Dental hospitalisation of Victorian children and young adults – prevalence, determinants, impacts and policy implications
John Gordon Rogers ORCID identifier: orcid.org/0000-0001-6211-0895
Submitted in total fulfilment of the requirements of the degree of Doctor of Philosophy
October 2016
Department of Medicine, Dentistry and Health Sciences The University of Melbourne
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Abstract
The number of Victorians who have had dental care under a general anaesthetic (DGA) has increased over the last 15 years. This procedure is necessary for dental treatment for some people. It is also costly and although there have been improvements in safety, is not without risk. Potentially Preventable Dental Hospitalisations (PPDHs), a subgroup of DGAs, were the highest of all potentially preventable hospitalisations of Victorians under 25 years of age in 2013-14.
The aims of the research were to analyse the prevalence, determinants, impacts and policy implications of dental hospitalisation of Victorian children and young adults from 2001-02 to 2013-14. Associations between hospitalisation and a broad range of factors were analysed using a mixed methods design within a social determinants framework. There was a particular focus on PPDHs.
A literature review was undertaken to identify literature in English on dental hospitalisations of children and young adults in high income countries. Four main research projects were conducted to analyse distribution and determinants. These complemented each other in determining the strength of associations between dental hospitalisation and influencing factors.
The qualitative component of the research comprised conducting in-depth semi- structured interviews with key players involved in dental hospitalisation in Victoria. Paediatric dentists, dental therapists, dental public health specialists and hospital admission decision makers were interviewed to determine what factors they considered most relevant to dental hospitalisation distribution and determinants.
Three large hospital data bases were interrogated for the quantitative component of the research. Data on dental hospitalisations for all ages in Victoria and Australia were analysed. The impact of dental hospitalisation was studied through research on mortality, morbidity and cost.
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Associations were found between dental hospitalisation and environmental structural determinants (access to fluoridated water, dental services, and general anaesthetic facilities), family factors (socioeconomic and cultural factors), and child intermediary factors (dental treatment needs, age, gender, behaviour, and cultural background). No access to community water fluoridation, poor access to primary dental care, and lower socioeconomic status were each found to be independently associated with higher PPDH rates among young children. Young adults were found to have the highest rates of DGAs, predominantly for the extraction of asymptomatic wisdom teeth.
Social gradients were identified to be marked in younger but not older age groups. Shifts to a greater child focus in health care, supplier-induced demand, increased private care, reductions in PPDH rates for young children, workforce imbalances, and opportunities for prevention including alternative options to DGAs were found.
Mortality from dental hospitalisations in Australia was calculated to be possibly as low as 1:1.35 million DGAs. Side effects are common. Significant public and private costs are incurred. Direct costs were estimated to be $570 million a year in Australia and total costs could be as high as $1.43 billion annually.
Six key implications for actions were identified to address the factors that increase dental hospitalisations of children and young adults. These include extending evidence-based prevention initiatives that prevent dental caries; developing Australian guidelines for DGA; use of PPDH rates as a measure of health system performance; enhancing training of oral health students and providers in alternatives to DGA; increasing parents’ and young adults’ oral health literacy about prevention and alternatives to DGA; and enhancing DGA oral health status surveillance systems.
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Declaration
This is to certify that
(i) the thesis comprises only my original work towards the PhD except where indicated in the Preface, (ii) due acknowledgement has been made in the text to all other material used, (iii) the thesis is less than 100,000 words in length, exclusive of tables, maps, bibliographies and appendices.
John Gordon Rogers
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Acknowledgements
I would like to acknowledge all those who have assisted me on my journey to construct this thesis. Many people have been generously supportive.
Grateful thanks to my three supervisors. Professor Mike Morgan was always available and a calm source of encouragement, humour, and patience. Emeritus Professor. Clive Wright provided wise insights into the complex systems that impact on dental public health policy. Associate Professor Kaye Roberts-Thomson constructively challenged ideas and approaches.
Thanks to my Advisory Panel for their sound advice - my supervisors plus Professor Ivan Darby (chair), Professor Geoffrey McColl, and Associate Professor Andrea De Silva. A/Prof De Silva also assisted in the analysis of the 2009 Victorian Child Health and Welfare Survey.
Thank you to everyone that I interviewed for being open and generous with their time.
I would like to acknowledge Geoff Adams for providing statistical and analytical support, and Claire Delany who pointed me in the right direction to undertake the qualitative study. Fellow staff at the Department of Health and Human Services have also been supportive, particularly Louise Galloway and Anil Raichur.
For comments on drafts above and beyond friendship I would like to thank Meredith Kefford, Pauline Sanders and Kate Wilkinson. For listening to the travails of the road and for their encouragement I would like to acknowledge Ben Witham, Andy Calder and comrades in my Men’s Group. Thanks also to the great team at Julio’s, North Fitzroy, for their interest, good humour and excellent coffee.
Finally I gratefully acknowledge my life long partner Anne for her forbearance and tolerance of my prolonged distraction and absences. Anne and my three beautiful children have made it possible for me to go on this journey to its end.
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Table of contents
Abstract ...... 2 Declaration ...... 4 Acknowledgements ...... 5 List of figures ...... 12 List of tables ...... 14 Chapter 1 ...... 18 Introduction ...... 18 1.1 Background ...... 18 1.2 Aim and research questions ...... 21 1.3 Scope of the study ...... 22 Chapter 2 ...... 23 Review of the literature on dental hospitalisation...... 23 2.1 Overview ...... 23 2.2 The concept of Potentially Preventable Dental Hospitalisations (PPDHs) ...... 25 2.3 Prevalence in Australia ...... 29 2.4 Prevalence in Victoria ...... 31 2.5 Reasons for admitting children and young adults ...... 32 2.7 Costs ...... 38 2.8 Treatment provided ...... 39 2.9 Contributing factors ...... 42 2.10 Contributing factors to Potentially Preventable Hospitalisations (PPHs)...... 46 2.11 Alternative child management options ...... 48 2.12 Gaps in the literature ...... 53 Chapter 3 ...... 55 Research approach ...... 55 3.1 Social determinants models for oral health ...... 55 3.2 A conceptual social determinants model for dental hospitalisation in Victoria ...... 60 Chapter 4 ...... 65
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Methodology ...... 65 4.1 Overview ...... 65 4.2 Research outline ...... 66 4.3 Prevalence, trends and determinants of dental hospitalisation in Victoria ...... 72 4.3.1 Analysis of the Victorian Admitted Episode Dataset (VAED) ...... 72 4.3.1.1 Descriptive analyses of the VAED ...... 73 4.3.1.2 Multivariate analysis of the VAED...... 75 4.3.2 Analysis of the 2009 Victorian Child Health and Welfare Survey (VCHWS) ...... 78 4.3.2.1 Descriptive analysis of the 2009 VCHWS...... 79 4.3.2.2 Multivariate analyses of the 2009 VCHWS...... 81 4.3.3 Additional data sources ...... 81 4.4 Impacts ...... 82 4.4.1 Mortality and morbidity ...... 82 4.4.2 Costs ...... 84 4.5 Analytical plan for quantitative data ...... 84 4.5.1 Analyses of VAED data ...... 84 4.5.2 Analyses of the 2009 VCHWS ...... 85 4.6 The view from key players (qualitative research) ...... 86 4.7 Analytical plan for qualitative data ...... 88 4.8 Combining qualitative and qualitative data ...... 89 Chapter 5 ...... 90 Results 1 – Dental hospitalisation prevalence, trends and determinants – Analysis of the Victorian Admitted Episode Dataset (VAED) ...... 90 5.1 Overview ...... 90 5.2 Prevalence and trends ...... 91 5.2.1 Summary ...... 91 5.2.2 Age and gender distribution ...... 93 5.2.3 Potentially preventable hospitalisation ranking ...... 96 5.2.5 Principal diagnosis ...... 99 5.2.6 Diagnosis-related groups ...... 103 5.2.7 Admission type – emergency and planned admissions...... 107
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5.2.8 Treatment provided ...... 109 5.2.9 Geographic variations ...... 111 5.2.10 Aboriginal and Torres Strait Islander people ...... 117 5.2.11 Socio-economic status ...... 120 5.2.12 Hospital insurance status...... 122 5.2.13 Country of birth...... 124 5.3 Multivariate analysis, 2008–09 and 2012–13 ...... 127 5.3.1 Descriptive statistics ...... 127 5.3.2 Bivariate analysis ...... 130 5.3.3 Multivariate analysis ...... 132 Chapter 6 ...... 137 Results 2 - Distribution and determinants of dental hospitalisation – Analysis of the 2009 Victorian Child Health and Welfare Study (VCHWS) ...... 137 6.1 Overview ...... 137 6.2 Descriptive statistics ...... 138 6.4 Multivariate modelling...... 150 Chapter 7 ...... 153 Results 3 – The view from key players (qualitative research results) ...... 153 7.1 Overview ...... 153 7.2 Theme 1 Criteria for Dental General Anaesthetics (DGAs) ...... 154 7.3 Theme 2 Child factors ...... 155 7.4 Theme 3 Dental provider factors ...... 156 7.4.1 Paediatric dentist factors ...... 156 7.4.2 General dentist factors ...... 158 7.4.3 Dental therapist factors ...... 159 7.5 Theme 4 Parent factors ...... 160 7.6 Theme 5 Risk ...... 162 7.7 Theme 6 Financial impact ...... 163 7.8 Theme 7 Access to general anaesthetic facilities ...... 163 7.9 Theme 8 Treatment provided and follow-up after a DGA ...... 165 7.10 Summary ...... 165
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Chapter 8 ...... 166 Results 5 –Australian and international comparisons ...... 166 8.1 Comparison of Victorian and Australian dental hospitalisation rates ...... 166 8.2 Comparison of Victorian and international dental hospitalisation rates ...... 170 Chapter 9 ...... 172 Results 4 – Impacts of dental hospitalisation ...... 172 9.1 Overview ...... 172 9.2 Mortality and morbidity ...... 173 9.2.1 Mortality and morbidity data bases...... 173 9.2.1.1 National Coronial Information System (NCIS) request ...... 173 9.2.1.2 Victorian Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) request...... 174 9.2.1.3 Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM) request ...... 174 9.2.2 Interviews with key players ...... 174 9.2.3 Estimation of mortality rates ...... 175 9.3 Cost of dental hospitalisation ...... 175 9.3.1 Funding system for dental hospitalisation in Victoria ...... 175 9.3.2 Costs in the private sector ...... 179 9.3.3 Australian studies ...... 179 9.3.4 Estimation of costs in 2012-13 ...... 181 9.3.4.1 Costs in Australia ...... 181 9.3.4.2 Costs in Victoria ...... 183 Chapter 10 ...... 186 Discussion ...... 186 Section 1...... 187 10.1 Overview ...... 187 Section 2...... 188 10.2 Research question one – the distribution and the determinants of the dental hospitalisation of children and young adults in Victoria ...... 188 10.2.1 Main research projects ...... 188
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10.2.1.1 Analysis of the VAED from 2001-02 to 2013-14 ...... 188 10.2.1.2 Multivariate analysis of the VAED 2008-09 and 2012-13 ...... 189 10.2.1.3 Analysis of the 2009 VCHWS ...... 190 Section 3...... 205 10.3 Associated research question one – Australian and international comparisons ..... 205 10.3.1 Victorian and Australian rates ...... 205 10.3.2 Victorian and international rates ...... 206 Section 4...... 208 10.4 Research question two - impact of dental hospitalisation ...... 208 10.4.1 Mortality ...... 208 10.4.2 Morbidity ...... 209 10.4.3 Monitoring and reporting ...... 210 10.4.4 Costs ...... 212 Section 5...... 213 10.5 Research question three – policy implications...... 213 10.5.1 Policy implication principles ...... 213 Environmental structural determinants ...... 214 10.5.2 Public health policy...... 214 Access to community water fluoridation ...... 214 10.5.3 Dental care system ...... 217 10.5.4 Health care system ...... 231 Socioeconomic and cultural context of the family ...... 238 10.5.5 Families’ socioeconomic status and prevention of PPDHs ...... 238 10.5.6 Cultural background...... 242 10.5.7 General parent factors ...... 245 Child intermediary determinants...... 249 10.5.8 Age ...... 249 10.5.9 Gender ...... 251 10.5.10 Dental treatment needs ...... 252 10.5.11 Child behavioural and ability factors ...... 254 Section 6...... 257
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10.6 Strengths and limitations of the research ...... 257 10.7 Research required...... 259 Chapter 11 ...... 260 Conclusion ...... 260 Appendices ...... 266 Appendix 1 Plain language statement ...... 267 Appendix 2 Consent form ...... 268 Appendix 3 Hospitalisations for dental procedures ...... 269 Appendix 4 Potentially preventable dental hospitalisations by Diagnosis Related Group by age group, Victoria, 2013–14...... 270 References ...... 271
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List of figures
Figure 1 Rates of dental hospitalisations (per 1,000 population) involving a general anaesthetic (DGA) in Australia by sex and age group, 2011–12 ...... 30 Figure 2 Rates of potentially preventable dental hospitalisations (per 1,000 population), by sex and age group, 2011–12...... 31 Figure 3 The spectrum of patient management ...... 50 Figure 4 Dahlgren and Whitehead’s social determinants of health model ...... 56 Figure 5 Conceptual framework for the social determinants of health ...... 57 Figure 6 Conceptual social determinants model for dental hospitalisation of children and young people in Victoria ...... 61 Figure 7 Rate of potentially preventable dental hospitalisations in Victoria from 2001–02 to 2013–14 ...... 93 Figure 8 Potentially preventable dental hospitalisations by age in Victoria, 2013–14 ..... 93 Figure 9 Rate of potentially preventable dental hospitalisations by age group from 2001– 02 to 2013–14 ...... 95 Figure 10 Potentially preventable dental hospitalisations in public hospitals by age, 2013– 14...... 97 Figure 11 Potentially preventable dental hospitalisations in private hospitals by age, 2013–14...... 98 Figure 12 Potentially preventable dental hospitalisations by principal diagnosis by age group, 2013–14 ...... 101 Figure 13 Potentially preventable dental hospitalisations by proportion of principal diagnosis by age group, 2013–14...... 101 Figure 14 Potentially preventable dental hospitalisations by Diagnosis Related Group by age group, 2013–14 ...... 104 Figure 15 Potentially preventable dental hospitalisations by Diagnosis Related Group proportion by age group, 2013–14 ...... 105 Figure 16 Potentially preventable dental hospitalisations by Department of Health and Human Services region and public and private patients, 2013–14 ...... 114
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Figure 17 Rate of potentially preventable dental hospitalisations of 0–4 year olds from 2001–02 to 2013–14 by metropolitan and rural residence...... 115 Figure 18 Rate of potentially preventable dental hospitalisations for 5–9 year olds from 2001–02 to 2013–14 ...... 115 Figure 19 Rate of potentially preventable dental hospitalisations for 10–19 year olds from 2001–02 to 2013–14 ...... 116 Figure 20 Potentially preventable dental hospitalisation rate ratios for 0–4 year olds by socioeconomic quintiles (IRSED), 2013–14...... 120 Figure 21 Potentially preventable dental hospitalisation rate ratios for 15–24 year olds by socioeconomic quintiles (IRSED), 2013–14...... 121 Figure 22 Potentially preventable dental hospitalisation rate ratios for people aged 25 and over by socioeconomic quintiles (IRSED), 2013–14 ...... 122 Figure 23 Potentially preventable dental hospitalisations by hospital insurance status frequency by age group, 2013–14 ...... 124 Figure 24 Rate of potentially preventable dental hospitalisations by access to community water fluoridation and socioeconomic status, 0–4 year olds, by postcode, Victoria, 2008– 09...... 135 Figure 25 Rate of potentially preventable dental hospitalisations by access to community water fluoridation and socioeconomic status, 0–4 year olds, by postcode, Victoria, 2012- 13...... 135 Figure 26 Potentially preventable dental hospitalisation rates per 1,000 population by Australian state and territories, 2001-02, 2005-6, 2009-10 and 2013-14...... 167 Figure 27 Potentially preventable dental hospitalisation rates per 1,000 population for Australian and Victorian 0-4 and 5-9 year olds, 2003-04, 2009-10, and 2013-14 ...... 168 Figure 28 Potentially preventable dental hospitalisation rates per 1,000 population for people with and without an Aboriginal background by Australian state and territories, 2012-13 ...... 169 Figure 29 Factors found to be associated with dental hospitalisation of children and young adults in Victoria ...... 195 Figure 30 The oral health education system synchronized to meet oral health needs. .. 229
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List of tables
Table 1 Potentially preventable hospitalisation categories and conditions ...... 28 Table 2 Potentially preventable dental hospitalisations in Victoria, 1997–98, 2004–05 and 2013–14...... 32 Table 3 Factors that influence oral health inequality and/ or influence the oral health of children not included in conceptual model ...... 63 Table 4 Summary of approaches to answer research questions ...... 67 Table 5 Methodological approach to identify strength of associations between social determinant factors and the dental hospitalisation of Victorian children and young adults showing data sources (Research question one) ...... 69 Table 6 Methodological approach to identify the impact of dental hospitalisation on Victorian children and young adults showing data sources (Research question two) ...... 71 Table 7 Principal diagnosis codes for dental hospitalisations - International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM) ...... 73 Table 8 Rates of potentially preventable hospitalisations in Victoria, 2013–14 ...... 92 Table 9 Potentially preventable dental hospitalisations by age group and gender in Victoria, 2013–14 ...... 94 Table 10 Potentially preventable dental hospitalisations by age group, rate and rank, 2013–14...... 96 Table 11 Potentially preventable dental hospitalisations by public and private hospitals, 2013–14...... 97 Table 12 Potentially preventable dental hospitalisations by public and private admissions by proportion of total PPDHs by age group, 2013–14...... 98 Table 13 Potentially preventable dental hospitalisations by principal diagnosis, 2013–14 ...... 99 Table 14 Potentially preventable dental hospitalisations principal diagnosis by public and private patients, 2013–14 ...... 103 Table 15 Potentially preventable dental hospitalisations diagnosis by Diagnosis Related Group, 2013–14 ...... 104
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Table 16 Potentially preventable dental hospitalisation diagnoses by Diagnosis Related Group (DRGs) by public and private patients, 2013–14 ...... 106 Table 17 Potentially preventable dental hospitalisations admission type by public and private patients, 2013–14 ...... 107 Table 18 Variation in emergency admissions for potentially preventable dental hospitalisations in 2004–05 and 2013–14, Victoria ...... 108 Table 19 Potentially preventable dental hospitalisations procedures, ICD-10 Block 1, 2013–14...... 109 Table 20 Proportion of potentially preventable dental hospitalisations procedures by public and private patients, ICD-10 block 1, 2013–14 ...... 111 Table 21 Potentially preventable dental hospitalisations by Department of Health and Human Services region and public and private hospitals, 2013–14 ...... 112 Table 22 Potentially preventable dental hospitalisations by Department of Health and Human Services region and public and private patients, 2013–14 ...... 113 Table 23 Rates of potentially preventable dental hospitalisations in Victoria, metropolitan and rural areas in 2013-14 and changes since 2001 ...... 117 Table 24 Potentially preventable dental hospitalisations by Aboriginal and/or Torres Strait Islander origin, 2013–14 ...... 118 Table 25 Comparison between characteristics of Aboriginal and non-Aboriginal potentially preventable dental hospitalisations in Victoria, 2004-05 and 2013-14 ...... 119 Table 26 Potentially preventable dental hospitalisations by hospital insurance status and age group, 2013–14 ...... 123 Table 27 Potentially preventable dental hospitalisations by 12 highest frequency countries of birth and age group, Victoria, 2013–14 ...... 125 Table 28 Potentially preventable dental hospitalisations of under 25 year olds by 12 highest frequency country of birth and age group, Victoria, 2013–14 ...... 126 Table 29 Descriptive statistics of 0–4 year olds admitted for potentially preventable dental hospitalisations by postcode in Victoria in 2008–09 and 2012–13...... 128 Table 30. Poisson regression between potentially preventable dental hospitalisations and remoteness, access to oral health professionals, access to community water fluoridation, and socioeconomic status for 0–4 year old children by postcode, Victoria, 2008–09a .. 131
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Table 31 Poisson regression between potentially preventable dental hospitalisations and remoteness, access to oral health professionals, access to community water fluoridation, and socioeconomic status for 0–4 year old children by postcode, Victoria, 2012–13 .... 132 Table 32 Summary profile of participants (children aged 1 to 12 years) in the 2009 Victorian Child Health and Welfare Survey – child and family factors for children who have not had , and had, a dental hospitalisation ...... 138 Table 33 Dental hospitalisation unadjusted (bivariate) and adjusted (multivariate) Poisson regression ...... 142 Table 34 Poisson regression incident rate ratios (IRR) and 95 per cent confidence intervals for dental hospitalisation of 1–8 year olds unadjusted IRR and adjusted IRR 145 Table 35 Poisson regression incident rate ratios (IRR) and 95 per cent confidence intervals for dental hospitalisation of 9–12 year olds unadjusted IRR and adjusted IRR ...... 147 Table 36 Key results: predictors of dental hospital admission by Poisson bivariate and multivariate analysis and age group, Victorian Child Health and Welfare Survey 2009 149 Table 37 Predictors of dental hospitalisation for 1-12 year olds, 2009 Victorian Child Health and Welfare Survey ...... 150 Table 38 Predictors of dental hospitalisation for 1-8 year olds, 2009 Victorian Child Health and Welfare Survey ...... 151 Table 39 Predictors of dental hospitalisation for 9-12 year olds, 2009 Victorian Child Health and Welfare Survey ...... 152 Table 40 Key themes from qualitative research about the dental hospitalisation of children in Victoria ...... 154 Table 41 Major oral health Diagnosis Related Groups description and frequency in Victorian public hospitals in 2012–13 ...... 177 Table 42 Weighted Inlier Equivalent Separation, Victorian dental cost weights 2001–02, 2004–05 and 2013–14 ...... 177 Table 43 Estimated direct expenditure on oral health Diagnosis Related Groups in Australian public and private hospitals in 2012–13 ...... 182 Table 44 Estimated public expenditure on major oral health Diagnosis Related Groups in Victorian public hospitals in 2012-13 ...... 183
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Table 45 Estimated direct expenditure on public potentially preventable dental hospitalisations in Victoria in 2013–14 ...... 184 Table 46 Estimated direct expenditure on private potentially preventable dental hospitalisations in Victoria in 2013– 14 ...... 185 Table 47 Key results: predictors of dental hospital admission by Poisson bivariate and multivariate analysis and age group, p<0.05, 2009 Victorian Child Health and Welfare Survey ...... 191 Table 48 Key results and policy implications of research into associations between social determinants factors and dental hospitalisation of children and young adults in Victoria ...... 197 Table 49 Policy implications of the research findings – key recommendations with relevant section for further details ...... 264
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Chapter 1
Introduction
1.1 Background
More children and young adults are admitted to hospitals in Victoria for dental care than for any other cause considered potentially preventable (VHISS 2015 1). Between 2001 –02 and 2013-14 over 200,000 under 25 year olds were admitted for dental reasons, almost half for potentially preventable dental care.
Children as young as one and two years of age are being admitted to hospital to have teeth extracted or filled under a dental general anaesthetic (DGA 2). Most of these admissions are for the treatment of dental caries, a preventable condition. High rates of dental hospitalisation of children have also been reported in other Australian states and territories (Jamieson, 2006 #287), and internationally - in New Zealand ( Whyman R, 2012, Whyman et al., 2014), England (Moles and Ashley, 2009, Deery et al., 2015, Shepherd and Ali, 2015), and Canada (Schroth et al., 2014).
Australia has a high rate of hospital admissions compared to other high income countries such as New Zealand, the United Kingdom, Canada, and the USA (Organisation for Economic Co-operation and Development (OECD), 2015)3. Unnecessary hospitalisations place extra costs on the health system and families and pose a degree of risk to patients.
1The Victorian Health Intelligence Surveillance System (VHISS) is a publicly accessible interactive website displaying public health indicators. It is maintained by the Victorian Department of Health & Human Services (DH&HS) and is accessible via -
In the financial year 2013 –14, there were 39,196 dental hospitalisations 4 (AIHW 2015) in Victoria. The age group with the highest hospitalisation rates was 15-24 year olds, predominantly for extraction of embedded and impacted teeth. A high proportion of these were wisdom teeth, some that were asymptomatic. There have been calls to review whether the high rate of extraction of asymptomatic wisdom teeth is a public health problem in Australia (Jamieson and Roberts-Thomson, 2008) (George et al., 2011) (Anjrini et al., 2014).
Almost half (15,406) of the dental hospitalisations in Victoria in 2013-14 were considered to be potentially preventable (VAED 20155). Potentially Preventable Hospitalisations (PPHs) are those conditions where hospitalisation is thought to have been avoidable if timely and adequate non-hospital care had been provided (AIHW, 2014a). The concept has been developed in Australia from work by Ansari and colleagues in Victoria on Ambulatory Care Sensitive Conditions (ACSC) (Ansari, 2001) 6. Considerable research and policy review is being undertaken in Australia to identify the distribution and determinants of PPHs and develop options to reduce them (Ansari, 2007) (Katterl et al., 2012).
Potentially Preventable Dental Hospitalisations (PPDHs) are a sub-set of hospitalisations for dental care. Admissions for procedures such as extraction of impacted wisdom teeth are not included as PPDHs as they are not deemed preventable.
PPHs, including PPDHs, are being used as a performance measure for the Australian health system. A high rate may indicate an increased prevalence of the conditions in the community, poorer functioning of the non-hospital care system or appropriate use of the
4For simplicity, the terms ‘hospitalisations’ and ‘admissions’ will be used rather than ‘separations’. Separation from a healthcare facility occurs anytime a patient (or resident) leaves because of death, discharge, sign-out against medical advice or transfer. The number of separations is often used as a measure of the utilisation of hospital services rather than admissions, because hospital abstracts for inpatient care are based on information gathered at the time of discharge. Data for DGAs are based on separations. 5Data for the study was obtained from the Victorian Admitted Episode Dataset (VAED). The VAED will be described in the Methodology chapter. 6The term PPHs will be used in this study as it used nationally in discussions on health care. PPHs and ACSC are defined by the same conditions. 19 hospital system to respond to greater need (AIHW, 2015a). Reducing PPHs is a specific objective in health care reform, with the aim of improving patients’ outcomes, reducing pressure on hospitals and enhancing health system efficiency and cost-effectiveness (Katterl et al., 2012). The direct and indirect costs of PPDHs are a further performance measure for the health system.
PPHs have been included in the National Healthcare Agreement (NHA) between the Australian Government and the state and territory governments as a performance indicator 7 (AIHW, 2015b). The indicator relates to the outcome that ‘Australians receive appropriate high quality and affordable primary and community health services’. PPDHs are among the 11 PPHs included in the NHA.
Dental hospitalisations that involve a DGA, may, or may not, be a PPDH. Also, some PPDH care is not provided under a general anaesthetic (GA). Most dental hospitalisations of children are PPDHs and do involve a DGA. PPDHs that do not involve a DGA are predominantly in people aged 55 years and older who are being treated for oral cancer.
Oral health professionals generally recognise that some dental admissions to hospital are required. Cases include for dental emergencies, and for people with treatment needs, anxiety or disabilities that make it difficult to provide care in a dental clinic. Case selection beyond these situations is debated. While some oral health professionals propose that dental treatment under general anaesthesia is the preferred model of care for more children with high dental care needs, others argue that it should be the last resort.
The Victorian PPDH rate per 1,000 population in 2013-14 was 2.7, second highest to diabetes complications of all PPHs. Almost half (45 per cent) of the PPDHs were of under 25 year olds. The rate for this age group was 3.7 per 1,000 people; this was the highest rate of all PPHs (VHISS 2015).
7 National Healthcare Agreement: P1 18-Selected potentially preventable hospitalisations, 2015. Accessed 7 March 2016 -
Unlike many other hospital admissions, most admissions for dental care do not require an overnight stay. In 2013 –14 in Victoria, 90 per cent of dental hospitalisations were same day admissions (VHISS 2015). While PPDHs ranked twelfth by total hospital bed days for all age groups, 0-24 year olds had the second highest number of bed days for PPDHs, after asthma, of all PPHs.
There was a 50 per cent increase in 0 –9 year old PPDH rates in Victoria between 1997 – 98 and 2004 –05 (Department of Human Services, 2007). However, more recently rates for 0 –9 year olds have decreased, while rates in 10 –24 year olds have increased (VHISS 2015).
While there have been a number of Australian studies published highlighting the high rate of dental hospitalisation of 15-24 year olds (Jamieson and Roberts-Thomson, 2008, Anjrini et al., 2014), data have not been published on Victorian rates for this age group.
1.2 Aim and research questions
The aim of the study was to research dental hospitalisation in Victoria to answer three principal and associated research questions. The research questions were:
Question one: What are the distribution and the determinants of the dental hospitalisation of children and young adults in Victoria?
Associated questions were: 1.1 What were the distribution and determinants of dental hospitalisation by prevalence, rates, diagnosis, dental treatment, and trends from 2001-02 to 2013- 14? 1.2 How do Victorian dental hospitalisation rates compare nationally and internationally?
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Question two: What are the impacts of dental hospitalisation on Victorian children, young adults and their families?
Associated questions were: 2.1 What is the extent of morbidity and mortality related to dental hospitalisation? 2.2 What are the costs related to dental hospitalisation?
Question three: What are the policy implications?
1.3 Scope of the study
The study focused on children and young adults because of the high prevalence of dental hospitalisations in under 25 year olds. As highlighted in the background section, 15-24 year olds have the highest DGA rates, and 0-24 year olds have the highest rates of PPDHs.
The key years of study were 2001–02 to 2013–14. This period allows sufficient time to analyse relevant trends. Data from 2000–01 were not used as not all hospitals provided data to the Department of Health Victoria 8 in that year. The latest hospitalisation data available were for 2013–14.
This chapter has provided background to the issue of dental hospitalisation in Victoria and has outlined the aim and the research questions. A review of the literature on dental hospitalisations will be presented in the next chapter followed by the development of a model to test contributing factors. The methodology used will then be outlined, followed by chapters on results and discussion of the extent of dental hospitalisations, their impacts and policy implications. Recommendations and conclusions will then be made.
8 In 2014 in Victoria, the Department of Health & Human Services (DH&HS) was formed from the amalgamation of the Department of Health (DH) and the Department of Human Services (DHS). 22
Chapter 2 Review of the literature on dental hospitalisation
2.1 Overview ...... 23 2.2 The concept of Potentially Preventable Dental Hospitalisations (PPDHs) ...... 25 2.3 Prevalence in Australia ...... 29 2.4 Prevalence in Victoria ...... 31 2.5 Reasons for admitting children and young adults ...... 32 2.6 Morbidity and mortality ...... 36 2.7 Costs ...... 38 2.8 Treatment provided ...... 39 2.9 Contributing factors ...... 42 2.10 Contributing factors to Potentially Preventable Hospitalisations (PPHs)...... 46 2.11 Alternative child management options ...... 48 2.12 Gaps in the literature ...... 53
2.1 Overview
A systematic review of the literature was undertaken to shape the research methodology in order to answer the research questions outlined in the Introduction. The focus was on the distribution and determinants of the dental hospitalisation of children and young adults, impacts, and policy implications.
The main literature review question was to identify what has been documented on the dental hospitalisation of children and young adults in Australia and other high income countries related to eight key topics. These topics were: the concept of Potentially Preventable Dental Hospitalisations (PPDHs); dental hospitalisation prevalence and trends; reasons for admission; mortality and morbidity; costs; treatment provided; contributing admission factors; and alternative options.
Literature related to the social determinants of oral health was also reviewed so that an explanatory model for the dental hospitalisation of children and young adults in Victoria could be developed. The second literature review question was: ‘What information and research gaps exist?’
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The search encompassed literature in English for the period January 2000–January 2016 focusing on 0-24 year olds. This period was considered sufficient to identify relevant material. Also, prior to 2000, there were less stringent regulations governing the provision of dental general anaesthetic (DGA) care in dental clinics in Australia. Frequency data of DGAs in dental clinics were not collected. Articles published prior to 2000 were reviewed if they had been referenced in more recent articles and appeared relevant.
International studies from high income countries that were relevant to the key topics were included. Preference was given to articles from New Zealand and the United Kingdom because of the similarities with the Australian health system related to DGA care. In the USA, DGAs are commonly undertaken in dental clinics as well as hospitals. Studies on the provision of DGAs in dental clinics were not included.
Studies on alternatives to DGA were included if they incorporated information about outcomes. Preference was given to systematic reviews.
Studies in languages other than English were not included in the review, except where there was a comprehensive abstract in English. Articles on repeat DGAs, individual case studies, or technical aspects of DGAs such as techniques, equipment or pharmacology were not included.
The main search terms were (Anaesthesia, Dental) 9 AND (general) with limits set to include references for 0-24 year olds for the period January 2000 to January 2016. Other combinations of the key topics were used. Sources included MEDLINE (via PubMed); the Cochrane Library; CINAHL; ProQuest Dissertations and Theses; Centre for Reviews and Dissemination databases ; Scopus; Google Scholar; dental text books; experts in dental public health; and reference lists of reviewed articles. Relevant grey literature such
9 Search engines also captured articles using the American spelling - anesthesia. “Anaesthesia, Dental” is a Medical Subject Heading [MeSH]. 24 as unpublished reports was also included. Government and dental association reports were sourced through a search of web sites.
A total of 1,107 articles, studies or reports were identified. Of these, 462 abstracts were reviewed for relevance, and 190 documents were considered to be in scope. These were subject to more in-depth analysis. A total of 160 documents have been referenced and appear in the footnotes or in the References. International studies included were predominantly from New Zealand, the United Kingdom, and Scandinavia.
The quality of the evidence of studies was determined using the GRADE system. The consolidated criteria for reporting qualitative research (COREQ) were used as a guide for ensuring the quality of the qualitative research (Tong et al., 2007).
A review of Australian systematic reviews of the epidemiology of Potentially Preventable Hospitalisations (PPHs) and interventions to prevent or divert these was also undertaken. Two systematic reviews were identified (Ansari, 2007) (Clinical Epidemiology & Health Service Evaluation Unit (CEHSEU), 2009) 10 , as well as a rapid review (Katterl et al., 2012), and a review by Muenchberger and Kendall of chronic PPHs (Muenchberger and Kendall, 2008).
2.2 The concept of Potentially Preventable Dental Hospitalisations (PPDHs)
As Ansari states in his comprehensive review of the concept and usefulness of PPHs 11 , conditions that are potentially preventable ‘ have long been conceptualized as inverse indicators of access to and quality of health care services’ (Ansari, 2007). Rutstein and colleagues explored the concept in their 1976 paper (Rustein et al., 1976). This approach was combined with analysis of hospitalisation rates in small geographic areas to allow the
10 Clinical Epidemiology & Health Service Evaluation Unit (CEHSEU), Melbourne Health. Report accessed on 7 March 2016 - < http://www.safetyandquality.gov.au/wp-content/uploads/2009/01/Potentially- preventable-hospitalisations-A-review-of-the-literature-and-Australian-policies-Final-Report.pdf > 11 Ansari uses the term Ambulatory Care Sensitive Conditions (ACSC), which as explained in the Introduction are the same as PPHs. 25 study of the hospitalisation of populations rather than individual patients (Billings and Hasselblad, 1989).
The next development, as Ansari notes, was that expert committees in the USA identified conditions considered to be ‘ambulatory care sensitive’. These were conditions ‘that if managed in a timely and efficient manner via primary health providers, would not result in subsequent hospitalisation’ . Classifications of PPH conditions have evolved since Billings and colleagues compiled their list (Billings et al., 1993), published after updating by Weissman and colleagues (Weissman et al., 1992).
The concept of PPHs has been used in Victoria for health service planning from the 1990s (Ansari, 2001). The underlying premise of PPHs indicators is that hospital admission data for selected conditions can be used to identify potential inadequacies in primary health care services (Ansari, 2007). Timely and effective ambulatory care can help reduce the risk of hospitalisation by preventing the onset of an illness or condition, controlling an acute episodic illness or condition, or managing a chronic disease condition.
The Australian Institute of Health and Welfare (AIHW) has proposed that a high rate of PPHs may be due to an increased prevalence of the conditions in the community, poorer functioning of the non-hospital care system, or an appropriate use of the hospital system to respond to greater need (AIHW, 2015a). The latter factor is supported by Weinberger and colleagues who reviewed hospitalisation rates for veterans in the United States. They concluded that higher rates of PPHs may actually reflect enhanced access to primary health care as it allows better detection of impairments in the primary health care setting (Weinberger et al., 1996).
The conclusion of the reviews of PPHs in Australia (Ansari, 2007) (Muenchberger and Kendall, 2008), Katterl and colleagues (Katterl et al., 2012), and the CEHSEU 2009 report (Clinical Epidemiology & Health Service Evaluation Unit (CEHSEU), 2009, is that, while researchers have shown that poor access to primary health care is strongly
26 related to higher rates of PPHs, many other factors need to be considered. These factors include: socioeconomic factors; geographic remoteness; hospital admission policies; physician admitting style; age; disease prevalence and severity; and propensity to seek care (Ansari, 2007).
Ansari has proposed at least four uses of PPHs to develop health policy: to identify pressures and gaps; to develop community profiles; to develop targeted interventions; and to evaluate the impact of interventions (Ansari, 2007). Rather than using PPH rates as indicators of sub-optimal primary care, they should be used to identify possible problems in the health system, which should then be investigated further (Ansari, 2001).
Identification of principal diagnosis codes representing PPDHs was initially undertaken by Billings and colleagues and Weissman and colleagues as part of the identification of codes for 11 other relatively common PPH conditions (Billings et al., 1993, Weissman et al., 1992). The principal diagnosis is the main diagnosis responsible for the person being admitted to hospital.
PPDHs are defined by the principal diagnosis codes of the International ICD-10-AM (International Statistical Classification of Diseases and Related Health Problems, 10 th Revision, Australian Modification) as outlined in Table 4.7, section 4.3.1. Conditions considered not preventable are excluded, for example, disorders of tooth development and extraction of impacted teeth such as wisdom teeth. ‘Embedded’ or ‘impacted’ teeth in principal diagnosis K01 are not included.
A total of 21 conditions are considered in Victorian and Australian government reports to be PPHs. The conditions are categorised into three broad groups as shown in Table 1.
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Table 1 Potentially preventable hospitalisation categories and conditions
Categories Conditions
Vaccine preventable These diseases can be prevented by proper Influenza, bacterial pneumonia, tetanus, vaccination. measles, mumps, rubella, pertussis and polio.
Acute Complicated appendicitis; These conditions may not be preventable but, dehydration/gastroenteritis; pyelonephritis; theoretically, would not result in hospitalisation if perforated ulcer; cellulitis; pelvic inflammatory adequate and timely care (usually non-hospital) was disease; ear, nose and throat infections; and received. dental conditions .
Chronic These conditions may be preventable through Diabetes complications, asthma, angina, behavioural modifications and lifestyle change, and hypertension, congestive heart failure and can be managed effectively by timely care (usually chronic obstructive pulmonary disease. non-hospital) to prevent deterioration and hospitalisation. Source: AIHWa 2015.
Dental conditions are categorised as ‘acute’ PPHs. However, conditions such as periodontal disease and also potentially dental caries, could be categorised as ‘chronic’. No articles were found in the literature review that questioned the categorisation of dental conditions.
PPDHs are a subset of total dental hospitalisations, as conditions considered not preventable are excluded. The number of PPDHs and total dental hospitalisations are actually similar for 0–9 year olds. This is because most dental admissions for young children are for treatment of dental caries which is considered preventable (Department of Human Services, 2007). However, for older age groups, total dental hospitalisations are much higher than PPDHs. One key factor is that the removal of impacted teeth comprises the majority of treatment provided for over 10 year olds, and this condition is not considered potentially preventable.
As mentioned in Chapter 1, PPHs including PPDHs are being used in Australia as a performance measure for the health system. In addition to their use as performance benchmarks for the National Healthcare Agreement, PPHs are reported in the annual
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Report on Government Services as a performance indicator for primary and community health 12 .
Australian literature on dental hospitalisation has predominantly looked at total dental hospitalisations with less focus on PPDHs of children and young adults. Only one study comprehensively analysed PPDHs of Victorian children and quantified the impact of contributing factors (Department of Human Services, 2007). No studies were found that analysed the relevance of the defining PPDHs principal diagnoses or reviewed treatment provided by age groups.
2.3 Prevalence in Australia
As mentioned in the Introduction chapter, high rates of dental hospitalisation of children have been reported in Australian states and territories and in other high income countries. Relevant international data will be presented in 8.2 when addressing associated question one, ‘How do Victorian dental hospitalisation rates compare nationally and internationally?’
In Australia in 2013-14, there were 142,939 hospitalisations for dental procedures 13 (AIHW, 2015a), 130,792 DGA admissions (AIHW: et al., 2016), and 63,456 PPDHs 14 (AIHW: et al., 2016). The DGA and PPHD rates were 5.9 per and 2.7 per 1,000 population respectively.
Rates of DGA by sex and age group for 2011-12 are shown in Figure 1. The overall rate of 5.7 per 1,000 population was similar to the 2013-14 rate.
12 Report on Government Services site accessed 7 March 2016 -
Figure 1 Rates of dental hospitalisations (per 1,000 population) involving a general anaesthetic (DGA) in Australia by sex and age group, 2011–12
Source: AIHW website, accessed 6 January 2014 -
The total number of hospitalisations for dental procedures requiring a general anaesthetic in 2011-12 was 128,712. The 15-24 year old age group had the highest rate of 16.3 per 1,000 population. People 65 years and over had the lowest rate – 1.7 per 1,000 population.
