012 DGA side effects common but are lessening Financial impact considerable

  Child intermediary factors Age Gender Dental treatment needs Behaviour and ability Socioeconomic and cultural context of family Family income, parents’ education, concession card status Food availability Health insurance Country of birth Child’s Aboriginal background Language spoken at home Dental Hospitalisation Environmental structural factors Public health policy Access to fluoridation Dental care system Access to dental services Dental provider factors Health care system Access to primary care/geographic remoteness Family function Access to general anaesthetic facilities General parent factors     Conceptual social determinants model for dental hospitalisation of young children

4. Fit with the social determinants model Environmental structural determinants SES and cultural context of family Child intermediary determinants DGA (PPDH) Dental system Access to dental care Dental provider Health system Access to ph care Access to GA Public health policy Access to community water fluoridation SES ATSI background Cultural background Social and family oral health literacy and norms Social support Dental treatment needs Age/Gender Behaviour/dental care anxiety/disability

5. Key messages Potentially preventable dental hospitalisations (PPDHs) can be prevented by extending evidence-based initiatives that prevent tooth decay. Further initiatives are required to train oral health students and providers in alternatives to dental general anaesthetics (DGA), and to increase parents' and young adults' oral health literacy about prevention and alternatives to DGA. Australian guidelines for DGA need to be established.

Acknowledgements Supervisors Advisory Committee members The interviewed Colleagues

Thank you jgrogers@unimelb.edu.au