JoAnna Scott

Finite-sample corrected generalized estimating equation of population average treatment effects in stepped wedge cluster randomized trials.

Stepped wedge designs are increasingly commonplace and advantageous for cluster randomized trials when it is both unethical to assign placebo, and it is logistically difficult to allocate an intervention simultaneously to many clusters. We study marginal mean models fit with generalized estimating equations for assessing treatment effectiveness in stepped wedge cluster randomized trials. This approach has advantages over the more commonly used mixed models that (1) the population-average parameters have an important interpretation for public health applications and (2) they avoid untestable assumptions on latent variable distributions and avoid parametric assumptions about error distributions, therefore, providing more robust evidence on treatment effects. However, cluster randomized trials typically have a small number of clusters, rendering the standard generalized estimating equation sandwich variance estimator biased and highly variable and hence yielding incorrect inferences. We study the usual asymptotic generalized estimating equation inferences (i.e., using sandwich variance estimators and asymptotic normality) and four small-sample corrections to generalized estimating equation for stepped wedge cluster randomized trials and for parallel cluster randomized trials as a comparison. We show by simulation that the small-sample corrections provide improvement, with one correction appearing to provide at least nominal coverage even with only 10 clusters per group. These results demonstrate the viability of the marginal mean approach for both stepped wedge and parallel cluster randomized trials. We also study the comparative performance of the corrected methods for stepped wedge and parallel designs, and describe how the methods can accommodate interval censoring of individual failure times and incorporate semiparametric efficient estimators.

Predictors of Unmet Dental Need in Children With Autism Spectrum Disorder: Results From a National Sample

OBJECTIVE Unmet dental need in children with autism spectrum disorder (ASD) is common. We tested hypotheses that lacking a medical home or having characteristics of more severe ASD is positively associated with having unmet dental need among children with ASD. METHODS Using data from the 2009 to 2010 National Survey of Children with Special Health Care Needs, we analyzed 2772 children 5 to 17 years old with ASD. We theorized that unmet dental need would be positively associated with not having a medical home and having characteristics of more severe ASD (eg, parent reported severe ASD, an intellectual disability, communication, or behavior difficulties). Prevalence of unmet dental need was estimated, and unadjusted and adjusted odds ratios, 95% confidence intervals, and P values were computed using survey methods for logistic regression. RESULTS Nationally, 15.1% of children with ASD had unmet dental need. Among children with ASD, those without a medical home were more apt to have unmet dental need than those with a medical home (adjusted odds ratio, 4.46; 95% confidence interval, 2.59-7.69). Children with ASD with intellectual disability or greater communication or behavioral difficulties had greater odds of unmet dental need than those with ASD without these characteristics. Parent-reported ASD severity was not associated with unmet dental need. CONCLUSIONS Children with ASD without a medical home and with characteristics suggestive of increased ASD-related difficulties were more apt to have unmet dental need. Pediatricians might use these findings to aid in identifying children with ASD who might not receive all needed dental care.

Population-centered Risk- and Evidence-based Dental Interprofessional Care Team (PREDICT): study protocol for a randomized controlled trial.

BackgroundTo improve the oral health of low-income children, innovations in dental delivery systems are needed, including community-based care, the use of expanded duty auxiliary dental personnel, capitation payments, and global budgets. This paper describes the protocol for PREDICT (Population-centered Risk- and Evidence-based Dental Interprofessional Care Team), an evaluation project to test the effectiveness of new delivery and payment systems for improving dental care and oral health.Methods/DesignThis is a parallel-group cluster randomized controlled trial. Fourteen rural Oregon counties with a publicly insured (Medicaid) population of 82,000 children (0 to 21 years old) and pregnant women served by a managed dental care organization are randomized into test and control counties. In the test intervention (PREDICT), allied dental personnel provide screening and preventive services in community settings and case managers serve as patient navigators to arrange referrals of children who need dentist services. The delivery system intervention is paired with a compensation system for high performance (pay-for-performance) with efficient performance monitoring. PREDICT focuses on the following: 1) identifying eligible children and gaining caregiver consent for services in community settings (for example, schools); 2) providing risk-based preventive and caries stabilization services efficiently at these settings; 3) providing curative care in dental clinics; and 4) incentivizing local delivery teams to meet performance benchmarks. In the control intervention, care is delivered in dental offices without performance incentives. The primary outcome is the prevalence of untreated dental caries. Other outcomes are related to process, structure and cost. Data are collected through patient and staff surveys, clinical examinations, and the review of health and administrative records.DiscussionIf effective, PREDICT is expected to substantially reduce disparities in dental care and oral health. PREDICT can be disseminated to other care organizations as publicly insured clients are increasingly served by large practice organizations.Trial registrationClinicalTrials.gov NCT02312921 6 December 2014. The Robert Wood Johnson Foundation and Advantage Dental Services, LLC, are supporting the evaluation.