The predominant treatment for 15-24 year olds was the removal of embedded or impacted teeth. This will be explored further in section 2.8 on the treatment provided under a DGA.
Rates of PPDHs by sex and age group for 2011-12 are shown in Figure 2. The overall PPDH rate of 2.8 (AIHW, 2014b), was similar to the 2013-14 rate of 2.7 per 1,000 population.
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Figure 2 Rates of potentially preventable dental hospitalisations (per 1,000 population), by sex and age group, 2011–12
Source: AIHW website, accessed 6 January 2014,
The age group with the greatest number of PPDHs was 5-9 year olds with a rate of 9.8 per 1,000 population. Children aged 0-4 years had the next highest rate of 5.3 per 1,000 population (AIHW, 2014b).
Australian dental hospitalisation rates for 0-9 year olds more than trebled between 1993- 94 to 2003-04, from 2.2 (per 1,000 children) to 7.31 per 1,000 children (Jamieson and Roberts-Thomson, 2006). Further data on dental hospitalisations in Australia by age group, trends and by Aboriginal and Torres Strait Islander status will be presented in 8.1. Victorian and Australian data will be compared.
2.4 Prevalence in Victoria
As highlighted in Chapter 1, in 2013–14 there were 15,406 PPDHs in Victoria. The rate per 1,000 population was 2.7, the second highest rate of all PPHs - diabetes complications was the most common PPH. Almost half of all PPDHs (45 per cent) were of under 25 year olds. In this age group, the rate of PPDHs was the highest of all PPHs (VHISS 2015).
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The most recently published comprehensive analysis of PPDHs in Victorian children found that in 2004–05, children under 10 had over four times higher PPDH rates than adults - 7.95 per 1,000 population compared to 1.90 per 1,000 (Department of Human Services, 2007). About two-thirds (65 per cent) of PPDHs in 0–4 year-olds were in public hospitals, compared to 40 per cent of these admissions in those aged 15-years or more (Department of Human Services, 2007).
This Department of Human Services study identified that PPDH rates increased by 34 per cent between 1997–98 and 2004–05, as shown in Table 2. PPDHs shifted from being the fifth, to the second most common PPH over this time. From 2004–05 to 2013–14, total PPDHs increased by six per cent (Table 2). As Victoria’s population increased, this represented a seven per cent decrease in rates. PPDHs continued as the second most 15 common ranking of PPHs in 2013–14 .
Table 2 Potentially preventable dental hospitalisations in Victoria, 1997–98, 2004–05 and 2013–14 Rate per 1,000 Rank by all Year Total PPDHs persons PPHs 1997 –98 8,840 2.2 5 2004 –05 14,481 2.9 2 2013 –14 15,406 2.7 2 Source: (Department of Human Services, 2007), VHISS 2015 .
2.5 Reasons for admitting children and young adults
The advantage of providing dental care under a GA is that more treatment can be provided than in a single visit to a dental clinic. Immediate relief of pain can be provided, and little cooperation is required from the child. There is less physical and mental stress for both the patient and the operator (Anderson et al., 2004). If there is nasal intubation, higher quality dental care can be provided because it is easier to manage saliva and the
15 These three time periods are used because the Department of Human Services study compared 1997–98 and 2004–05 data, and 2013–14 data were the most recent available. 32 tongue in the more controlled environment. In addition, a dental GA can be more convenient for carers as the number of dental visits can be reduced.
Studies in New Zealand (Anderson et al., 2004) (Malden et al., 2008) (Gaynor and Thomson, 2012), England (Aljafari et al., 2014, Goodwin et al., 2015b, de Souza et al., 2016), Canada (Amin et al., 2006), Sweden (Ridell et al., 2015), and Holland (Klaassen et al., 2008, Klaassen et al., 2009) have concluded that dental care under a GA improves the quality of life for the child and his or her family. While a DGA in these studies did cause a high prevalence of side effects (to be covered in section 2.6), parents generally reported a high level of acceptance of the procedure for their children.
Most studies interviewed parents of children undergoing a DGA, but not the children. In a recent United Kingdom study, children were interviewed about their DGA experience, providing insights into how to improve the experience. (Rodd et al., 2014). No recent studies were found that examined parents’ and children’s experience of DGAs in Australia.
There is debate about the extent of dental hospitalisation that is appropriate for children. While there is agreement that cases such as emergency care can often only be undertaken under a GA, and that it would be preferable for oral diseases such as dental caries to be prevented entirely, proponents emphasise the quality and convenience benefits of a GA, while others highlight the costs and potential health risks.
In the handbook of paediatric dentistry that is used to train Australian dental clinicians, Alcaino and colleagues identify the situations they consider automatically indicate the need for a general anaesthetic – multiple carious lesions and abscessed teeth in multiple quadrants in very young children; severe facial cellulitis; and facial trauma (Alcaino, 2013) . Alcaino and colleagues note that, while the use of a GA is the most expensive form of treatment, it has increased globally ‘due to the increase in availability, safety, and an understanding that it is the most appropriate way in which to manage young children requiring extensive dental treatment ’ . They suggest that this is ‘ in-line with the
33 management of most other invasive medical procedures that are performed under anaesthesia around the world’ (Alcaino, 2013).
A different view is outlined in the United Kingdom National Clinical Guidelines in Paediatric Dentistry , developed by the Royal College of Surgeons, Faculty of Dental Surgery (Davies et al., 2008). These guidelines state that as the majority of operative dental care can be carried out using either local anaesthesia or local anesthesia with conscious sedation this ‘sets dentistry aside from other paediatric specialties where GA is the norm’ .
The United Kingdom guidelines also state that patient/carer preferences are a condition that rarely justifies a GA, ‘except where other techniques have already been tried’ . Similarly, the UK Clinical guidelines and integrated care pathways for the oral health care of people living with learning disabilities, also developed by the Royal College of Surgeons, Faculty of Dental Surgery with the British Society for Disability and Oral Health, includes the statement, that a DGA for people with a disability should be the ‘ last choice of treatment’ (Royal College of Surgeons of England, 2012).
Alcaino and colleagues note that ‘although most children will cope with dentistry in the normal setting, many may benefit from delivery of extensive dentistry in one session under GA’ . Their approach may indicate a shift in attitude by Australian paediatric dentists towards the use of DGAs. In the 2008 edition of the Handbook of pediatric dentistry , Cameron suggested that the need for a DGA is the clinician’s last solution to treating a child’s dental problem (Cameron, 2008). Cameron added that ‘ In most instances, a caring attitude in association with a period of familiarisation will allow the child to be treated conservatively’ and that ‘If, after seeing the child several times, the clinician feels the child needs dental work, but is unmanageable, a general anaesthetic should be considered’ . These comments are not included in the 2013 edition of the handbook.
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The chapter in the 2013 edition of the handbook, by Alcaino and colleagues does retain the three questions from the 2008 edition to determine whether admission for a GA is necessary – • Could the patient be managed more conservatively? • Has the child undergone a period of familiarisation? • Has there been a history of emotional trauma associated with the dental environment?
Alcaino and colleagues do stress the importance of balancing needs against risks, as well as the need to consider economic factors (public health access and private insurance), cultural factors, and access to anaesthetic facilities (Alcaino, 2013).
Dental treatment under a GA does not necessarily improve the subsequent behaviour of the child in the dental clinic, and repeat GAs can occur. Klaassen and colleagues found that children’s dental fears did not change after a DGA and that children need guidance in reducing dental fear after treatment under a GA (Klaassen et al., 2008, Klaassen et al., 2009). Anderson and colleagues recommend that a preventive program should follow a DGA to increase a child’s confidence in coping with dental care, and minimise future treatment requirements (Anderson et al., 2004).
Review of grey literature from public dental services in Australia determined that there are no standard Australian policy guidelines regarding specialist referral and public dental care under a GA. States and territories have developed their own approaches.
Several studies in the United Kingdom have identified that general dentists referring children for care under a GA do not always follow relevant referral guidelines. Clayton and Mackie determined that almost half (47 per cent) of general dentists did not comply with referral guidelines (Clayton and Mackie, 2003). Tyrer found that there was scope for significant reduction in provision of DGAs if guidelines were followed (Tyrer, 1999). These studies highlight the importance of monitoring and evaluating guidelines.
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2.6 Morbidity and mortality
The mortality rate due to anaesthesia in Australia was estimated to be 1:53,000 in all age groups and 1:150,000 in children in 2005 (Alcaino, 2013) 16 . This all age group mortality rate is similar to the rate of 1:58,664 reported for Victoria for the period 2003–05 (Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM). An estimated mortality rate of 1:250,000 for DGAs in children is quoted in the Scottish Dental clinical guidance, prevention and management of dental caries in children document, but no reference is cited (Scottish Dental Clinical Effectiveness Program, 2010 17 ).
There are no published Australian figures documenting morbidity in children arising from DGA (Alcaino, 2013). The paucity of adequate data on DGA morbidity and mortality has been highlighted in an international survey of paediatric dentists (Wilson and Alcaino, 2011) and through a review in the United States (Lee et al., 2013).
Amin and colleagues assessed the dental literature and found that the most common post- operative complaints following a DGA were related more to the dental treatment than the GA - that is oral pain (Amin and Harrison, 2006, Amin et al., 2006). This supported a previous finding by Alcaino and colleagues (Alcaino et al., 2000). Other impacts include child and parent anxiety, emotional reaction of the child to tooth loss, bleeding, drowsiness, sore throat, nausea and vomiting (Amin and Harrison, 2006, Amin et al., 2006).
Needleman and colleagues reviewed 11 studies of DGA morbidity in children undertaken between 1985 and 2006 (Needleman et al., 2008). They noted that it was difficult to compare the results because of methodological problems in many of the studies. For example there was a lack of reliable and validated pain scales plus limited use of comparative statistics to evaluate potentially relevant variables such as age, gender and
16 The source for this mortality rate was not identified. 17 Accessed on 7 March 2016 from -
In 2009 Farsi and colleagues conducted a follow-up review of post-operative morbidities among children who underwent a DGA (Farsi et al., 2009). They concluded that, while common, impacts have generally been reported as mostly short term and of mild severity. They noted that the prevalence of vomiting has decreased since the 1990s, probably because of developments in anaesthetic drugs and techniques.
A recent Canadian study examined postoperative DGA pain in children by having parents use validated pain scales (Wong et al., 2015). Moderate to severe pain was reported in almost half (48.5 per cent) of the children.
Recent qualitative research in the United Kingdom has studied DGA from the child’s (Rodd et al., 2014) and parent’s (Goodwin et al., 2015a) perspectives. In Rodd and colleagues study, children aged 6–11 years maintained a video diary to document their feelings and experiences. Some impacts of the DGA that the children recorded were those identified in earlier studies, such as nausea, bleeding and tiredness. Additional physical and psychological impacts included feeling ‘weird and wobbly’, hunger, disturbed eating, being scared and worried, and discomfort from the IV cannula. Positive outcomes included satisfaction that their dental problem was fixed, and being given rewards and attention from family members (Rodd et al., 2014). Goodwin and colleagues found that some parents were shocked at the amount of blood and the behavioural state of their child (Goodwin et al., 2015a).
Possible impacts of GAs in general, rather than just related to a DGA, are listed on the United Kingdom National Health Service (NHS) website 18 . Most side effects are noted to
18 Accessed on 10 January 2015 -
• Feeling sick and vomiting after surgery – about 33 per cent of people feel sick after an operation. This usually occurs immediately, although some people may continue to feel sick for up to a day. • Shivering and feeling cold – about 25 per cent of people experience this. Shivering may last for 20–30 minutes after the operation. • Confusion and memory loss – this is more common in elderly people and is usually temporary. • Dizziness • Bruising and soreness – this may develop in the area that was injected or had a drip fitted. It usually heals without treatment. • Sore throat – found in about 40 per cent of people if a tube is inserted either into the mouth or down the throat. • Lip or dental damage – about five per cent of people may have small cuts to their lips or tongue from the tube, and around 1 in 4,500 people may have damage to their teeth.
2.7 Costs
Nine published studies were found that estimated the cost of dental hospitalisations in Australia. Most studies used different methodologies.
Richardson and Richardson estimated the direct cost of the approximately 50,000 PPDHs per annum to be $233 million, based on 2008-09 data (Richardson and Richardson, 2011). The National Advisory Council on Dental Health 2012 report noted that public expenditure on public hospital admissions for oral disease in 2008-09 was $84 million, based on data from the National Hospital Cost Data Collection Cost Report Round 13 (Department of Health 2012 19 ).
19 Report accessed on 7 March 2016 - Comprehensive analyses have been conducted in Western Australia on oral health admissions for children younger than 15 years (Alsharif et al., 2015b, Alsharif et al., 2015a); for people 18 years and older (Kruger and Tennant, 2015d); for people older than 65 years (Kruger and Tennant, 2015a); for PPDHs (Kruger and Tennant, 2015b); and for the removal of impacted teeth (George et al., 2011, George et al., 2012, Anjrini et al., 2015). Estimates of national costs have been made in some of these studies. Anjirini and colleagues estimated that the average annual direct cost of hospitalisations for removal of impacted teeth in 15-34 year olds in Australia was $350 million. The total cost was estimated at $531 million when indirect costs of absenteeism and transport were included (Anjrini et al., 2015). One study was found that identified dental hospitalisation costs in Victoria. A Department of Health study determined that the direct cost of PPDHs in public hospitals in 2000-01 was $19.7 million (Department of Human Services, 2002a). No studies were found that estimated public and private dental hospitalisation costs in Victoria. 2.8 Treatment provided As outlined in 2.3 and shown in Figure 1, the highest rate of dental hospitalisation in Australia in 2011–12 was of 15 to 24 year olds, mostly for extraction of embedded or impacted teeth. Children under 10 years old had the next highest rate of dental hospitalisations, with extractions and restorations the most common treatments. (Department of Human Services, 2007). Anjirini and colleagues compared rates of impacted teeth removal in Western Australia, the United Kingdom and France from 1999–2000 to 2008–09 (Anjrini et al., 2014). They found that England had rates approximately five times less than France and seven times less than Western Australia. They concluded that these differences could be explained by the implementation of the National Institute for Health and Care Excellence (NICE) B29/$File/Final%20Report%20of%20the%20NACDH%20- %2026%20February%202012%20%28PUBLICATION%29.pdf >. 39 guidance on the extraction of wisdom teeth (NICE 2000 20 ) in the United Kingdom, and the absence of similar guidelines in France and Australia 21 . Anjirini and colleagues stated that the - ‘presence of good-quality clinical guidelines for dental procedures, especially those requiring access to high-cost health system facilities and treatment, has the potential long-term opportunity to more efficiently, and cost effectively manage care and target it to those most in need’ (Anjrini et al., 2014). The Scottish Intercollegiate Guidelines Network (SIGN) 22 released a guideline on the management of unerupted and impacted third molar teeth in 1999 that was similar to the NICE guideline (SIGN 1999). However, it included several additional indications for prophylactic removal (Richards 2000). This guideline was withdrawn in February 2015 as it was more than 10 years old. Healthcare Improvement Scotland 23 stated that – ‘Without a full review of the evidence it is not possible to be certain that the guideline: remains relevant to NHS Scotland; makes recommendations based on the most up-to-date evidence for best practice; does not recommend unsafe practice; and complies with current mandatory advice or government policy’. 24 The NICE guidance on the extraction of wisdom teeth is still in place in England. A Cochrane review on surgical removal versus retention for the management of asymptomatic wisdom teeth did not find any randomised controlled trials (RCTs) that compared the impact on quality of life of removal of these teeth with their retention (Mettes et al., 2012). These authors found only one RCT that reviewed the effect of removal of impacted wisdom teeth on lower incisor crowding. This study was considered 20 Accessed 11 November 2015 - The authors of the Cochrane review concluded that there was insufficient evidence to support or refute prophylactic removal of asymptomatic wisdom teeth in adults. They noted that the ‘limited information on the prevalence of pathology related to third molars in older patients suggests that the prophylactic removal of all impacted molars before adulthood may not be justified’. The authors also recognised that the decisions about extraction or retention may be influenced by who was paying the bill – the patient or the public system – and possibly by professional liability. They concluded that ‘Watchful monitoring of asymptomatic third molar teeth may be a more prudent strategy’ (Mettes et al., 2012). Anjirini and colleagues followed up their 2014 paper on international benchmarking with cost effectiveness modelling of a ‘watchful monitoring strategy’ compared with prophylactic removal of asymptomatic wisdom teeth under a GA (Anjrini et al., 2015). They concluded that watchful monitoring was a more cost-effective alternative in the Australian context, with potential annual cost savings of from $420 to $513 million. Rates of extraction of wisdom teeth are considerably higher in females than in males. Jamieson and Roberts-Thomson found that from 1998–99 and 2004–05 in Australia, the dental hospitalisation rates of females aged 15 years or more were 46 per cent higher than those of their male counterparts (Jamieson and Roberts-Thomson, 2008). George and colleagues found that Western Australian females aged 20–24 years were almost 1.8 times more likely to be hospitalised for removal of impacted teeth than males of the same age (George et al., 2011). In 2010–11, Australian women between 15–24 years of age were 62 per cent more likely to have been admitted to hospital for dental care than young men (Chrisopoulos and Harford, 2013). Jamieson and Roberts-Thomson suggest that the higher female rate may be because females are more motivated to receive such care, or more fearful about treatment for 41 potential traumatic procedures in the dental clinic under local, rather than general, anaesthesia (Jamieson and Roberts-Thomson, 2008). They note that females, in general, receive more dental care. 2.9 Contributing factors A wide range of contributing factors to the dental hospitalisation of children and young adults has been reported in the literature. The strength of the evidence varies. Some reports include only descriptive data, with fewer including multivariate analyses. Further analysis of the quality of key studies will be presented in the Discussion chapter. Only one comprehensive analysis of relevant factors for dental hospitalisation in Victorian children was identified. This study included a multivariate analysis of PPDHs from 1997-98 to 2004-05 (Department of Human Services, 2007). Twelve factors that contribute to dental hospitalisations of children and young adults were identified from studies in Australia and other high income countries. These factors include individual characteristics, and cultural, health system and socioeconomic determinants. Age Figures 1 and 2 show 2011-12 Australian DGA and PPDH rates by age. Highest rates of DGA were in 15-24 year olds. Children aged 5-9 years had the highest PPDH rates. This pattern was repeated in 2013-14 (AIHW: et al., 2016). Prior to 2005, Australian children under five years had the highest DGA rates (Jamieson and Roberts-Thomson, 2006). Gender Male dental hospitalisation rates have been shown to be higher in younger children, with female rates higher for other age groups – in Australia from 1998-99 to 2004-05 (Jamieson and Roberts-Thomson, 2006), and 2013-14 (AIHW: et al., 2016), and in 42 Victoria in 2004-05 (Department of Human Services, 2007). The higher DGA rates for females have been particularly marked in the 15–24 year age group. Dental treatment needs Dental caries has been the major reason for dental hospitalisation of children in Australia (Jamieson and Roberts-Thomson, 2006), and Victoria (Department of Human Services, 2007). Treatment of dental caries as the predominant factor for dental hospitalisation of children has been reported in other high income countries such as New Zealand (Whyman et al., 2014, Whyman R, 2012), Scotland (Macpherson et al., 2005), England (Moles and Ashley, 2009, Deery et al., 2015, Shepherd and Ali, 2015), Canada (Schroth et al., 2014), and. Sweden (Savanheimo et al., 2012). Behaviour, dental fear or anxiety Higher DGA rates in young children with behavioural problems, dental fear or anxiety have been reported widely - in Australia (Alcaino et al., 2000, Hallett and O'Rourke, 2006), Scotland (Macpherson et al., 2005), England (Balmer et al., 2004), Sweden (Savanheimo et al., 2012) and Finland (Taskinen et al., 2014). Other individual factors Slack-Smith and colleagues analysed Western Australian data and determined that an intellectual disability, and or a birth defect, increases the likelihood of children under two years being hospitalised for dental reasons (Slack-Smith et al., 2013). Cultural background Culturally and linguistically diverse backgrounds, including Aboriginal or Torres Strait Islander background, have been shown to be associated with dental hospitalisation of children and young adults. Australian rates for dental hospitalisation of Aboriginal and Torres Strait Islander children under 10 years of age were higher than in non-Aboriginal and Torres Strait 43 Islander children from 2010-11 to 2013-14 (AIHW: et al., 2016). The reverse was the case for 10 to 24 year olds. Rates of dental hospitalisation have been shown to be higher in children from families recently migrated to high income countries such as Australia (Alcaino et al., 2000), Denmark (Haubek et al., 2006) and Sweden (Savanheimo et al., 2012). Access to dental care Burnham and colleagues showed that reduced access to dental care in London, England led to an increasing number of hospital admissions for facial infections (Burnham et al., 2011). Dental provider factors Jamieson and Roberts-Thomas proposed a number of dental provider factors that could have led to the increase in dental hospitalisations of Australian children between 1993-94 and 2004-05 (Jamieson and Roberts-Thomson, 2006). These included an increased number of paediatric dentists whose preferred model of care may be a GA; reluctance of dentists to treat children with complex dental presentations in the dental chair; not enough dental personnel to treat children at high risk of dental caries in the preventive stages of dental disease; and rising fears of litigation among those who may have previously performed dental GA in non-hospital settings. No Australian studies were found that quantified any of these proposed factors. Access to community water fluoridation Analysis of PPDHs in Victorian children aged 0–14 years admitted in 2004–05, found that PPDH rates were significantly associated with lack of fluoridation coverage (R2= 0.397, p < 0.001) and poverty (R2= 0.419 p < 0.001) (Department of Human Services, 2007). In multivariate analyses, which included both fluoridation and poverty variables as predictors, fluoridation and poverty were independently significant predictors of dental 44 admission rates at the Primary Care Partnership (PCP) 25 level (Department of Human Services, 2007). The reduction in 0-4 year old PPDH rates after the introduction of community water fluoridation was identified in another Victorian study (Rogers and Morgan, 2010). The impact of community water fluoridation to reduce dental hospitalisation of children has been shown recently in England, Israel and New Zealand. In two studies in England, 45 to 53 per cent fewer under five year olds were found to have been hospitalised for dental caries in areas that had fluoridated water (Public Health 2014 26 ) (Young et al., 2015). Klivitsky and colleagues determined that access to community water fluoridation may prevent approximately half of the hospitalisations of under 18 year olds for dental infections in Israel (Klivitsky et al., 2015). Kamel and colleagues identified that New Zealand children from low-fluoride areas, were likely to have more decayed teeth and undergo a DGA at a younger age, than children from fluoridated areas (Kamel et al., 2013). Data recording practices in hospitals There may be more complete enumeration of data by hospital administration personnel in recent years (Jamieson and Roberts-Thomson, 2006). Geographic remoteness All-age rates of PPDHs in Australia are highest in areas considered geographically remote. Areas considered ‘very remote’ had PPDH rates of 3.7 per 1,000 population in 2013-14 compared to 2.6 per 1,000 population in major cities (AIHW: et al., 2016). 25 Victoria's Primary Care Partnership (PCP) strategy ‘brings together local health and human service providers who work together within voluntary alliances to improve access to services and provide continuity of care for people in their community’ . The state’s PCPs involve ‘ hospitals, community health services, Primary Health Networks, local governments, mental health services, drug treatment services and disability services’ . (Victoria State Government website, accessed 31 October 2015 - < https://www2.health.vic.gov.au/primary-and-community-health/primary-care/primary-care-partnerships >.) 26 Water fluoridation. Health monitoring report for England 2014. accessed on 7 March 2016 from Public Health England website - Socioeconomic status of the family The Victorian study of 2004-05 PPDHs found that children aged 0–14 years whose families were living in relative poverty had higher PPDH rates when controlling for access to dentists and access to community water fluoridation (Department of Human Services, 2007). As mentioned under the access to community water fluoridation section above, in multivariate analyses, which included both fluoridation and poverty variables as predictors, fluoridation and poverty were independently significant predictors of dental admission rates at the PCP level (Department of Human Services, 2007). Butler and colleagues’ study of children aged 0–4 years who had PPHs in Victoria from 2003–09, showed a clear socioeconomic gradient for dental admissions (Butler et al., 2013). The gradient for PPDHs was the steepest of all PPHs in this age group. The social gradient for PPDH rates in Victorian 0-9 year olds has also been shown for the period 2001-02 to 2009-10 (Rogers and Morgan, 2012). Rates for 10 to 19 year olds however, were found to follow an inverse gradient in this study, with young people living in more advantaged areas having the highest PPDH rates. 2.10 Contributing factors to Potentially Preventable Hospitalisations (PPHs) The review of Australian systematic reviews of the epidemiology of PPHs, and interventions to prevent or divert these, was undertaken to determine if any findings were relevant to the prevention of PPDHs. As mentioned in section 2.2, the search identified two systematic reviews (Ansari, 2007) and the CEHSEU 2009 report (Clinical Epidemiology & Health Service Evaluation Unit (CEHSEU), 2009), a rapid review (Katterl et al., 2012), and a review of chronic PPHs (Muenchberger and Kendall, 2008). In his comprehensive review of the literature up to 2005, Ansari explored the concept of PPHs using a critical interpretive synthesis (CIS) method. 27 Ansari identified predictors 27 Under the CIS methodology, information is re-categorised and interpreted to generate a comprehensive critical narrative argument using both quantitative and qualitative evidence. 46 of PPHs and factors that affect variations in rates. The 10 factors identified were: demographics (age, gender and race); socioeconomic status; rurality; health system factors (access to primary health care, physician admitting practice); prevalence; lifestyle factors; environment; adherence to medication; propensity to seek care; and severity of illness. Ansari found that few studies have tested true measures of access to care and that although associations have been shown at the patient level between higher quality ambulatory care and lower rates of admissions, there was little evidence on whether access improvements to primary health care can reduce PPHs in an areas (Ansari, 2007). Ansari determined that there was also limited research on the size of effects and the interrelationships between factors. The CEHSEU report included a review of the PPH literature from 2005 – June 2009 to update Ansari’s review. Forty-nine studies published after Ansari’s review were found; 44 from Australia and five from the USA. These additional studies reiterated the importance of the factors Ansari had identified. One conclusion was that there are conflicting results in regard to the association between PPH rates and the three factors - physician supply, rurality and continuity of care. Muenchberger and Kendall’s review related to hospitalisation among people with chronic disease (Muenchberger and Kendall, 2008). Although dental conditions are considered to be ‘acute’ in the definition of PPDHs, this review is instructive, as hospitalisation factors for ‘chronic’ conditions such as asthma and diabetes may have relevance to PPDHs. A total of 82 studies were examined. No formal meta-analysis of key determinants of hospitalisation was conducted because of the wide variation among the studies. Muenchberger and Kendall concluded that health status, age and socioeconomic status were the most studied factors. They also found that age, gender, socioeconomic status, race and access to health care were significantly associated with an increased risk of PPHs due to chronic conditions. Hospitalisation was not considered to be a consequence 47 of any single factor in isolation; rather it was the result of a complex interplay of factors at all levels (person-related factors, physician factors, health system, geographical and environmental factors). Katterl and colleagues undertook a rapid review 28 focusing on the Australian and international literature on PPHs 29 related to improved primary health care service delivery (Katterl et al., 2012). Due to the short time period of eight weeks their review was not systematic or comprehensive. The latest article included was published in early 2012. Factors associated with inhibiting or increasing rates of PPH were identified in the three categories of individual level (11 factors), health service system (six factors), and environmental (two factors). Further health system factors identified in Katterl’s review – with degree of effect and strength of evidence estimated – were prior hospitalisation (moderate, strong); availability of hospital beds (moderate, weak); coordination of care or integrated services (weak-moderate, very strong); and self-management supports (weak, weak). Most of the factors identified in the reviews of PPHs have also been found to be associated with PPDHs, as presented in section 2.9. Four main factors were not found in the literature on PPDHs - physician admitting style; propensity to seek care; lack of social support and poor mental health. The latter two factors were found to have a moderate effect on hospitalisation, with recognition that there were interrelationships with socioeconomic factors. The four additional factors were considered when the methodology for this study was developed. 2.11 Alternative child management options Ideally, conditions that lead to dental hospitalisation would be prevented. Few studies were found that addressed preventing PPDHs directly. As the majority of PPDHs are 28 Rapid reviews are short literature reviews that focus on research evidence, with a view to facilitating evidence-based policy development. 29 The term ‘potentially avoidable hospitalisation’ was used in the review and was acknowledged as meaning the same as PPH. 48 linked to dental caries (Department of Human Services, 2007), interventions to prevent this disease are likely to reduce PPDHs particularly in children. These interventions may be primary, secondary or tertiary. Comprehensive primary prevention of oral disease amongst disadvantaged groups requires addressing the social determinants of health - the ‘upstream’, ‘causes of causes’, and the political and economic drivers (Watt and Sheiham, 2012). Although health professionals can advocate for the social determinants to be addressed, and can take some local action (Watt et al., 2014), changing these factors requires action predominantly beyond the scope of the health system. Policy implications and recommendations to prevent PPDHs in Victoria will be addressed in the Discussion chapter, based on the results of the research and the relevant literature. This section will review the literature on alternatives to DGAs. The United Kingdom paediatric dental guidelines for children outline a spectrum of patient management as shown in Figure 3. The four approaches are behaviour management, local anesthesia, sedation and GA 30 . Glasman describes these approaches as the treatment options continuum (Glassman, 2009). 30 General anaesthesia is defined as a drug-induced state characterised by absence of purposeful response to any stimulus, loss of protective airway reflexes, and depression of respiration and disturbance of circulatory reflexes (Australian and New Zealand College of Anaesthetists 2010). 49 Figure 3 The spectrum of patient management Source: UK National Clinical Guidelines in Paediatric Dentistry 2008. (Davies et al., 2008) . Several behaviour management programs have been implemented in Australia recently to divert young children from a DGA. An oral health therapist staffed clinic at the Royal Dental Hospital of Melbourne (RDHM) was able to treat 34 per cent of the 956 children who had been referred to the hospital for a DGA 31 . The focus in the clinic was on careful behaviour management. These were preliminary results and the clinic is being further evaluated. In Western Australia, a pragmatic randomised control trial compared the minimum intervention dentistry approach, based on atraumatic restorative treatment procedures (MID-ART), against the standard care approach for preschool children with dental caries (Arrow and Klobas, 2015). At 12 months follow up, there was a 45 per cent lower rate of referral for specialist care in the MID-ART group. These children also reported lower levels of dental fear. Widmer and colleagues outline eight behavioural methods for reducing anxiety in children: tell-show-do; playful humour; distraction; positive reinforcement; modelling; 31 Dental Health Services Victoria (DHSV) website accessed on 7 March 2016 - Sedation approaches comprise relative analgesia (using nitrous oxide), oral sedation and intravenous sedation. In conscious sedation, verbal contact and protective reflexes are maintained, whereas in a GA these are lost. Four levels of sedation are recognised: • minimal sedation: awake and calm and responding to command with ventilatory and cardiovascular function unaffected • moderate sedation: sleepy but responding to command with adequate spontaneous ventilation and cardiovascular function maintained • conscious sedation: similar to moderate, and the term preferred and used in dentistry, and • deep sedation: asleep and not easily aroused but respond to painful stimuli. Ability to maintain ventilatory function impaired and may require assistance. In the UK this is described as light general anaesthesia (NICE clinical guidance 112 32 ). Alcaino and colleagues note that nitrous oxide is useful in relieving anxiety and offers a safe and relatively easy technique for providing dental care to children (Alcaino, 2013). Other alternative DGA approaches to assist in providing dental care to children are hypnosis and cognitive-behavioural therapy. Al-Harasi and colleagues reviewed the evidence on the use of hypnosis for managing children under dental treatment and concluded that there is not sufficient evidence to support its use (Al-Harasi et al., 2010). Cognitive behavioural therapy is another approach to manage children whose dental care cannot be undertaken under local anaesthesia with either nitrous oxide or midazolam 33 alone (Newton et al., 2012). In a recent review of sedation practice in the United Kingdom, more than a third (37 per cent) of practitioners who use sedation for dental care stated that if a child under 13 years old could not be managed under local anaesthesia 32 Accessed at NICE website on 7 March 2016 - https://www.nice.org.uk/guidance/cg112 >. 33 A drug used to reduce anxiety or produce drowsiness or anesthesia prior to certain medical procedures or surgery. 51 with either nitrous oxide or midazolam alone, they would refer the child to a psychologist for cognitive-behavioural therapy. The sedation of children for diagnostic and therapeutic procedures is an area of rapid change and controversy (Alcaino, 2013). The controversy is related to adverse sedation- related events and poor outcomes. Best practice guidelines have been developed by the Australian and New Zealand College of Anaesthetists (ANZCA) to support uniform standards for administration of sedation and/or analgesia for medical, dental and surgical procedures by medical and dental practitioners 34 . Before they are able to offer sedation to their patients, Australian dentists require endorsement by the Dental Board of Australia (DBA), which involves undertaking a prescribed training course. Currently the only course in Australia is provided at Westmead Hospital in New South Wales. In 2015, Ashley and colleagues updated their 2012 systematic review of randomised trials to evaluate the safety, effectiveness and efficiency of sedation compared to GA for the provision of dental treatment to under 18 year olds (Ashley et al., 2012, Ashley et al., 2015). They did not find any new studies that were eligible to be included. Their earlier review had identified 16 studies for potential inclusion but, on reading the full texts, none were found to be eligible. Their conclusion remained that further RCTs are needed that compare the use of dental GA with sedation to quantify differences such as morbidity and cost. Similarly in their 2012 Cochrane review, Lourenco-Matharu and colleagues concluded that there is weak evidence that oral midazolam is an effective sedative agent for children undergoing dental treatment, and very weak evidence that nitrous oxide may also be effective. They recommended that further well-designed clinical trials should be undertaken to evaluate other potential sedation agents (Lourenco-Matharu et al., 2012). 34 Accessed 10 January 2015 - Barriers to the availability of alternative child management options to a DGA include gaps in the education and experience of oral health professionals to manage children, and limited equipment and facilities (Jamieson and Roberts-Thomson, 2006, Nelson and Xu, 2015). The literature on preventing PPHs in general may offer lessons that can be applied to reducing PPDHs. The most recent review of the Australian research determined that there was evidence for six approaches: early detection, early treatment and symptom management; creating supportive environments; self-management support; service delivery and coordination; local liveability (access to primary health care); and socioeconomic opportunity (Katterl et al., 2012). 2.12 Gaps in the literature Gaps in the literature can be reviewed in relation to the three research questions outlined in section 1.2. Considering question one on distribution and the determinants of dental hospitalisation of children and young adults in Victoria, a range of factors has been identified from the literature that influences dental hospitalisation. Most of the data however, are from cross sectional studies which limits the ability to ascribe causality. Few studies have measured the strengths of associations or controlled for other factors. A comprehensive analysis of Victorian PPDH prevalence and trends was undertaken for the period 1997-98 to 2004-05 (Department of Human Services, 2007), and this requires updating. There are data on dental hospitalisation rates by Australian state and territory to compare Victoria’s situation, but no studies were found comparing Victorian or Australian rates with rates from other high income countries. 53 While three international studies have determined the associations between children’s dental hospitalisation, socioeconomic status, and access to community water fluoridation, it would add value to analyse the possible confounding impact of access to primary dental care. No Victorian data were found on dental provider factors in Victoria such as physician practicing style, or on health system factors such as access to GA facilities. The concept of PPDHs has not been reviewed in the literature. It is timely to consider whether PPDHs should remain in the ‘acute’ PPHs category. Also to review whether all age PPDH rates, or rates for specific ages, are appropriate as indicators of health system functioning. Similarly, implications of the high DGA rates for young women 15-24 years of age require consideration. There is limited data to answer research question two on the impact of dental hospitalisation in Victoria. Information on mortality and morbidity has not been published. And the most recent data on costs of dental hospitalisation are from 2008-09 for Australia and 2001-02 for Victoria. The next two chapters outline the research approach and methodology employed to address the key gaps identified in the literature in order to answer the three research questions. 54 Chapter 3 Research approach 3.1 Social determinants models for oral health ...... 55 3.2 A conceptual social determinants model for dental hospitalisation in Victoria ...... 60 3.1 Social determinants models for oral health The literature review revealed that dental hospitalisation is a significant health issue in Victoria, in Australia, and in other high income countries, particularly for children and young adults. This is because of the cost to families and the health system, and the possibility of adverse health effects. In addition, there is scope to reduce the rate of potentially preventable dental hospitalisations (PPDHs), which are the highest cause of all potentially preventable hospitalisations among Victorians under 25 years old. As outlined in Chapter 1, the aim of the study was to research the dental hospitalisation of Victorian children and young adults to answer three research questions. Firstly about distribution and determinants, secondly about impacts, so that the third question on policy implications could be addressed. A conceptual model outlining factors associated with dental hospitalisation was constructed to assist in answering the research question about distribution and determinants. The rationale for the model follows. In the early 1990’s, Dahlgren and Whitehead outlined a model that built on the social determinants of health concept as a way to understand the root causes of health 35 . They 35 Dahlgren G, Whitehead M (1993). Tackling inequalities in health: what can we learn from what has been tried? Working paper prepared for the King’s Fund International Seminar on Tackling Inequalities in Health, September 1993, Ditchley Park, Oxfordshire. London, King’s Fund, accessible in: Dahlgren G, Whitehead M. (2007) European strategies for tackling social inequities in health: Levelling up Part 2. Copenhagen: WHO Regional office for Europe - Figure 4 Dahlgren and Whitehead’s social determinants of health model Source: Dahlgren and Whitehead 1993 (see footnote 35). In 2006, Patrick and colleagues built on the social determinants concept to explain oral health outcomes (Patrick et al., 2006). Their framework included the environment, the economy, social contexts, cultural practices as well as individual factors. A year later in 2007, Fisher-Owen proposed that community, family and child-level influences shape the oral health of children (Fisher-Owens et al., 2007). In the same year, Watt outlined approaches to tackling the social determinants of oral health inequities (Watt, 2007). More recently, there have been proposals that the Commission on the Social Determinants of Health (CSDH) framework for the social determinants of health (Commission on Social Determinants of Health, 2008, World Health Organization, 2010), could be adapted to help explain oral health inequalities (Sheiham et al., 2011, 56 Watt and Sheiham, 2012, Watt, 2012, Watt et al., 2014, Watt et al., 2015). The CSDH framework is shown in Figure 5. Figure 5 Conceptual framework for the social determinants of health Source: (World Health Organization, 2010). The framework posits that the socioeconomic and political context (that is, governance, macroeconomic policies, social policies, public policies and cultural and societal values) interrelates with socioeconomic position, social class, gender, ethnicity, education, occupation and income as structural determinants. These factors link with intermediary determinants (that is, material circumstances, behaviours and biological factors, and psychological factors) to impact on equity in health and wellbeing. The structural and intermediary determinants are considered to feedback and influence each other. Social cohesion, social capital 36 and the health system are also seen as important in this framework. 36 Rouxel and colleagues, in their recent review of the literature on social capital and oral health, noted that social networks and social support are related concepts to social capital ROUXEL, P. L., HEILMANN, A., AIDA, J., TSAKOS, G. & WATT, R. G. 2015. Social capital: theory, evidence, and implications for oral health. Community Dent Oral Epidemiol, 43 , 97-105. They concluded that there is not strong evidence for 57 Lee and Divaris developed a framework to identify actions for eliminating the sources of oral health disparities (Lee and Divaris, 2013). They based their model on identification of the multi-level influences on oral health (Fisher-Owens et al., 2007), and on factors related to oral health disparities (Patrick et al., 2006) (Watt and Sheiham, 2012). While Lee and Divaris referred to the Commission on Social Determinants of Health report of 2008 (Commission on Social Determinants of Health, 2008), they did not mention the CSDH 2010 framework (World Health Organization, 2010). However, the factors within their model included the determinants included in the CSDH 2010 framework. These authors saw the macroeconomic environment linking to the population and community levels, that then influences the person-level and consequently oral health outcomes (Lee and Divaris, 2013). Lee and Divaris proposed that disparities, due to unequal distribution of wealth, resources, location, social status, discrimination and historical reasons, influence those disparities, due to differences in community and family characteristics, education, knowledge and understanding, health literacy and access to care. Predisposing characteristics (that is, oral health beliefs and cognition, and cultural norms and values) and enabling resources (that is, community resources and engagement; family environment; access to oral health care services; and health workforce characteristics) were seen to link with mediators such as perceived social standing and stress due to social disadvantage across the life course. Disparities in oral health outcomes result. Watt’s 2014 conceptual framework for social determinants of oral health inequalities is adapted from the WHO CSDH framework (Watt et al., 2014). Political and economic drivers are seen as the structural determinants (that is, macroeconomic policies; social and welfare policies, political autonomy; historical/colonial factors; and globalisation) that influence two categories of intermediary determinants. The first category (social arguing that social capital influences oral health but that ‘ social capital appears as a potential social determinant of oral health’ . 58 class; gender; ethnicity; occupation; and income) then influences the second category of intermediary determinants (living and working conditions; food security; social capital; age, genetics; inflammatory processes; infections; stress; perceived control; social support; quality of care; appropriate access; and evidence-based preventive orientation) which leads to oral health inequalities and social gradients. The oral health models outlined above are theoretical concepts. Broomhead and colleagues claim that a study they undertook in Sheffield, United Kingdom is the first to examine predictors of the distribution of dental caries in children using a conceptual model based on the social determinants of health (Broomhead et al., 2014). They tested a model to explain the distribution of dental caries in five year olds based on the WHO CSDH framework. Their ‘simplified model’ was shaped by the data that they could obtain from local and national sources. Concurrent to Broomhead and colleagues’ work, Fontanini and colleagues also developed a hypothetical model based on the CSDH framework. They tested whether social support and social networks were intermediary social determinants of dental caries in Brazilian adolescents (Fontanini et al., 2015). As in the CSDH approach, both the Broomhead and Fontanini models included structural and intermediary determinants. Broomhead and colleagues found that a measure of socioeconomic status, the Index of Multiple Deprivation (IMD) 37 , explained 60 per cent of the dental caries variance. Adding 13 other indicators explained 70 per cent of the variance. Structural determinants (that is, social position, education, employment and 37 The IMD is an area-based composite measure of deprivation calculated by totaling seven weighted domains: income; employment; education; skills and training; living environment; health, deprivation and disability; crime; and barriers to housing and services. Five of the other 13 indicators used were classified as structural determinants: all-cause mortality in under 75 year olds; education test scores; school attendance; employment; and family income. The remaining eight indicators were identified as intermediary determinants: material circumstances (IMD living domain and IMD barriers to housing and services); social cohesion (IMD crime domain and total crime incidence); psychosocial factors (child wellbeing index score); behaviors (obesity in four and five year olds, and fruit and vegetable consumption); and the health care system (emergency hospital admissions for those less than five years of age) BROOMHEAD, T., BAKER, S., JONES, K., RICHARDSON, A. & MARSHMAN, Z. 2014. What are the most accurate predictors of caries in children aged 5 years in the UK. Community Dent Health, 31 , 111-116.. 59 income) accounted for 68 per cent of the variance, while intermediary determinants (that is, material circumstances, social cohesion, psychosocial factors, behaviours and the health care system) accounted for 2.5 per cent. Five indicators were found to be statistically significant (p<0.05): education; income; the living domain; and the two social cohesion indicators (IMD crime domain and total crime incidence crime domain). Broomhead and colleagues acknowledge limitations of their study including analyses performed at the neighbourhood, not the individual, level; possible distortion with the use of the IMD score; and no account made of caries-specific risk factors such as exposure to fluoride. They concluded that a large prospective study is required in the United Kingdom to investigate the full range of factors in the CSDH model. Fontanini and colleagues determined that dental caries levels were associated with low numbers of social networks and low levels of social support from family. 3.2 A conceptual social determinants model for dental hospitalisation in Victoria For this research study a social determinants model was developed (Figure 6) to explain dental hospitalisation rates in Victorian children and young adults. The model is based on the literature on contributing factors to dental hospitalisation (section 2.9); factors linked to PPHs (section 2.10); social determinants theory and practice related to oral health outcomes (section 3.1); and on whether Victorian data were available. 60 Figure 6 Conceptual social determinants model for dental hospitalisation of children and young people in Victoria Public health policy Access to fluoridation Food availability Health insurance Dental care system Family income, Access to dental services parents’ education, Age Dental provider factors concession card status Gender Environmental structural Socioeconomic and Child intermediary Dental factors cultural context of family factors Hospitalisation Dental treatment needs Country of birth Health care system Behaviour and ability Access to primary Child’s Aboriginal background care/geographic remoteness Language spoken at home Family function General parent factors Health care system Access to general anaesthetic facilities 61 The model included three categories of determinants (factors): environmental structural; socioeconomic and cultural context of the family; and child intermediary. Potential structural factors included were environmental factors relating to public health policy (access to community water fluoridation), the dental system (access to dental services and dental provider factors); and the health system (access to primary health care/geographic remoteness, and access to general anaesthetic facilities via admission policy and practice). Factors related to the socioeconomic and cultural context of the family included in the model were: family income, education, concession card status, food availability, health insurance, country of birth of the mother and the child, language other than English spoken at home, general parent factors and family function. The cultural context also included whether a child came from an Aboriginal or Torres Strait Islander background. Factors related to the child were: age; gender; dental treatment needs, and behaviour and ability. These are considered as intermediary determinants. It was proposed that the three categories of determinants are inter-related. Environmental structural factors were hypothesised to shape the socioeconomic and cultural context of the family, which interact with child intermediary determinants to influence the likelihood of dental hospitalisation. Several environmental factors in the conceptual model, such as access to dental care and dental provider factors could be considered to be intermediary determinants. They are included as environmental structural determinants because they are shaped by health and social public policies. The model is not as comprehensive as the CSDH (World Health Organization, 2010), Lee and Divaris (Lee and Divaris, 2013) or Watt (Watt et al., 2014) frameworks. Several of the overarching structural determinants described as the socioeconomic and political context in the CSDH framework, the macro-environment (Lee and Divaris, 2013), or 62 political and economic drivers (Watt et al., 2014), have not been included because of lack of data that could be linked to the available data sets on dental hospitalisation in Victoria. Other factors not included in the model that have been identified as influencing the oral health of children and/or oral health inequalities (Fisher-Owens et al., 2007) (Watt et al., 2014) (World Health Organization, 2010), are listed in Table 3. These include child determinants that influence oral health such as biological and genetic endowment and health behaviours and practice (diet, oral hygiene and use of dental services) (Fisher- Owens et al., 2007). Table 3 Factors that influence oral health inequality and/ or influence the oral health of children not included in conceptual model Environmental structural Socioeconomic and cultural Child intermediary determinants context of family determinants Macroeconomic Social capital*,** Biologic and genetic policies**,*** Health status of parents* endowment* Social and welfare policies** Health behaviours and Health behaviours and Governance*** practices of family* practice* – diet, oral Physical environment* Stress, perceived control, hygiene, use of dental Culture and societal social support *,**,*** services values*,*** Physical safety* Family composition* Sources:*Fisher-Owen 2007, ** Watt 2014, ***WHO 2010. Data on environmental structural determinants such as macroeconomic policies and governance were not available to incorporate in the model. Elements of public health policy, such as access to community water fluoridation, and health system policy, are included in the model and touch to some extent on social policies and the physical environment. Data on social capital and factors such as stress, perceived control, and social support 38 were not available to examine an association with dental hospitalisation. However, the 38 In their summary of the role of psychosocial and behavioural factors that shape oral health inequalities, Tsakos, Aida and Alzahrani note that social support is included along with social cohesion and social networks within social relationships, Section 2.4 in TSAKOS, G., AIDA, J. & ALZAHRANI, S. 2015. The 63 available data on family functioning may overlap with these factors. Data on health behaviours and practices of the family, including their dental care preferences and propensity to seek care that may be associated with dental hospitalisation, were also not available. The methodology for testing the conceptual model and answering the further research questions will be outlined in the following chapter 4. role of psychosocial and behavioural factors in shaping oral health inequalities. In: WATT, R. G., DO, L. & NEWTON, T. (eds.) Social inequalities in oral health: from evidence to action. London: International Centre for Oral Health Inequalities Research and Policy., a ccessed 15 March 2016 -. 64 Chapter 4 Methodology 4.1 Overview ...... 65 4.2 Research outline ...... 66 4.3 Prevalence, trends and determinants of dental hospitalisation in Victoria ...... 72 4.3.1 Analysis of the Victorian Admitted Episode Dataset (VAED) ...... 72 4.3.1.1 Descriptive analyses of the VAED ...... 73 4.3.1.2 Multivariate analysis of the VAED ...... 75 4.3.2 Analysis of the 2009 Victorian Child Health and Welfare Survey (VCHWS)...... 78 4.3.2.1 Descriptive analysis of the 2009 VCHWS ...... 79 4.3.2.2 Multivariate analyses of the 2009 VCHWS ...... 81 4.3.3 Additional data sources ...... 81 4.4 Impacts ...... 82 4.4.1 Mortality and morbidity ...... 82 4.4.2 Costs ...... 84 4.5 Analytical plan for quantitative data ...... 84 4.5.1 Analyses of VAED data ...... 84 4.5.2 Analyses of the 2009 VCHWS ...... 85 4.6 The view from key players (qualitative research) ...... 86 4.7 Analytical plan for qualitative data ...... 88 4.8 Combining qualitative and qualitative data ...... 89 4.1 Overview This chapter will present the methodological approach used to address the three research questions. The basis for addressing questions one and two was the exploration of factors included in the conceptual social determinants model for dental hospitalisation described in Chapter 3. The third question, concerning policy implications, was explored through analysis of the qualitative and quantitative research. The study period from 2001–02 to 2013–14 was chosen for the most intense analysis to gain an understanding of recent trends in dental hospitalisation in Victoria. Victorian data from 2000–01 and 2002–03 were not used as the data were not available. 65 4.2 Research outline 4.2.1 A mixed methods approach The study used a mixed methods approach, employing quantitative and qualitative methods. According to Taket, a mixed methods approach helps to ‘ tease out the complex interactions of different factors’ (Taket, 2013). This approach enabled more detailed examination of a larger number of factors related to dental hospitalisation than was possible if only quantitative or only qualitative methods had been used. An outline of the research projects undertaken to answer the research questions are shown in Table 4. The approach employed, the focus, and the main data sources are shown. The dependent factor in the research was dental hospitalisations. In summary, quantitative data about dental hospitalisations came from detailed hospital admission records, a survey of Victorian children, and from studies and reports. The qualitative data was collected from interviews with key players involved in the dental hospitalisation of children in Victoria. These interviews assisted in teasing out the lived experiences of participants and helped to provide explanations for the quantitative data 39 . 39 This is a form of triangulation – the use of methods that enable a phenomenon to be studied from different angles and uses different sources to gain a more nuanced understanding of the issues. Triangulation methods are ‘ multiple methods, researchers, data sources, or theories’ TAKET, A. 2013. The use of mixed methods in health research. In: LIAMPUTTONG, P. (ed.) Research methods in health: foundations for evidence-based practice. 2nd ed. Melbourne: Oxford University Press.. 66 Table 4 Summary of approaches to answer research questions Research question 1. What are the distribution and the determinants of the dental hospitalisation of children and young adults in Victoria? 1.1 What were the distribution and determinants of dental hospitalisations by prevalence, rates, diagnosis, dental treatment, and trends from 2001-02 to 2013-14? Research approach and main data sources : Four main projects were conducted with a focus on children and young adults: • Analysis of the Victorian Admitted Episode Dataset (VAED) from 2001-02 to 2013-14. • Multivariate analysis of the VAED for 2008-09 and 2012-13. • Analysis of the 2009 Victorian Child Health and Welfare Survey (2009 VCHWS). • Qualitative research – interviews with key players involved in the dental hospitalisation of children in Victoria. 1.2 How do Victorian rates compare nationally and internationally? Research approach and data source : Analysis of government reports and literature review. Research question 2. What are the impacts of dental hospitalisation on Victorian children, young adults and their families? 2.1 What is the extent of morbidity and mortality? Research approach and data sources : Analysis of data from the National Coronial Information Service (NCIS), the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM), the Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM), government reports, literature review, and interviews with key players. 2.2 What are the costs? Research approach and data sources : Analysis of government reports, literature review and interviews with key players. Research question 3. What are the policy implications? Research approach and data sources : Conclusions about policy implications drawn from the results of the quantitative and qualitative research including the literature review. 67 4.2.2 Addressing research question one The methodological approach and data sources used to determine the associations between twelve independent factors in the conceptual social determinants model and dental hospitalisation, are outlined in Table 5. Dental hospitalisation was the dependent factor (variable). These factors sit within the three main categories of the social determinants model: environmental structural determinants; the socioeconomic and cultural context of families; and child intermediary determinants. The distribution of dental hospitalisation was examined by reviewing prevalence, rates, diagnosis, dental treatment, and trends by age, gender, public and private admissions and geographic distribution. Methodological details are outlined under each of the data sources in the following sections. Data to answer the ancillary question of ‘How do Victorian rates compare nationally and internationally?’, were obtained from Australian Institute of Health and Welfare (AIHW) reports and reports identified through the literature review, as described in section 4.3.3. 68 Table 5 Methodological approach to identify strength of associations between social determinant factors and the dental hospitalisation of Victorian children and young adults showing data sources (Research question one) How association with dental Factors Data sources hospitalisation is measured Environmental structural determinants Public health policy Fluoridation status of child’s Fluoridation status 1. Access to community water geographical area of residence linked to VAED 40 fluoridation Dental care system Oral health professional:population AHPRA 41 and ABS 42 2. Access to dental services ratio in geographical area of residence data linked to VAED 3. Dental provider factors Qualitative research based on Interview results 3.1 Paediatric dentists interviews with key players 43 and Literature review 3.2 General dentists and literature review dental therapists Remoteness category of child’s VAED and ABS Health care system geographical area of residence 4. Access to primary health services – geographic Parents perception of access to basic 2009 VCHWS 44 remoteness health services Review of Victorian hospital policy and DH&HS 45 policy 5. Access to general anaesthetic funding guidelines and interviews with documents facilities – admission policy and hospital admission decision makers practice Review of dental association reports ADA 46 documents and submissions 40 VAED – Victorian Admitted Episode Dataset. 41 AHPRA – Australian Health Practitioner Regulation Agency. 42 ABS – Australian Bureau of Statistics. 43 Paediatric dentists, dentists, dental therapists and dental public health specialists 44 2009 VCHWS – 2009 Victorian Child Health and Welfare Survey. 45 DH&HS – Department of Health and Human Services, Victoria. 46 ADA – Australian Dental Association. 69 How association with dental Factors Data sources hospitalisation is measured Socioeconomic and cultural context of family Household income 6. Families’ socioeconomic status Respondent parent’s education level Concession card status 2009 VCHWS Private health insurance status Food security IRSED 47 score for residential area VAED Public or private admission Country of birth of mother and child 2009 VCHWS 7. Cultural background Aboriginal or Torres Strait Islander background of child VAED, 2009 VCHSW Language other than English spoken at VCHWS home 8. General parent factors Interviews with key players Interview results Family function 2009 VCHWS Child intermediary determinants 9. Age VAED, 2009 VCHWS 10. Gender VAED, 2009 VCHWS 11. Dental treatment needs Dental treatment provided VAED, AIHW reports Emergency PPDHs VAED Toothache and extraction experience 2009 VCHWS 12. Behaviour and ability Parent report of child’s behaviour and 2009 VCHWS ability 4.2.3 Addressing research question two Addressing question two on the health impacts and costs of dental hospitalisation entailed analysing government reports and studies in the literature, plus interviewing key players 47 IRSED - Index of Relative Socioeconomic Disadvantage, as described in section 4.3.1.1. 70 (Table 6). In addition, mortality and morbidity data related to dental hospitalisation were requested from the National Coronial Information Service (NCIS), the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) in Victoria, and the Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM). Funding systems for dental hospitalisations were reviewed to identify whether their characteristics influence prevalence. Costs in the private sector were identified in interviews with the key players. Table 6 Methodol ogical approach to identify the impact of dental hospitalisation on Victorian children and young adults showing data sources (Research question two) Impact of DGAs Data sources 1. Mortality and morbidity Review of the literature Interviews with paediatric dentists and dental public health specialists Data from the NCIS 48 , CCOPMM 49 and the VCCAMM 50 2. Costs to families and to the Review of the literature health system Interviews with paediatric dentists and dental public health specialists Payment systems for dental hospitalisation 4.2.4 Addressing research question three Policy implications – the essence of the third research question – were explored through analyses of the quantitative and qualitative research. More detail about the data sources used, and how they were modified and reduced for analysis, is presented in the following sections along with the analytical plan. Ethics approval Ethics approval for the research was obtained from the Melbourne Dental School Human Ethics Advisory Committee (Approval ID 1136281). 48 NCIS – National Coronial Information Service. 49 CCOPMM – Consultative Council on Obstetric and Paediatric Mortality and Morbidity. 50 VCCAMM – Victorian Consultative Council on Anaesthetic Mortality and Morbidity. 71 4.3 Prevalence, trends and determinants of dental hospitalisation in Victoria Two main databases were the sources for the quantitative data analysed – the Victorian Admitted Episode Dataset (VAED) and the 2009 Victorian Child Health and Welfare Survey (2009 VCHWS). 4.3.1 Analysis of the Victorian Admitted Episode Dataset (VAED) The VAED is the Victorian Department of Health and Human Service’s (DH&HS) collection of data on all admissions to Victorian public and private hospitals. A comprehensive range of demographic, diagnosis and treatment factors are captured at the individual unit record level. The VAED data files contain a line for each separation. A separation is an episode of admitted patient care. The VAED data on PPDHs from 2001–02 to 2013–14 were obtained from the DH&HS. PPDH cases were identified using the principal diagnosis codes from the International Statistical Classification of Diseases and Related Health Problems, 10 th Revision, Australian Modification (ICD-10-AM) that are acknowledged as being potentially preventable in Australia by the AIHW (AIHW: et al., 2016). These principal diagnosis codes are listed in Table 7. Conditions considered not preventable are excluded – for example disorders of tooth development, cleft lip and palate conditions, and extraction of embedded or impacted teeth such as wisdom teeth. 72 Table 7 Principal diagnosis codes for dental hospitalisations - International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD- 10-AM) Dental conditions considered potentially preventable (PPDHs) K02 Dental caries K03 Other diseases of hard tissues of teeth K04 Diseases of the pulp and periapical tissues K05 Gingivitis and periodontal disease K06 Disorders of gingival and edentulous alveolar ridge K08 Other disorders of teeth and supporting structures K098 Other cysts of oral region, not elsewhere classified K099 Cysts of oral region (unspecified) K12 Stomatitis and related lesions K13 Other diseases of lip and mucosa Dental conditions not considered potentially preventable K00 Disorders of tooth development and eruption K01 Embedded and impacted teeth K07 Dentofacialanomalies (including malocclusion) K091 Developmental (nonodontogenic) cysts of the oral region K092 Other cysts of the jaws K10 Other diseases of the jaws K11 Diseases of salivary glands K14 Diseases of the tongue K090 Developmental odontogenic cysts Source: AIHW website accessed on 31 October 2015 - < www.aihw.gov.au/hospitals-data/ar-drg- data-cubes >. 4.3.1.1 Descriptive analyses of the VAED Prevalence, rates and trends of PPDHs were analysed for the period 2001–02 to 2013–14. Reasons for admissions were reviewed by principal diagnosis and diagnostic related groups (DRG). DRG refers to an ‘Australian admitted patient classification system which provides a clinically meaningful way of relating the number and type of patients treated in a hospital (that is, casemix) to the resources required by the hospital’ 51 51 AIHW website accessed on 31 October 2015 -- < www.aihw.gov.au/hospitals-data/ar-drg-data-cubes >. 73 Treatment provided and duration of stay were also analysed to identify patterns. The PPDH admissions of children and young people under twenty five years of age were analysed in more detail. The dependent factor for analysis was PPDHs (either prevalence or rates). Rates of PPDH by age group were generated using estimated resident population (ERP) counts of demographic stratifications from the Australian Bureau of Statistics (ABS) National Censuses of 2001, 2006 and 2011. The age-standardised rate for an area is the number of hospital admissions, expressed per 1,000, that would occur in that area if it had the same age structure as the standard population and the local age-specific rates of the area are applied. Directly standardised admission rates were calculated by dividing the number of admissions by the actual local population in a particular age group, multiplied by the proportion of the standard population for that particular age group, and summed across the relevant age groups. The independent factors analysed from the VAED data (as included in Table 5) were: • Age, gender and postcode of patient’s usual residence. • Patient type – ‘public’/‘private’/ ‘Department of Veterans’ Affairs’/or ‘other’. • Admission type – ‘emergency’/‘planned from the waiting list’/or ‘other admission’. • Private health insurance status – ‘yes’/‘no’/ or ‘status not known’. • Indigenous status – ‘not Indigenous’/‘Indigenous – Aboriginal but not Torres Strait Islander origin’/‘Indigenous – Torres Strait Islander but not Aboriginal origin’/‘Indigenous – Aboriginal and Torres Strait Islander origin’/‘question unable to be asked’/ or ‘patient refused to answer’. • Country of birth – using the Australian Standard Classification of Countries for Social Statistics. • Preferred language – the language most preferred by the patient for communication. • Socioeconomic status by postcode of residence. The Index of Relative Socio-economic Disadvantage (IRSED) was used to identify the impact of socioeconomic status on PPDH rates. The IRSED quintiles were sourced from 74 the 2006 and 2011 ABS national censuses. IRSED is one of the four Socio-economic Indexes for Areas (SEIFA) used by the ABS to rank areas in Australia according to relative socioeconomic advantage and disadvantage. 52 The IRSED attributes scores of disadvantage to local areas based on a composite of characteristics such as low income, low educational attainment, high unemployment, and employment in relatively unskilled occupations. These factors indicate relative disadvantage. A low score indicates a high proportion of relatively disadvantaged people in an area. The index is assigned to areas, not to individuals. It indicates the collective socioeconomic characteristics of the people living in an area. The IRSED index is used in a wide range of reports by organisations such as the ABS and AIHW as it is considered to be valid and reliable. Analyses were performed at state (Victoria), metropolitan and rural area, DH&HS region, and local government levels. Multivariate analysis was conducted at the postcode level, as will be described below. 4.3.1.2 Multivariate analysis of the VAED The associations between PPDH rates, as the dependent factor, and four independent factors from the conceptual social determinants model were examined. These factors were: access to oral health professionals (as a proxy for access to dental services); geographic remoteness (as one indication of access to primary health services); access to community water fluoridation; and socioeconomic status. Factors were chosen because of the evidence base, theoretical plausibility and availability of data. Gender was not included as a variable in the multivariate analysis because the bivariate analysis determined it was not as significant for 0-–4 year olds as the four factors chosen. 52 ABS 2011, Socio-economic Indexes for Areas (SEIFA), accessed on 30 August 2015 – 75 Analyses were undertaken for 2008–09 and 2012–13 to provide a four-year time series using the previous multivariate analyses on factors associated with PPDHs in Victoria for 2004–05 (Department of Human Services, 2007). The year 2012–13 was the latest year for which complete data were available. The geographical level of analysis was the postcode. Using available data, this was the smallest geographical level possible to achieve the most accurate correlation between factors and PPDH rates. Rates of PPDHs Rates of PPDHs for Victorian 0-4 year olds by postcode were generated by dividing the number of PPDHs (obtained from the VAED) by the Estimated Residential Population of this age group (obtained from the ABS). Rates per 1,000 children aged 0-4 yeas were generated for the years 2008-09 and 2012-13. Remoteness The ABS Australian Statistical Geography Standard Remoteness Structure was used as an indicator of geographic remoteness. This provides ‘a classification for the release of statistics that inform policy development by classifying Australia into large regions that share common characteristics of remoteness’ 53 . There are five main classes of remoteness area - Major Cities; Inner Regional; Outer Regional; Remote; and Very Remote. Only 13 of Victoria’s 719 postcodes are in the ‘Remote’ category. Data from these 13 postcodes were combined with adjacent ‘Outer Regional’ postcodes. There are no ‘Very Remote’ postcodes in Victoria. The Remoteness Structure is refined after each Census. The 2006 version (based on the 2006 Census) was used for the 2008–09 analyses. The 2011 version (based on the 2011 Census) was used for the 2012–13 analyses. 53 ABS website, accessed on 23 February 2015 - Access to oral health professionals For the 2008–09 analyses, the number of dentists per postcode by main practice address in 2006 was provided by the DBA. For the 2012–13 analyses the number of dentists and dental therapists (including oral health therapists) per postcode by main practice address was obtained from the Australian Health Practitioner Regulation Agency (AHPRA). A per postcode rate of dentists for 2008–09, and oral health professionals (dentists, dental therapists and oral health therapists) for 2012–13, was calculated by dividing the number of practitioners by the ABS Estimated Residential Population of 0–4 year olds by postcode for 2009 and 2012, respectively. A tertile scale was generated with the cut-off values for each tertile determined by dividing the 2012–13 postcodes into thirds. Access to community water fluoridation Access to community water fluoridation was identified using the fluoridation status of Victorian postcodes. Data were obtained from the DH&HS for 2004 and 2008. Postcodes were designated ‘fluoridated’ if the majority of the population in the postcode had access to a reticulated water supply with a fluoride concentration of at least 0.7 parts per million (ppm). In ‘non-fluoridated’ postcodes the fluoride concentration was below 0.7 ppm. The year 2004 was used to determine the impact of fluoridation on PPDH rates for 0–4 year olds in 2008–09. This allowed for all 0–4 year olds to have potentially benefitted from the preventive impact of fluoridation on tooth decay. Similarly, the fluoridation status of postcodes in 2008 was used for the analysis of PPDH rates in 2012–13. Socioeconomic status IRSED was used to identify the impact of socioeconomic status on PPDH rates. This index has been described in section 4.3.1.1. The plan followed for analysing VAED data is described in section 4.5.1. 77 4.3.2 Analysis of the 2009 Victorian Child Health and Welfare Survey (VCHWS) The 2009 Victorian Child Health and Welfare Survey (VCHWS) was conducted by the Victorian Department of Education and Early Childhood Development (DEECD) (Department of Education and Early Childhood Development, 2009). It was a computer assisted telephone interview (CATI) survey of parents/carers of a representative sample of 0–12 year old Victorian children 54 . The aims of the 2009 VCHWS were to: • Provide baseline and ongoing data that will be used to support and inform planning, implementation and evaluation of child health, wellbeing, development and learning policies, services and programs throughout Victoria. • Allow comparisons of how children are faring over time in metropolitan and rural areas and in major demographic groups throughout Victoria. The survey included a suite of oral health questions. Of particular interest to research on dental hospitalisation was the question ‘Has (child) ever had any dental treatment in hospital under general anaesthetic?’ All households with a telephone where children (or a child) aged under 13 years usually live, were considered to be ‘in-scope’. Children from rural Victoria were over-sampled to allow for analysis of health inequalities between metropolitan and rural areas. The survey data were weighted to reflect the probability of selection of the household, the child within the household, and the age, sex and geographical distribution of Victoria’s child population (0 to less than 13 years). The CATI interviews were carried out with parents (or carers) of children aged under 13 years. Households were contacted at random using random digit dialling, a technique that 54 Data were provided by the Victorian DEECD. 78 ensured that all households with a telephone within a selected area had an equal chance of being invited to participate. Respondents to the survey were selected on the basis that they were proficient in English, could answer all questions without the assistance of an interpreter, were over 18, and were the individual who knew 'the most about the health and daily routine of the child'. Individuals that did not meet these criteria were not included in the survey. One interview, focusing on one randomly selected child, was carried out per household. Interviews lasted for approximately 23 minutes and covered a broad range of issues relating directly to the child, the child’s family and neighbourhood. 4.3.2.1 Descriptive analysis of the 2009 VCHWS The dependent factor for analysis was a dental hospitalisation, determined by the response to the question - ‘Has (child) ever had any dental treatment in hospital under general anaesthetic?’ The 17 independent factors analysed (as included in Table 4.1) were: Child factors • Age and gender. • Dental treatment need: – experience of toothache – ‘Has (child) ever had a toothache?’. – treatment received – ‘Has (child) ever had a tooth extracted because of a dental problem?’. • Child’s health care needs: – ‘Does (child) need or use more medical care, mental health or educational services than is usual for most children of the same age?’. – ‘Does (child) have a functional limitation shown for 12 months or more?’. 79 – ‘Does (child) have any kind of emotional, developmental or behavioural problem for which he or she needs or gets treatment or counselling?’. Family factors • Residence – Metropolitan Melbourne or rural. • Concession card holder status of parent – ‘Other than a Medicare card, is (child) listed as a dependent on a health care card or a pensioner concession card?’. • Private health insurance – ‘Apart from Medicare, is your family currently covered by health insurance?’. • Socioeconomic status – determined by the IRSED score for the geographical area, divided into quintiles 55 . • Household income – ‘less than $10,000’/‘$10,000 to less than $20,000’/ ‘$20,000 to less than $40,000’, then bands of $20,000 to ’$120,000 and over’. • Respondent parent’s education level – ‘some primary school’/‘completed primary school’/‘some high school’/‘completed high school’/‘TAFE or Trade Certificate or Diploma’/‘University’. (Few respondents answered ‘some primary school’ and their data were omitted. Answers of ‘completed primary school’ were included in the ‘some high school’ category.). • Food security – ‘In the last 12 months, were there times that you ran out of food, or couldn’t afford to buy any more?’. • Family functioning. The level of family functioning was measured using the General Functioning Scale of the McMaster Family Assessment Device, a validated set of questions used to provide a measure of family functioning. The scale uses 12 items. For analysis, the scores were categorised into ‘healthy’ and ‘poor’ family functioning. • Perceived access to basic health care – ‘Is there access to basic health services such as a health centre or medical clinic in this neighbourhood?’. • Language other than English spoken at home – ‘Do you speak a language other than English at home?’. 55 Using 2006 ABS Postal Area (POA) data. 80 Options for answering each question included ‘don’t know’ and ‘refused’. Data in these fields were not included in analyses. Analyses were performed at the state (Victoria) and metropolitan and rural area levels. 4.3.2.2 Multivariate analyses of the 2009 VCHWS As with the VAED data, VCHWS dental hospitalisation data were not normally distributed, consequentially Poisson regression was used to determine the relative importance of contributing factors on the DGA rate. The 17 independent factors were included in the regression analysis. 4.3.3 Additional data sources Hospital admission policies Hospital admission policies and funding guidelines were obtained from the DH&HS website 56 . The funding systems for hospitals and day procedure centres in Victoria were reviewed to determine whether characteristics may influence the admission rate for dental hospitalisation. Department officers provided clarification in a number of policy areas. Dental treatment needs of children and young adults Data on the dental treatment provided to people hospitalised were obtained from the VAED and from AIHW reports. Emergency PPDH admissions were obtained from the VAED. Toothache and extraction experience were obtained from the 2009 VCHWS questions on the need for dental treatment. Australian and international dental hospitalisation data These data were obtained through the literature search detailed in Chapter 2, particularly from the AIHW’s annual reports on hospital statistics (for example (AIHW, 2015a). These reports include data on DGAs and PPDHs at the Australian state and territory level. 56 DH&HS website - < https://www2.health.vic.gov.au/ >. 81 4.4 Impacts 4.4.1 Mortality and morbidity Data on mortality and morbidity associated with DGAs were obtained as part of the literature review described in Chapter 2. These impacts were also within the scope of the interviews with health professionals described in section 4.6. Data were also sought from one national and two Victorian data sets: the National Coronial Information System (NCIS); the Victorian Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM); and the Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM). A request was made to the NCIS for a search on deaths reported by an Australian state or territory coroner between July 2000 and December 2012 ‘where general anaesthesia given in the context of dental surgery contributed to the death’ . Information was sought on deaths of people of any age. The NCIS is an electronic database of coronial information containing case details from the coronial files of all Australian states and territories, and New Zealand, except Queensland, dating to 1 July 2000. It contains Queensland data from 1 January 2001. Data were available up to December 2012. Funding for the NCIS comes from each Australian state and territory and New Zealand. Coronial information is provided by the coroner of each jurisdiction. Source material includes police reports of deaths, autopsy reports, toxicology reports and coronial findings. Additional data is provided by the ABS and Safe Work Australia. The NCIS is managed by the Victorian Department of Justice under the direction of a Board of Management. The second request was made to the CCOPMM, the ‘Council’, for information on deaths related to dental general anaesthesia in Victoria from 2001–12. This time period was 82 specified because of the research focus on DGA trends from 2001–02 to 2013–14. The Council is supported by the DH&HS and provides advice to the Minister for Health on issues relating to perinatal, maternal and paediatric mortality and morbidity 57 Data are provided to the CCOPMM by all public and private hospitals (including private day procedure centres) on maternal deaths and all births; perinatal deaths; birth weight; birth defects; infant and child deaths up to, but not including, the eighteenth birthday. The data collections are managed by the Clinical Councils Unit within the DH&HS, Victoria. The Council’s primary role is to review all maternal, perinatal and child deaths (up to, but not including, the eighteenth birthday) in Victoria in order to consider the clinical features of each case, to assess preventability, and make recommendations to the health system arising from the review of cases and best available evidence. While access to data for statistical and research purposes can be granted to researchers, the Council is restricted by Regulation 10 of the Public Health and Wellbeing Regulations 2009, and cannot release information which identifies any patient, practitioner or institution, without appropriate consent being obtained. The third request was made to the VCCAMM for information on mortality and morbidity related to dental general anaesthesia in Victoria from 2001–12. The function of VCCAMM is to identify avoidable causes of morbidity or mortality related to anaesthesia, and to disseminate the results of deliberations in order to improve the safety and quality of anaesthesia practice 58 . Data are received from anaesthetists, medical practitioners, hospital anaesthetic departments and the State Coroner’s Office. As with the CCOPMM, VCCAMM is supported by the DH&HS, Victoria. 57 CCOPMM website accessed on 20 November 2015 - < https://www2.health.vic.gov.au/hospitals-and- health-services/quality-safety-service/consultative-councils/council-obstetric-paediatric-mortality >. 58 VCCAMM website accessed on 20 November 2015 - 4.4.2 Costs Dental hospitalisation costs were identified via studies accessed through the literature review, from Victorian DH&HS reports and policy documents such as funding guidelines, and from the interviews as detailed in section 4.6. 4.5 Analytical plan for quantitative data In the analyses of the VAED and the 2009 VCHWS, the significance of associations between factors was determined using Poisson bivariate and multivariate regression. Poisson regressions were conducted because the distribution of dental hospitalisation was not normal. Incident rate ratios (IRR) were generated; these are the ratio of incidence rates and show relative rates of factors. Negative binomial regression was performed which did not significantly affect the efficiency of the models. Pseudo R 2 and chi 2 tests were used to test the goodness of fit of models. Statistical analyses were undertaken using Stata 12.1 (StataCorp, Texas, USA). Statistical significance was set at p<0.05. The candidate conducted the analysis with assistance from an academic specialist in dental statistics. 