Temperament as a Predictor of Nitrous Oxide Inhalation Sedation Success

&NA; Little is known about implications of temperament for children who receive nitrous oxide inhalation sedation (N2O/O2) for dental care. The aim of this study was to investigate whether child temperament is associated with success in N2O/O2. Child‐caregiver dyads were enrolled from patients aged 36‐95 months receiving dental care with N2O/O2 at a university‐based pediatric dental clinic. To assess child temperament, 48 caregivers completed the Childrens Behavior Questionnaire Short Form. Patient behavior was abstracted from Frankl scores recorded in the patients chart. The overall behavioral failure rate was 15% (n = 7/48). There was no significant difference in sedation outcome associated with sex, health, insurance status, or complexity of treatment provided. Sedation outcome was significantly associated with the broad temperament domain of Effortful Control and its subscales Attentional Focusing and Inhibitory Control. The Negative Affectivity subscales of Frustration, Sadness, and Soothability and the Extraversion/Surgency subscales Activity and Impulsivity were also significantly associated with sedation outcome. The results of this study suggest that Effortful Control is associated with behavior during dental treatment with N2O/O2. The subscales of Attention Focusing, Inhibitory Control, Frustration, Fear, Sadness, Soothability, Activity, and Impulsivity may also be important determinants of child behavior during dental treatment.

Survival of Teeth Restored with Atraumatic Restorative Treatment in aPediatric Rural Population

Objectives: To determine the overall 5-year survival rate of teeth treated by atraumatic restorative treatment (ART) delivered by general practitioners in a rural population in Washington State, USA. Methods: Inclusion/exclusion criteria included children (≤ 12 years and younger) who received ART on asymptomatic carious primary teeth without history of previous restoration (N=178). For this longitudinal study, data collection included demographics, health status, initial date of ART placement, date of ART re-placement, and baseline dmft/DMFT. Variables collected at follow ups included appointment dates, dmft/DMFT, final restorative treatment, pulp therapy, and extraction. Descriptive statistics were calculated for all variables while Kaplan-Meier survival curves were used to summarize overall treatment success. Unadjusted and adjusted hazard ratios (HR) from Cox Proportional Hazard Regression with robust standard error were used to compare survival rates for variables of interest (P<0.05). Results: The overall 5-year survival rate of primary teeth receiving ART restorations was 69.5%. While age, gender, baseline dmft/DMFT, tooth type, and number of ART surfaces were not associated with tooth survival time, child’s health status had a significant association (p=0.02). Conclusion: Among this pediatric rural population, a significant tooth survival rate was observed following treatment with ART. Replenishing ART was successful in extending survival tooth until their natural exfoliation or placement of a definitive restoration.

Racial disparities in orthodontic service use for Medicaid-enrolled children: An evaluation of the Washington Medicaid program

INTRODUCTION We assessed the relationship between race and orthodontic service use for Medicaid-enrolled children. METHODS This cross-sectional study focused on 570,364 Medicaid-enrolled children in Washington state, ages 6 to 19 years. The main predictor variable was self-reported race (white vs nonwhite). The outcome variable was orthodontic service use, defined as children who were preauthorized for orthodontic treatment by Medicaid in 2012 and subsequently received orthodontic records and initiated treatment. Logistic regression models were used to test the hypothesis that nonwhites are less likely to use orthodontic care than are whites. RESULTS A total of 8223 children were approved by Medicaid for orthodontic treatment, and 7313 received records and began treatment. Nonwhites were significantly more likely to use orthodontic care than were whites (odds ratio [OR] = 1.18; 95% confidence interval [CI] = 1.02, 1.36; P = 0.031). Hispanic nonwhite children were more likely to use orthodontic care than were non-Hispanic white children (OR = 1.42; 95% CI = 1.18, 1.70; P <0.001). CONCLUSIONS In 2012, nonwhite children in the Washington Medicaid program were significantly more likely to use orthodontic care than were white children. The Washington Medicaid program demonstrates a potential model for addressing racial disparities in orthodontic service use. Future research should identify mechanisms underlying these findings and continue to monitor orthodontic service use for minority children in Medicaid.