4.5.1 Analyses of VAED data The distribution of PPDH rates by postcode was reviewed prior to analysis, and data from postcodes with populations of less than ten 0-4 year olds and PPDH rates above 30 per 1,0000 were combined with neighboring postcodes. Three models were generated showing the associations between PPDH rates and combinations of the four factors described in section 4.3.1.2: access to oral health professionals; geographic remoteness; access to community water fluoridation; and socioeconomic status. Model 1 included all factors. ‘Remoteness’ was excluded in Model 2 because of the close correlation with each of the other independent factors. In effect, ‘remoteness’ is a proxy for these other three factors. This is because a higher proportion of inner and outer regional postcodes as defined by the ABS Remoteness Structure 84 (4.3.1.2) have a lower rate of oral health professionals, do not have community water fluoridation, and are also more likely to be socioeconomically disadvantaged compared to metropolitan postcodes. Model 3 included fluoridation status and socioeconomic status (as defined by IRSED quintiles outlined in section 4.3.1.1). An interaction term (access to fluoridation by socioeconomic status) was added to investigate whether the effect of access to fluoridation was similar in each IRSED quintile. 4.5.2 Analyses of the 2009 VCHWS The survey data were weighted to reflect the probability of selection of the household; the child within the household; and the age, sex and geographic distribution of Victoria’s child population, zero to 12 years. The Spearman test was used to determine correlations between the factors. Analyses were carried out using the survey command in Stata. Responses of ‘borderline’ and ‘concern’ for the question ‘Does child have any kind of emotional, developmental or behavioural problem for which he or she needs or gets treatment or counselling?’ were combined. For multivariate analysis, the factors that were not significant after bivariate analysis (at p<0.1) were removed. Socioeconomic status by SEIFA was omitted as it is a scaled factor and there were other factors that measured socioeconomic status. ‘Experience of toothache’ was not included in the second round of modelling as a Spearman’s rank correlations coefficient test showed close collinearity with ‘ever had a tooth extracted’. Poisson multivariate analysis was undertaken with factors progressively removed to achieve the highest F value. Models were generated for the three age groupings studied: 1-12 year olds, 1-8 year olds and 9-12 year olds. 85 4.6 The view from key players (qualitative research) A thematic analysis 59 framework was used to explore dental hospitalisation issues through interviews with key players working predominantly in the public sector in Victoria. The key players were paediatric dentists, dental therapists, dental public health specialists and hospital admission decision makers. In-depth semi-structured interviews were conducted about factors related to dental hospitalisation, and particularly PPDHs in Victorian children and young adults from 2001–02 to 2013–14. The aim of the interviews was to capture participants’ views on the relative importance of factors and to quantify the impact of factors, where possible. The candidate conducted all of the interviews. Paediatric dentists were interviewed because their specialty provides comprehensive, therapeutic oral health care to children from birth through adolescence. The specialty also includes care for certain patients beyond adolescence who demonstrate physical and/or emotional problems. Dentists were included because of their predominant role in providing oral health care to all age groups. Dental therapists were interviewed because their training focuses on providing oral health care to children and young people. Dental public health specialists were involved because of their population oral health perspective. Their specialty considers the population as a whole rather than focusing on individual patients. They are aware of opportunity cost, that is, that resources expended on one person are then not available for someone else. The specialty also has a focus on reducing oral health inequalities through implementation of evidence-based interventions across the life course. Finally, hospital admission decision makers were interviewed to explore factors relating to the policy and practice of dental hospitalisation in Victoria. These health professionals were able to clarify aspects of the funding systems for hospitalisation. 59 Thematic analysis is the ‘identification of themes through a careful analysis of the data’ DAVIDSON, M. D., HALCOMB, E.J., AND GHOLIZADEH,L, 2013. Focus groups in health research. In: LIAMPUTTONG, P. (ed.) Research methods in health: foundations for evidence-based practice. Melbourne: Oxford University Press. A ‘ theme’ is a ‘grouping of data that emerges from the research and to which the researcher gives a name’ ibid. 86 A purposive and snowballing sampling technique was used to select the paediatric dentist sample 60 . Three prominent paediatric dentists in Victoria with knowledge and experience related to dental hospitalisation were selected. They then recommended others with pertinent experience. The sample of dental therapists, dental public health dentists and hospital admission decision makers was also selected purposively, depending on participants’ experience related to dental hospitalisation of Victorian children. The snowballing technique was again employed to enroll further participants. Participants were provided with a plain language statement about the research (Appendix 1) and asked to sign a consent form (Appendix 2). Open-ended questions were prepared to shape the interviews and provide the opportunity for participants to raise additional issues. The questions sought views on key factors related to PPDHs such as: children’s dental treatment needs; perspectives on oral health professionals, parents’, and children’s issues; guidelines, costs and risks; and access to operating theatres. Participants were able to articulate their views on important factors linked to dental hospitalisation in Victoria. The semi-structured nature of the discussions encouraged participants to respond more freely than a structured interview format. Interviews generally ran from 60 to 90 minutes. Data on rates of PPDHs for Victorian children and young adults from 2001–02 to 2012– 13 by age group (0–4, 5–9, 10–14 and 15–19 year olds) were graphed. Data for 2013–14 were not available when the interviews were held. These graphs were prepared as prompts for the interviews to assist in obtaining participants views on trends in PPDH rates. They helped to focus the interviews on the research questions. Comprehensive notes were taken during the interviews by the candidate. These notes were compiled and provided to the participants to check their accuracy. The discussions 60 Purposive sampling is ‘widely used to select small numbers of people who share perceptions, behaviours or experience or contexts relevant to the study aims’ . Participants are chosen that will be able to ‘provide rich or in-depth information about the issue being examined, not a representative sample as in quantitative research’ HOWIE, L. Ibid.Narrative enquiry and health research. Snowball sampling begins by ‘selecting one or a few participants with pertinent knowledge or experience and asking them to identify others with similar experience’ ibid. 87 were not taped in order to maintain a collegiate tone . Several participants clarified points they had made in the interviews when they read the interview notes. An iterative process was used whereby participants with the broadest experience of providing DGAs in a range of public and private settings were re-contacted when a significant new theme emerged from later interviews. This allowed experienced participants to comment on the relevance of the new information. These participants were contacted up to four times to explore concepts in more depth. Memos or ‘notes to self’ on emerging categories, ideas and additional people to interview were written during the interviewing process 61 . Sampling was continued until no new themes were being raised by participants. That is when data saturation was reached 62 . The checklist for reporting qualitative research studies involving in-depth interviews was used as a guide to improve the quality of the research - the consolidated criteria for reporting qualitative research (COREQ) (Tong et al., 2007). 4.7 Analytical plan for qualitative data A thematic analysis of the interview discussions was undertaken by the candidate with assistance from an academic specialist in qualitative research. Transcripts of the interviews were read and re-read to gain a thorough understanding of the data collected. Initial themes were generated by analysing the interview transcripts and highlighting recurring categories. Data were entered into a spreadsheet, listing themes and the participants who had mentioned each theme. 61 Such memos are an important part of the coding process used in grounded theory. 62 Data saturation is considered to occur when ‘ little or no new data is being generated and new data fits into the categories already developed’ LIAMPUTTONG, P. 2013. The science of words and the science of numbers: research methods as foundations for evidence-based practice in health. In: LIAMPUTTONG, P. (ed.) Research methods in health: foundations for evidence-based practice. Melbourne: Oxford University Press. 88 The memos written during the interviewing process were reviewed to support an understanding of the concepts within the data. Themes were reviewed and participant responses placed under different themes as a more complete understanding of the data emerged. Several participants offered case studies that they considered representative of situations where children had DGAs. Transcripts of these case studies were checked with the participants for accuracy. 4.8 Combining qualitative and qualitative data The results of the research will be presented in the following chapters according to the outline of the methodology. Results related to question one on distribution and determinants, will be presented in Chapter 5 (analysis of the VAED), Chapter 6 (analysis of the 2009 VCHWS), and Chapter 7 (the view from the key players). These chapters will address prevalence, trends and determinants of dental hospitalisation in Victoria. Chapter 8 will present comparisons with Australian and international data. Results related to question two on the impact of dental hospitalisations will be presented in Chapter 9. The Discussion, Chapter 10, will bring together the results under the categories in the social determinants framework. Quantitative data from Chapters 5, 6, 8, and 9 will be combined with the qualitative data from Chapter 7 to allow comprehensive discussion about each of the social determinants factors. Addressing the third research question on policy implications will then be possible in the last section of the Discussion, Chapter 10. 89 Chapter 5 Results 1 – Dental hospitalisation prevalence, trends and determinants – Analysis of the Victorian Admitted Episode Dataset (VAED) 5.1 Overview ...... 90 5.2 Prevalence and trends ...... 91 5.2.1 Summary ...... 91 5.2.2 Age and gender distribution ...... 93 5.2.3 Potentially preventable hospitalisation ranking ...... 96 5.2.5 Principal diagnosis ...... 99 5.2.6 Diagnosis-related groups ...... 103 5.2.7 Admission type – emergency and planned admissions ...... 107 5.2.8 Treatment provided ...... 109 5.2.10 Aboriginal and Torres Strait Islander people ...... 117 5.2.11 Socio-economic status ...... 120 5.2.12 Hospital insurance status ...... 122 5.2.13 Country of birth ...... 124 5.3 Multivariate analysis, 2008–09 and 2012–13 ...... 127 5.3.1 Descriptive statistics ...... 127 5.3.2 Bivariate analysis ...... 130 5.3.3 Multivariate analysis ...... 132 5.1 Overview In this chapter the results of the analyses of the data base of all hospital admissions in Victoria, the Victorian Admitted Episode Dataset (VAED), will be presented to address the first research question – What are the distribution and the determinants of the dental hospitalisation of children and young adults in Victoria? The first section of the chapter will outline the results of an analysis of VAED data from 1997-98 to 2013-14. The focus will be on Potentially Preventable Dental Hospitalisations (PPDHs), data from 2013-14, and trend data. Trends were analysed from 1997-98 and in more detail from 2001-02 and 2004-05. This was because only summary data was 90 available from 1997-98, more granular data was available from 2001-02, and a comprehensive analysis of 2004-05 data had been published. Data will be presented on frequency, age and gender distribution, variations in public and private admissions and reasons for admissions by principal diagnosis and Diagnostic Related Groups (DRGs). Treatment provided will be analysed by procedure and intervention codes. Variations by geographic areas will be followed by a breakdown by Aboriginal background, socioeconomic status, health insurance status, and country of birth. The second section will present results of a multivariate analysis of PPDH data for the two years, 2008-09 and 2012-13. These years were chosen because 2012-13 was the most recent year for which detailed data was available, and 2008-09 was the mid point between 2012-13 and 2004-05. As outlined in the methodology chapter, four factors were included to identify their associations with PPDHs in 0-4 year olds. 5.2 Prevalence and trends 5.2.1 Summary In 2013–14 there were over two million (2,488,678) admissions to private and public hospitals in Victoria (AIHW 2015). There were almost 40,000 (39,196) admissions for dental services (AIHW 2015) and almost 40 per cent (39 per cent, 15,406 63 ) of these were PPDHs (VHISS). The PPDH rate per 1,000 population was 2.7, the second-highest rate of all PPHs (Table 8). The highest number of PPH admissions was for diabetes complications (102,280), a rate of 17.5 per 1,000 persons. After PPDHs, the next highest-ranking conditions were 63 The number of PPDHs in Victoria in 2013-14 has been published as 15,406 in the VHISS and as 15,652 by the AIHW AIHW:, CHRISOPOULOS, S., HARFORD, J. E. & ELLERSHAW, A. 2016. Oral health and dental care in Australia: Key facts and figures 2015. Canberra: Australian Institute of Health and Welfare.. 2013-14 VAED data analysed for this study includes 15,059 PPDHs. The VAED total is lower than the VHISS total because patients from interstate are excluded. 91 chronic obstructive pulmonary disease (COPD), pyelonephritis, congestive cardiac failure, iron deficiency anaemia, cellulitis and asthma. Table 8 Rates of potentially preventable hospitalisations in Victoria, 2013–14 Rate per 1,000 Condition population Diabetes complications 17.5 Dental 2.7 COPD 2.6 Pyelonephritis 2.6 Congestive cardiac failure 2.4 Iron deficiency anaemia 2.4 Cellulitis 1.8 Asthma 1.8 ENT infections 1.3 Convulsions and epilepsy 1.3 Source: VHISS 2015. Most PPDHs in 2013–14 were same-day admissions (90 per cent, 13,539 patients), with five per cent overnight stay (816) and 5 per cent multi-day stay (704). The average PPDH length of stay was 1.2 bed days. Total PPDHs were ranked twelfth by total PPHs bed days. Bed days for PPDHs among under 25 year olds were ranked second to asthma PPHs. From 1997-98 to 2013-14, PPDHs increased by 74 per cent (from 8,840 to 15,406) and rates increased by 23 per cent (from 2.2 to 2.7 per 1,000 population). The PPDH rate was fifth highest of all PPHs in 1997–98, and as mentioned above, second highest in 2013-14. Figure 7 shows data from 2001-02 to 2013-14. The PPDH rate was 2.6 per 1,000 population in 2001–02, increased to 3.03 in 2008–09, and was 2.7 in 2013–14 (Figure 7). This represented a statistically significant increase of 8 per cent between 2001–02 and 2013–14. 92 Figure 7 Rate of potentially preventable dental hospitalisations in Victoria from 2001 – 02 to 2013–14 3.5 3 2.5 2 1.5 1 0.5 Rateper 1,000 population 0 2001- 2003- 2004- 2005- 2006- 2007- 2008- 2009- 2010- 2011- 2012- 2013- 02 04 05 06 07 08 09 10 11 12 13 14 Source: VHISS 2015. 5.2.2 Age and gender distribution The distribution of PPDHs by age in 2013–14 is shown in Figure 8, while Table 9 shows the distribution by age group and gender. Figure 8 Potentially preventable dental hospitalisations by age in Victoria, 2013–14 800 600 400 Frequency 200 0 0 20 40 60 80 100 AGE Source: VAED 2013-14. 93 Table 9 Potentially preventable dental hospitalisations by age group and gender in Victoria, 2013–14 Age group Male Female Total 0–4 749 659 1,408 5–9 1,400 1,268 2,668 10 –14 352 396 748 15 –19 392 554 946 20 –24 395 530 925 25 –29 286 340 626 30 –34 291 310 601 35 –39 280 303 583 40 –44 407 369 776 45 –49 336 469 805 50 –54 402 526 928 55 –59 462 528 990 60 –64 396 446 842 65 –69 352 435 787 70 –74 265 245 510 75 –79 198 189 387 80 –84 102 154 256 85+ 104 169 273 Total 7,169 7,890 15,059 Source: VAED 2013-14 Admissions were concentrated in the youngest age groups, with 0-9 year olds comprising 27 per cent of total PPDHs (4,078 of 15,059). The highest frequency was in the 5–9 year old age group (2,668) followed by the 0–4 year age group (1,408). The highest numbers of admissions were for four year olds (694), five year olds (732), and six year olds (637). A total of 193 two-year-olds were admitted. The younger age group had a higher proportion of males (53 per cent of 0–9 year-olds), and there were more females in most of the older age groups. The highest proportion of females, 61 per cent, was amongst those aged 80 years or more. In the 15–24 and 45–50 year old age groups, 58 per cent were female. Overall, 52 per cent of admissions were females. 94 PPDH rates in children and young adults varied considerably by age group between 2001-02 and 2013-14, as shown in Figure 9. Figure 9 Rate of potentially preventable dental hospitalisations by age group from 2001 –02 to 2013–14 PDH in Victorian children 2001-02 to 2013-14 10 8 6 4 2 Rate per 1,000 population 1,000 Rate per 0 2001- 2003- 2004- 2005- 2006- 2007- 2008- 2009- 2010- 2011- 2012- 2013- 02 04 05 06 07 08 09 10 11 12 13 14 0-4 yr olds 7.91 7.32 7.14 7.01 5.41 5.21 4.75 4.71 5 4.75 3.78 3.85 5-9 yr olds 7.98 8.01 8.73 8.18 7.93 8.53 8.92 9.37 8.88 8.67 7.47 7.85 10-19 yr olds 1.56 1.76 1.99 2.06 2.01 2.46 2.68 2.47 2.51 2.73 2.46 2.58 Source: VHISS 2015. Among 0–4 year olds PPDH rates decreased by 51 per cent from the peak in 2001–02 (7.91 per 1,000 population) to 2013–14 (3.85). The peak age for PPDHs increased from four years in 2003–04 to six years in 2012–13 (data not shown). In public hospitals, the peak ages were four and five years. The peak age in private hospitals was six years. The number of two year olds who have had a PPDH decreased over this period. There were 275 two year olds hospitalised in 2004–05, 207 in 2007–08 and 193 in 2013–14. This represents a decrease of 30 per cent from 2004–05 to 2013–14. The PPDH rate for 5–9 year olds peaked in 2009–10 at 9.37. Rates were similar in 2001– 02 (7.98) and 2013–14 (7.85). For 10–19 year olds, PPDH rates increased by 65 per cent between 2001–02 and 2013– 14, but from a lower base than rates in the younger age groups (1.56 to 2.58). Increases were higher among 15–19 year olds (75 per cent) than 10–14 year olds (54 per cent). 95 5.2.3 Potentially preventable hospitalisation ranking PPDH rates by age group and rank against other PPHs varied by age as shown in Table 10. Table 10 Potentially preventable dental hospitalisations by age group, rate and rank, 2013–14 PPDH rate per Age (years) PPDHs 1,000 population PPHs rank 0–4 1,421 3.9 3 5–9 2,746 7.9 1 10 –14 803 2.4 1 15 –19 971 2.7 1 20 –24 958 2.3 1 0-24 6,899 3.7 1 25+ 8,507 2.2 7 All 15,406 2.7 2 Source: VHISS 2015. PPDH rates were the highest ranked PPHs for each five-year age group among 5-24 year olds, and for 0-24 year olds. Among 0-4 year olds, PPDHs ranked third after asthma and ear, nose and throat infections. The PPDH rate per 1,000 population for 0-24 year olds was almost 70 per cent (68 per cent) higher than the PPDH rate for 25 year olds and over - 3.7 compared to 2.2. Among 0-4 year olds, PPH rates for asthma were more than twice the PPDH rate - 10.2 compared to 3.9 per 1,000 children. However, among 5-9 year olds, the PPDH rate was almost double that of the asthma rate - 7.9 to 4.3. PPDH rates were also higher than asthma rates among 10-14 year olds (2.41 compared to 1.4), 15-19 year olds (2.7 compared to 0.7), and 20-24 year olds (2.3 compared to 0.8). 96 5.2.4 Public and private admissions Most (9,080, 60 per cent) of PPDHs in 2013–14 were in private hospitals, including day procedure centres as shown in Table 11. Table 11 Potentially preventable dental hospitalisations by public and private hospitals, 2013–14 Total PPDH Public hospitals Private hospitals Total Number 5,979 9,080 15,059 Percentage 40 60 100 Source: VAED 2013-14. The age profile in public and private hospitals was similar in that higher numbers of 0-9 year olds were admitted than in any other age groups (Figures 10 and 11). However, there was a higher proportion of 15–24 year olds and middle aged admissions to private hospitals. This reflects the differences in treatment patterns in public and private hospitals that will be explored in the next section. Figure 10 Potentially preventable dental hospitalisations in public hospitals by age, 2013–14 450 400 350 300 250 200 Frequency 150 100 50 0 1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 101 Age Source: VAED 2013-14. 97 Figure 11 Potentially preventable dental hospitalisations in private hospitals by age, 2013–14 350 300 250 200 150 Frequency 100 50 0 1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 101 Age Source: VAED 2013-14. Almost 1,000 (968) private patients were treated in public hospitals (Table 12). This represented 16.2 per cent of public hospital patients (968 of 5,979) and 6.4 per cent of total PPDHs (968 of 15,059). There were 10,084 private patients in total, comprising 66.7 per cent of all PPDHs. Table 12 Potentially preventable dental hospitalisations by public and private admissions by proportion of total PPDHs by age group, 2013–14 Public hospitals Private hospitals Total patients Age group Public patients Private patients Private hospital (years) (%) (%) patients (%) No. (%) 0–4 729 (52) 89 (6) 590 (42) 1,408 (100) 5–9 1,189 (45) 202 (7) 1,277 (48) 2,668 (100) 10 –14 301 (40) 52 (7) 395(53) 748 (100) 15 –19 208 (22) 22 (2) 716 (76) 946 (100) 20 –24 214 (23) 34 (4) 677 (73) 925 (100) 25+ 2,370 (27) 569 (7) 5,425 (66) 8,364 (100) Total 5,011 (33) 968 (6) 9,080 (60) 15,059 (100) Note that private patients in public hospitals comprised 6.4%, and private hospital patients comprised 60.3% of total patients, to give a total of private patients of 66.7%. Source: VAED 2013-14. Public patients comprised a third of all PPDHs. Young children were more likely to be admitted to public hospitals while people over 10 years were more likely to be admitted to private hospitals. Among 0–4-year-olds, 58 per cent were admitted to public hospitals. 98 More than half (52 per cent) of 5–9-year-olds were admitted to public hospitals. Of these children, seven per cent were private patients. The proportions of PPDHs that were in the private sector 64 by age group were: 60 per cent for 10–14 year olds; 78 per cent for 15-19 year olds; 77 per cent for 20–24 year olds; and 73 per cent for those 25 years or more. There has been a shift to privately funded care. From 2004-05 to 2013-14, the proportion of PPDHs that were in private hospitals increased from 53 per cent (Department of Human Services, 2007) to 60 per cent. Among 0-4 year olds, the proportion of PPDHs in private hospitals increased from 35 per cent DHS to 42 per cent over this time. 5.2.5 Principal diagnosis As explained in section 4.3.1, PPHs are defined via principal diagnosis codes. These are shown by ICD-AM code, frequency and proportion of admissions in Table 13. Table 13 Potentially preventable dental hospitalisations by principal diagnosis, 2013–14 % of total ICD-AM Code Description No. admissions K02 Dental caries 7,976 53 K08 Other disorders of teeth and supporting structures 3,283 22 K04 Diseases of the pulp and periapical tissues 1,654 11 K13 Other diseases of lip and oral mucosa 703 5 K05 Gingivitis and periodontal disease 590 4 K12 Stomatitis and related lesions 471 3 Other diseases of hard tissues of teeth; Disorders Other K03, of gingival and edentulous alveolar ridge; cysts of K06, K09 oral region 382 2 Total 15,059 100 Source: VAED 2013-14 64 That is PPDHs in private hospitals plus private patients in public hospitals. 99 Conditions in code K04, diseases of the pulp and periapical tissues, are a consequence of dental caries. Most of the K04 diagnoses were periapical abscess without sinus (K047 65 ) (89 per cent). Codes K02 and K04 can be combined to give a total of almost two thirds (64 per cent) of diagnoses directly attributable to dental caries. Other diseases of the teeth and supporting structures (K08) totaled 22 per cent. These cases included: loss of teeth due to accident, extraction or local periodontal disease (K081) (16 per cent of total K08); other specified disorders of the teeth and supporting structures such as atrophy of alveolar ridge and retained dental roots (K088) (12 per cent); and disorders of teeth and supporting structures, unspecified (K089) (61 per cent). The next ranked principal diagnoses were: other diseases of lip and oral mucosa (K130) (five per cent of all cases); gingivitis and periodontal disease (K05) (four per cent); and stomatitis and related lesions (K12) (three per cent). Other diseases of hard tissues of teeth (K03), disorders of gingival and edentulous alveolar ridge (K06), and cysts of the oral region (K09), totaled two per cent. Variation by age Diagnoses varied by age as shown in Figures 12 and 13. Figure 12 presents PPDH principal diagnosis by age group, and Figure 13 the proportion of principal diagnosis by age group. 65 Each code has subcodes. 100 Figure 12 Potentially preventable dental hospitalisations by principal diagnosis by age group, 2013–14 Frequency 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 0-4 5-9 85+ 14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 Other 116 98 97 148 183 126 113 93 138 156 177 158 142 144 93 61 50 46 K08 23 42 119 380 329 162 131 111 219 197 231 343 302 285 177 127 53 50 K04 71 191 35 47 91 88 129 103 114 116 160 137 106 95 57 52 28 34 K02 11982337497 371 322 250 228 276 305 336 360 352 292 263 183 147 125 143 Age groups Source: VAED 2013-14. Figure 13 Potentially preventable dental hospitalisations by proportion of principal diagnosis by age group, 2013–14 100% 90% 80% 70% 60% Other K08 50% K04 40% K02 30% 20% 10% 0% 4 9 9 4 9 4 0- -2 -4 -5 -7 5_ _19 0-24 0-54 5-69 0-84 85+ 10_14 15 2 25 30-34 35-39 40 45-49 5 55 60-64 6 70 75-79 8 Age groups Source: VAED 2013-14. For each age group, codes K02, K04 and K08 comprised at least 80 per cent of all diagnoses. Almost all 0–4 year olds (90 per cent) and 5–9 year olds (95 per cent) had 101 principal diagnoses related to dental caries (K02 and/or K04). Children under ten years had virtually no diagnoses of other disorders of the teeth and supporting structures (K08) (two per cent). A smaller proportion of diagnoses in the 15–24 year age groups related directly to dental caries (44 per cent) compared to younger children. These age groups had a higher proportion of diagnoses of other disorders of the teeth and supporting structures (38 per cent). The latter were predominantly disorders of the teeth and supporting structures, unspecified (K089). Age groups between 55–79 years, also had higher proportions of diagnoses coded K08, above 30 per cent of total diagnoses. Most were K089. The highest proportion of diagnoses coded K081 was among 60–69 year olds – loss of teeth due to accident, extraction or local periodontal disease. This age group had 10 per cent of total diagnoses coded K081. Variation by patient type A similar proportion of public and private PPDH principal diagnoses were dental caries (K02) (54 per cent of public patients and 53 per cent of private patients) as shown in Table 14. The proportion of PPDHs for gingivitis and periodontal disease, in public and private patients, was also similar (K05) (three per cent in public patients and four per cent in private patients). 102 Table 14 Potentially preventable dental hospitalisations principal diagnosis by public and private patients, 2013–14 ICD -AM Code Public patients Private patients % of public % of total % of private % of total No. patients patients No. patients patients K02 2,689 54 18 5,204 53 35 K08 495 10 3 2,728 28 18 K04 753 15 5 875 9 6 K13 346 7 2 349 3 2 K05 227 3 2 356 4 2 K12 328 7 2 128 1 1 K03,K06,K09 173 3 1 204 2 1 Total* 5,011 100 33 9,844 100 65 *Note: The proportion of public and private patients total does not add to 100 per cent of the total of 15,059 patients admitted because the total excludes 204 patients coded as ‘compensable’, ‘Department of Veterans’ Affairs’ and ‘ineligible’. Source: VAED 2013-14. The data showed variations between public and private principal diagnosis codes for: other disorders of teeth and supporting structures (K08) - 10 per cent of public patients and 28 per cent of private patients; diseases of the pulp and periapical tissues (K040) - 15 per cent of public patients and nine per cent of private patients; and for stomatitis and related lesions (K12) - seven per cent of public patients and one per cent of private patients. 5.2.6 Diagnosis-related groups Diagnosis Related Groups (DRGs) 66 are used in Victoria to determine funding levels for public hospitals. Five DRGs comprised 97 per cent of PPDHs in 2013–14, as shown in Table 15. The predominant DRG was for dental extractions and restorations, comprising 72 per cent of cases (D40Z) (10,874 of 15,059). 66 The DRG system is a method of classifying patients that have similar clinical conditions and similar levels of resource use. Nationally, the Australian Refined Diagnosis Related Groups (AR-DRG) classification is used, which incorporates the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM). 103 Table 15 Potentially preventable dental hospitalisations diagnosis by Diagnosis Related Group, 2013–14 % of total DRG Description No. admissions D40Z Dental extractions and restorations 10,874 72 D14Z Mouth and salivary gland procedures 1,496 10 D67B Oral and dental disease except extractions and restorations –same day 1,112 7 D67A Oral and dental disease except extractions and restorations – multi stay 656 4 D04B Maxillo surgery – without complications 589 4 Other Including D12Z – (156, 1%) 332 2 Total* 15,059 100 *Note: Totals 100 per cent when the row values are taken to the first decimal point. Source: VAED 2013-14 Variation by age Figures 14 and 15 show DRGs by age group. Figure 14 presents the actual numbers of the main DRGs for each age group. Figure 15 shows the proportion each DRG comprises by age group. Data for these figures are shown in Appendix 4. Figure 14 Potentially preventable dental hospitalisations by Diagnosis Related Group by age group, 2013–14 3000 2500 Other 2000 D67A+B 1500 D40Z D14Z 1000 D04B 500 0 00- 05- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85+ 04 09 14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 Source: VAED 2013-14. 104 Almost all admissions of children aged of 0–9 years67 were classified as dental extractions and restorations (DRG D40Z); 0–4 year olds 89 per cent, and 5–9 year olds 95 per cent. More than 80 per cent of PPDHs of 10–14 year olds (85 per cent) and 15–19 year olds (83 per cent) were also coded D40Z. For those 20 years and older, the proportion of PPDH coded D40Z decreased until the 65–69 year age group (51 per cent), and then increased to 79 per cent in those 85 years or more. Oral and dental disease, except extractions and restorations (D67A and D67B), were most common in 30–34 year olds (20 per cent). Mouth and salivary gland procedures (D14Z) peaked among 65–69 year olds (19 per cent), while maxillo surgery without complications (D04B) was proportionally highest among 55–59 year olds (11 per cent). Figure 15 Potentially preventable dental hospitalisations by Diagnosis Related Group proportion by age group, 2013–14 100% 80% Other 60% D04B D14Z 40% D67A +B D40Z 20% 0% 00- 05- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- Tot 85+ 04 09 14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 al Other 1% 0% 1% 1% 2% 2% 2% 3% 3% 3% 4% 3% 5% 3% 3% 3% 2% 3% 2% D04B 0% 0% 1% 1% 2% 3% 2% 5% 6% 7% 8% 11%10% 10% 6% 2% 0% 0% 4% D14Z 2% 2% 7% 6% 9% 11% 11% 11%12% 16% 16% 15%18% 19% 15% 16% 12% 7% 10% D67A +B 7% 2% 6% 8% 10%16% 23% 16%20% 16% 15% 14%14% 17% 20% 19% 12% 11%12% D40Z 89% 95%85% 83% 76%68% 62% 64%59% 58% 57% 57%52% 51% 56% 60% 73% 79%72% Source: VAED 2013-14. 67 The DRG codes for children two years of age were D40Z (85 per cent), D67A and B (10 per cent), and D14Z (five per cent). 105 Variation by patient type Variation by DRG diagnoses for public and private patients having PPDH are outlined in Table 16. Table 16 Potentially preventable dental hospitalisation diagnoses by Diagnosis Related Group (DRGs) by public and private patients, 2013–14 DRG Public patients Private patients % of private % of public % of total patients % of total No. patients patients No. (%) patients (%) D40Z 3,063 61 20 7,676 78 51 D14Z 549 11 4 918 9 6 D67B 758 15 5 346 4 2 D67A 505 10 3 134 1 1 D04B 15 <1 <1 565 6 4 Other 121 2 1 205 2 1 Total* 5,011 100 33 9,844 100 65 Source: VAED 2013-14.. *Note: Excludes the 204 patients coded as ‘compensable’, ‘Department of Veteran Affairs’ and ‘ineligible’ therefore the proportion of public and private patients total does not add to 100 per cent of the total 15,059 patients admitted. The DRG code D40Z comprised a lower proportion of DRGs for public patients (61 per cent) compared to private patients (78 per cent). Half of all DRGs relating to private patients were coded D40Z (51 per cent). The DRG code D67B, and the higher morbidity multi-stay D67A cases were predominantly public patients – 1,236 (eight per cent of total patients) compared to 480 private cases (three per cent). Maxillo surgery (D04B) cases were almost all private patients – 565 compared to 15. 106 5.2.7 Admission type – emergency and planned admissions In the VAED, PPHs are recorded as: ‘an emergency admission through an emergency department’; ‘other emergency admission’ 68 ; ‘planned admission from a waiting list’; and ‘other patient’. Table 17 shows the numbers and proportions of PPDHs by public, private and other patients with the two emergency admission types combined. The ‘other patient’ category, which includes ‘compensable’, ‘Department of Veterans’ Affairs’ and ‘ineligible’ patients. Tab le 17 Potentially preventable dental hospitalisations admission type by public and private patients, 2013–14 Other Public patients Private patients patients Total Admission type (%) (%) (%) (%) Emergency 1,028 (21) 149 (2) 30 (15) 1,207 (8) From waiting list 1,365 (27) 340 (3) 6 (3) 1,711 (11) Other admissions 2,618 (52) 9,355 (95) 168 (82) 12,141 (81) Total 5,011 (100) 9,844 (100) 204 (100) 15,059 (100) Source: VAED 2013-14. The proportions shown in Table 5.11 are the percentages of admission type within the public, private and ‘other’ 69 categories. For example, of the 5,011 public patients, 1,028 (21 per cent) were classified as ‘emergency’, compared to 149 (two per cent) of private patients. A total of 1,207 PPDH (eight per cent) were classified as emergencies. Public patients comprised 85 per cent of total emergency PPDHs (1,028 of 1,207). The highest proportion of emergencies was in the 50–54 year old age group (103, representing 21 per cent of total PPDH for that age group). The 30–34 year old age group had the highest number of emergency admissions (131, representing 17 per cent of total PPDHs 68 ‘Other emergency admissions’ are for a patient not arising from presentation at the emergency department at the hospital of admission, or arising from a hospital which does not report data to the Victorian Emergency Minimum Dataset (DH&HS Data definitions, VAED manual, 22nd edition, July 2012). 69 The ‘other’ category apart from public and private patients comprises patients paid for by the Department of Veteran Affairs, the Victorian Workcover Authority or the Transport Accident Commission. 107 for that age group). In the age groups 0–4 and 5–9 years, 4.8 per cent and 2.3 per cent of PPDHs, respectively, were categorised as emergencies. A higher proportion of public patients who had PPDHs were from hospital waiting lists – 27 per cent, compared to three per cent of private patients. Patients aged 5–9 years were more likely to be from waiting lists (19 per cent). Private patients were more likely to be classified as ‘other admissions’ – 95 per cent compared to 52 per cent of public patients. Emergency care trends The numbers and proportions of PPDHs that were emergency admissions have increased over the past 10 years. Emergency data from 2004–05 and 2013–14 are compared in Table 18. Total emergency PPDH admissions almost doubled over the 10 years from 607 (4.4 per cent of all 2004–05 admissions) to 1,207 (8.0 per cent of all 2013–14 admissions). The increase has been a steady trend. In 2008–09 there were 1,062 emergency admissions, comprising 6.4 per cent of all PPDH admissions (data not shown). Among children 0–14 years old, the number and proportion of emergency admissions have also increased. In 2004–05 there were 128 children who were emergency admissions (2.3 per cent of PPDHs in this age group), and the number increased to 156 in 2013–14 (3.2 per cent of PPDHs). Overall the total numbers of PPDHs of children have decreased from 5,551 in 2004–05 to 4,824 in 2013–14. Table 18 Variation in emergency admissions for potentially preventable dental hospitalisations in 2004–05 and 2013–14, Victoria 2004 –05 2013 –14 PPDH s Emergency PPDH s Emergency Age group (years) No. No. % No. No. % 0–4 2,191 55 2.5 1408 68 4.8 5–9 2,707 50 1.8 2668 62 2.3 10 –14 653 23 3.5 748 26 3.5 0–14 5,551 128 2.3 4824 156 3.2 15+ 8,265 479 5.8 10,235 1,051 10.3 Total 13,816 607 4.4 15,059 1,207 8.0 Sources: VAED 2004-05 and 2013-14. 108 5.2.8 Treatment provided Treatment provided in public and private hospitals is recorded in the VAED by procedure according to in the International Classification of Diseases – ICD-10-AM Australian Classification of Health Interventions (ACHI). As shown in Table 19, within the first block of procedures 70 , in 2013–14, 59 per cent of procedures were extraction of teeth – 33 per cent by surgical removal and 26 per cent by non-surgical extraction. The proportion of these procedures performed on public, private and ‘other’ patients is shown in the last three columns of Table 19. ‘Other patients’ are those in the patient type categories of ‘compensable’, ‘Department of Veterans’ Affairs’ and ‘ineligible’. These three categories totaled 204 patients (14 per cent of total patients). Table 19 Potenti ally preventable dental hospitalisations procedures, ICD -10 Block 1, 2013 – 14 % of Public Private Other ICD-10 proced- patients patients patients Block Description No. ures % % % 458 Surgical removal of teeth 4,949 33 11 87 2 457 Non -surgical removal of teeth 3,666 26 25 74 1 485 Dental drug therapy 1,295 9 100 0 0 465, Fillings 466 777 5 32 67 1 453 -455 Preventative dental services 494 3 20 79 1 400 Dental implant 476 3 3 93 3 1888 Hyperbaric oxygen therapy 408 3 67 33 0 Other 2,994 20 Total 15,059 100 33 66 1 Source: VAED 2013-14. Note: No values were recorded in block 1 for 699 patients. 70 The procedure block is a one to four digit number that identifies a group of related ICD-10-AM procedure codes. The procedure codes, sometimes called intervention codes, comprise seven digit numbers and reflect the interventions used for diagnosis and/or treatment. For example, dental services are mainly included within blocks 450–490 with some treatment such as dental implants outside this range (code 400). The non-surgical removal of teeth is coded 457, with procedure code 9731101 used for the removal of one tooth, 9731102 for two teeth, and so on. 109 Table 19 only shows data from the first block of procedures for 2013-14. Procedures were recorded for 31 blocks. All blocks would need to be reviewed to obtain a complete picture of procedures provided. The majority of tooth extractions were in private patients (87 per cent of surgical extractions and 74 per cent of non-surgical extractions). Dental drug therapy was the third highest PPDH-related procedure recorded, comprising nine per cent of procedures. These procedures include ‘Intravenous cannulation and establishment of infusion for dental procedures’ (intervention code 9792800) and ‘Provision of medication/medicament for dental procedure’ (intervention code 9792700). All these procedures were performed on public patients. Fillings comprised five per cent of procedures recorded in Block 1 and were mostly provided to private patients (67 per cent). Dental implants were provided to 476 patients, representing three per cent of all procedures 71 . Almost all implants (93 per cent) were provided to private patients. A further three per cent of procedures were preventative dental services. These services included dental prophylaxis and bleaching, and applying fissure sealants. Hyperbaric oxygen 72 therapy was provided to 408 patients, comprising three per cent of procedures recorded in Block 1. Two thirds (67 per cent) of these procedures were provided to public patients. The difference in procedures provided to public and private patients is shown in Table 20. 71 There were a total of 1,422 implant procedures provided in 2013-14. 72 Hyperbaric oxygen therapy can reduce cancer growth (Hyperbaric oxygen therapy and cancer – a review. Accessed on 1 December 2015- < http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3510426/ >). 110 Table 20 Proportion of potentially preventable dental hospitalisations procedures by public and private patients, ICD-10 block 1, 2013–14 Public patients Private patients ICD-10 Block Description % % 458 Surgical removal of teeth 11 44 457 Non -surgical removal of teeth 18 28 485 Dental drug therapy 26 0 465, 466 Fillings 5 5 453 -455 Preventative dental services 2 4 400 Dental implant <1 5 1888 Hyperbaric oxygen therapy 6 1 Other 33 13 Total 100 100 Source: VAED 2013-14 The most common procedures provided to public patients were dental drug therapy (26 per cent), non-surgical removal of teeth (18 per cent), and surgical removal of teeth (11 per cent). For private patients the most common procedures were surgical removal of teeth (44 per cent), non-surgical removal of teeth (28 per cent), fillings (5 per cent) and implants (5 per cent). 5.2.9 Geographic variations The variation in PPDHs by DH&HS regions and by public and private hospitals in 2013– 14 is shown in Table 21. 111 Table 21 Potentially preventable dental hospitalisations by Department of Health and Human Services region and public and private hospitals, 2013–14 Public Private % public hospital hospital Total hospital Region patients patients patients patients Barwon South Western 494 901 1,395 35 Grampians 364 206 570 64 Loddon Mallee 632 339 971 65 Hume 247 150 397 83 Gippsland 354 71 425 83 Eastern metropolitan 315 3,643 3,958 8 Southern metropolitan 414 1,367 1,781 23 North & West metropolitan 3,159 2,403 5,562 57 Total 5,979 9,080 15,059 40 Source: VAED 2013-14. The proportion of patients attending public hospitals varied from 83 per cent in Hume and Gippsland regions to eight per cent in Eastern region. Overall 40 per cent of patients were treated in public hospitals. In rural regions (Barwon South Western, Grampians, Loddon Mallee, Hume, and Gippsland), 56 per cent of patients attended public hospitals, compared to 34 per cent in metropolitan regions. The variation by public and private patients is shown in Table 22. The differences between Tables 21 and 22 are that private patients can be admitted to public hospitals, and Table 22 excludes the 204 ‘other’ patients coded ‘compensable’, ‘Department of Veterans’ Affairs’ and ‘ineligible’. In both tables, the region indicates where the hospitalisation took place, not necessarily where the patient lived. 112 Table 22 Potentially preventable dental hospitalisations by Department of Health and Human Services region and public and private patients, 2013–14 % Public Private Total* public Region patients patients patients patients Barwon South Western 427 941 1,368 31 Grampians 290 277 567 51 Loddon Mallee 439 525 964 46 Hume 181 211 392 46 Gippsland 202 221 423 48 Eastern metropolitan 282 3,619 3,901 7 Southern metropolitan 378 1,350 1,728 22 North & West metropolitan 2,812 2,700 5,512 51 Total* 5,011 9,844 14,855 34 *Note: Excludes the 204 patients coded as ‘compensable’, ‘Department of Veterans’ Affairs’ and ‘ineligible’. Source: VAED 2013-14. C1Block Description Proportion of all treatments (%) The proportion of public patients varied from 51 per cent in Grampians and North & West metropolitian regions to seven per cent in Eastern metro region. Overall a third (34 per cent) of patients were public patients. A total of 3,754 PPDHs occurred in hospitals located in the five rural regions, representing 25 per cent of all PPDHs. Overall 4,672 rural residents (31 per cent of all PPDHs) had a potentially preventable dental hospitalisation, as a significant proportion attended a metropolitan hospital for treatment. The relative rates of PPDH by DH&HS region are shown in Figure 16. Standardised admission rate ratios are presented with 95 per cent confidence intervals. Grampians region had the highest PPDH rates, while Eastern metropolitan region had the lowest. There was a three-fold variation in PPDH rates between the Grampians and Eastern metropolitan regions. 113 Figure 16 Potentially preventable dental hospitalisations by Department of Health and Human Services region and public and private patients, 2013–14 Source: VHISS 2013-14. The PPDH rates were higher in rural areas in 2013-14 with variations by age groups. The all-age rural rate was 3.3 per 1,000 population, 24 per cent higher than the metropolitan rate of 2.5 (data not shown). Rural rates were 64 per cent higher in 0-4 year olds, 77 per cent higher in 5-9 year olds, and eight per cent higher in 10-19 year olds. Trends in PPDH rates between 2001-02 and 2013-14 also varied by age groups as shown in Figures 17, 18 and 19, and 5.13, and in Table 23. Among 0–4 year olds there was a 59 per cent decrease in rural rates from 2001–02 to 2013–14 (Table 23). Metropolitan rates decreased by 43 per cent between 2001–02 (5.82) and 2013–14. (3.34). The rural to metropolitan ratio decreased from 1:2.3 to 1:1.6. 114 Figure 17 Rate of potentially preventable dental hospitalisations of 0 –4 year olds from 2001–02 to 2013–14 by metropolitan and02 ruralto 2013-14 residence 14 12 10 8 6 4 Rate per 1000 population 1000 per Rate 2 0 2001- 2003- 2004- 2005- 2006- 2007- 2008- 2009- 2010- 2011- 2012- 2013- 02 04 05 06 07 08 09 10 11 12 13 14 Metro 5.82 5.27 5.46 5.31 3.9 3.72 3.76 3.75 4.36 4.16 3.08 3.34 Rural 13.16 12.63 11.58 11.55 9.59 9.43 7.62 7.52 6.86 6.46 5.86 5.41 Source: VHISS 2015. While Victorian PPDH rates in 5-9 year olds were stable over the 13 years to 2013-14 (Figure 18 and Table 23), metropolitan rates increased by eight per cent, while rural rates decreased by seven per cent (Table 23). Figure 18 Rate of potentially preventable dental hospitalisations for 5 –9 year ol ds from 2001–02 to 2013–14 2013-14 16 14 12 10 8 6 4 2 Rates per 1,000 population 0 2001-02 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 M etro 6.03 6.24 6.99 6.36 5.78 6.57 6.71 7.54 7.35 7.02 5.89 6.53 12.44 12.11 12.78 12.43 13.16 13.36 14.48 14.04 12.81 13.18 11.78 11.52 Rural Source: VHISS 2015. 115 Among 10-19 year olds, PPDH rates increased by 63 per cent across Victoria between 2001-02 and 2013-14 (Figure 19 and Table 23). This was from a lower base than for younger children – the PPDH rate for 10-19 year olds was 2.6 per 1,000 population in 2013-14 compared to rates of 7.9 for 5-9 year olds and 3.9 for 0-4 year olds per 1,000 population. The increase in rates for 10-19 year olds was greater in metropolitan regions (86 per cent) than in rural regions (34 per cent). Figure 19 Rate of potentially preventable dental hospitalisations for 10 –19 year olds from 2001–02 to 2013–14 3.5 3 2.5 2 1.5 Rate per 1,000 population 1,000 per Rate 1 0.5 0 200 200 200 200 200 200 200 2010- 2011- 2012- 2013- 3-04 4-05 5-06 6-07 7-08 8-09 9-10 11 12 13 14 M etro 1.58 1.89 1.99 1.92 2.36 2.67 2.3 2.33 2.59 2.35 2.53 Rural 2.16 2.22 2.21 2.19 2.67 2.68 2.86 2.91 3.08 2.73 2.69 Source: VHISS 2015. Table 23 shows the change in rates for each group between 2001-02 and 2013-14. In addition to the changes among 10-19 year olds described above, it also shows that while the total all age PPDH rate for Victoria increased by eight per cent up to 2013-14, there was a 19 per cent increase in metropolitan rates and a decrease of eight per cent in rural rates. 116 Table 23 Rates of potentially preventable dental hospitalisations in Victoria, metropolitan and rural areas in 2013-14 and changes since 2001 Age group Victoria Metropolitan Rural (years) 2013 -14 Change from 2013 -14 Change from 2013 -14 Change from 2001-02 (%) 2001-02 (%) 2001-02 (%) 0-4 3.9 -51 3.3 -43 5.4 -59 5-9 7.9 -1 6.5 +8 11.5 -7 10 -19 2.6 +63 2.5 +86 2.7 +34 0-19 4.2 -13 3.7 +3 5.5 -26 All ages 2.7 +8 2.5 +19 3.3 -8 Source: VHISS 2015. The magnitude of variation in PPDH rates between geographical areas increased with decreasing size of the area. Rural PPDH rates for 0-4 year olds in 2013-14 were 1.6 fold higher than metropolitan rates, with variation between DH&HS regions 2.4 fold, and variation between local government areas 73 18 fold 74 (data not shown). 5.2.10 Aboriginal and Torres Strait Islander people In 2013–14, 196 people who identified as being of Aboriginal and/or Torres Strait Islander origin had a PPDH. Table 24 shows PPDHs by age group and whether people were: of Aboriginal but not Torres Strait Islander origin (160 people); Torres Strait Islander but not Aboriginal origin (7); or both Aboriginal and Torres Strait Islander origin (29). The question on Indigenous status was not able to asked of 30 people and 490 people refused to answer. 73 Victoria has 79 local government areas. 74 In 2013-14, the Surf Coast local government area PPDH rate for 0-4 year olds was 1.0 per 1,000 population compared to the local government area of Ararat’s rate of 17.9 per 1,000 population. 117 Table 24 Potentially preventable dental hospitalisations by Aboriginal and/or Torres Strait Islander origin, 2013–14 ATSI* origin Neither Question Patient Aboriginal plus TSI** Aboriginal unable to refused to Age group origin origin or TSI origin be asked answer Total 0–4 28 5 1,248 3 124 1,408 5–9 62 10 2,358 3 235 2,668 10 –14 7 4 697 2 38 748 15 –19 12 1 920 13 946 20 –24 11 904 1 9 925 25 –29 7 2 605 4 8 626 30 –34 5 3 584 1 8 601 35 –39 4 1 565 2 11 583 40 –44 5 2 755 4 10 776 45 –49 7 784 4 10 805 50 –54 4 1 916 1 6 928 55 –59 5 1 974 3 7 990 60 –64 2 1 835 2 2 842 65 –69 1 782 4 787 70 –74 2 508 510 75 –79 2 381 4 387 80 –84 255 1 256 85+ 1 272 273 Total 160 36 14,343 30 490 15,059 Source: VAED 2013-14. Notes: * ATSI – Aboriginal and Torres Strait Islander, ** TSI – Torres Strait Islander. People with an Aboriginal and/or Torres Strait Islander background comprised 1.4 per cent of patients whose Indigenous status was able to be identified (196 of the 14,539 patients) 75 . This was a doubling of the proportion of 0.7 per cent in 2004-05 (Table 25). Just more than half (52 per cent) of the Aboriginal PPDH admissions in 2013-14 were female (101 of 196 patients). This was the same gender split for non-Aboriginal PPDH admissions. 75 The DH&HS convention in documents is to use the term ‘Aboriginal’ to refer to both Aboriginal and Torres Strait Islander people and in preference to the acronym ‘ATSI’. These conventions will be followed in this thesis except for brevity in Table 24. 118 Table 25 Comparison between characteristics of Aboriginal and non-Aboriginal potentially preventable dental hospitalisations in Victoria, 2004-05 and 2013-14 2004 —05 2004 —05 2013 —14 2013 -14 Aboriginal non Aboriginal Aboriginal non Aboriginal Total PPDHs 99 14,593 196 15,210 Proportion of all PPDHs 0.7% 99.3% 1.4% 98.6% Proportion of PPDHs 0 -9 years old 67% 35% 54% 28% Proportion public hospital patients NA 47% 81% 40% Proportion rural residents 83% 31% 63% 31% Sources: VAED 2004-05 and 2013-14. More than half (54 per cent) of PPDHs of people with an Aboriginal background were 0- 9 years of age in 2013-14, compared to 28 per cent of all PPDHs in non-Aboriginal people that was in this age group. The proportions of younger people in each group decreased over the ten years from 2004-05 (67 to 54 per cent in Aboriginal PPDHs and 35 to 28 per cent in non-Aboriginal PPDHs). Twice as many Aboriginal people were public hospital patients in 2013-14, compared to non-Aboriginal people (81 compared to 40 per cent). Almost two-thirds of Aboriginal people who had PPDHs in 2013-14 lived in rural regions (63 per cent). Non-aboriginal people were half as likely to be rural residents (31 per cent). The proportion of Aboriginal people living rurally decreased from 83 per cent in 2004-05, while the proportion of non- Aboriginal people living rurally remained the same in both years. In 2012-13 76 , people with an Aboriginal background living in Victoria had an 11 per cent higher PPDH rate than non-Aboriginal people (3.0 compared to 2.7 per 1,000 population). As will be presented in Chapter 8, section 8.2, on Victorian and national comparisons, the gap nationally was 25 per cent (ROGS 2015). 76 Most recent data available. 119 5.2.11 Socio-economic status The PPDH rate by socioeconomic status varied markedly by age group. A step-wise social gradient existed for 0–4 year olds in 2013-14, with children living in the most disadvantaged quintile (quintile 1) having the highest rate of PPDHs and those living in the least disadvantaged (quintile 5) having the lowest (Figure 20). Children living in quintile 1 were 2.1 times more likely to have had a PPDH than those in quintile 5. Figure 20 Potentially preventable dental hospitalisation rate ratios for 0 –4 year olds by socioeconomic quintiles (IRSED), 2013–14 Source: VHISS 2013-14. A step-wise social gradient was also evident among 5-9 year olds but was less steep. The ratio between the most and least disadvantaged quintiles was 1.7. Among 10-14 year olds, there were no differences in PPDH rates except for quintile 2 (the second most disadvantaged) which had a higher PPDH rate than any other quintile. Among 15-24 year olds there was a U-shaped distribution of PPDHs with the highest rates in the least disadvantaged area followed by the most disadvantaged areas with the lowest rates in quintile 3 (Figure 21). The rate ratio in quintile 1 was 0.99 (CI 0.88-1.10), 0.66 (0.58-0.75) in quintile 3, and 1.50 (1.37-1.64) in quintile 5. 120 Figure 21 Potentially preventable dental hospitalisation rate ratios for 15 –24 year olds by socioeconomic quintiles (IRSED), 2013–14 Source: VHISS 2013-14. For PPDHs in people aged 25 years and more, the socioeconomic pattern did not show a clear gradient in 2013-14 (Figure 5.16). There was no statistically significant difference between quintiles 1 and 5, however there had been a social gradient in this age group for each year from 2003-04 to 2012-13 (data not shown). The pattern was different from the all PPH rate ratios for this age group in 2013-14 which did show a social gradient (Figure 5.14). The PPH rate ratio in quintile 1 (1.12; 1.11-1.19) was significantly higher than that in quintile 5 (0.82; 0.81-0.83). 121 Figure 22 Potentially preventable dental hospitalisation rate ratios for people aged 25 and over by socioeconomic quintiles (IRSED), 2013–14 Source: VHISS 2013-14 5.2.12 Hospital insurance status The PPDH rate by hospital insurance status and age group is shown in Table 26 and Figure 23. Hospital insurance status is recorded regardless of whether the person elects to be a public or a private patient. More than 50 per cent (53 per cent) of PPDHs were for people recorded as having hospital insurance (7,962 of 15,059). About a third (35 per cent) of people admitted had no hospital insurance (5,212) and insurance status was not known for 12 per cent (1,885). Children under five years had the highest proportion of ‘unknown hospital insurance status’ (29 per cent). Thirty eight per cent did not have hospital insurance, and about a third (32 per cent) did have insurance. Of those in this age group whose insurance status was known, 54 per cent (538 of 1,001) did not have hospital insurance. The age groups between 25–44 years had the lowest proportion of those without insurance (45 per cent). 122 Table 26 Potentially preventable dental hospitalisations by hospital insurance status and age group, 2013–14 Hospital No hospital Status not Age group insurance insurance known Total 0–04 463 538 407 1,408 5–09 1,100 897 671 2,668 10 –14 354 257 137 748 15 –19 615 237 94 946 20 –24 550 276 99 925 25 –29 231 313 82 626 30 –34 260 277 64 601 35 –39 261 260 62 583 40 –44 343 357 76 776 45 –49 439 313 53 805 50 –54 545 339 44 928 55 –59 654 295 41 990 60 –64 570 250 22 842 65 –69 599 173 15 787 70 –74 375 126 9 510 75 –79 273 110 4 387 80 –84 185 70 1 256 85+ 145 124 4 273 7,962 5,212 1,885 15,059 Total (53%) (35%) (12%) (100%) Source: VAED 2013-14. Those aged 15–24 years and 45–84 years who had PPDHs had the highest proportion of hospital insurance – 55 per cent and above. The highest proportion was 65–69 year olds at 76 per cent. The PPDH frequency by hospital insurance status is shown in Figure 23. The peak numbers with hospital insurance were the age groups 5–9, 15–24 and 50–69 year olds, all having above 540 private PPDHs. 123 Figure 23 Potentially preventable dental hospitalisations by hospital insurance status frequency by age group, 2013–14 1200 1000 800 Yes 600 No Not known Frequency 400 200 0 4 -04 -34 -4 -54 -64 0 0 0 10-14 20-24 30 40 50 6 70-74 80-84 Age group Source: VAED 2013-14. Only five per cent (263 of 5,011) of public patients had hospital insurance, 63 per cent (3,167) did not, and insurance status was not known for 32 per cent (1,581). Almost 80 per cent of private patients had hospital insurance (7,679 of 9,844 – 78 per cent), 20 per cent did not (1,867), and for three per cent (298), insurance status was not known. 5.2.13 Country of birth More than 80 per cent (12,346 of 15,059 – 82 per cent) of PPDHs were of people born in Australia or Australia’s External Territories, as shown in Table 27. This proportion increased to 85 per cent when the 498 cases where country of birth was not stated were excluded. Table 27 also shows frequency and proportions by country of birth for under 25 year olds and for those 25 years and older. Patients from 11 countries of birth other than Australia comprised 8.1 per cent of the total PPDHs: England (2.1 per cent); Italy (1.2 per cent); New Zealand (one per cent); and the United Kingdom, India, Germany, Greece, Scotland, South Africa, China and Vietnam all less than one per cent. The remaining 114 countries comprised 6.6 per cent of PPDHs. 124 Table 27 Potentially preventable dental hospitalisations by 12 highest frequency countries of birth and age group, Victoria, 2013–14 Country All ages Under 25 years 25 years and over % of % of country country No. % No. frequency No. frequency 1. Australia* 12,346 82.0 5,961 48 6,385 52 2. England 309 2.1 25 8 284 92 3. Italy 174 1.2 4 2 170 98 4. New Zealand 155 1.0 35 23 120 77 5. United Kingdom** 118 0.8 14 12 104 88 6. India 107 0.7 20 19 87 81 7. Germany 67 0.4 7 10 60 90 8. Greece 60 0.4 1 2 59 98 9. Scotland 59 0.4 2 3 57 97 10. South Africa 57 0.4 13 23 44 77 11. China 57 0.4 12 21 45 79 12. Vietnam 53 0.4 10 19 43 81 Other countries 993 6.6 241 24 752 76 No data*** 504 3.3 350 69 154 31 100% of 44% of 56% of Total 15,059 6,695 8,364 total total total Notes: * Includes External Territories. ** United Kingdom, Channels Islands and Isle of Man. *** Includes not stated (498), Inadequately described (2), and Not elsewhere classified (4). Source: VAED 2013-14. The proportion of PPDHs by age varied by country of birth. People born in Australia were more likely to be under 25 years of age than people born in any other country. Almost half (48 per cent) of PPDHs among Australian-born people were under 25 years, compared to a quarter (27 per cent) of people not born in Australia. No other country in the top 12 for PPDH frequency had more than 23 per cent of PPDHs in under 25-year olds. Countries of birth with the highest proportion of PPDHs among those 25 years and older were: England (284 of 309, 92 per cent); Italy (170 of 174, 98 per cent); the United Kingdom (104 of 118, 88 per cent); India (87 of 107, 81 per cent); Germany (60 of 67, 90 125 per cent); Greece (59 of 60, 98 per cent); Scotland (57 of 59, 97 per cent); and Vietnam (43 of 53, 81 per cent). The 12 countries of birth with the highest frequency of PPDHs among young people are listed in Table 28. Five countries are included that were not in the top 12 total PPDH list in Table 27. The frequency and proportion of PPDHs for patients under 25 years from these countries were: Iran (21 PPDH and 91 per cent); Malaysia (19 and 38 per cent); the Philippines (16 and 44 per cent); Burma (14 and 88 per cent); and Thailand (12 and 71 per cent). No other country apart from Australia had more than eight PPDHs among 0–4 year olds. Table 28 Potentially preventable dental hospitalisations of under 25 year olds by 12 highest frequency country of birth and age group, Victoria, 2013–14 Under 25 Under 25 years Total years Country No. No. % 1. Australia* 5,961 12,346 48 2. New Zealand 35 155 23 3. England 25 309 8 4. Iran 21 23 91 5. India 20 107 19 6. Malaysia 19 50 38 7. Philippines 16 36 44 8. United Kingdom** 14 118 12 9. Burma 14 16 88 10. South Africa 13 57 22 11. China 12 54 21 12. Thailand 12 17 71 Other countries ??? ??? ??? No data*** 591 9 Total 6,695 44 * Includes External Territories. **United Kingdom, Channels Islands and Isle of Man. *** Includes not stated, inadequately described, and not elsewhere classified. Source: VAED 2013-14. The proportion of patients who had PPDHs who were born in Australia varied from 91 per cent among 10–24 year olds to 60 per cent in the 80–84 age group. 126 5.3 Multivariate analysis, 2008–09 and 2012–13 5.3.1 Descriptive statistics Descriptive statistics of 0–4 year olds admitted for PPDHs by postcode in 2008–09 and 2012–13 are shown in Table 29. 127 Table 29 Descriptive statistics of 0 –4 year olds admitted for potentially preventable dental hospitalisations by postcode in Victoria in 2008–09 and 2012–13 2008–09 2012–13 Postcodes PPDHs Weighted Postcodes PPDHs Weighted n=371 n=1,607 PPDH rate n=344 n = 1,297 PPDH rate No. (%) No. (%) per 1,000* No. (%) No. (%) per 1,000** Independent Not 95% CIs Not 95% CIs variables weighted weighted Remoteness Major cities 3.41 3.11 193 (52.0) 987 (61.4) (3.19, 3.62) 185 (53.8) 836 (64.5) (2.90, 3.21) Inner regional 6.89 5.56 125 (33.7) 467 (29.1) (6.27, 7.52) 117 (34.0) 353 (27.2) (4.98, 6.14) Outer regional*** 11.27 9.18 53 (14.3) 153 (9.5) (9.48, 13.05) 42 (12.2) 108 (8.3) (7.44, 10.91) Access to oral health professionals **** Lowest access 5.91 6.42 142 (38.3) 388 (24.1) (5.32, 6.50) 113 (32.8) 252 (19.4) (5.62, 7.21) Medium access 3.96 3.55 104 (28.0) 597 (37.1) (3.64, 4.28) 114 (33.1) 602 (46.4) (3.27, 3.84) Highest access 4.03 3.28 125 (33.7) 622 (38.7) (3.71, 4.34) 117 (34.0) 443 (34.2) (3.97, 3.58) Fluoridation status Fluoridated 3.51 3.23 199 (53.6) 996 (62.0) (3.30, 3.73) 210 (61.0) 907 (69.9) (3.02, 3.44) Not fluoridated 7.00 6.20 172 (46.4) 611 (38.0) (6.42, 7.53) 134 (39.0) 390 (30.1) (5.59, 6.82) Socioeconomic status Q1 (most 7.37 5.91 disadvantaged) 50 (13.5) 401 (25.0) (6.65, 8.10) 51 (14.8) 302 (23.3) (5.25, 6.58) Q2 5.90 4.28 69 (18.6) 276 (17.2) (5.20, 6.60) 61 (17.7) 227 (17.5) (3.72, 4.83) Q3 4.64 4.02 69 (18.6) 329 (20.5) (4.14, 5.14) 53 (15.4) 242 (18.7) (3.52, 4.53) Q4 3.44 2.95 85 (22.9) 336 (20.9) (3.07, 3.81) 88 (22.6) 281 (21.7) (2.61, 3.30) Q5 (most 2.62 2.90 advantaged) 98 (26.4) 265 (16.5) (2.30, 2.93) 91 (26.5) 245 (18.9) (2.54, 3.26) Notes: * Unweighted PPDH rate for 2008–09 was 5.14 per 1,000 children 0–4 years of age (PPDH total of 1,607 with a population of 312,524). ** Unweighted PPDH rate for 2011–13 was 4.07 per 1,000 children 0–4 years of age (PPDH total of 1,297 with a population of 318,997). *** Includes three postcodes in 2008–09 and one postcode in 2012–13 that were classified as ‘rem ote’. **** Tertile scale: lowest access <2 registered oral health professionals per 1,000 population; medium access 2 – <7.4: highest access = and >7.4. 128 In 2008–09 there were 1,607 PPDH among 0–4 year olds in Victoria. These children lived in 371 postcodes where there were 312,524 children in this age group. The unweighted PPDH rate was 5.14 per 1,000 children. In 2012–13 the number of PPDHs decreased to 1,297 in 344 postcodes. The number of 0–4 year olds living in these postcodes was 318,997, giving an unweighted PPDH rate of 4.07 per 1,000 children. This was a 21 per cent decrease from 2008–09 (p<0.0001). While most children with PPDH admissions lived in major cities (61.4 per cent in 2008– 09 and 64.5 per cent in 2012–13), rates of PPDH increased with increasing remoteness because of the smaller populations in inner and outer regional areas. The PPDH rates were 3.41 per 1,000 population in major cities compared to 11.27 in outer regional areas in 2008–09, and 3.11 and 9.18 respectively in 2012–13. The only statistically significant difference between the two years in the PPDH rate by remoteness was for inner regional areas where the rate decreased from 6.89 to 5.56 per 1,000 population. Postcodes with the lowest level of access to oral health professionals had the highest PPDH rates. Rates were 5.91 and 6.42 in 2008–09 and 2012–13, respectively, in these postcodes which had the lowest level of access, compared to 3.96 and 3.55 in postcodes with medium level of access, and 4.03 and 3.28 in postcodes with the highest level of access to oral health professionals. Just over half (53.6 per cent) of the postcodes were fluoridated in 2008–09, (199 of 371). There were 11 more fluoridated postcodes in 2012–13, when the proportion of fluoridated postcodes reached 61 per cent (210 of 344). Between 2008–09 and 2012–13, the number of postcodes with any PPDHs decreased from 371 to 344. Children living in fluoridated postcodes had statistically significantly lower PPDH rates than children living in non- fluoridated postcodes – 50 per cent less in 2008–09 (3.51 compared to 7.00), and 48 per cent less in 2012–13 (3.23 compared to 6.20). Non-fluoridated postcodes had smaller populations than fluoridated postcodes in both years. In 2008-09, the populations of 0–4 year olds ranged between five and 3,495 129 children in non-fluoridated postcodes, and between five to 6,872 children in fluoridated postcodes. Non-fluoridated postcodes were predominantly in rural areas where population density is lower than in the major cities. In both 2008–09 and 2012–13, there was a sharp social gradient in PPDH rates. Rates decreased with increasing socioeconomic status – from 7.37 and 5.91 in the most disadvantaged quintile (Q1) to 2.62 and 2.90 in the most advantaged quintile (Q5) for the two years. 5.3.2 Bivariate analysis The unadjusted (crude) IRRs for the four variables were determined by bivariate Poisson analysis . As shown in the first columns of Tables 30 and 31, children living in outer regional postcodes had over three times (IRR 3.31, p<0.0001) the PPDH rate of children living in metropolitan postcodes in 2008–09, and 2.95 times (IRR 2.95, p<0.0001) in 2012–13. The rate for children living in inner regional areas was double (IRR 2.02, p<0.0001) the metropolitan rate in 2008–09, and 1.79 times (IRR 1.79, p<0.0001) in 2013–14. Greater concentration of oral health professionals was associated with lower PPDH rates in both years, but was only statistically significant in those postcodes which had the higher rate of access (equal to or more than 7.4 oral health professionals per 1,000 population). In 2008-09, postcodes with the lowest access had 47 per cent higher rates of PPDHs (IRR 1.47, p<0.0001) than postcodes with the highest concentration of oral health professionals. The difference in 2012-13 was almost double (IRR 1.96, p<0.0001). Children living in non-fluoridated postcodes had almost twice the rates of PPDH compared to children in fluoridated postcodes – IRR 1.98, p<0.000 in 2008–09 in 2008- 09, and IRR 1.92, p<0.0001 in 2012–13. 130 The IRR values show a clear socioeconomic gradient in PPDH rates in both years. In 2008–09, children living in the most disadvantaged postcodes (Q1) had almost three times (IRR 2.82, p<0.0001) the PPDH rate of children living in the most advantaged postcodes (Q5). The gradient was not as steep in 2012–13, with rates in quintile 1 twice (IRR 2.04, p<0.0001) as high as in quintile 5. Quintiles 1 to 4 each had statistically significantly higher PPDH rates than quintile 5 in 2008–09. In 2012–13, the rate for quintile 4 was not statistically significantly different from that for quintile 5 (IRR 1.02, p<0.837). Table 30 . Poisson regression between potentially preventable dental hospitalisations and remoteness, access to oral health professionals, access to community water fluoridation, and socioeconomic status for 0–4 year old children by postcode, Victoria, 2008–09a Unadjusted Adjusted Model 1 Model 2 Model 3 Pseudo R 2 0.21 0.18 0.18 Chi 2 p<0.0001 p<0.0001 p<0.0001 Variables IRR IRR IRR IRR p 95% CIs p 95% CIs p 95% CIs p 95% CIs Remoteness Major cities 1.00 1.00 Inner regional 2.02**** (1.81, 2.56) 1.55**** (1.33, 1.80) Outer regional 3.31**** (2.79, 3.92) 2.38**** (1.90, 3.00) Access to oral health professionals (rate:1,000) a Lowest access 1.47**** (1.29, 1.67) 1.21** (1.06, 1.38) 1.20** (1.05, 1.36) Medium access 0.98 (0.88, 1.00) 0.95 0.92 (0.82, 1.04) Highest access 1.00 1.00 1.00 Access to fluoridation (0.85, 1.07) Yes 1.00 1.00 1.00 1.00 No 1.98**** (1.79, 2.19) 1.20* (1.04, 1.40) 1.72**** (1.54, 1.91) 1.78**** (1.60, 1.97) Socioeconomic status Q1 (most disadvantaged) 2.82**** (2.41, 3.29) 2.36*** (2.01, 2.77) 2.53**** (2.16, 2.97) 2.52**** (2.15, 2.95) Q2 2.26**** (1.91, 2.67) 1.45*** (1.21, 1.75) 1.77**** (1.48, 2.10) 1.78**** (1.49, 2.12) Q3 1.77**** (1.51, 2.08) 1.42*** (1.19, 1.68) 1.50**** (1.27, 1.78) 1.48**** (1.25, 1.74) Q4 1.32** (1.12, 1.55) 1.20* (1.01, 1.41) 1.19* (1.01, 1.41) 1.19* (1.00, 1.40) Q5 (least disadvantaged) 1.00 1.00 1.00 1.00 Notes: * p<0.05, **p<0.01, ***p<0.001, **** p<0.0001. a Tertile scale as per Table 5.22. 131 Table 31 Poisson regression between potentially preventable dental hospitalisations and remoteness, access to oral health professionals, access to community water fluoridation, and socioeconomic status for 0–4 year old children by postcode, Victoria, 2012–13 Unadjusted Adjusted Model 1 Model 2 Model 3 Pseudo R 2 0.13 0.12 0.10 Chi 2 p<0.0001 p<0.0001 p<0.0001 IRR IRR IRR IRR Variables p 95% CIs p 5% CIs p 95% CIs p 95% CIs Remoteness Major cities 1.00 1.00 Inner regional 1.79**** (1.58, 2.02) 1.32** (1.13, 1.55) Outer regional 2.95**** (2.41, 3.60) 1.83**** (1.43, 2.34) Access to oral health professionals (rate:1,000) a Lowest access 1.96**** (1.68, 2.29) 1.41**** (1.90, 1.66) 1.47**** (1.24, 1.74) Medium access 1.08 (0.96, 1.23) 1.03 (0.90, 1.17) 1.00 (0.88, 1.14) Highest access 1.00 1.00 1.00 Access to fluoridation Yes 1.00 1.00 1.00 1.00 No 1.92**** (1.71, 2.17) 1.28** (1.09, 1.51) 1.59**** (1.40, 1.81) 1.75**** (1.55, 1.97) Socioeconomic status Q1 (most disadvantaged) 2.04**** (1.72, 2.42) 1.57*** (1.31, 1.87) 1.70**** (1.43, 2.03) 1.75**** (1.47, 2.08) Q2 1.48**** (1.23, 1.77) 1.16 (0.96, 1.41) 1.28* (1.06, 1.53) 1.37** (1.14, 1.64) Q3 1.39**** (1.16, 1.66) 1.18 (0.98, 1.42) 1.23* (1.03, 1.48) 1.22* (1.02, 1.47) Q4 1.02 (0.86, 1.21) 0.95 (0.79, 1.23) 0.95 (0.80, 1.30) 0.96* (0.81, 1.14) Q5 (least disadvantaged) 1.00 1.00 1.00 1.00 Notes: * p<0.05, **p<0.01, ***p<0.001, **** p<0.0001. a Tertile scale as per Table 5.2. 5.3.3 Multivariate analysis Model 1 Poisson multivariate analysis determined that the four variables remained statistically significantly associated with PPDH rates for both years after controlling for each of the other variables, as shown in Model 1 in Tables 30 and 31. This model explained 21 per cent of the variance in 2008–09 and 13 per cent in 2012–13, as indicated by the Pseudo R2 values with chi 2 p<0.0001 for both years. 132 Children living in postcodes in outer regional areas were over two (IRR 2.38, p<0.0001) and almost two (IRR 1.83, p<0.001) times more likely to have had a PPDH compared to children living in major cities in 2008–09 and 2012–13 respectively. Residence in inner regional areas was associated with 55 per cent (1.55, p<0.0001) and thirty two per cent (1.32, p<0.001) higher PPDH rates in the two years. Living in postcodes with the lowest level of access to oral health professionals increased the PPDH rate by 21 per cent (IRR 1.21, p<0.004) and 41 per cent (IRR 1.44, p<0.0001) in the two years. Children living in non-fluoridated postcodes had 20 per cent (IRR 1.20, p<0.015) and 28 per cent (IRR 1.28, p<0.002) higher rates of PPDH in 2008–09 and 2012–13 than children living in fluoridated postcodes. The largest difference between the unadjusted and adjusted IRRs were in socioeconomic status quintiles in 2012–13. While Q1 to Q4 remained statistically significantly associated with PPDH rates in 2008–09, only Q1 was significantly associated with PPDH rates in 2012–13, (IRR 1.57, p<0.0001). Model 2 Remoteness was excluded in Model 2 because it is in effect a proxy for the other three variables. The greater the geographic remoteness, the less access there is to both oral health professionals and community water fluoridation, and the lower the socioeconomic status. The three variables remained statistically significantly associated with PPDH rates when remoteness was removed. Model 2 explained 18 per cent of the variance in PPDH rates in 2008–09, and 10 per cent in 2012–13 (chi 2 p<0.0001 for both years). Under Model 2, children living in postcodes with limited access to oral health professionals had 20 per cent (IRR 1.20, p<0.007) and 47 per cent (IRR 1.47, p<0.0001) higher PPDH rates in 2008–09 and 2012–13 respectively. These are similar rates for the access variable in Model 1. Residence in non-fluoridated postcodes remained highly statistically significantly associated with higher PPDH rates in both years. Children living in postcodes without community water fluoridation had 72 per cent (IRR 1.72, p<0.0001) and 59 per cent (IRR 133 1.59, p<0.0001) higher PPDH rates than their counterparts in fluoridated postcodes after controlling for access to oral health professionals and socioeconomic status in the two studied years. These differences equate to 42 and 37 per cent lower PPDH rates in fluoridated compared to non-fluoridated postcodes in 2009–09 and 2012–13 after adjusting for access to oral health professionals and socioeconomic status. PPDH rates were significantly associated with socioeconomic status Q1 to Q4 in 2008– 09 and Q1 to Q3 in 2012–13. Children living in the most disadvantaged postcodes were 2.53 and 1.7 times more likely to have had a PPDH than children in the most advantaged postcodes in the two years (IRR 2.53, p<0.0001 and IRR 1.70, p<0.0001). Model 3 The last model generated, Model 3, included access to community water fluoridation and socioeconomic status to examine the relationship between these two variables and PPDH rates. Model 3 explained 18 per cent of the variance in PPDH rates in 2008–09 and 10 per cent in 2012–13 (chi 2 p<0.0001 for both years). As in Model 2, residence in non-fluoridated postcodes remained statistically significantly associated with higher PPDH rates in both years. Children living in postcodes without community water fluoridation had 78 per cent (IRR 1.78, p<0.0001) and 75 per cent (IRR 1.75, p<0.0001) higher PPDH rates than their counterparts in fluoridated postcodes after controlling for socioeconomic status. This equates to 44 and 43 per cent lower PPDH rates in fluoridated postcodes. Socioeconomic Q1 to Q4 remained significantly associated with PPDH rates in 2008–09, as did Q1 to Q3 in 2012–13. PPDH rates by access to community water fluoridation and socioeconomic status were mapped for 2008–09 and 2012–13, as shown in Figures 24 and 25. An interaction term (access to fluoridation by socioeconomic status) was added to investigate whether the effect of access to fluoridation was similar in each socioeconomic category. 134 Figure 24 Rate of potentially preventable dental hospitalisations by access to community water fluoridation and socioeconomic status, 0–4 year olds, by postcode, Victoria, 2008–09 Rate per 1,000population per Rate Q1 Q2 Q3 Q4 Q5 Fluoridated 6.22 3.89 3.59 3.14 2.48 Non fluoridated 11.07 8.47 6.61 4.49 4.32 Note: Q1 to Q5 are IRSED quintiles. Source: VAED 2013-14 Figure 25 Rate of potentially preventable dental hospitalisations by access to community water fluoridation and socioeconomic status, 0–4 year olds, by postcode, Victoria, 2012-13 R a t e p p e o r p 1 , 0 0 0 Q1 Q2 Q3 Q4 Q5 Fluoridated 5.11 3.45 3.6 2.6 2.68 Non fluoridated 7.71 7.9 5.22 4.78 5.66 Source: VAED 2013-14 135 The higher PPDH rates in postcodes that were non fluoridated and most disadvantaged are evident in Figures 24 and 25. The social gradient in PPDH rates between the most disadvantage quintile (Q1) and the most advantaged (Q5) for a fluoridated and non- fluoridated postcode is clear. It was more marked in 2008–09, with stepwise lower rates with increasing socioeconomic status in both fluoridated and non-fluoridated postcodes. In 2012–13 PPDH rates were highest in the more disadvantaged Q1 and Q2 and lowest in the most advantaged Q4 and Q5. Between 2008–09 and 2012–13, the PPDH rates in fluoridated and non-fluoridated postcodes decreased in all quintiles except in Q5, and in non-fluoridated Q4 postcodes, but this was not statistically significant. In 2008–09, children living in the most disadvantaged and non-fluoridated postcodes had 4.5 times the rate of PPDH than children living in the most advantaged and fluoridated postcodes (11.07 compared to 2.48 per 1,000). With the relative increase in PPDH rates in Q5 in 2012–13, the ratio between non-fluoridated Q1 and fluoridated Q5 rates was 2.9 (7.71 compared to 2.68 per 1,000). As presented earlier under the section on descriptive statistics, overall, children living in fluoridated postcodes had 50 and 48 per cent lower PPDH rates in 2008–09 and 2012–13, respectively. 136 Chapter 6 Results 2 - Distribution and determinants of dental hospitalisation – Analysis of the 2009 Victorian Child Health and Welfare Study (VCHWS) 6.1 Overview ...... 137 6.2 Descriptive statistics ...... 138 6.3 Bivariate statistics ...... 141 6.4 Multivariate modelling ...... 150 6.1 Overview In this chapter, results of the analysis of the 2009 Victorian Child Health and Welfare Study (VCHWS) will be presented. Descriptive statistics comparing child and family factors between children who have experienced a dental hospitalisation and those who have not will be outlined. Bivariate and multivariate poisson regression analyses that indicate the strength of association between these factors and dental hospitalisation rates will then be presented. The VCHWS involved computer assisted telephone interviews with parents on behalf of 5,025 randomly selected Victorian children aged under 13 years. The interviews took place between February and May 2009. A response rate of 75 per cent was achieved. The question for determining factors associated with dental hospitalisation under general anaesthesia was ‘Has the child ever had any dental treatment in hospital under general anaesthetic?’ Children under one year of age were excluded from the analysis because few teeth have erupted by that age. The parents of the remaining 4,624 children were asked if their child had teeth and if they had ever been to a dentist. A total of 3,464 children were in this group. Their parents were then asked if their child had ever had any dental treatment in hospital under general anaesthetic. In total, 250 children were reported 137 to have experienced a dental hospitalisation with 3,214 children not having had a dental hospitalisation. 6.2 Descriptive statistics A summary profile of the 3,214 children who have not had a dental hospitalisation compared to the 250 children who have had a dental hospitalisation, is provided in Table 32. Numbers and weighted frequencies are shown. The data are weighted as explained in the analysis of data in section 4.5.2. There were 21 child and family factors studied. Definitions for each of the factors are detailed in section 4.3.2.1. Confidence intervals are included in the table and statistically significant differences between the two groups are highlighted in bold type. Table 32 Summary profile of participants (children aged 1 to 12 years) in the 2009 Victorian Child Health and Welfare Survey – child and family factors for children who have not had , and had, a dental hospitalisation Children who have not had a dental Children with have had a dental hospitalisation hospitalisation Factors n = 3,214 n = 250 Weighted frequency (%) Weighted frequency (%) n (95% CI) n (95% CI) Child factors Gender Male 1,544 50.60 (48,52, 52.67) 141 55.33 (47.76, 62.65) Female 1,670 49.40 (47.33, 51.48) 109 44.67 (37.35, 52.24) Age 1–4 years 425 13.54 (12.19, 15.02) 10 3.48 * (1.70, 6.98) 5–8 years 1,184 39.70 (37.69, 41.75) 101 39.78 (32.82, 47.17) 9–12 years 1,605 46.76 (44.69, 48.83) 139 56.74 (49.31, 63.88) Cultural background Aboriginal or Torres Strait Islander background Yes 43 1.22 (0.84, 1.76) 5 2.18 (0.67, 6.81) No 3,171 98.78 (98.24, 99.16) 245 97.82 (93.19, 99.33) Country of birth Australia 3,022 93.50 (92.39, 94.46) 234 92.69 (87.68, 95.76) Not in Australia 192 6.50 (5.54, 7.61) 16 7.31 (4.24, 12.32) Oral health Ever had a toothache Yes 915 18.8 (17.6, 20.4) 167 65.18 (57.75, 71.93) No 2,229 81.0 (79.7 –82.4) 83 34.82 (28.07, 42.25) 138 Ever had a tooth extracted Yes 414 11.03 (9.84, 12.35) 137 52.13 (44.65, 59.51) No 2,800 88.97 (87.65, 90.16) 113 47.87 (40.49, 55.35) Needs and behaviour Child needs or uses more services Yes 383 11.10 (9.87, 12.47) 59 19.91 (14.81,26.23) No 2,831 88.90 (93.61, 95.44) 191 80.09 (73.77, 85.19) Functional limitation shown for 12 months or more Yes 186 5.40 (4.56, 6.39) 31 11.23 (7.29, 16.93) No 3028 94.60 (93.61, 95.44) 219 88.77 (83.07, 92.71) Child has behavioural difficulties Yes 322 9.61 (8.44, 10.93) 47 17.60 (12.69, 23.90) No 2,892 90.39 (89.07, 91.56) 203 82.40 (76.10, 87.31) Family factors Rurality Metropolitan Melbourne 1,598 70.82 (69.89, 71.73) 97 60.94 (54.29, 67.22) Rural 1,614 29.18 (28.27, 30.11) 153 39.06 (32.78, 45.71) Socioeconomic status Card holder status Yes 918 26.75 (24.96, 28.61) 98 37.44 (30.51, 44.93) No 2,296 73.25 (71.39, 75.04) 152 62.56 (55.07, 69.49) Private health insurance status Yes 1,710 56.54 (54.50, 58.57) 111 48.42 (41.03, 55.89) No 1,504 43.46 (41.43, 45.50) 139 51.58 (44.11, 58.97) IRSED quintile 1 (most disadvantaged) 601 15.18 (13.83, 16.62) 59 21.12 (15.63, 27.91) 2 656 16.41 (15.04, 17.88) 70 22.90 (17.69, 29.10) 3 550 17.02 (15.51, 18.64) 43 18.45 (13.19, 25.19) 4 711 23.80 (22.05, 25.63) 43 16.93 (12.26, 22.93) 5 (most advantaged) 682 27.60 (25.76, 29.52) 35 20.60 (14.72, 28.06) Respondent parent’s education Some high school 666 18.01 (16.52, 19.60) 71 23.57 (18.02, 30.20) High school 558 17.40 (15.88, 19.02) 49 19.31 (14.21, 25.68) TAFE, trade or diploma 805 24.07(22.36, 25.88) 60 25.10 (19.16, 32.14) University 1,177 40.52 (38.49, 42.58) 70 32.03 (25.28, 39.62) Household income 1 Less than $20,000 228 6.82 (5.83, 7.97) 29 14.05 (9.21, 20.86) $20,000 – < $40,000 376 12.32 (10.94, 13.83) 38 14.84 (10.29, 20.93) $40,000 – < $60,000 476 14.97 (13.53, 16.54) 38 15.44 (10.72, 21.74) $60,000 – < $80,000 559 18.53 (16.91, 20.26) 36 14.55 (10.05, 20.59) $80,000 – < $100,000 490 17.13(15.56, 18.83) 39 16.42 (11.44, 23.00) $100,000 – < $120,000 334 11.32 (10.04, 12.73) 22 9.60 (6.15, 14.69) $120,000 and over 477 18.91 (17.23, 20.72) 26 15.11 (10.01, 22.17) Household income 2 Less than $40,000 604 17.44 (15.92, 19.07 67 26.02 (20.00, 33.10) $40,000 and above 2,610 82.56 (80.93, 84.08) 183 73.98 (66.90, 80.00) 139 Family ran out of food in last 12 months Yes 178 4.87 (4.08, 5.79) 27 10.79 (7.04, 16.21) No 3,036 95.31 (94.21, 95.92) 223 89.21 (83.79, 92.96) Family health Family functioning Poor 240 6.53 (5.62, 7.59) 24 8.12 (5.01, 12.89) Healthy 2,974 93.47 (92.41, 94.38) 226 91.88 (87.11, 94.99) Perceived poor access to basic health care Yes 310 7.56 (6.62, 8.62) 26 7.97 (5.01, 8.62) No 2,904 92.44 (91.38, 93.38) 224 92.03 (87.56, 94.99) Cultural background Country of birth of mother Australia 3,022 93.5 (92.39, 94.46) 234 92.69 (87.68, 95.76) Not in Australia 192 6.5 (5.54, 7.61) 16 7.31 (4.24, 12.32) Language spoken at home English 2,776 85.53 (81.85, 85.09) 216 80.40 (72.74, 86.32) Language/s other than English 438 16.47 (13.68, 27.26) 34 19.6 (14.91, 18.15) Source: VCHWS 2009 *Values in bold indicate statistically significant difference between the two groups (p<0.05). There was a relatively even split of girls and boys in the group that had not experienced a dental hospitalisation. While there was a trend for a higher proportion of boys in the dental hospitalisation group, the gender differences were not statistically significant. A higher proportion of children aged 9-12 years was in the dental hospitalisation group. An increase in dental hospitalisation rates by age was expected as the survey question was whether the child had ever had a dental hospitalisation. It was not possible to identify the age at which a child had been hospitalised. There were statistically significant differences between the no dental hospitalisation group and the dental hospitalisation group for 12 of the 21 child and family factors. The greatest difference between the groups related to dental treatment needs. Children who had been hospitalised for dental reasons were 3.5 times more likely to have had a toothache and almost five times more likely to have had a tooth extracted 77 . The dental 77 The close association is expected as tooth extraction may be related to the treatment in hospital, and toothache-related to the need for the dental hospitalisation. 140 hospitalisation group was more likely to come from rural Victoria, not Melbourne. This group was were also more likely to need or use more services than other children their age; had shown functional limitations for 12 months or more; and were more likely to have had behavioural difficulties. Several socioeconomic factors differed between the two groups. Children in the dental hospitalisation group were more likely to come from families with a concession card holder; where annual household earnings were less than $40,000; and where the family had run out of food in the last 12 months. There was a higher proportion of parents with only high school education, and a lower proportion of parents with a university education, in the dental hospitalisation group compared to the non hospitalisation group. However, the differences were not statistically significant at the p<0.05 level. Similarly there were non-statistically significant higher proportions of families living in disadvantage SEIFA quintiles in the hospitalisation group. Other factors for which there was no difference between the groups were: Aboriginal background; family’s health insurance status; family functioning; perceived access to basic health care services; country of birth of the child; country of birth of the mother; and language spoken at home. 6.3 Bivariate statistics Poisson regression incidence rate ratios (IRR) were calculated to identify associations between child and family factors and dental hospitalisation. Both unadjusted (bivariate) and adjusted (multivariate) IRR were determined (Table 33). The multivariate analysis was adjusted for all the other factors found significant in the first analysis. Confidence intervals and p values are included in the table. 141 Table 33 Dental ho spitalisation unadjusted (bivariate) and adjusted (multivariate) Poisson regression Adjusted IRR Unadjusted IRR (adjusting for all factors) IRR (95% CI) p IRR (95% CI) p Child factors Gender Male 1.28 (0.94, 1.73) 0.114 1.32* (0.99, 1.76) 0.056* Female 1.00 1.00 Oral health Ever had a toothache Yes 5.51 (4.00, 759) 0.0001 2.55 (1.70, 3.82) 0.0001 No 1.00 1.00 Ever had a tooth extracted Yes 9.61 (7.11, 12.99) 0.0001 5.57 (3.85, 8.06) 0.0001 No 1.00 1.00 Needs and behaviour Child needs or uses more services Yes 2.02 (1.38, 2.96) 0.0001 1.55* (1.00, 2.42) 0.051* No 1.00 1.00 Functional limitation shown for 12 months or more Yes 2.37 (1.49, 3.76) 0.0001 1.41 (0.80, 2.49) 0.237 No 1.00 1.00 Child has behavioural difficulties Yes 1.93 (1.27, 2.93) 0.002 1.02 (0.66, 1.57) 0.934 No 1.00 1.00 Family factors Rurality Metropolitan Melbourne 1.00 1.00 Rural 3.76 (2.86, 4.95) 0.0001 2.55 (1.87, 3.48) 0.0001 Socioeconomic status Card holder status Yes 1.67 (1.22, 2.28) 0.002 1.00 (0.66, 1.53) 0.988 No 1.00 1.00 Socioeconomic status by 1RSD quintile 1 (most disadvantaged) 2.40 (1.47, 3.92) 0.0001 1.15 (0.71, 1.81) 0.571 2 2.43 (1.52, 3.84) 0.0001 1.08 (0.66, 1.76) 0.758 3 1.63* (0.97, 2.71) 0.063* 0.98 (0.58, 1.66) 0.945 4 1.03 (0.62, 1.71) 0.901 0.79 (0.48, 1.32) 0.364 5 (most advantaged) 1.00 1.00 Respondent parent’s education Some high school 1.92 (1.28, 2.88) 0.002 1.13 (0.80, 1.87) 0.354 High school 1.50* (0.98, 2.32) 0.064* 1.14 (0.72, 1.79) 0.576 TAFE, trade or diploma 1.44* (0.95, 2.16) 0.083* 1.09 (0.71, 1.67) 0.691 University 1.00 1.00 142 Household income Less than $40,000 1.67 (1.18, 2.36) 0.004 0.97 (0.61, 1.54) 0.611 $40,000 and above 1.00 1.00 Family ran out of food in last 12 months Yes 2.61 (1.60, 4.24) 0.0001 1.22 (0.80, 1.87) 0.354 No 1.00 1.00 Family health Family functioning Poor 1.39 (0.82, 2.34) 0.217 1.57* (0.94, 2.60) 0.082* Healthy 1.00 1.00 Perceived poor access to basic health care Yes 1.30 (0.79, 2.16) 0.307 0.91 (0.54, 1.53) 0.711 No 1.00 1.00 Cultural background Language spoken at home English 1.00 1.00 Language/s other than English 1.04 (0.68, 1.59) 0.854 1.23 (0.77, 1.96) 0.383 Note: Values in bold are statistically significantly different at the level p <0.05 to their reference value (1.00); values with an * are different from their reference value (1.00) at the level p <0.10. The bivariate analysis determined statistically significant associations (at the level p<0.05) between dental hospitalisation and 11 of the 15 factors. Multivariate analysis found three factors to be significant at p<0.05, and a further three factors that were associated with dental hospitalisation at the level p<0.10. In descending order of unadjusted IRR, significant factors were: child ever had a tooth extracted (IRR 9.61, p<0.0001); child ever had toothache (IRR 5.51, p<0.0001); rural residence (IRR 3.76, p<0.0001); family ran out of food in the last 12 months (IRR 2.61, p<0.0001); living in the two most disadvantaged SEIFA quintiles (2.40 in quintile 5 and 2.43 in quintile 4); child had shown functional limitations for 12 months or more (IRR 2.37, p<0.0001); child needs or uses more services than other children their age (IRR 2.02, p<0.0001); child has behavioural difficulties (IRR 1.93, p<0.002); parent did not complete high school (IRR 1.92, p<0.002); parent has a concession card (IRR 1.67, p<0.002); and family income less than $40,000 (IRR 1.67, p<0.004). Factors that were significant at the p<0.05 level by adjusted IRR were: child ever had a tooth extracted (IRR 5.57, p<0.0001); child ever had toothache (2.55, p<0.0001); and 143 rural residence (2.55, p<0.0001). Those that were significant at the p<0.01 level were: poor family functioning (1.57, p<0.082); child needs or uses more services than other children their age (1.55, p<0.051); and male (1.32, p<0.056). Four factors were found not to be significant at the level p<0.10 after bivariate analysis – being male, family functioning, perceived access to basic health care, and language spoken at home. However, the first two factors were significant at p<0.10 after multivariate analysis. The associations between factors and dental hospitalisation were examined by age to account for life stage related differences. The age groups 1–8 years and 9–12 years were used to examine associations for younger and older children. This split of age groups created almost equal-sized groups – 1,609 and 1,605 children, respectively. Unadjusted and adjusted IRR for these age groups are presented in Tables 6.3 and 6.4. 144 Table 34 Poisson regression incident rate ratios (IRR) and 95 per cent confidence intervals for dental hospitalisation of 1–8 year olds unadjusted IRR and adjusted IRR Adjusted IRR Unadjusted IRR (adjusting for all factors) IRR (95% CI) p IRR (95% CI) p Child factors Gender Male 1.09 (0.71, 1.69) 0.693 1.03 (0.66, 1.62) 0.891 Female 1.00 1.00 Oral health Ever had a toothache Yes 8.67 (5.48, 13.74) 0.0001 3.48 (1.87, 6.50) 0.0001 No 1.00 1.000 Ever had a tooth extracted Yes 13.62 (8.76, 21.16) 0.0001 5.03 (2.50, 10.15) 0.0001 No 1.00 1.00 Needs and behaviour Child needs or uses more services Yes 2.75 (1.64, 4.62) 0.001 2.17 (1.10, 4.29) 0.026 No 1.00 1.00 Functional limitation shown for 12 months or more Yes 2.74 (1.38, 5.45) 0.004 1.29 (0.55, 3.06) 0.559 No 1.00 1.00 Child has behavioural difficulties Yes 2.25 (1.29, 3.95) 0.004 0.97 (0.48, 1.96) 0.924 No 1.00 1.00 Family factors Rurality Metropolitan Melbourne 1.00 1.00 Rural 4.57 (3.02, 6.91) 0.0001 2.49 (1.46, 4.25) 0.0001 Socioeconomic status Card holder status Yes 2.68 (1.73, 4.15) 0.001 1.28 (0.72, 2.28) 0.406 No 1.00 1.00 Socioeconomic status by IRSED quintile 1 (most disadvantaged) 5.05 (2.18, 11.71) 0.001 1.82 (0.73, 4.54) 0.200 2 6.49 (2.92, 14.41) 0.001 1.80 (0.69, 4.71) 0.232 3 4.69 (2.00, 11.02) 0.001 1.82 (0.75, 4.43) 0.187 4 2.90 (1.26, 6.66) 0.012 1.95 (0.86, 4.42) 0.110 5 (most advantaged) 1.00 1.00 Household income Less than $40,000 2.52 (1.55, 4.09) 0.001 1.23 (0.66, 2.30) 0.510 $40,000 and above 1.00 1.00 145 Respondent parent’s education Some high school 2.56 (1.36, 4.81) 0.004 1.00 (0.51, 1.97) 0.999 High school 2.62 (1.42, 4.83) 0.002 1.37 (0.73, 2.60) 0.319 TAFE, trade or diploma 2.05 (1.12, 3.77) 0.021 1.25 (0.66, 2.30) 0.493 University 1.00 1.00 Food insecurity – family ran out of food in last 12 months Yes 3.21 (1.62, 6.39) 0.001 0.87 (0.42, 1.79) 0.711 No 1.00 1.00 Family health Family functioning Poor 2.19 (1.04, 4.61) 0.038 2.07* (1.00, 4.31) 0.050* Healthy 1.00 1.00 Perceived poor access to basic health care Yes 1.47 (0.64, 3.40) 0.365 0.67 (0.20, 2.29) 0.524 No 1.00 1.00 Cultural background Language spoken at home English 1.00 1.00 Language/s other than English 1.14 (0.62, 2.10) 0.670 1.13 (0.53, 2.40) 0.757 146 Table 35 Poisson regression incident rate ratios (IRR) and 95 per cent confidence intervals for dental hospitalisation of 9–12 year olds unadjusted IRR and adjusted IRR Adjusted IRR Unadjusted IRR (adjusting for all factors) IRR (95% CI) p IRR (95% CI) p Child factors Gender Male 1.44* (0.95, 2.20) 0.089* 1.47 (1.00, 2.16) 0.049 Female 1.00 1.00 Oral health Ever had a toothache Yes 3.75 (2.42, 5.84) 0.001 1.96 (1.16, 3.31) 0.012 No 1.00 1.00 Ever had a tooth extracted Yes 8.05 (5.27, 12.30) 0.001 5.96 (3.75, 9.54) 0.001 No 1.0 1.00 Needs and behaviour Child needs or uses more services Yes 1.52 (0.87, 2.65) 0.140 1.17 (0.69, 1.99) 0.549 No 1.00 1.00 Functional limitation shown for 12 months or more Yes 2.03 (1.09, 3.75) 0.025 1.70 (0.84, 3.42) 0.140 No 1.00 1.00 Child has behavioural difficulties Yes 1.63* (0.91, 2.93) 0.099* 1.11 (0.67, 1.83) 0.684 No 1.00 1.00 Family factors Rurality 0 Metropolitan Melbourne 1.00 1.00 Rural 3.27 (2.27,4.72) 0.001 2.43 (1.65, 3.58) 0.001 Socioeconomic status Card holder status Yes 1.09 (0.69, 1.71) 0.717 0.78 (0.42, 1.44) 0.423 No 1.00 1.00 Socioeconomic status by IRSED quintile 1 (most disadvantaged) 1.45 (0.80, 2.65) 0.224 0.99 (0.57, 1.73) 0.969 2 1.23 (0.68, 2.24) 0.495 0.82 (0.47, 1.44) 0.485 3 0.76 (0.39, 1.45) 0.402 0.66 (0.33, 1.32) 0.243 4 0.49 (0.25, 0.96) 0.038 0.47 (0.24, 0.90) 0.024 5 (most advantaged) 1.00 1.00 Household income Less than $40,000 1.15 (0.70, 1.89) 0.583 0.93 (0.46, 1.87) 0.834 $40,000 and above 1.00 1.00 147 Respondent parent’s education Some high school 1.44 (0.85, 2.45) 0.179 1.17 (0.65, 2.12) 0.593 High school 0.90 (0.48, 1.69) 0.738 0.93 (0.48, 1.82) 0.834 TAFE, trade or diploma 1.06 (.61, 1.85) 0.835 0.95 (0.56, 1.62) 0.860 University 1.00 1.00 Food insecurity – family ran out of food in last 12 months Yes 2.14 (1.09, 4.21) 0.027 1.41 (0.81, 2.46) 0.220 No 1.00 1.00 Family health Family functioning Poor 0.93 (0.45, 1.92) 0.853 1.19 (0.55, 2.58) 0.654 Healthy 1.00 1.00 Perceived poor access to basic health care Yes 1.14 (0.64, 2.15) 0.677 0.98 (0.59, 1.64) 0.950 No 1.00 1.00 Cultural background Language spoken at home English 1.00 1.00 Language/s other than English 0.92 (0.52, 1.63) 0.772 1.24 (0.71, 2.16) 0.458 The numbers of factors statistically significantly associated with a child being hospitalised for dental care determined by Poisson analysis varied by age group. Table 36 is a summary of Tables 33, 34 and 35, showing by ✔ only the statistically significant factors for the three age groups (p<0.05). The two factors, ‘ever had toothache’ and ‘ever had a tooth extracted’ have been combined into ‘high dental treatment needs’. 148 Table 36 Key results: predictors of dental hospital admission by Poisson bivariate and multivariate analysis and age group, Victorian Child Health and Welfare Survey 2009 1-8 year olds 9-12 year olds 1-12 year olds Factors Bivariate Multivariate Bivariate Multivariate Bivariate Multivariate analysis analysis analysis analysis analysis analysis Child factors Male ✔ High dental treatment ✔ ✔ ✔ ✔ ✔ ✔ needs* Needs services ✔ ✔ ✔ Functional limitation ✔ ✔ ✔ Behavioural difficulties ✔ ✔ Family factors Rural dwelling ✔ ✔ ✔ ✔ ✔ ✔ Concession card ✔ ✔ Socioeconomic status by ✔ ✔ ✔ ✔ SEIFA quintile Annual income less than ✔ ✔ $40,000 Parents education ✔ ✔ Food insecurity ✔ ✔ ✔ Family functioning ✔ No Note : * High dental treatment needs combines ‘Ever had toothache’ and ‘Ever had a tooth extracted’. High dental treatment needs and rural dwelling were the most significant factors across each age group. More child behavioural factors were evident for 1-8 year olds and for 1- 12 years. Children 1-8 years of age were more than twice as likely to have been hospitalised for dental treatment if they needed more general services (IRR 2.75), had behavioural difficulties (IRR 2.25), or functional limitations (IRR 2.74) as shown in Table 34. Socioeconomic factors were also more significant for the younger age group. There was a clear socioeconomic gradient for 1-8 year olds with a fivefold difference between the most disadvantaged SEIFA quintile (IRR 5.05) and the most advantaged (IRR 1.00) (Table 34). The pattern for 9-12 year olds was more U-shaped, with the second highest IRR in the most advantaged quintile (Table 35). Parent’s education level followed a stronger social gradient in the younger age group as did concession card status and household income. Children from families which had run out of food in the previous year 149 were more likely to have been hospitalised, with higher likelihood amongst younger children – IRR 3.21 for 1-8 year olds and IRR 2.4 for 9-12 year olds. Children whose parents perceived that they had limited access to basic health services were more likely to have been hospitalised, but the association was not significant. Language spoken at home was also found to be not statistically significant. 6.4 Multivariate modelling To further refine the multivariate analysis, factors that were not significant after bivariate analysis (at the level of p<0.1) were removed. Socioeconomic status by SEIFA was omitted as it is a scaled factor and there were other factors that measured socioeconomic status. Experience of toothache was not included in the second round of modelling as a Spearman’s rank correlations coefficient test showed close collinearity with ‘ever had a tooth extracted’. Poisson multivariate analysis was undertaken with factors progressively removed to achieve the highest F value. Tables 37, 38 and 39 show the results of the analyses for the three age groups. Table 37 Predictors of dental hospitalisation for 1-12 year olds, 2009 Victorian Child Health and Welfare Survey Model 1 Model 2 F value 85.36 114.09 Probability > F p<0.0001 p<0.0001 Factors IRR IRR p 95% CIs p 95% CIs Child factors Male 1.35** (1.01, 1.81) Ever toothache 2.62***** (1.77, 3.89) Ever extraction 5.66***** (3.90, 8.22) 8.53***** (6.37, 11.43) Child needs services 1.74*** (1.71, 2.58) 1.88*** (1.28, 2.74) Family factors Rural dwelling 2.68***** (2.04, 3.52) 3.00***** (2.29, 3.93) *p<0.1 ** p<0.05,***p<0.01,****p<0.001,***** p<0.0001. The three factors in the final model for 1-12 year olds were ‘ever extraction’ (IRR 8.53, p<0.0001), ‘rural dwelling’ (IRR 3.00, p<0.0001), and ‘child needs services’ (IRR 1.88, 150 p<0.01). Being ‘male’, as shown in model 1 Table 6.6, was associated with dental hospitalisation when controlling for other factors (IRR 1.35, p<0.01), but not as strongly as the other factors. The F value showed a highly significant relationship between dental hospitalisation and the three factors in model 2 - F(3, 3611) = 114.09, p<.0001. Table 38 Predictors of dental hospitalisation for 1-8 year olds, 2009 Victorian Child Health and Welfare Survey Model 1 Model 2 Model 3 F value 43.56 64.24 76.14 Probability > F p<0.0001 p<0.0001 p<0.0001 Factors IRR IRR IRR p 95% CIs p 95% CIs p 95% CIs Child factors Ever toothache 3.68***** (1.95, 6.94) Ever extraction 4.92***** (2.59, 9.39) 10.82***** (6.76, 17.3) 10.41***** (6.80, 15.92) Child needs services 2.24** (1.21, 4.15) 2.63*** (1.44, 4.91) Family factors Rural dwelling 2.81***** (1.80, 4.40) 3.53***** (2.28, 5.48) 3.04***** (2.00, 4.63) Card holder 1.52* (0.96, 2.40) 1.91*** (1.25, 2.93) Family functioning 2.04* (0.96, 4.33) *p<0.1 ** p<0.05,***p<0.01,****p<0.001,***** p<0.0001. Factors in the final model for 1-8 year olds were ‘ever extraction’ (IRR 10.41, p<0.0001), ‘rural dwelling’ (IRR 3.04, p<0.0001), and that a parent held a government concession card (IRR 1.91, p<0.01). The F value showed a highly significant relationship between dental hospitalisation and these three factors - F(3, 3644) =76.14, p<.0001. ‘Family functioning’ and ‘child needs services’ were significant factors in model 1. 151 Table 39 Predictors of dental hospitalisation for 9-12 year olds, 2009 Victorian Child Health and Welfare Survey Model 1 Model 2 Model 3 F value 40.04 40.21 49.74 Probability > F p<0.0001 p<0.0001 p<0.0001 Factors IRR IRR IRR p 95% CIs p 95% CIs p 95% CIs Child factors Male 1.51** (1.03, 2.22) 1.56** (1.05, 2.31) 1.62** (1.09, 2.40) Ever toothache 2.07*** (1.28, 3.36) Ever extraction 6.08***** (3.84, 9.63) 7.66***** (5.12, 11.48) 7.67***** (5.11, 11.52) Functional 1.72* (0.94, 3.13) 1.82** (1.04, 3.20) limitation Family factors Rural dwelling 2.45***** (1.73, 3.45) 2.56***** (1.81, 3.60) 2.59***** (1.83, 3.65) *p<0.1 ** p<0.05,***p<0.01,****p<0.001,***** p<0.0001. Factors in the final model for 9-12 year olds were ‘ever extraction’ (IRR 7.67, p<0.0001), ‘rural dwelling’ (IRR 2.59, p<0.0001), and ‘male’ (IRR 1.62, p<0.01). The F value showed a highly significant relationship between dental hospitalisation and these three factors - F(3, 4988) = 49.74, p<.0001). ‘Functional limitation’ was a significant factor in models 1 and 2. ‘Male’ produced a higher F value in model 3 than ‘functional limitation’. The multivariate modelling showed that the two most significant factors associated with dental hospitalisation across all age groups were high dental needs (whether a child ever had a tooth extracted or ever had a toothache), and whether the child lived in a rural area. These factors were shown to be independently significant predictors of dental hospitalisation. The other most significant factors were that a child needs more services for 1-12 year olds, having a parent that has a concession card for 1-8 year olds, and being male for 9-12 year olds. 152 Chapter 7 Results 3 – The view from key players (qualitative research results) 7.1 Overview ...... 153 7.2 Theme 1 Criteria for DGAs ...... 154 7.3 Theme 2 Child factors ...... 155 7.4 Theme 3 Dental provider factors ...... 156 7.4.1. Paediatric dentist factors ...... 156 7.4.2 General dentist factors ...... 158 7.4.3 Dental therapist factors ...... 159 7.5 Theme 4 Parent factors ...... 160 7.6 Theme 5 Risk ...... 162 7.7 Theme 6 Financial impact ...... 163 7.8 Theme 7 Access to general anaesthetic facilities ...... 163 7.9 Theme 8 Treatment provided and follow-up after a DGA ...... 165 7.10 Summary ...... 165 7.1 Overview Qualitative research was conducted to understand more about factors that influence dental hospitalisation frequency of children in Victoria. These data complemented the quantitative data analysis. Five paediatric dentists 78 and 13 dentists, dental therapists, dental public health specialists and hospital admission decision makers were interviewed. Over fifty hours of focused discussion were conducted during 30 sessions. A thematic analysis of the interviews identified eight key themes relevant to understanding the frequency of dental hospitalisation of children in Victoria since 2000. 78 These were the paediatric dentists who had the most extensive experience of the dental hospitalisation of children in Victoria, particularly in the public sector. 153 The themes that emerged are presented in Table 40. They were: criteria for dental general anaesthetics (DGAs); child factors; dental provider factors; parent factors; risk; financial impact; access to general anaesthetic facilities; and treatment provided. Theme 3, dental provider factors, comprised paediatric dentist factors, general dentist factors and dental therapist factors. Table 40 Key themes from qualitative research about the dental hospitalisation of children in Victoria 1. Criteria for DGAs 2. Child factors 3. Dental provider factors 3.1. Paediatric dentist factors 3.2. General dentist factors 3.3. Dental therapist factors 4. Parent factors 5. Risk 6. Financial impact 7. Access to general anaesthetic facilities 8. Treatment provided and follow up after DGAs The focus was on DGAs as almost all children who are hospitalised for dental care have treatment under a GA. Issues raised within each theme will now be explored. In chapter 10, Discussion, information from the interviews will be considered along with results of the broader analysis of dental hospitalisation factors undertaken as outlined in the methodology chapter. 7.2 Theme 1 Criteria for Dental General Anaesthetics (DGAs) While all participants indicated that a DGA was required for young children with extensive or complex dental treatment needs and/or behavioural issues, there were variations in views about the appropriate threshold. No published Australian guidelines on criteria for DGAs were acknowledged as best practice by participants. 154 ‘The Australasian Academy of Paediatric Dentistry published guidelines in 2005- 06 but there have not been any updates. They are no longer relevant’. (Paediatric dentist) Participants working in the public system noted that there were no standard Australian policy guidelines for referral for publicly-funded DGAs. ‘It would be fantastic to establish a national group to agree on guidelines that can be accepted at a national level’. (Paediatric dentist) 7.3 Theme 2 Child factors The two main areas raised by participants relating to child factors were dental treatment needs and an increase in ‘child focus’. All but one of the paediatric dentists considered that the dental treatment needs of children appeared to have increased since 2000, with an increase in facial swellings and demand for emergency DGAs. The other paediatric dentist indicated that he had ‘not observed much change’ . Several dental providers noted that dental decay prevalence was higher in children of recent migrant groups such as the Somali community. The possible increase in the prevalence of Molar Incisor Hyperplasia 79 (MIH) was raised by several paediatric dentists. This is an issue because teeth with MIH can be highly sensitive and difficult to treat in the dental chair, potentially precipitating the need for a DGA. The paediatric dentist with most understanding of the epidemiology of MIH believed that the prevalence of MIH has probably not increased, rather that the diagnosis of MIH has improved. He suggested that MIH may have been masked in the past by 79 Molar Incisor Hyperplasia (MIH) is a condition affecting the first adult molar teeth and occasionally the adult incisor teeth. It is a developmental condition affecting teeth forming during the last trimester of pregnancy and the first four years of life. 155 higher caries rates and had not been diagnosed by dental clinicians, especially in primary teeth. There was agreement that there is now a greater emphasis on the child’s attitude toward dental treatment compared to 30 years ago. The child is now more likely to be asked than told what they want or need. Behavioural management techniques used in dentistry have changed. Older paediatric dentists noted that, in the 1970s and 1980s, it was acceptable practice in Australia to hold children down in the dental chair. ‘There is now less acceptance by children, parents and dental providers of ‘chasing the child’ and ‘rough and tumble’ in the dental chair’. (Paediatric dentist) A paediatric dentist with experience working in a children’s hospital noted that there has been a general increase in ‘child focus’ across all health disciplines. ‘The accepted best practice is ‘do not stress the child’. (Paediatric dentist) A ‘pain free’ policy has led to a shift to using general anaesthesia in the hospital for procedures previously undertaken under local anaesthesia. For example, short general anaesthesia is now used for lumbar punctures in order to be kinder (or ‘less stressful’) to the child. Nitrous oxide sedation is also now in widespread use in hospital medical clinics and its use has also increased in the hospital dental clinics. 7.4 Theme 3 Dental provider factors 7.4.1 Paediatric dentist factors The three main areas relating to paediatric dentists identified by participants were quality of care, case selection for DGAs, and the financial viability of practices. 156 Four of the five paediatric dentists indicated that a DGA can be the preferred model of care. ‘Higher quality treatment is possible, especially for preschool children’ . (Paediatric dentist) ‘It can be more predictable with less complications’. (Paediatric dentist) These informants considered that treatment under a DGA can be less haphazard and provide the most efficient outcome. Dental treatment completed in a one-hour DGA session could require four to six appointments in a dental clinic. It was noted that the quality of care possible also depends on the length of the GA session. Two of the paediatric dentists stated that undertaking a DGA does not necessarily allow higher quality care to be provided, nor does it improve the chances of being able to provide subsequent care to children in a dental clinic. It was noted that under a GA it is difficult to obtain an x-ray and may not be possible to check the occlusion (bite). In addition, quality can be compromised because of mouth rather than nasal intubation. Many anaesthetists do not like using nasal intubation. A paediatric dentist referred to research showing that a DGA does not necessarily reduce the anxiety a child may have about receiving dental treatment in a dental clinic. Paediatric dentists used different criteria for case selection for a DGA. A commonly mentioned indicator was if the child required treatment in all four quadrants of the mouth. However, some operators have a lower DGA threshold such as when a child will not tolerate the placement of rubber dam. Several paediatric dentists spoke of peers who tend to use DGA as a ‘first resort’ or as the ‘default choice’. On some occasions paediatric dentists are asked for a second opinion about whether a child requires a DGA. 157 ‘In most cases when I am asked for a second opinion the treatment could be provided in the dental clinic’. (Paediatric dentist) Four paediatric dentists spoke of the change in attitudes toward DGAs by general and paediatric dentists. ‘Twenty years ago, treating a young child under GA was generally seen as a failure by clinicians to manage care in the dental clinic. Fewer hold this view now’. (Paediatric dentist) The possibility that DGAs can be important for the financial viability of a paediatric dental practice was noted. One paediatric dentist said that ‘It is difficult to run a business just placing fissure sealants’ . Another indicated that there is potential for overtreatment during the DGA because of the need to provide sufficient dental care to make the DGA financially viable for the dental providers business. Several paediatric dentists mentioned that recently trained specialists are likely to have student debts that have built up over the three years of specialist training. These may be in addition to debts from their dental training. 7.4.2 General dentist factors All of the clinician participants (the paediatric dentists, general dentists, and dental therapists) considered that general dentists are reluctant to treat young children due to a lack of confidence because they do not have the necessary training or experience. A general view was that there was not sufficient practical experience at the undergraduate level. For example, a paediatric dentist noted that students may not have the opportunity to give a block local anaesthetic to a child, or learn about alternative sedation techniques to DGAs such as using nitrous oxide (relative analgesia). It was noted that, while students at the Melbourne Dental School have 15–16 half-day clinical sessions in paediatric dentistry, there was a shortage of appropriate patients. Many children who attend the student clinics only require basic care such as 158 examinations and the placement of fissure sealants. The small proportion of children with high treatment needs is often not suitable for dental students. Teaching relative analgesia in the Melbourne Dental School dentistry course as an alternative child management technique to a DGA ceased in the early 1990s. Recently dental students have been given lectures on the use of nitrous oxide, and hands-on training is planned. One paediatric dentist considered it unnecessary to teach relative analgesia in the dentistry course. His view was that an interested practitioner could undertake further postgraduate training. However, it was also noted that post graduate training options are limited. ‘It is a tragic loss of opportunity that there is no course of training in intravenous sedation available in Victoria’. ‘There is a desperate need for a wider range of options than avoidance of treatment or full general anaesthesia’. (Dentist) Three participants raised an issue about perception of the professional status of dentists. ‘If a general dentist is having difficulty managing the dental care of a child, he or she may refer the child to a paediatric dentist in order to save face with parents’. (Dentist) Concerning changes in general dental practice, participants mentioned that there are now more referral options with increased numbers of registered paediatric dentists and, as noted under child factors, less acceptance by children, parents and dental providers of ‘rough and tumble’ in the dental chair. 7.4.3 Dental therapist factors Participants noted that more private practices are employing dental therapists who manage most of the dental care for children. Clinician interviewees acknowledged that 159 dental and oral health therapists are generally highly skilled in managing children in the dental chair. The dental therapist participants spoke of cases where they were asked to provide a second opinion after parents had been told by a general or paediatric dentist that their child would require a DGA. In these cases the dental therapists reported that they were able to manage the child in the dental chair 80 . Dental public health specialists noted that oral health and dental therapist training focuses on managing the clinical care of children and young people. They also noted that most therapists work in the public dental system where there are more children with high dental treatment needs. 7.5 Theme 4 Parent factors While parents were not interviewed, most study participants commented on parent factors that affected the frequency of DGAs. Comments were made about convenience, parenting styles, oral health literacy, guilt, cultural variations, and obtaining second opinions. Participants noted that some parents consider a DGA to be convenient because treatment can be completed in one session, rather than three or more visits to a dental clinic. This means that parents do not need to take as much time off work and there is less expense for childcare for other children. ‘A DGA is attractive to parents who are time-poor and asset-rich’. (Paediatric dentist) Several respondents mentioned an increase in ‘permissive’ parenting styles compared to ‘authoritative’ or ‘authoritarian’ styles, which may have led to an increase in DGAs as parents were less likely to insist on their child ‘behaving in the dental chair’. 80 As in Case study B described in the ‘parent factors’ section which follows. 160 Comments were made about the wide variation in oral health literacy among parents. Several participants mentioned that parents accessing private care for their child generally had higher oral health literacy, but some were influenced by anti-fluoride articles they had accessed on the internet. These parents were more likely to use herbal toothpastes that do not have the caries-preventing impact of fluoride toothpastes. There was also variation in how primary teeth were valued by parents. Some parents were not aware of the impact of diet on oral health. Others were, but considered it too difficult to change feeding habits and a DGA was the price they were prepared to pay, as in Case study A described by a paediatric dentist below. Case study A All three children in a family had treatment under a DGA. The family lived on a farm and the mother said that she found it hard to manage the children alone while her husband was undertaking farm duties. The mother commented that it was easier to accept a DGA rather than change childcare practices that may have increased the risk of dental caries. Several paediatric and general dentists noted that parents can become defensive when issues of diet are raised, possibly because of feelings of guilt that their child had dental caries. ‘Some parents feel guilty that their child has tooth decay’. (Paediatric dentist) More parents are asking that white fillings rather than silver crowns are used to cap decayed molar teeth. The paediatric dentists who mentioned this considered that parents were concerned that visible dental work was a sign of parental neglect. A general dentist commented that there may be a tendency for paediatric dentists to ‘trade on’ parental guilt when discussing the need for a DGA. 161 Paediatric dentists noted that there are cultural variations in parental attitudes toward DGAs. For example, some people with Asian backgrounds were more concerned about the risks of a DGA. Paediatric dentists with experience overseas noted that DGA rates in children were generally lower in Asian countries than in Australia. Paediatric dentists noted that some parents are reluctant for their children to have care under a DGA. The cases studies below, contributed by a dental public health specialist and a paediatric dentist, are examples of where second opinions (Case study B) or alternative treatments (Case study C) were being sought. Case study B A paediatric dentist who examined a six year old boy with toothache told his mother after taking a radiograph that there was a deep cavity that would need to be treated under general anaesthesia. The mother took her child to a public dental clinic for a second opinion. Another radiograph was taken and pathology that required a DGA for treatment was not detected. The child was treated satisfactorily in a public dental clinic. The participant who described the case acknowledged that clinicians can recommend different treatment plans, but believed that there may have been an element of hasty prescription of a DGA in this situation. Case study C A mother contacted a public dental hospital after hearing about the Hall Crown Study. This study was researching the outcome of using a simpler crown technique that can be used in the dental chair to cap molar teeth with extensive decay. The mother said that she did not want her child to have a general anaesthetic for the placement of the four stainless steel crowns that a dentist had recommended. The Hall Crowns were placed in the dental clinic without problems. 7.6 Theme 5 Risk Dental public health specialists raised the risks of DGAs more often than paediatric and general dentists. When paediatric dentists mentioned risk, they indicated that the safety of 162 a DGA had improved with new anaesthetic drugs and better monitoring. The newer anaesthetic agents have fewer side effects. With better monitoring, problems are detected earlier when intervention can occur. Nausea was noted by some paediatric dentists as a still common side effect. Paediatric dentists noted that DGA-linked child deaths were rare in Australia. The only fatalities mentioned were the death of a young child in Broken Hill in 1998 and a fatality in a Brisbane dental clinic more than 20 years ago. Both deaths were associated with the children’s underlying medical problems. 7.7 Theme 6 Financial impact Participants mentioned costs to the family and to the health system. Paediatric dentists reported that costs ranged from $2,500 to $8,000 in the private sector, with most admissions costing between $3,500 and $5,000. There are three cost components: the anaesthetist’s fee, clinician’s fee and facility bed fee. 7.8 Theme 7 Access to general anaesthetic facilities Three issues concerning access to operating theatres were identified from participants’ responses: cost effectiveness, dental provider issues and rural hospital issues. Participants who had worked in the private hospital system noted that general dental treatment of children was perceived as less economically viable for a facility than extraction of wisdom teeth, the placement of grommets, or the removal of tonsils and adenoids. Whereas a dental clinician may see three to five children in a three-hour session, a maxillofacial surgeon could extract the wisdom teeth of 10 patients, grommets could be placed in the ears of six children, or 10–15 cataract operations could be performed. 163 Participants with experience in the public system commented that a DGA can be a lower priority than a general anaesthetic for procedures that are monitored for waiting times by the DH&HS and publically reported. The opportunity cost of using the limited theatre resources for DGAs was that less time was available for procedures for which waiting times are reported publicly. Respondents commented that in busy hospitals there was a pressure on access to operating theatres. ‘There is never enough theatre time’ . ‘If it is not counted (for waiting list reporting) it does not count’. (Hospital admission decision maker) Clinicians noted that access to operating theatres was more difficult in the public system compared to the private system. However, they did note that some paediatric dentists and general dentists complained about poor access to private facilities for DGAs. Both an experienced general dentist and a hospital manager said that clinicians who appreciated that private hospitals and day procedure centres need to make a profit, and arranged their cases and length of treatment accordingly, appeared to have little problem accessing theatres. It was noted by several participants that clinicians may have to travel to suburbs away from their dental practice to access theatres. Hospital managers indicated there may be fewer barriers to DGAs in smaller rural hospitals, compared to larger metropolitan facilities. This is because small rural hospitals in Victoria are globally funded, not casemix 81 funded, and have fewer medical specialty services competing for theatre time. It was noted that rural hospitals can have a regular general anaesthetic session for local dentists, that is, a ‘dental list’ every week or month. Where this occurs, there is some pressure on dentists to use these sessions and not risk losing them. 81 Casemix funding is discussed in section 9.3.1. 164 7.9 Theme 8 Treatment provided and follow-up after a DGA Paediatric dentists explained that emergency DGA cases, where a child has an infected tooth causing a swollen face, can take less than 15 minutes in theatre because only the teeth that are causing pain or infection and grossly decayed teeth are extracted. Non- emergency sessions are generally longer and more comprehensive treatment is provided. The need to provide appropriate dental treatment under DGA was mentioned by most paediatric dentists. ‘Just splashing GIC 82 everywhere’ and placing GIC in primary molars was no substitute for proactive treatment such as using crowns’. (Paediatric dentist) Paediatric dentists working in the public sector spoke of the need for ‘aggressive treatment’ to reduce the prevalence of repeat DGAs. Most dentists indicated the need to follow up the family after their child’s DGA. 7.10 Summary These qualitative results from the interviews will be discussed with the results from the quantitative research in the discussion chapter. Issues raised within the eight identified themes will be incorporated into discussion about the relevant social determinants factors. 82 GIC, the acronym for glass ionomer cement, is a filling material. 165 Chapter 8 Results 5 –Australian and international comparisons 8.1 Comparison of Victorian and Australian dental hospitalisation rates ...... 166 8.2 Comparison of Victorian and international dental hospitalisation rates ...... 170 This chapter presents the findings of the research undertaken to address the associated question to research question one - ‘How do Victorian rates compare nationally and internationally?’. 8.1 Comparison of Victorian and Australian dental hospitalisation rates In 2013-14, there were 142,572 admissions for dental services in Australia with 39,196 in Victoria (AIHW, 2015a). Victoria’s dental hospitalisation rate was slightly (six per cent) higher, than Australian rate – 6.7 compared to 6.3 per 1,000 population (AIHW, 2015a). A lower proportion of Victoria’s dental admissions was potentially preventable - 40 per cent (15,771 PPDHs of 39,196 dental admissions), compared to the proportion for Australia of 45 per cent (63,910 PPDHs of 142,572 dental admissions). Victoria’s PPDH rate of 2.8 per 1,000 population, was slightly higher than the Australian rate of 2.7 per 1,000 population (AIHW: et al., 2016). Victorian and national variations in PPDH rates will be presented by jurisdiction over time, by age group and by Aboriginal background. All jurisdictions have shown an increase in PPDH rates between 2001-02 and 2013-14 (Figure 26). 166 Figure 26 Potentially preventable dental hospitalisation rates per 1,000 population by Australian state and territories, 2001-02, 2005-6, 2009-10 and 2013-14. 4 3.5 3 2.5 2 1.5 Rateper 1,000 pop 1 0.5 0 Victoria NSW Qld WA SA Tas ACT NT Total 2001-02 2005-06 2009-10 2013-14 Sources: Report on Government Services 2005-06, Australian hospital statistics 2001-02 and 2008-09, (AIHW: et al., 2016). Victorian PPDH rates increased less than national rates between 2001-02 and 2013-14 (Figure 26). The national increase in PPDH rates between these years was 23 per cent (from 2.2 to 2.7 per 1,000 population), compared to Victoria’s increase of 12 per cent (from 2.5 to 2.8). However Victoria did start from a higher base in 2001-02, with a PPDH rate of 2.5 per 1,000 population compared to Australia’s rate of 2.2 per 1,000 population. Victoria is the only jurisdiction where PPDH rates decreased since 2005-06. Victoria had the third highest PPDH rate of the eight jurisdictions in 2001-02 and in 2013-14 was ranked fifth. Western Australia and South Australia have consistently had the highest PPDH rates. Rates of PPDH vary markedly by age group. Victorian and Australian rates for 0-4 and 5- 9 year olds are shown in Figure 27. Comparable Victorian and Australia data are shown for 2003-04, 2009-10 and 2013-14. 167 Figure 27 Potentially preventable dental hospitalisation rates per 1,000 population for Australian and Victorian 0-4 and 5-9 year olds, 2003-04, 2009-10, and 2013-14 10 9.4 9 9.3 9 8 7.9 8 7.6 7.3 6.9 7 6 5.3 4.7 4.7 5 3.9 4 3 Rateper 1,000 pop 2 1 0 Aust. 0-4 Vic. 0-4 Aust. 5-9 Vic. 5-9 2003-04 2009-10 2013-14 Sources: (Jamieson and Roberts-Thomson, 2006) (Chrisopoulos and Harford, 2013) (AIHW: et al., 2016) VAED/VHISS. Note that the Australian 2003-04 data is for all dental hospitalisations, not only PPDHs. However, over 95 per cent of dental hospitalisations in 0-9 year olds are PPDHs (Department of Human Services, 2007). Note that the Australian 2003-04 data is for all dental hospitalisations, not only PPDHs. However, over 95 per cent of dental hospitalisations in 0-9 year olds are PPDHs (Department of Human Services, 2007). Victorian PPDH rates for young children were generally lower than Australian rates between 2003-04 and 2013-14 (Figure 27). While rates in 0-4 year olds decreased in Victoria and nationally over these years, Victoria’s decrease was greater than for Australia – 47 per cent compared to 30 per cent. In 2013-14 Victorian PPDH rates in this age group were 17 per cent lower than national rates (3.9 compared to 4.7 per 1,000 population). Rates for 5-9 year olds were similar to those for 0-4 year olds in 2003-04 but by 2013-14 they had become twice as high (4.7 compared to 9.3 nationally and 3.9 compared to 7.9 in Victoria per 1,000 population). Victorian rates in this age group have decreased over the 11 years, and in 2013-14 were 15 per cent lower than national rates (7.9 compared to 9.3 per 1,000 population). 168 Rates of PPDH vary across jurisdictions according to Aboriginal and Torres Strait Islander background (Figure 28). Figure 28 Potentially preventable dental hospitalisation rates per 1,000 population for people with and without an Aboriginal background by Australian state and territories, 2012- 13 6 5.2 5 4.4 3.9 3.8 4 3.6 3.6 3.4 3.5 3.0 3.0 2.8 3 2.7 2.8 2.8 2.3 2.1 2.1 2 Rate per 1,000 1,000 pop per Rate 1.5 1 0 Victoria NSW Qld WA SA Tas ACT NT Total Non-Aboriginal background Aborginal background Source: Report on Government Services 2015. In 2012-13 in Victoria, people with an Aboriginal background had an 11 per cent higher PPDH rate than non-Aboriginal people (3.0 compared to 2.7 per 1,000 population) (RoGS Steering Committee, 2015) 83 . This difference was the lowest of all jurisdictions. The variation nationally was 25 per cent and the greatest difference was in the Northern Territory (148 per cent). In Tasmania, the PPDH rate was 56 per cent lower for people with an Aboriginal background. Victoria ranked equal sixth with New South Wales in PPDH rates for people with an Aboriginal background. Jurisdictions with higher proportions of people with an 83 Accessed from Australian Government Productivity Commission website on 19 January 2016 - 169 Aboriginal background living in remote areas had higher PPDH rates – the Northern Territory, Western Australia, South Australia and Queensland. 8.2 Comparison of Victorian and international dental hospitalisation rates There are limited published data on international dental hospitalisation rates for children or adults. Some data are available from England, Canada and New Zealand. Comparisons can be complicated because the age groups and years reported differ, and rates may be for all dental hospitalisations, for PPDHs, or only for dental caries. Adjusting for these differences, dental hospitalization rates for children in Victoria appear similar to English rates, with Canadian and New Zealand rates relatively higher. Rates of DGA among 0-4 year olds in Manitoba, Canada, were about twice Victorian PPDH rates between 2002-03 and 2006-07 - 14.2 compared to approximately 7.0 per 1,000 population (Schroth et al., 2014) (VHISS 2015). Among 5-9 year olds in 2013-14, the rate of hospitalisation for dental caries in 5-9 year olds in England was approximately 8.5 per 1,000 population 84 , similar to the Victorian rate of 8.3 85 . Dental reasons were the most common cause of admission for this age group in both places. Whyman and colleagues found higher PPDH rates in New Zealand compared to Australian children. Between 2005 and 2009, rates in three and four year olds were approximately 22 per 1,000 population and in 5-8 year olds approximately 14 per 1,000 population. These latter rates were similar to the rates found by Schroth and colleagues in Manitoba, Canada. Whyman and colleagues found even higher rates in people with a Maori and/or Pacific Islander background, with inequities having increased since the 1990’s (Whyman R, 2012, Whyman et al., 2014). 84 Estimation from data from Health & Social Care Information Centre 2015 (Health & Social Care Information Centre - < http://www.hscic.gov.uk/ >) and population estimates from Wikipedia accessed on 3 January 2016. 85 Data from VAED/VHISS adjusted to recognise that 95 per cent of PPDHs of 5-9 year olds in 2013-14 were related to dental caries (see section 5.2.5.). 170 All-age PPDH rates have been similar in Victoria and New Zealand. In both places the PPDH rates increased from 1997-98 to 2008-09. Rates for Victoria and New Zealand were 2.2 and 1.8 per 1,000 population respectively in 1997-98, 2.9 and 2.7 in 2004-05, and 2.8 and 3.0 in 2009 (VHISS/ VAED) (Whyman R, 2012). 171 Chapter 9 Results 4 – Impacts of dental hospitalisation 9.1 Overview ...... 172 9.2 Mortality and morbidity ...... 173 9.2.1 Mortality and morbidity data bases ...... 173 9.2.1.1 National Coronial Information System (NCIS) request ...... 173 9.2.1.2 Victorian Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) request ...... 174 9.2.1.3 Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM) request ...... 174 9.2.2 Interviews with key players ...... 174 9.2.3 Estimation of mortality rates ...... 175 9.3 Cost of dental hospitalisation ...... 175 9.3.1 Funding system for dental hospitalisation in Victoria ...... 175 9.3.2 Costs in the private sector ...... 179 9.3.3 Australian studies ...... 179 9.3.4 Estimation of costs in 2012-13 ...... 181 9.3.4.1 Costs in Australia ...... 181 9.3.4.2 Costs in Victoria ...... 183 9.1 Overview This chapter presents the results of the research that was conducted to answer the second research question – ‘What are the impacts of dental hospitalisation on Victorian children, young adults and their families?’ The associated questions were – ‘What is the extent of morbidity and mortality related to dental hospitalisation?’ and ‘What are the costs related to dental hospitalisation?’ 172 9.2 Mortality and morbidity 9.2.1 Mortality and morbidity data bases 9.2.1.1 National Coronial Information System (NCIS) request The requested National Coronial Information System (NCIS) Unit search on ‘deaths reported by an Australian State or Territory Coroner between July 2000 and December 2012 where general anaesthesia given in the context of dental surgery contributed to the death’ was undertaken on 17 February 2015. The NCIS was searched using the keywords ‘dental’, ‘dentist’, ‘teeth’, ‘tooth and extraction’ for cases that were closed and where the injury was caused by an anaesthetic. A manual review of the coding of all cases in the NCIS dataset was undertaken in order to confirm that the cases were of relevance. The keyword search produced a significant number of results, as it is routine to comment on teeth in an autopsy. A number of cases were excluded as they related to the use of anaesthetic gas for the purposes of intentional self-harm. The coronial documentation of remaining cases was manually evaluated to determine whether the deceased had received the anaesthetic in the course of dental surgery. One death was identified – a male aged between 0–9 years who suffered a number of congenital problems including recurrent apnoeic episodes. It was established at the post- mortem examination that the child had an acute chest infection at the time of the procedure and that this was the most likely underlying cause of death. Shortly after a number of teeth had been extracted, the child developed an abnormal heart rhythm and was unable to be resuscitated. The NCIS Unit also undertook a brief review of relevant literature through a University of Melbourne EBSCOhost keyword search. The review indicated that the low number of results was generally consistent with the number that would be expected. The NCIS Unit 173 also indicated several limitations of their data sources that will be raised in the Discussion chapter, section 10.4.1. 9.2.1.2 Victorian Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) request The Victorian Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) reviewed the CCOPMM database and reported on 22 June 2014 that there were no deaths in Victoria related to dental anaesthesia in 0–14 year olds from 2001 to 2012, and in 15–17 year olds from 2005–12. Prior to 2005, CCOPMM collected data up only until the fifteenth birthday. 9.2.1.3 Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM) request The response to the request to the Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCAAMM) for DGA mortality and morbidity data in Victoria from 2000–12 was that the database ‘did not contain this type of information’. 9.2.2 Interviews with key players As detailed in the results from the interviews with key players in Chapter 7, dental public health specialists raised the risks of DGAs more often than paediatric and general dentists. When paediatric dentists mentioned risk, they indicated that the safety of DGAs had improved with new anaesthetic drugs and better monitoring. The newer anaesthetic agents were noted to have fewer side effects but that nausea was still common side effect. Paediatric dentists noted that DGA-linked child deaths were rare in Australia. The fatalities mentioned were the death of a young child in Broken Hill in 2008 and a fatality in a Brisbane dental clinic over 20 years ago. Both deaths were associated with the 174 children’s underlying medical problems. The DGA fatality case in 2008 was that of the young child included in the NCIS report. 9.2.3 Estimation of mortality rates As noted in 9.2.1.1, one death was identified as having occurred under a DGA between 2000 and 2012 in Australia. Over this time there were approximately 1.35 million DGAs in Australia 86 (AIHW hospital statistics reports). These data would indicate that the mortality rate for DGA over this time was 1:1,350,000. However, this rate is an estimate given the caveats placed on the NCIS data as will be explained in section 10.4.1. No deaths of 0-14 year olds were identified as having occurred under a DGA between 2001 and 2012 in Victoria (CCOPMM 2014). There were approximately 73,500 children under 15 years of age who had a DGA over this period in Victoria. It is not possible to determine a rate with these data. 9.3 Cost of dental hospitalisation 9.3.1 Funding system for dental hospitalisation in Victoria The funding systems for hospitals and day procedure centres in Victoria were reviewed to attempt to quantify the cost of dental hospitalisation and to determine whether the characteristics of these systems may influence admission rates. Public hospitals in Victoria are funded by the Department of Health and Human Services (DH&HS) by a combination of casemix funding (approximately 60 per cent) and specific grants. Casemix funding allocates resources according to the numbers, types and average cost of treating patients. Patients are classified into a Diagnosis Related Group (DRG) according to the principal diagnosis. The DRG system is a method of classifying patients 86 This takes account of Queensland data not being included between June and December 2000 (see 4.4.1). 175 that have similar clinical conditions and similar levels of resource use. 87 Nationally, the Australian Refined Diagnosis Related Groups (AR-DRG) classification is used, which incorporates the International Statistical Classification of Diseases and Related Health Problems, 10 th Revision, Australian Modification (ICD-10-AM). Cost weights are calculated for each DRG and represent a relative measure of resources used by hospitals in treating inpatients. These weights reflect the recurrent cost of the activity. They are calculated as the ratio of the average cost of all episodes (admissions or separations) in a DRG to the average cost of all episodes across all DRGs. Public hospitals are required to report costs for all operating and funded activity. Cost weights are reviewed annually to reflect actual costs and Consumer Price Index (CPI) and wage increases. A cost-weighted separation is called a Weighted Inlier Episode Separation (WIES). Public hospitals receive an annual budget consisting of WIES funding for a target level of activity plus a range of specified grants. Health service management is then responsible for allocating the annual budget across different areas of the hospital. Small rural hospitals are funded by block grants and not by casemix and WIES. The major DRGs that cover oral health care are shown in Table 41 by frequency in public hospitals for 2012–13. The highest frequency DRG was D40Z ‘Dental extractions and restorations’ followed by DRG D67A ‘Oral and dental disorders except extractions and restoration’ and DRG D67B same day stay ‘Oral and dental disorders except extractions and restoration’. 87 Average cost weights are ‘estimates of the relative costliness of admitted patient care’ AIHW 2015a. Admiited patient care 2013-14: Australian hospital statistics. Canberra: Australian Institute of Health and Welfare.. They are an indication of the costliness of a DRG relative to all other DRGs such that the average cost weight for all separations is 1.00. For example, a separation for a DRG with a cost weight of 5.0 costs, on average, 10 times as much as a separation with a cost weight of 0.5. 176 Table 41 Major oral health Diagnosis Related Groups description and frequency in Victorian public hospitals in 2012–13 DRG DRG description No. % D40Z Dental extractions and restorations 7,045 64 D67A Oral and dental disorders except extractions and restorations – multi day 1,179 11 D67B Oral and dental disorders except extractions and restorations – same day 1,893 15 D04A Maxillo surgery with complications 221 2 D04B Maxillo surgery without complications 667 6 Total 11,005 100 Source: VAED 2014 Table 42 shows the WIES cost weights for each oral health DRG for 2001–02, 2004–05 and 2013–14 (Department of Health 2001, 2004, 2013)88 . The WIES for D04A ‘Maxillo surgery with complications’ was the highest of the oral health DRGs at 1.8583 in 2013– 14, reflecting the more complex care required for these cases. DRG D67B had the lowest WIES at 0.2063. DRG D14Z ‘Mouth and salivary gland procedures’ is also included. Table 42 Weighted Inlier Equivalent Separation, Victorian dental cost weights 2001 –02, 2004–05 and 2013–14 DRG DRG description 2001–02 2004–05 2013–14 D40Z Dental extractions and restorations 0.4514 0.5112 0.4926 D67A Oral and dental disorders except extractions and restorations – multi day NR 0.5494 0.3729 D67B Oral and dental disorders except extractions and restorations – same day NR 0.1783 0.2063 D67Z Dental and oral diseases except extractions and restorations 0.2086 NR NR D04A Maxillo surgery with complications 0.9066 1.1974 1.8583 D04B Maxillo surgery without complications 1.1265 1.1345 1.4368 D08Z Mouth procedures 0.5639 NR NR D14Z Mouth and salivary gland procedures NR 0.5300 0.6454 Note: NR = not relevant because of changes in DRG coding. For example D08Z was replaced by D14Z after 2001-02. Sources: DH 2001, 2004, 2013. 88 2013-14 data accessed from the DH&HS website on 19 January 2016 - WIES dental cost weights from 2001–02 to 2013–14 were examined to determine whether the DRG price paid for dental DRGs may have been a factor in the DGA admissions trend over this period. There were three changes in DRGs between 2001–02 and 2004–05 as shown in Table 42. The DRG D67Z ‘Dental and oral diseases except extractions and restorations’ was split into D67A ‘Oral and dental disorders except extractions and restoration’ and D67B same day stay ‘Oral and dental disorders except extractions and restoration’. The DRG DO8Z ‘Mouth procedures’ was discontinued and replaced by D14Z ‘Mouth and salivary gland procedures’. Cost weights for most of the dental DRGs increased between 2001-02 and 2013-14 (Table 42). Only weights for DRG D67A fell – by 37 per cent from 2004–05. The increases for DRGs D40Z, D67B, D04A, D04B, and D08Z were 9 per cent, 23 per cent, 105 per cent, 20 per cent and 19 per cent, respectively. The public WIES price in 2013–14 ranged between $4,248 for major providers (for example, the Royal Hospital of Melbourne) to $4,674 for a sub-regional and local hospital. Private patients in public hospitals received 76 per cent of the public patient price – $3,229 for major providers and $3,553 for sub-regional and local providers. These arrangements meant that in 2013–14, the price paid by the DH&HS for a public patient admitted to a major public hospital for DRG D4OZ was $2,093 ($4,248 x cost weight 0.4926). Whether the public funding system influences dental hospitalisation rates in Victoria will be discussed in section 10.2.2.3.2. The discussion will consider the outcome of the interviews with key players about this issue, along with reflections on the quantitative data outlined above. 178 9.3.2 Costs in the private sector One of the key themes explored in the semi-structured interviews with oral health professionals was the cost of a DGA (7.7). In the private sector, costs ranged from $2,500 to $8,000 with most admissions costing between $3,500 and $5,000. There are three cost components – the anaesthetist’s fee, clinician’s fee and facility bed fee. Medicare provides less than $200 for the anaesthetist’s fee. Some anaesthetists may accept just the Medicare payment for children from financially disadvantaged families, but generally their fee is about $550–600. The facility fee depends on the length of the operation. In 2012 a day care facility in western Melbourne was charging from $500 for 30 minutes to $1,400 for 120 minutes. Practitioner fees vary markedly depending on the length and type of procedures and their practice fee scales. A private practitioner generally needs to cover the costs of running their practice while in theatre. Private insurance rebates for DGAs cover a relatively small proportion of the cost. Most policies have an annual limit of less than $1,000 per person. Some health funds will not reimburse costs incurred beyond a certain length of time in theatre. 9.3.3 Australian studies The literature review identified nine published studies that estimated the cost of dental hospitalisations in Australia (section 2.7). The studies used a range of different methodologies. Estimates of Australian costs in 2008-09 include: $84 million for public expenditure on public hospital dental admissions (Australian Government, 2012) 89 ; $233 million for 89 Final Report of the National Advisory Council on Dental Health, accessed from the Commonwealth Department of Health website on 19 January 2016 - PPDHs in 2008-09 (Richardson and Richardson, 2011); and direct costs of $350 million with total costs of up to $531 million, for hospitalisations for removal of impacted teeth in 15-34 year olds (Anjrini et al., 2015). Anjirini, Kruger and Tennant, estimated that the average direct cost of third molar removal under GA was $2,644 (Anjrini et al., 2015). The total cost was estimated to be $4,494 (a 70 per cent additional cost) for a non-insured person, and $5,664 (a 114 per cent additional cost) for an insured person 90 . These analyses updated the work undertaken by George and colleagues in 2011 and 2012 on estimating the cost of removal of impacted teeth in Western Australia (George et al., 2011, George et al., 2012). Alsharif, Kruger and Tennant, estimated that the average direct cost per admission of Western Australian under 15 year olds for the 10 years to 2008-09 was $2,039 (Alsharif et al., 2015b). They assumed that indirect costs were 1.5 times direct costs, based on the work of Drummond and colleagues (Drummond et al., 1997) which increased the estimated total cost per admission to $5,234. Costs of dental hospitalisations in Western Australia have also been estimated for all ages (Kruger and Tennant, 2015c) and for people older than 65 years (Kruger and Tennant, 2015a). The only study on dental hospitalisation costs in Victoria found in the review of the literature was a Victorian Department of Health study from 2002. The direct cost of PPDHs in public hospitals in Victoria in 2000-01 was estimated to be $19.7 million (Department of Human Services, 2002b). 90 Non-direct costs were out of pocket costs (payments to hospitals) and indirect costs (absenteeism from work and travel). 180 9.3.4 Estimation of costs in 2012-13 9.3.4.1 Costs in Australia There are three main approaches to classifying hospitalisation activity for oral health – via DRGs, procedure chapters (dental services 450–490), or principal diagnosis (dental services K0–K14). DRGs are most commonly used for estimating costs or expenditure. The four Australian studies found in the literature which estimated the costs of hospital admissions due to oral health conditions all used DRG costs. Expenditure on dental hospitalisation in Australia can be estimated from DRG data in the National Hospital Cost Data Collection (NHCDC) cost reports 91 . To estimate public expenditure for 2011-12, the actual average cost per oral health DRGs for public hospitals from the NHCDC Round 17, 2012-13 can be used. Estimating private sector costs is more difficult than estimating public sector expenditure. Separate cost weights are usually estimated for the public and private sectors because of the differences in the range of costs recorded in public and private hospitals. However, private sector cost weights do not include all costs of the activity 92 . The most recent private hospital cost weights are for 2011–12 (NHCDC Cost Report Round 16, 2011–12, IHPA 2013b). These cost weights were calculated using data provided by a sample of overnight private hospitals and ‘may not accurately reflect the average cost weights for private free standing day hospital facilities’ (AIHW, 2015a). For a broad estimate of direct costs for dental hospitalisations, it can be argued that private sector costs are similar to, and not likely to be less than, public sector costs as determined by NHCDC reports. For example, the NHCDC Round 17, 2012-13, 91 Data to estimate public hospital expenditure on dental DRGs in the report of the National Dental Advisory Council on Dental Health were sourced from the NHCDC Cost Report Round 13, 2008–09 AUSTRALIAN GOVERNMENT 2012. Final Report of the National Advisory Council on Dental Health Canberra: Department of Health. 92 For example, imaging, pathology and medical costs are not generally reported for private hospitals as many are outsourced or charged directly to the patients by providers AIHW 2015a. Admiited patient care 2013-14: Australian hospital statistics. Canberra: Australian Institute of Health and Welfare. 181 determined that the average cost for DRG D40Z, the most common dental DRG, was $3,029 (NHCDC Australian Public Hospitals Cost Report 2012-13, Round 17) (Independent Hospital Pricing Authority, 2015). This amount is at the lower end of average costs for private DGAs reported during the interviews with key players (section 7.7). If it is assumed that private sector expenditure for each of the oral health DRGs is similar to public expenditure, the estimated public and private expenditure on the major oral health DRGs in Australia in 2012–13 was $571.8 million, as shown in Table 43 93 . The average cost per DRG is from the NHCDC Australian Public Hospitals Cost Report 2012-13, Round 17. Table 43 Estimated direct expenditure on oral health Diagnosis Related Groups in Australian public and private hospitals in 2012–13 Total DRG No. Average $ $ million D40Z 125,524 3,028 380.1 D67A 7,100 4,341 30.8 D67B 11,479 1,152 13.2 D04A 1,353 12,186 16.5 D04B 7,886 8,478 66.9 D14Z 13,703 4,691 64.3 Total 167,045 571.8 Sources: AIHW 2014, NHCDC Australian Public Hospitals Cost Report 2012-13, Round 17 (Independent Hospital Pricing Authority, 2015). If it is assumed that indirect costs are 1.5 times direct costs (Drummond et al., 1997), indirect costs would have been $857.7 million and total costs would have been $1.43 billion in 2012-13. 93 If only DRGs D40Z, D67A and D67B had been included, the total cost would have been $421.1 million. 182 This is the estimated expenditure in the public and private system by families, health insurance and public hospitals. The highest proportion of expenditure would have been in the private sector. Over 80 per cent (82 per cent) of dental services provided in hospitals in 2013-14 were in the private sector. At a similar proportion in 2012-13, private sector direct costs would have been $703.3 million, and total costs $1.18 billion. 9.3.4.2 Costs in Victoria The estimated expenditure on the six major oral health DRGs in public hospitals in Victoria in 2012–13 was $23.9 million, as shown in Table 44. The frequency of each DRG is shown with its cost weight and the WIES price for 2012– 13 94 . Table 44 Estimated public expenditure on major oral health Diagnosis Related Groups in Victorian public hospitals in 2012-13 WIES price Total DRG No. Cost weight $ $ million D40Z 7,045 0.4902 4,278 14.8 D67A 1,179 0.3438 4,278 1.7 D67B 1,893 0.2197 4,278 1.8 D04A 221 1.826 4,278 1.7 D04B 667 1.3554 4,278 3.9 D14Z 1,253 0.6321 4,278 3.4 Total 12,258 23.9 Note: WIES price is the outer metropolitan and large regional hospital price. Source: DH 2012 (Department of Health, 2012). WIES funding comprises approximately 60 per cent of public hospital funding (Department of Health, 2013) 95 . Assuming that applies for oral health DRGs, their cost would have been approximately $39.8 million ($23.9m x 10/6) in 2012-13. 94 Data for 2012–13 was used because data on dental DRG, non PPDHs data for 2013–14 were not available. 95 Acute admitted casemix funding accounts for approximately 60 per cent of health service funding, with the department providing additional funding in the form of block funding and special grants. 183 The estimated direct expenditure on public PPDHs in 2013–14 is presented in Table 45. There was a total of 5,011 public PPDHs. Cost weights for each DRG, and the public WIES price are shown. Table 45 Estimated direct expenditure on public potentially preventable dental hospitalisations in Victoria in 2013–14 96 WIES price Expenditure DRG No. Cost weight $ $ million D40Z 3,063 0.4926 4,364 6.6 D67A 505 0.3792 4,364 0.8 D67B 758 0.2063 4,364 0.7 D04A 6 1.8583 4,364 0.05 DO4B 15 1.4368 4,364 0.09 D14Z 549 0.6454 4,364 1.5 D12Z 51 0.5038 4,364 0.1 Other 64 - - - Total 5,011 9.9 Sources: DH 2013, DH&HS 2015. When the same public expenditure calculations are applied to private PPDHs, expenditure in the private sector would have been $23.8 million in 2013–14, as shown in Table 46. 96 The WIES20 price of $4,364 for outer metropolitan and large regional hospitals is used as an estimate of the state-wide price. The WIES20 price ranged from $4,284 for major providers to $4,674 for sub-regional and local providers. DRG 12Z is included in this table but not in tables 8.1, 8.2 or 8.3 because these 64 hospitalisations were the subset of total D12Z admissions that were categorised as potentially preventable. 184 Table 46 Estimated direct expenditure on private potentially preventable dental hospitalisations in Victoria in 2013– 14 WEIS price Expenditure DRG No. Cost weight $ $ million D40Z 7,811 0.4926 4,364 1.7 D67A 151 0.3792 4,364 0.2 D67B 354 0.2063 4,364 0.3 D04A 14 1.8583 4,364 0.1 DO4B 574 1.4368 4,364 3.6 D14Z 947 0.6454 4,364 2.7 D12Z 104 0.5038 4,364 0.2 Other 93 - - - Total 10,048 23.8 Sources: DH 2013, DH&HS 2015. Combined public and private expenditure would have totaled $33.7 million in 2013-14. If the same assumption is made as for costing public oral health DRGs, that WIES funding comprises approximately 60 per cent of direct costs, the combined public and private expenditure on PPDHs would have been $56.2 million ($33.7 million x 10/6) in 2013-14. 185 Chapter 10 Discussion Section 1 ...... 187 10.1 Overview ...... 187 Section 2 ...... 188 10.2 Research question one – the distribution and the determinants of the dental hospitalisation of children and young adults in Victoria ...... 188 10.2.1 Main research projects ...... 188 10.2.1.1 Analysis of the VAED from 2001-02 to 2013-14 ...... 188 10.2.1.2 Multivariate analysis of the VAED 2008-09 and 2012-13 ...... 189 10.2.1.3 Analysis of the 2009 VCHWS ...... 190 10.2.1.4 Qualitative study – the view of key players ...... 193 10.2.3 Fit of findings to the social determinants model ...... 194 Section 3 ...... 205 10.3 Associated research question one – Australian and international comparisons ..... 205 10.3.1 Victorian and Australian rates ...... 205 10.3.2 Victorian and international rates ...... 206 Section 4 ...... 208 10.4 Research question two - impact of dental hospitalisation ...... 208 10.4.1 Mortality ...... 208 10.4.2 Morbidity ...... 209 10.4.3 Monitoring and reporting ...... 210 10.4.4 Costs ...... 212 Section 5 ...... 213 10.5 Research question three – policy implications ...... 213 10.5.1 Policy implication principles ...... 213 Environmental structural determinants ...... 214 10.5.2 Public health policy ...... 214 10.5.3 Dental care system ...... 217 10.5.4 Health care system ...... 231 Socioeconomic and cultural context of the family ...... 238 10.5.5 Families’ socioeconomic status and prevention of PPDHs ...... 238 10.5.6 Cultural background ...... 242 10.5.7 General parent factors ...... 245 Child intermediary determinants ...... 249 10.5.8 Age ...... 249 10.5.9 Gender ...... 251 10.5.10 Dental treatment needs ...... 252 10.5.11 Child behavioural and ability factors ...... 254 Section 6 ...... 257 10.6 Strengths and limitations of the research ...... 257 10.7 Research required ...... 259 186 Section 1 10.1 Overview The discussion section will be organised under the three main research questions: What are the distribution and the determinants of the dental hospitalisation of children and young adults in Victoria?; What are the impacts?; and what are the policy implications? In Section 2, the determinants, or factors, for dental hospitalisation that have been identified during the four main research projects will be summarized. The fit of the research findings to the model will then be discussed under the categories in the social determinants model presented in Chapter 3, Figure 6. Section 3 will cover the extent of dental hospitalisation in Victoria compared to Australian and international data. This will answer the associated question to research question one. Research question two, concerning the impacts of dental hospitalisation, will be discussed in terms of mortality, morbidity, and cost in Section 4. Discussion on policy implications for Victoria (research question three) will follow in Section 5. Finally, strengths and limitations of the research will be outlined. 187 Section 2 10.2 Research question one – the distribution and the determinants of the dental hospitalisation of children and young adults in Victoria The first research question was - What are the distribution and the determinants of the dental hospitalisation of children and young adults in Victoria? The two associated questions were - 1 What were the distribution and the determinants by prevalence, rates, diagnosis, dental treatment, and trends from 2001-02 to 2013-14? 2 How do Victorian rates compare nationally and internationally? Associated question one will be discussed in relation to the results of the four main research projects that were conducted, the results of ancillary research, and reference to relevant literature. The main research projects were: analysis of the Victorian Admitted Episode Dataset (VAED) from 2001-02 to 2013-14 presented in Chapter 5; multivariate analysis of the 2008-09 and 2012-13 VAED, Chapter 5; analysis of the 2009 Victorian Child Health and Welfare Survey (2009 VCHWS), outlined in Chapter 6; and the outcome of the interviews with key players, documented in Chapter 7. Associated question two will be addressed after discussion of the determinants. 10.2.1 Main research projects Four main research projects were conducted to answer the question about the distribution and the determinants of dental hospitalisation by prevalence, rates, diagnosis, trends and associated dental treatment. The key results will be briefly outlined before discussing findings according to the categories of the social determinants model. 10.2.1.1 Analysis of the VAED from 2001-02 to 2013-14 The analysis of the VAED reviewed the distribution and the determinants of dental hospitalisation in Victoria by prevalence, rates, diagnosis, trends and dental treatment up to 2013-14. Admission data for PPDHs in public and private hospitals for the ten years 188 from 2004-0 to 2013-14 were analysed. Summary Victorian PPDH data from 2001-02 to 2003-04 and Australian dental hospitalisation data were also analysed. There were 142,442 dental hospitalisations 97 in 2013-14 in Australia and 39,196 in Victoria (AIHW, 2014a). Young women between 15-24 years of age had the highest rates of hospitalisation, predominantly for the extraction of impacted and embedded teeth. Of the dental hospitalisations in 2013-14, just under half (63,910, representing 45 per cent in Australia and 15,406 representing 39 per cent in Victoria), were potentially preventable dental hospitalisations (PPDHs). These PPDHs were the highest cause of all acute potentially preventable hospitalisations (PPHs), and second to diabetes complications of all PPHs. When ranked by bed days, PPDHs were the 12 th cause of PPHs in Victoria in 2013-1498 (VHISS). There was a 74 per cent increase in the number of PPDHs from 1997-98 to 2013-14 in Victoria, an increase in the rate of 23 per cent. Children under 10 years had the highest rates, particularly 5-9 year olds living in rural areas. Two thirds (67 per cent) of PPDHs in 2013-14 were private admissions. 10.2.1.2 Multivariate analysis of the VAED 2008-09 and 2012-13 Multivariate analysis of the VAED in 2008-09 and 2012-13 identified associations between four key independent factors and the PPDH rates of Victorian 0-4 year olds. The results of the multivariate analysis will be discussed first as a whole, and then referred to under the social determinants categories. 97 These were admissions for dental services. There were 130,792 admissions requiring a general anaesthetic AIHW:, CHRISOPOULOS, S., HARFORD, J. E. & ELLERSHAW, A. 2016. Oral health and dental care in Australia: Key facts and figures 2015. Canberra: Australian Institute of Health and Welfare.. 98 The lower ranking by bed days is because most PPDH are same day admissions . 189 The four independent factors chosen were included because of the evidence-base, theoretical plausibility as per the social determinants model, and the availability of data. The analysis was performed at the post code level for the years 2008-09 and 2013-14. Independent factors were geographic remoteness, access to oral health professionals, access to community water fluoridation, and socioeconomic status (section 4.3.1.1). The Pseudo R 2 values for the three models ranged between 0.21 (21 per cent) for Model 1 in 2008–09, and 0.10 (10 per cent) for Model 3 in 2012–13 (5.3). These levels are considered to reflect a moderate relationship between the dependent variable, PPDH rate, and the independent variables on the basis that less than 0.1 represents a weak relationship, 0.1 to 0.3, a moderate relationship, and greater than 0.3, a strong relationship. The four independent variables were found to be each statistically significantly associated with PPDH rates at the postcode level when controlling for the other variables. This was the case in both 2008–09 and 2012–13 as shown in Tables 29 and 30. In Model 1 ‘remoteness’ was the strongest predictor of PPDH rates when controlling for the other variables in Model 1. When remoteness was excluded in Model 2, because it is closely correlated with the other three variables, each remaining variable remained significantly associated with PPDH rates in both years. 10.2.1.3 Analysis of the 2009 VCHWS The analysis of the 2009 VCHWS examined the strength of associations between dental hospitalisation and 21 child and family factors. Definitions of each factor are outlined in section 4.3.2. Table 47 (as presented in Chapter 6, Table 36), shows those 13 factors 99 that were found to be statistically significantly associated with dental hospitalisation. 99 High dental treatment needs combines ‘ever had toothache’ and ‘ever had a tooth extracted’. 190 Table 47 Key results: predictors of dental hospital admission by Poisson bivariate and multivariate analysis and age group, p<0.05, 2009 Victorian Child Health and Welfare Survey 1-8 year olds 9-12 year olds 1-12 year olds Factors Bivariate Multivariate Bivariate Multivariate Bivariate Multivariate analysis analysis analysis analysis analysis analysis Child factors Male ✔ High dental ✔ ✔ ✔ ✔ ✔ ✔ treatment needs* Needs services ✔ ✔ ✔ Functional limitation ✔ ✔ ✔ Behavioural ✔ ✔ difficulties Family factors Rural dwelling ✔ ✔ ✔ ✔ ✔ ✔ Concession card ✔ ✔ Socioeconomic status ✔ ✔ ✔ ✔ by SEIFA quintile Annual income less ✔ ✔ than $40,000 Parents education ✔ ✔ Food insecurity ✔ ✔ ✔ Family functioning ✔ Notes: * High dental treatment needs combines ‘Ever had toothache’ and ‘Ever had a tooth extracted’. Multivariate modelling showed that the two most significant factors associated with dental hospitalisation across all age groups were high dental needs (whether a child had a tooth extracted or ever had a toothache), and whether the child lived in a rural area. These factors were independently significant predictors of dental hospitalisation. The other factors that were significant were that a child needed more services for 1-12 year olds, having a parent that had a concession card for 1-8 year olds, and being male for 9-12 year olds. The best fit model in Poisson regression for 1-12 year olds, that is the model with the highest F value, comprised high dental needs (child had an extraction), rural dwelling, and child needed more services. For 1-8 year olds, the best fit model included ‘ever extraction’, rural residence, and that the parent was a concession card holder. Among 9- 12 year olds, the best fit model comprised ‘ever extraction’, rural residence, and ‘male’. 191 It was more likely that children who lived in rural areas did not have access to community water fluoridation. The impact on dental hospitalisation will be discussed under community water fluoridation, section 10.2.2.1. Socioeconomic factors were more significant for the younger age group. This was evident in a clear socioeconomic gradient for 1-8 year olds. The pattern for 9-12 year olds was more U-shaped. There was also a higher likelihood that younger children from families which had run out of food in the previous year were more likely to have been hospitalised. The implications of these findings will be discussed under socioeconomic status, section 10.2.2.4 and 10.5.5. Bivariate analysis determined that in addition to the factors identified by multivariate analysis mentioned above, child factors statistically significantly associated with dental hospitalisation were functional limitations and behavioural difficulties. An additional family factor found to be significant for 1-8 year olds, was a lower level of family functioning. Implications will be discussed further under the relevant categories of the social determinants model. Factors found to be not statistically significantly associated with dental hospitalisation were: country of birth of the child or of the mother; Aboriginal background of the child; family’s health insurance status; household income when ranked in $20,000 bands; parent who perceived that the family had poor access to primary health care; and language spoken at home. Indicative trends were found with several of these factors. Implications of these findings will also be discussed under the relevant categories of the social determinants model. 192 10.2.1.4 Qualitative study – the view of key players The fourth main research project was interviews with dentists, dental therapists, dental public health specialists and hospital admission decision makers to determine their views of the factors that influence the dental hospitalisation of children in Victoria. These interviews provided nuanced insights to complement the quantitative research. While the sample was only a relatively small proportion of the dental and hospital policy professionals in Victoria, it included the most influential people associated with dental hospitalisation in the public sector. Many have also worked in the private sector. The five paediatric dentists interviewed had a combined experience of over 140 years in paediatric dentistry. Similarly the other 13 interviewees are recognised by their peers as authoritative in their field. Fifty hours of focused discussion were conducted over 30 sessions. Additional data were obtained from government documents and websites, professional association reports, text books, and articles. Eight themes were identified through thematic analysis. The themes were: criteria for DGA care; child factors; dental provider factors; parent factors; risk; financial impact; access to general anaesthetic facilities; treatment provided and follow up after DGA care. There was overlap between concepts and links within some of the themes. Key findings within each theme will be discussed under the relevant social determinants factors. 193 10.2.3 Fit of findings to the social determinants model It is clear that a complex interaction of many factors influences whether a child or young adult will experience a dental hospitalisation. This study examined a range of factors that were hypothesised to be associated with frequency of dental hospitalisation in Victoria as in the conceptual social determinants model outlined in chapter 3, Figure 3. Figure 29 highlights (in boxes) factors found to be associated with dental hospitalisation through the research. 194 Figure 29 Factors found to be associated with dental hospitalisation of children and young adults in Victoria Public health policy -Access to fluoridation Food availability Health insurance Dental care system Family income, parents’ education, Age -Access to dental services- concession card status Dental provider factors Gender Environmental structural Socioeconomic and cultural Child intermediary Dental factors context of family factors Hospitalisation Dental treatment needs Country of birth Health care system - Child’s Aboriginal background Behaviour and ability Access to primary care/geographic remoteness Language spoken at home Family function General parent factors Health care system - Access to general anaesthetic facilities 195 Table 48 presents the key results against the factors in the model. Policy implications in the form of recommendations are included against each of the social determinant categories. Further context for each recommendation will be discussed in the policy implications section, 10.5. 196 Table 48 Key results and policy implications of research into associations between social determinants factors and dental hospitalisation of children and young adults in Victoria Social determinants factors Key results of research Policy implications – Recommendations with relevant section Environmental structural determinants Lower PPDH rates in 0 -4 year olds living in fluoridated areas. IRR for children living in non - R1. Extend community water fluoridation Public health policy fluoridated areas 1.72, p<0.0001 in 2008-09 and IRR 1.59, p<0.0001 in 2012-13, when to communities with a population of over 1. Access to community controlling for access to oral health professionals and socioeconomic status. When 1,000 people (10.5.2). water fluoridation controlling for socioeconomic status, IRR 1.78, p<0.0001 and IRR 1.75, p<0.0001, equating R2. Establish programs to extend the to 44% and 43% lower PPDH rates in fluoridated postcodes in 2008-09 and 2012-13*. preventive effects of fluoride to families in small communities or living off the water grid (10.5.2). Higher PPDH rates in 0-4 year olds with the lowest level of access to oral health R3. Enhance screening of young children Dental care system professionals, when controlling for access to fluoridation and socioeconomic status, IRR by primary health care workers to 2. Access to dental services 1.20, p<0.001 in 2008-09 and IRR 1.47, p<0.0001 in 2012-13)*. facilitate early intervention and referral to Increase of 356% in the number of 0-4 year olds accessing public dental services between dental services, particularly for 2001-02 and 2012-13 (from 6,523 to 29,713). Greater increase in rural areas - 487%, disadvantaged children (10.5.3.1). R4. Continue delivery of the CDBS 100 compared to 302% in metropolitan Melbourne (public dental services data). through public and private sectors (10.5.3.1). Variation in DGA case selection among dental clinicians. Guidelines require updating **. R5. Upd ate guidelines for DGA s (10.5.3.2). 3. Dental provider factors Excess supply of dentists and paediatric dentists, and shortage of dental therapists (HWA 3.1 Paediatric dentists 2014). R6. Enhance training of oral health 3.2 General dentists and Changing approach to DGA due to enhanced child focus in health care generally (limit students and providers in: dental and oral health discomfort; ‘do not stress’ the child); increase in safety; treatment shifts 101 ; and parent - alternatives to DGAs for children and 102 therapists demand **. - people-centered care (10.5.3.2). High training debts for paediatric dentists. Potential issue of supplier-induced demand **. R7. Review the need to establish a Younger dentists may not feel competent to treat children in the clinic because they have 100 Child Dental Benefits Schedule. 101 Treatments previously provided in the dental chair, such as extractions for orthodontic care, are increasingly being performed under DGA. 102 Train to the AHPRA code of conduct standards for health professionals. 197 not had the necessary training and experience **. conscious sedation course in Victoria Few Victorian clinicians endorsed to undertake conscious sedation (DBA). (10.5.3.2). Health care system 0-4 year olds living in outer regional postcodes had three times higher PPDH rates than 4. Access to primary health those in metropolitan postcodes (2008-09 - IRR 3.3, p<0.0001, 2012-13 – IRR 2.95, services – geographic p<0.0001), in bivariate analysis*. R8. Use PPDH rates for 0-9 year olds as a remoteness 1-12 year olds living in rural areas had three times higher dental hospitalisation rates measure of health system performance than children living in metropolitan Melbourne (IRR 3.0, p<0.0001), controlling for dental (10.5.4.1). treatment needs and child requiring more services than other children ***. PPDH rates for 0-19 year olds in DH&HS rural regions were 24% higher than in R9. Review the use and definition of PPDH metropolitan Melbourne in 2013-14, with extent varied by age – 64% for 0-4 year olds, rates for people aged 10 years and over as 103 77% for 5-9 year olds, and 8% for 10-19 year olds *. a measure of health system performance No differences in dental hospitalisation rates of children whose parents did, or did not, (10.5.4.1). perceive that they had poor access to basic health services***. (R1, R2, R3 and R4 also relevant) 5. Access to general Hospital and Day Procedure Centre policy can markedly affect access to DGA facilities**. R10. Enhance recording, monitoring and anaesthetic facilities – While some dental clinicians expressed concern at lack of access to GA facilities, there reporting of DGA mortality and morbidity admission policy and may not be a significant issue of access in the private sector**. (10.5.4.2). practice Limited systems for recording, monitoring and reporting on DGA significant adverse events. R11. Expand the number of oral health Main Diagnostic Related Group (DRG) for oral health, D40Z, considered too broad as DRGs (10.5.4.2). cannot reflect the wide diversity of care that is provided**. Socioeconomic and cultural context of family 6. Families socioeconomic status Concession card status Children, 1 -8 years of age, who were dependents of concession card holders, had almost twice the dental hospitalisation rates of children of non-card holder parents (IRR 1.91, p<0.01) in multivariate analysis when controlling for dental needs and rural dwelling***. Private health insurance No difference in dental hospitalisation rates for 1-12 year olds from families with, or without, private health insurance***. 103 Higher PPDH rates in outer regional areas associated with less access to water fluoridation and oral health professionals, and lower socioeconomic status because of their combined impact on dental caries. 198 IRSED quintile score for Clear step -wise socioeconomic (social) gradient for PPDHs in 0-9 year olds, particularly in residential area 0-4 year olds. In 2008-09 in multivariate analysis controlling for access to fluoridation, 0-4 year old children in the most disadvantaged areas (IRSED quintile 1) had PPDH rates 2.5 times higher than children in the most advantaged quintile 5 (IRR 2.52, p<0.0001). In 2012–13, the multiplier was 1.75 times (IRR 1.75, p<0.0001)*. R 12. Enhance evidence-based oral health For 15-24 year olds there was a U-shaped gradient in 2013-14, with the highest rate in the promotion initiatives that prevent dental most advantaged quintile. For those 25 years and over there was not a clear social caries (10.5.5). gradient unlike for other PPH. However, there had been a reverse gradient for each of the previous 10 years*. (R1, R2, R3 and R4 also relevant) Social gradient for 1-8 year old dental hospitalisation rates in bivariate analysis but not for 9-12 year olds***. Level of education of Children, 1 -8 years of age, whose mothers did not c omplete high school, had 2.5 times mother higher dental hospitalisation rates than children of mothers who completed university (IRR 2.56, p<0.004) in bivariate analysis***. Household income Children, 1 -8 years of age, in families with annual household income less than $40,000, had 2.5 times higher dental hospitalisation rates than children in households with incomes of $40,000 and above (IRR 2.52, p<0.001) in bivariate analysis. There was no difference in dental hospitalisation rates for 9-12 year old children by household income at these incomes***. Food security Children from families which had run out of food in the previous year were more likely to have been hospitalised, with higher likelihood amongst younger children – IRR 3.21, p<0.001 for 1-8 year olds in bivariate analysis***. Public or private admission Public and private admissions showed variation by age, location and complexity of care. Children under 0-9 years, rural residents, people with an Aboriginal background, and people requiring complex care more likely to be treated in public hospitals. Over 10 year olds more likely to be treated privately. Shift toward private care - 53% of PPDH in public hospitals in 2004-05, compared to 60% in 2013-14 104 . A higher proportion of DGA occur in the private sector In Australia – 79% of dental admissions by procedure in 2013-14 (AIHW 2015). 104 Private patients totaled 67% in 2013-14 as there were 6% of patients in public hospitals who were private patients. 199 7. Cultural background Higher PPDH rates in Australian born compared to those born overseas *. Further analysis required to determine age adjusted rates. Country of birth of mother No differences between Australian and overseas born found***. R13. Monitor children's PPDH rates, and child Higher dental hospitalisation rates in children of migrants found in international studies particularly those from high risk groups (Literature review, chapter 2). such as children from an Aboriginal Aboriginal or Torres Strait In 2012 -13, Victorians with an Aboriginal background had PPDH rates 11% higher than background and children from culturally Islander background of other Victorians. The national gap was 25% (ROGS 2014). and linguistically diverse backgrounds family In 2013-14, Aboriginal people admitted for a PPDH were more likely to be rural residents (10.5.6). (65% compared to 31% of non-Aboriginal PPDH), young (54% compared to 28% among 0- 9 year olds), and patients in public hospitals (81% compared to 40%) *. Language other than No differences found among 1 -12 year olds in 2009 VCHWS ***. English spoken at home Higher dental hospitalisation rates in children of migrants found in international studies (Literature review). 8. General parent factors Convenience of a GA for income -rich and time -poor fami lies***. Information asymmetry between parents and dental providers***. R14. Increase parents’ and young adults’ Children, 1-8 years of age, from families that had a lower level of functioning were twice oral health literacy about prevention and 105 as likely to have been hospitalised for dental reasons (IRR 2.19, p<0.038), in bivariate alternative options to DGA (10.5.7). analysis. Strong link between family function and disadvantage (DEEDC Report on Victorian children 2010). Child intermediary determinants 9. Age PPDH in 0 –4 year olds: Steep social gradient. Most (90%) dental care for treatment of dental caries. 51% decrease in rates between 2001-02 and 2013-14 (59% decreases in R3 rural and 43% in metropolitan areas). 58% of admissions in public hospitals*. PPDH in 5–9 year olds: Highest rates of PPDH of any age group. Social gradient not as steep as for 0-4 year olds. Most (95%) dental care for treatment of dental caries. Rate of 7.9 per 1,000 population similar to the 2001-02 rate of 8.0 per 1,000 population. Reduction in rates between 2009-10 and 2013-14. Peak age for PPDH has increased from four years in 2004-05 to five years in 2013-14. 52% of admissions in public hospitals*. PPDH in 10-19 year olds: U-shaped socioeconomic gradient with the highest rate in the 105 To allow them to make an informed choice about treatment options. 200 most advantaged quintile for 15 -19 year olds, with gradient flat for 10 -14 year olds. Higher proportion of dental care for extraction of teeth for orthodontic reasons. 63% increase in rates between 2001-02 and 2013-14 (86% increase in rural and 34% in metropolitan areas) from a lower base than 0-9 year olds. 70% of admissions in private R15. Develop Australian guidelines for hospitals*. removal of asymptomatic wisdom teeth (10.5.8). DGA in 15–24 year olds: highest rate of all age groups, with female rates over 60% higher than males (AIHW 2014). 10. Gender In 2013 -14, higher PPDH rates in females, except for 0 –9 year old age group. Overall, 52% of PPDH admissions females *. See ‘Age’ above re higher rates of females admitted for DGA. 11. Dental treatment Children were more likely to have been hospi talised for dental care if they had a tooth needs extracted (IRR 5.57, p<0.0001) or had a toothache (IRR 2.55, p<0.0001), in bivariate R16. Enhance oral health status analysis***. surveillance systems (10.5.10). Increase in children admitted for emergency dental care between 2004-05 and 2013-14*. Limited data available on the population oral health status of Victorian children. Some indication of a decrease in children’s caries rates since the mid 2000’s (2006, 2009 and 2013 VCHWS, Public dental services data). These data show lower caries experience in children living in areas with community water fluoridation. 12. Behaviour and ability Children with behavioural or ability issues were about twice as likely to have been hospitalised for dental care. In bivariate analysis for 1-12 year olds, significant associations (R1, R2, R3, R4 and R12 relevant) were found for children who needed more services than is usual for most children of the same age (IRR 2.02, p<0.001); children who had a functional limitation for 12 months or more (IRR 2.37, p<0.001); and children who had emotional, developmental or behavioural problems (IRR 1.93, p<0.002). In multivariate analysis, controlling for the other 14 child and family factors, the need for services in 1-8 year olds was significant (IRR 2.17, p<0.026). Sources: *VAED, ** Interview with key players, ***2009 VCHWS, **** AIHW. 201 Where linked data was available, the fit of the model was moderate. Multivariate analysis of the VAED for 0-4 year olds and the VCHWS for 1-12 year olds found strong association with factors in the model’s three areas. Independent associations were found in multivariate analysis of the VAED between PPDHs for young children and access to community water fluoridation, socioeconomic status and access to oral health professionals, when controlling for each of the other factors. Analysis of the 2009 VCHWS, found that family (rural dwelling, concession card holding) and child factors (age, high dental treatment need, need for general health services, male), were strongly associated with dental hospitalisation. Other social determinants factors were found to be associated with dental hospitalisation in bivariate analysis as shown in Table 48. Factors not found to be statistically significantly associated with dental hospitalisation in the VCHWS were private health insurance status, country of birth of the child or the mother, and language spoken at home. As raised in the preceding discussion on these factors, they may be associated with dental hospitalisation in other contexts. It became evident from the qualitative research that approaches to dental hospitalisation of children have changed as a result of societal, technical and dental provider influences. While the influences behind a changing approach have been referred to in the discussion on social determinants factors, the impact of these factors on the complexity of decision making related to dental hospitalisation becomes clearer when they are summarised together. The influences can be categorised into six linked areas: child; parent; technical and treatment changes; general dentists; paediatric dentists; and treatment approaches. A common issue raised in the interviews with the key players was the development of an enhanced child focus in health care. This is evident in the approach at the Children’s Hospital of Melbourne, which is ‘to not stress the child’, generally translated into a pain-free policy. In dentistry the enhanced child focus is evident in less acceptance of ‘rough and tumble in the chair’ by dental providers and parents. 202 As identified in the interviews with dental providers, twenty years ago treating a young child under GA was generally seen as a failure by clinicians for not being able to manage care in the dental clinic. This is less likely to be the attitude today. Changes in parent expectations and demands were also mentioned in the interviews. It was noted that some parents appreciate the convenience of a DGA, especially those who are time-poor and asset-rich. The safety of DGA has increased with improved anaesthetic drugs. Also, treatment approaches have changed, such as more orthodontic extractions being undertaken under DGA rather than under local anesthetic in a dental clinic. Most key players perceived that younger dentists are reluctant to treat children in the dental clinic because they lack the necessary training and experience. Paediatric dentist factors included changes in case selection and financial pressures. Training debts can be up to half a million dollars as will be described in 10.5.3.2. Combined with an oversupply of paediatric dentists, also to be discussed in 10.5.3.2, there may be a tendency toward supplier-induced care. All of these changes may be why some senior paediatric dentists are suggesting that DGA can be more widely used. Shifting views of DGA case selection are evident in comparing the 2008 and 2013 editions of the Handbook of Pediatric Dentistry, the influential Australian paediatric text book. As noted in the literature review, the statement in the earlier edition that DGA represented the clinician’s last ‘solution to treating a child’s dental problem’ (Cameron, 2008), is not included in the 2013 edition. The later edition notes that ‘Although most children will cope with dentistry in a normal setting, many may benefit from the delivery of extensive dentistry in one session under GA’ (Alcaino, 2013). The research identified the complex nature of decision making around dental hospitalisation for children at the oral health professional and parent level. Decisions whether children should receive dental treatment under GA can be complex and raise diagnostic conundrums. The interests of the child, parent and dental provider may align or differ. Issues in the social 203 processes between these participants include power relations, information asymmetry, parental guilt, professional prestige, and commercial pressures. Further research with a medical sociology lens would deepen understanding of the complexities related to decision making for DGA. 204 Section 3 10.3 Associated research question one – Australian and international comparisons 10.3.1 Victorian and Australian rates While Victorian PPDH rates have been higher than the Australian average since 2001-02, Victoria was the only jurisdiction where rates decreased between 2005-06 and 2013-14. In 2001-02, Victoria had the third highest PPDH rate of the eight jurisdictions. By 2013-14 Victoria was ranked fifth with a rate just above the national average, 2.8 compared to 2.7 per 1,000 population (AIHW: et al., 2016), as shown in Figure 26. PPDH rates rose in all jurisdictions between 2001-02 and 2013-14, with Victorian rates rising less than national rates. PPDH rates for 0-4 year olds decreased nationally between 2001-02 and 2013-14, with a greater decrease in Victoria – 47 per cent compared to 30 per cent (Figure 27). National PPDH rates for 5-9 year olds increased over this time period while Victorian rates decreased. The greater decrease in PPDH rates in Victorian 0-9 year olds is likely to be linked to extension of community water fluoridation, and increased access to public dental services for young children. These two initiatives have been more extensive in Victoria than in other jurisdictions. The variation in PPDH rates across jurisdictions for people with an Aboriginal or Torres Strait Islander background (Figure 28) is likely to be partly because of the higher proportions of people with an Aboriginal background who live in remote areas in several jurisdictions. In 2012-13, rates were higher in the Northern Territory, Western Australia, South Australia and Queensland. There was less difference in PPDH rates for people with an Aboriginal background in Victoria than the national average 106 . 106 The gap in Victoria was 11 per cent and 25 per cent nationally. The gap between PPDH rates in Aboriginal and non-Aboriginal Victorians is not as great as the gap in PPH between Aboriginal and non-Aboriginal Australians. In 2013-14, Aboriginal Australians were over three times more likely to have a PPH (AIHW 2015 Australian hospital statistics 2015). 205 10.3.2 Victorian and international rates The limited published data available on dental hospitalisation rates for children in high income countries (8.2) indicate that rates for 5-9 year olds are similar in England (Health & Social Care Information Centre 107 ). Victorian rates for 0-4 year olds appear lower than in New Zealand (Whyman R, 2012) (Whyman et al., 2014) and in Manitoba, Canada (Schroth et al., 2014). The proportions of children with an Indigenous background were higher in New Zealand and Manitoba than in Victoria. Dental reasons were the most common cause of admission to hospital for 5-9 year olds in Victoria and England in 2013-14. Just over eight children in 1,000 in this age group were hospitalised for dental caries in both places. Victoria and New Zealand have similar all-age PPDH rates. According to the most recent data published from New Zealand, rates increased in both places from 1997 to 2009 (Whyman et al., 2014). There is some evidence that children’s dental hospitalisation rates are lower in countries where there is a comprehensive universal oral health system (Savanheimo et al., 2012). In Finland, all people are eligible for publicly funded dental services, free of charge at the point of delivery. Nearly all children and adolescents access publicly funded treatment. Conscious sedation is used when a child is extremely non-cooperative, often with high levels of dental fear, and/or when there is need for extensive dental care (Savanheimo et al., 2012, Savanheimo and Vehkalahti, 2014). As in Victoria, dental hospitalisation rates for children were higher in disadvantaged areas in England, Manitoba, and New Zealand. A significant variation in rates across geographical areas is clear in England. Over the period 2010-11 to 2012-13, there was a 66-fold variation in rates of 107 Estimation from data from Health & Social Care Information Centre website accessed on 3 January 2016 at - < http://www.hscic.gov.uk/ >, and population estimates from Wikipedia. 206 admissions for dental caries in 1-4 year olds by Clinical Commissioning Groups (CCG) (Public Health England 2015 108 ). Further analysis is required to compare the extent of variation of admissions for dental caries in 1-4 year olds across geographic areas in Victoria, but it would appear from 2013-14 data that variations are not as great as in England. As described in 5.2.9, the variation in PPDH rates for 0- 4 year olds between local government areas was 18-fold. Further analysis would need to take account of the relative populations of Victorian local government areas and English CCGs. Overall dental hospitalisation rates are higher in Australia than in England, primarily because of higher rates of extraction of wisdom teeth (Anjrini et al., 2014). Further research is required to determine if this is a public health issue; this is discussed in section 10.5.8. 108 Public Health England. The NHS Atlas of Variation in Healthcare: Reducing unwarranted variation to increase value and improve quality, September 2015, accessed 3 January 2016 - Section 4 10.4 Research question two - impact of dental hospitalisation Research question two was ‘What is the extent of morbidity and mortality?’ and ‘What are the costs?’ of dental hospitalisation. 10.4.1 Mortality The mortality rate from DGA is low. Just one death was identified as having occurred among approximately 1.35 million DGA undertaken in Australia between 2000 and 2012 (NCIS 2015). In Victoria, no deaths of 0-14 years olds were identified as having occurred among approximately 73,500 DGA undertaken between 2001 and 2012 (CCOPMM 2014). These data should be considered as indicative as there are several caveats. The Australian mortality data were collected from source material such as the police report of death, autopsy reports, toxicology reports and coronial findings from nine jurisdictions. The National Coronial Information System (NCIS) Unit that compiled the data advised that: This dataset does not claim to be representative of all relevant cases within the time period specified. This may be due to cases still under coronial investigation, missing data, occasional processing and coding errors. It is acknowledged that quality and consistency of these documents may vary between and within each jurisdiction. There are also differences between jurisdictions as to legislation governing the reporting of a death to a coroner, which can impact on the type, quality and quantity of the information collected and reported by each jurisdiction. These differences will have an impact on the information available in the NCIS. The NCIS Unit also indicated that there may different operational processes between jurisdictions. The type of surgery an individual has undergone prior to their death is not routinely recorded in the NCIS, so there is a possibility of under-reporting. 208 While the limitations of the NCIS data appear considerable, the finding of one DGA-linked death in Australia is consistent with the Victorian Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) finding of no DGA-linked deaths in Victoria since 2001, and data from the key players interviewed. The paediatric dentists and dental public health specialists interviewed did not mention any deaths other than that of the child included in the NCIS report. It is evident that the risk of death from DGA in Australia between 2000 and 2012 was extremely low. Investigation of DGA mortality since 2000 indicates that rates may have decreased in Australia, and may be lower than for GA in general. Estimated GA mortality rates published in 2005 were 1:53,000 in all age groups and 1:150,000 in children (Alcaino, 2013). The all age group mortality rate was similar to the rate of 1:58,664 reported for Victoria for the period 2003–05 (Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM). 10.4.2 Morbidity While it is possible to obtain data on DGA mortality via the NCIS and CCOPMM, these data bases do not contain information on DGA morbidity. The VCAAMM also does not capture data on DGA related morbidity. In 2013, Alcaino and colleagues noted that there were no published data on DGA morbidity available for Australia (Alcaino, 2013). A review of the literature up to January 2016 also did not reveal Australian data. The paucity of adequate data on morbidity and mortality has been highlighted in the United States (Lee et al., 2013), and via an international survey of paediatric dentists (Wilson and Alcaino, 2011). The implications for policy will be discussed later in this section. The most common post-operative complaints following DGA reported in the literature are related more to the dental treatment than the GA, predominantly oral pain (Amin et al., 2006) (Alcaino et al., 2000). Other impacts include nausea and vomiting, child and parent anxiety, emotional reaction of the child to tooth loss, bleeding, drowsiness, and sore throat. While 209 common, impacts are generally reported as short term and of mild severity (Needleman et al., 2008, Farsi et al., 2009). Recent qualitative research in the United Kingdom has studied children’s DGA from the child’s (Rodd et al., 2014) and parent’s (Goodwin et al., 2015a) perspectives. In Goodwin and colleagues’ study, children aged 6–11 years maintained a video diary to document their feelings and experiences. Some of the impacts that the children recorded were those identified in earlier studies, such as nausea, bleeding and tiredness. Additional physical and psychological impacts included hunger, disturbed eating, being scared/worried and discomfort from the IV cannula. Positive outcomes included satisfaction that their dental problem was fixed and being given rewards and attention from family members (Rodd et al., 2014). Goodwin and colleagues found that some parents were shocked at the amount of blood and the behavioural state of their child (Goodwin et al., 2015a). Several of the pediatric dentists interviewed noted that the prevalence of nausea and vomiting had decreased since the 1990s because of improved anaesthetic drugs and techniques. Farsi also made this observation based on his review of DGA morbidity (Farsi et al., 2009). 10.4.3 Monitoring and reporting Generally the health care system in Victoria has an excellent safety record with few adverse events. Systems are in place to help to assure and to monitor quality inpatient care which provide public safeguards and can potentially identify serious DGA morbidity. The four domains of the clinical governance policy framework in the Victorian public health system over the period of the study were: consumer participation; clinical effectiveness; an effective workforce; and risk management (encompassing incident reporting and management). Part of the risk management domain was the requirement to report sentinel events 109 . From 2002-03 to 2012-13 there were 109 A sentinel event is a ‘rare event, leading to serious patient harm or death, which is specifically caused by healthcare rather than the patient’s underlying condition or illness’ DEPARTMENT OF HEALTH 2014. Supporting patient safety: Sentinel event program - Annual report 2011–12 and 2012–13. Melbourne: Victorian Department of Health.. Sentinel events are investigated to identify deficiencies in healthcare systems and processes, so that actions can be put in place to either prevent recurrence or reduce harm. 210 just 10 recorded ‘complications of anaesthetic management’ identified through the sentinel event program of the Victorian Department of Health and Human Services (Department of Health, 2014) 110 . These cases covered all procedures on all age groups and may not have caused mortality. In addition to the sentinel event program, all public and private hospitals in Victoria are required to meet Australian Health Service Standards developed by the Australian Commission on Safety and Quality in Healthcare (ACSQHC) 111 . The intention of the national standards is to protect healthcare recipients from harm and improve the quality of health service provision. There have been calls to increase the monitoring of sentinel and serious reportable events in Australian health care services. Jackson and colleagues reviewed the reporting of sentinel events in Victoria and recommended adding more data codes to improve the use of routine patient data collected in Australian hospitals to monitor sentinel and serious reportable events (Jackson et al., 2009). The authors advised caution in omitting voluntary reports because it is possible in these reports to make more nuanced judgments about severity and causation. Internationally there have been calls for enhanced monitoring and reporting of DGA mortality and morbidity as mentioned in 10.4.2. Lee and colleagues analysed media reporting of deaths associated with paediatric dental sedation and general anaesthesia in the US and called for the creation of a national database of adverse outcomes to provide an estimate of the incidence and prevalence of morbidity and mortality (Lee et al., 2013). Papineri McIntosh and colleagues found in their review of the literature on intravenous sedation undertaken in children, that there was inconsistency in reporting of side effects (Papineni McIntosh et al., 2015). They recommended the use of a standardised significant events reporting tool developed by the World SIVA International Sedation Task Force (Mason et al., 2012). 110 The Supporting patient safety: Sentinel event program – Annual report 2011-12 and 2012-13 document was accessed from the DH&HS website on 19 December 2015 - Reporting tools could include outcome variables proposed by Ashley and colleagues for further studies of sedation and DGA. These include common measures of morbidity, patient satisfaction, quality of life, and cost (Ashley et al., 2015). More recent research in England has provided insights into the impact of DGA from the child’s (Rodd et al., 2014) and parent’s perspectives (Goodwin et al., 2015a). Such qualitative studies should be conducted in Australia to help identify what is patient-centred best practice. In addition, development and application of a standardised significant events reporting tool could be considered, as recommended by McIntosh and colleagues in 2014 when they discussed the need for future studies of sedation in paediatric dentistry (Papineni McIntosh et al., 2015). 10.4.4 Costs Costs of dental hospitalisation for children and young adults can be significant. In the private sector, parents pay the facility (hospital or day procedure centre), the anaesthetist, and the treating dentist. The key players interviewed indicated that private dental admissions can cost between $2,500 and $8,000, with most costing between $3,500 and $5,000 (7.7 and 9.3.2). Costs are predominately ‘out of pocket’. Medicare reimbursement is only available for part of the anaesthetist fee. Private insurance rebates may cover only half of the total costs. The average cost of a dental hospitalisation to government through care in the public sector was estimated to be $3,028 in 2012-13 for the most common dental procedures (9.3.4.1). This amount does not include all overheads such as capital costs. The direct cost of dental hospitalisation in Australia is approximately $570 million annually if it assumed that the average cost of a private sector admission is similar to a public sector admission (9.3.4.1). There are also other indirect costs for families such as child care for other children and loss of income from taking time off work. Drummond and colleagues estimate indirect costs of hospitalisation as being 1.5 times direct cost (Drummond et al., 1997). If this were the case for dental hospitalisation, the total cost per year in Australia would be approximately $1.43 billion. 212 Section 5 10.5 Research question three – policy implications 10.5.1 Policy implication principles The third research question was ‘What are the policy implications’ of the findings of the studies undertaken. Policy recommendations have been included in the summary of the key results according to the social determinants model (Table 48). In this section, the basis for the recommendations will be discussed more fully. Given the strong association between the dental hospitalisation of young children and social determinants, it is appropriate that recommendations about policy should be considered through an equity lens. According to the World Health Organisation, equity is the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically 112 Oral health inequalities are considered to be differences in levels of oral health that are avoidable and deemed unfair and unjust (Watt et al., 2016) 113 . All those interviewed in the qualitative study agreed that it is preferable to prevent dental disease, and when there is disease, to manage it through early intervention. Alternatives to dental hospitalisation will be discussed under dental care system factors. Prevention of PPDHs will be addressed under socioeconomic factors because of the strong association between poor oral health and disadvantage. Socioeconomic status plays a role in health behaviour, environmental exposures and health care utilisation (Lee and Divaris, 2013). The recommendations provide a starting point for discussion. Some are general and others more specific. Details about responsible parties, costs, and timelines will need to be negotiated. Recommendations for further research that is required will be outlined in section 10.7. 112 Accessed from the World Health Organisation (WHO) website 9 January 2016 - http://www.who.int/healthsystems/topics/equity/en/ >. 113 Watt and colleagues note that the term disparities and inequities are also used in different contexts but essentially have a similar meaning to inequality . 213 Environmental structural determinants 10.5.2 Public health policy Access to community water fluoridation Analysis of the VAED Multivariate analyses of Victorian PPDHs in 2008-09 and 2012-13 (5.3.3) determined that living in an area without community water fluoridation was associated with higher PPDH rates among 0-4 year olds after controlling for socioeconomic status and access to oral health professionals. Children living in postcodes without community water fluoridation had higher PPDH rates (72 per cent in 2008-09 and 59 per cent in 2012-13) than their counterparts in fluoridated postcodes after controlling for access to oral health professionals and socioeconomic status (Model 2, Tables 30 and 31). These differences equate to 42 and 37 per cent lower PPDH rates for children living in fluoridated compared to non-fluoridated postcodes. When controlling for socioeconomic status (Model 3, Tables 30 and 31), postcodes without community water fluoridation had 78 and 75 per cent higher PPDH rates than their counterparts in fluoridated postcodes, equating to 44 and 43 per cent lower PPDH rates in fluoridated postcodes for 2008– 09 and 2012–13. Analysis of the 2009 VCHWS The results of the analysis of the 2009 VCHWS supported the preventive impact of community water fluoridation on PPDH rates for 1-12 year olds. While families’ access to community water fluoridation was not recorded, children who lived in rural areas were less likely to have access to community water fluoridation than children who lived in Melbourne. In multivariate modelling that controlled for other child and family factors, rural residence was a statistically significant factor in dental hospitalisation. 214 General discussion The link between community water fluoridation and lower PPDH rates is the dental caries preventive effect of fluoride (National Health and Medical Research Council [NHMRC]) 114 . As identified in the analysis of the principal diagnosis codes for PPDHs in 5.2.5, the principal diagnosis for 90 per cent of Victorian 0–4 year olds who had a PPDH in 2013-14 was dental caries. The reduction in PPDH rates between 2008–09 and 2012–13 among 0–4 year olds may be partly attributed to the extension of community water fluoridation in Victoria over this period. While Melbourne’s water supplies have been fluoridated since 1977, most rural water supplies have only been progressively fluoridated since the mid 2000’s. In 2005, three quarters (76 per cent) of Victorians could access fluoridated water. A concerted Victorian Government effort extended coverage to 90 per cent by 2011(Neil, 2011). The impact on dental hospitalisation of community water fluoridation and socioeconomic status has been shown in four previous studies: in Victoria among under 15 year olds (Department of Human Services, 2007); in Israel among under 18 year olds (Klivitsky et al., 2015); and in two studies in England among under five year olds (Public Health England, 2014) 115 (Young et al., 2015). The lower dental hospitalisation rates of children living in fluoridated compared to non- fluoridated postcodes – 44 per cent in 2008–09 and 43 per cent in 2012–13 – found in this study are consistent with the findings of comparatively lower rates of 53 per cent (Klivitsky et al., 2015), 45 per cent (Public Health England, 2014), and 55 per cent (Young et al., 2015). The current study also found that access to community water fluoridation was associated with dental hospitalisations for 0-4 year olds when controlling for access to oral health professionals as well as socioeconomic status. The international studies noted above did not control for access to dental care. 114 Accessed from the NHMRC site on 6 January 2016 - In 2016, 90 per cent of Victorians have access to reticulated fluoridated water (Australian Government, 2015). About half of the 10 per cent of Victorians without access to optimally fluoridated water are connected to water grids, while the remaining five per cent depend on rain water tanks for their supply. The situation is as described by Neil in 2011 with more than half a million Victorians able to benefit from the extension of community water fluoridation (Neil, 2011). Fluoridation of drinking water remains the most effective and socially equitable means of achieving community-wide exposure to the caries prevention effects of fluoride (National Health and Medical Council 2013 - NHMRC 116 ). Australia’s National Oral Health Plan 2015-2024 , recommends the extension of community water fluoridation to communities with populations of over 1,000 people, and to extend access to the preventive benefit of fluoride to smaller communities (Australian Government, 2015). The National Oral Health Plan recommends that extending community water fluoridation to smaller communities should be considered to redress oral health inequalities. Improved design and reduced costs of small fluoridation plants make this more feasible. For families that are off the water grid, other approaches to extend access to the preventive effects of fluoride should be considered. Initiatives include use of fluoridated bottled water, and toothbrushing or fluoride mouth rinsing programs in schools. A further option is fluoride varnish programs for children at high risk to dental caries. These could be integrated into other primary health care services such as the Maternal and Child Health nurse program. Non-registered oral health professionals have been shown to be able to apply fluoride varnish to young children’s teeth in the Northern Territory (Rogers, 2011). Recommendation 1: Extend community water fluoridation to communities with populations of over 1,000 people. 116 Accessed from the NHMRC website on 6 January 2016 - Recommendation 2: Establish programs to extend the preventive effects of fluoride to families in small communities or living off the water grid. 10.5.3 Dental care system 10.5.3.1 Access to dental services Access to dental services was included as a factor in the social determinants model because of the concept behind PPHs, that PPHs may be prevented if there is access to primary health care before a hospitalisation is required. The association between PPDHs and access to dental services was assessed in multivariate analysis of the VAED for 2008-09 and 2012-13 by determining access to oral health professionals by post code. Analysis of the VAED As identified in the methodology, 4.3.1.2, the rate of dentists by post code was used in the analysis of 2008-09 VAED data, and the rate of dentists, dental therapists, and oral health therapists was used in the 2012-13 VAED data analysis. Statistically significant associations with PPDH rates were found for 0-4 year olds. In bivariate analysis, children living in post codes with the lowest level of access had PPDH rates twice as high as children living in postcodes with the highest level of access in 2012-13 (Table 31). In Model 1, access to oral health professionals was the third strongest predictor of PPDH rates, after remoteness and socioeconomic status quintile 1 (Tables 30 and 31). In Model 2, access to oral health professionals was the weakest predictor of PPDH rates after access to community water fluoridation and socioeconomic status (Tables 30 and 31). General discussion The stronger association between lower PPDH rates for 0-4 year olds and access to oral health professionals in 2012–13 compared to 2008–09 is likely to be linked to the increased access to 217 public dental care for preschool children over these five years in Victoria. The number of 0-4 year olds accessing public dental care increased by 62 per cent between 2008-09 and 2012-13, from 18,367 to 29,713 (DHSV data accessed 2014). Enhanced access may partially explain the decrease in PPDH rates for 0-4 year olds of 20 per cent over this time as shown in Figure 17. Also, access increased proportionally more in rural areas where the decrease in PPDH rates was greater. In rural areas, access to public dental services by 0-4 year olds increased by 89 per cent, with a 23 per cent decrease in PPDH rates, compared to a 49 per cent increase in access in metropolitan Melbourne and an 18 per cent decrease in PPDH rates. Access to public dental services for young children has consistently increased since 2001-02, which may have contributed to the decrease in PPDH rates for this age group over this time. As between 2008-09 and 2012-13, the increase in access has been proportionally higher in rural regions where the decrease in PPDH rates has been greater. The significant increase in the number of 0-4 year olds accessing public dental care between 2001 and 2014, particularly in rural areas, is likely to have contributed to the reduction in PPDH rates over this time. Increases were almost 3.5 times in rural areas and three times in Melbourne. Children with the lowest level of access to oral health professionals had 47 per cent higher PPDH rates than children with the highest access in 2012-13, when controlling for socioeconomic status and access to community water fluoridation (10.5.2). The impact on PPDH rates by socioeconomic status was 70 per cent 117 , and by access to community water fluoridation, 59 per cent, in modelling including these three factors. Screening for oral health problems and facilitating early intervention is important. Mathur and colleagues found that interventions to address the relative influence of deprivation were successful only in individuals that were disease free, highlighting the need to intervene early (Mathur et al., 2014). 117 Comparing 0-4 year olds living in the most disadvantaged IRSED quintile with 0-4 year olds living in the most advantaged quintile. 218 Primary health care workers have been shown to be able to screen young children for oral health problems and to refer for dental care when appropriate (Rogers, 2011). Workers who can perform this role include Maternal Child Health nurses, general medical practitioners, and Aboriginal/Indigenous health workers. It is essential to have a robust referral system so that dental care is readily accessible. Enhanced access for 0-4 year olds has been assisted since 2013 by the introduction of the Child Dental Benefit Schedule (CDBS) by the Commonwealth Government. Under the CDBS, lower income families receive financial support for basic dental services for children aged 2–17 years 118 . As at February 2016, the Commonwealth Government had only assured public sector provision under the CDBS until 30 June 2016. Recommendation 3: Enhance screening of young children by primary health care workers to facilitate early intervention and referral to dental services, particularly for disadvantaged children. Recommendation 4: Continue delivery of the Child Dental Benefits Schedule (CDBS) through the public and private dental sectors. 10.5.3.2 Dental provider factors The research found significant changes in the number and practice of dental providers in Victoria over the last 20 years. Interviews with key players identified changes within the paediatric dentist, general dentist and dental therapist work forces. Issues that emerged concerned case selection for DGA, workforce imbalances, training in alternatives to DGA and people-centred care. These issues will be discussed after considering the changes in the three workforce groups and clinician practice style. 118 Accessed from the Department of Human Services website on 19 January 2016 - 219 Paediatric dentists The five main issues concerning paediatric dentists that came from the interviews with key players were case selection; enhanced child focus; quality of dental care; the increased number of paediatric dentists; and the financial viability of private practices. Case selection is discussed below under guidelines for dental hospital admission. Case selection and possibly the viability of a paediatric dentist’s private practice contribute to ‘physician practice style’, a factor linked to rates of potentially preventable hospitalisations (Ansari 2007). The association with dental hospitalisation will be discussed in the following section on oral health clinician practice style. While all dental clinicians indicated that a DGA was required for some children and young people with high dental treatment needs and/or behavioural issues, views about thresholds varied. Some paediatric dentists considered that the Australasian Academy of Paediatric Dentistry (AAPD) guidelines published in 2005-06 required updating. Interviewees working in the public system noted that there were no standard Australian policy guidelines for referral for publicly funded DGA. There was consensus from paediatric dentists that there is now an enhanced child focus in health care including changes in behavioural management techniques used in dentistry. There is now less acceptance by children, parents and dental providers of ‘chasing the child’ and ‘rough and tumble’ in the dental chair. This shift is evident at the Royal Children’s Hospital in Melbourne where accepted best practice is to be kinder and, ‘not stress the child’, with a ‘pain free’ policy. Procedures previously undertaken under local anaesthesia, such as lumbar punctures, are now conducted using short acting general anaesthesia. There is widespread use of nitrous oxide sedation in the hospital medical clinics and its use has also increased in the hospital dental clinic. In relation to quality of dental care, treatment under a DGA can provide high quality care, especially if the anaesthetic session is sufficiently long, and if intubation can be nasal instead of oral. However, limitations were raised by several of the interviewees and highlighted in the literature review. A DGA does not necessarily reduce a child’s anxiety toward dental care in a dental clinic. It is important to follow up with the child and their family after hospitalisation through preventive checkups in a dental clinic (Klaassen et al., 2009) . 220 The increased number of paediatric dentists is evident in the registration data from the Dental Board of Australia 119 (DBA). In 1995 there were four paediatric dentists, three in the public and one in the private sector (Australasian Academy of Paediatric Dentistry (AAPD), 2013). In September 2015, the number had increased to 34, most working in the private sector 120 . The ratio of the specialty to population was similar across Australian states and territories (0.49 to 100,000) except for a higher ratio in Victoria (0.55 to 100,000) and in Tasmania and the Northern Territory where there were no registered specialists. A 2014 Health Workforce Australia (HWA) report on the future of Australia’s oral health workforce assessed that there was ‘no current perceived shortage’ 121 of paediatric dentists in the private sector in metropolitan areas and that the supply of paediatric dentists will ‘exceed demand in the near future’ (Health Workforce Australia, 2014). In the public sector and rural and remote areas, there was some level of expressed demand that exceeded the available paediatric dentist workforce. The assessment was made after predicting future workforce supply and demand, as determined from expert opinion, from jurisdictions, and from the profession (Health Workforce Australia, 2014). Estimates of an excess of paediatric dentists were based on 2012 registration data. Between 2012 and September 2015 122 there was a 37 per cent increase in the number of paediatric dentists registered in Australia - from 90 to 123 123 , which has increased the extent of over supply. 119 To be eligible to gain registration with the DBA as a paediatric dentist, a person must be a qualified dentist, have a minimum of two years general dental practice experience, and complete an approved postgraduate program of study in paediatric dentistry. There are five approved three-year Doctor of Clinical Dentistry in Paediatric Dentistry programs in Australia. 120 Accessed from DBA website on 12 December 2015 - In their submission to the HWA review, the AAPD expressed concern about the impact of the high tuition fees charged by universities to complete both general dental and specialist qualifications. Graduates ‘expect higher financial returns in the private sector to justify their investment in their education and/or pay off their student loans’ (Australasian Academy of Paediatric Dentistry (AAPD), 2013). Student fees can be considerable. A domestic (Australian) student at the Melbourne Dental School, on graduation with a Doctor of Clinical Dentistry (DCD) that allows them to register as a paediatric dentist, would incur tuition fees of $220,000 to $437,000. The pathway at the University of Melbourne involves obtaining a Bachelor of Medical Science (BMSc) and then a Doctor of Dental Surgery (DDS), as described in Box 10.1. 222 Box 10.1 Student fees to qualify as a paediatric dentist at the University of Melbourne 124 The qualification to become a paediatric dentist at the Melbourne Dental School, University of Melbourne, is the Doctor of Clinical Dentistry (DCD). The candidate for this three year fee paying course must be a registered dentist. The fee in 2016 is $39,552, and the indicative total course fee is $129,688. International students will pay $57,728 in 2016 with a total course fee of $181,988. The qualification required to become a dentist at the Melbourne Dental School is the Doctor of Dental Surgery (DDS), a four year graduate entry course. The composition of the 90 places available each year is a mix of domestic Commonwealth Supported Places (CSP), domestic full fee paying places, and international places. The CSP are subsidised by the Australian Government. Students that access a CSP pay a contribution amount that is determined by the Australian Government, based on the subjects undertaken. These students can receive a loan under the Higher Education Contribution Scheme (HECS) 125 . They are required to repay the loan after graduation when their income reaches a certain level. The indicative total course fee for the four years is approximately $50,000. The 2016 fee for a domestic full fee paying student in the DDS course is $62,112. The indicative total course fee for the four year course is $267,711 for a domestic student and $320,950 for an international student. The typical entry to the DDS is the three year Bachelor of Medical Science (BMSc) degree offered by the University of Melbourne. Domestic students enroll in a CSP or a full fee paying place. The 2016 fee for a CSP is $10,440 and the indicative total course fee is approximately $40,000. The 2016 fee for a full fee paying place is $59,600, which would indicate a total course fee of approximately $200,000. A domestic student on graduation as a paediatric dentist in the future would incur, at minimum, in 2016 dollars, approximately $40,000 for the BMSc course, $50,000 for the DDS course, and $129,688 for the DCD course, a total of almost $220,000 ($219,688). If the student had filled a full fee paying place in the DDS course, they would incur a total of approximately $437,000 ($437,399). If they had also filled a full fee paying place in the BMSc course, they would incur a total of approximately $637,000. 124 Accessed from the University of Melbourne website on 10 December 2015 - Dentists The consensus from the interviews with dental providers was the perception that younger dentists are reluctant to treat children through a lack of confidence because they have not had the necessary training and experience. Most dentists do not offer conscious sedation. The limited training of dental students in treating children, and the few continuing professional development courses on alternatives to DGA were mentioned. It was noted by a paediatric dentist that a dental student could graduate without having performed a block local anaesthesia (a more difficult injection in the back of the mouth). The proportion of Victorian dentists offering conscious sedation is lower than that in Wales and also in New South Wales. Dental practitioners must be endorsed by the DBA to undertake conscious sedation. In December 2014, there were five Victorian practitioners with endorsement out of a total of 86 Australian practitioners (DBA 2015). This was a reduction from the six Victorian practitioners endorsed in December 2013. By comparison, there were 46 practitioners endorsed in New South Wales in both of these years. By population, New South Wales had seven times more practitioners endorsed than Victoria in 2014. One interviewee stated that it was a ‘tragic loss of opportunity that there is no course of training in intravenous sedation available in Victoria’ and that ‘There is a desperate need for a wider range of options than avoidance of treatment or full general anaesthesia’. There is a need to understand the barriers faced by Victorian dental practitioners to becoming endorsed to undertake conscious sedation. It is likely that training and cost of equipment are key issues. The 2014 HWA report assessed that there was a perceived excess supply of dentists in Australia. That is that the current workforce ‘exceeds existing expressed service demand, including across geographic areas’ (Health Workforce Australia, 2014). In 2012, there were 12,767 practicing dentists who reported their primary role as a clinician in Australia (Health Workforce Australia, 2014). 224 Dental and oral health therapists Dental therapists are the primary health care worker for children in public dental programs. They have proved capable of providing high quality care (Nash et al., 2014). Oral health therapists are dual qualified as a dental therapist and dental hygienist. Both dental therapists and oral health therapists work in a structured professional relationship with a dentist. Interviewees noted that more private general dental practices are employing dental therapists and oral health therapists to treat children. The HWA assessed that there was a national shortage of dental therapists - that is ‘some level of expressed demand exceeding the available workforce’ (Health Workforce Australia, 2014). In 2012 there were 1,006 dental therapists practicing as clinicians (Health Workforce Australia, 2014). The position of oral health therapists was assessed as ‘no current perceived shortage’ (Health Workforce Australia, 2014). In 2012 there were 642 employed as clinicians. The HWA commented that funding constraints in the public sector result in most oral health therapists working in the private sector (Health Workforce Australia, 2014). Dental and oral health therapists are being used in targeted public sector programs to reduce the number of children requiring dental hospitalisation. They provide care to children referred for a DGA and have been successful in treating children in the dental surgery, avoiding the need for hospitalisation. These programs were described in the literature review (2.11). Oral health clinician practice style Key players interviewed commented on the variation in the threshold dental clinicians use to determine whether a child requires dental hospitalisation. The importance of DGAs to the financial viability of a paediatric dentist practice was also raised. These two elements may influence ‘practice style’, a factor linked to PPHs (Ansari, 2007). Ansari in his review of factors that influence PPHs, noted that physician practice style including hospital admitting practice, can be associated with PPH rates (Ansari, 2007). Australian 225 (Jamieson and Roberts-Thomson, 2006) and New Zealand (Whyman et al., 2014) researchers have suggested that oral health clinician style may influence dental hospitalisation rates. Jamieson and Roberts-Thomson suggested that one possible reason for the increased rate of dental hospitalisation of Australian children between 1997-98 and 2003-2004 was the increased number of paediatric dentists, ‘whose preferred modality for treatment may be a general anaesthetic’ (Jamieson and Roberts-Thomson, 2006). Whyman and colleagues proposed that the ‘changing pattern of dental practice’ may help explain the trends in the dental hospitalisation of children and young people in New Zealand (Whyman et al., 2014). Dental hospitalisation is to some extent what investigators of medical practice variation call ‘preference-sensitive’ (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2013) 126 . Variation may reflect differences in patient or clinician preferences or cost. A 2013 review by the ACSQHC into medical practice variation noted that information asymmetry in health care can be an issue, and that patient preferences can be driven by clinicians. This phenomenon is referred to as ‘supplier-induced demand’ (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2013). The other driver of medical care variation identified in the ACSQHC report was ‘supply- sensitive care’ – when more resources, equipment and workforce are available, the more they will be used (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2013). Where the impacts of such additional inputs have been studied, ‘often there is no evidence that this leads to better outcomes than in areas where less intervention is practiced’ (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2013). . Supplier-induced demand may have been a factor in one of the case studies of dental hospitalisation presented (Case study B, section 7.5). The increase in the paediatric dentist workforce and the need to repay large student loans may be relevant. Several paediatric dentists expressed concern that a DGA was sometimes used as a first rather than a last resort. 126 Accessed from the Australian Commission on Safety and Quality in Health Care (ACSQHC) website on 19 January 2016 - However, the dental hospitalisation rate of 0-9 year olds in Victoria has fallen over the last year, which may indicate that supplier-induced demand is not a major factor. The importance of acknowledging the information asymmetry between parents and providers, and the need for informed consent for care, will be discussed in the section on policy implications. Guidelines for DGA While all dental clinicians interviewed indicated that DGA was required for some children and young people with high dental treatment needs and/or behavioural issues, views about thresholds varied. Some saw a DGA as the last resort, while others had a lower threshold for hospitalisation. Several paediatric dentists considered that the guidelines published by the AAPD in 2005-06 required updating. Interviewees working in the public system noted that there were no standard Australian policy guidelines for referral for publicly funded DGA. The main hospital that provides public DGA in Victoria, the Royal Dental Hospital of Melbourne (RDHM), has referral guidelines for dentists in the public and private sectors. Several interviewees suggested that these require review. Other states and territories have their own arrangements. There may be some benefit if jurisdictions share their guidelines and, where appropriate, develop consistent guidelines for DGA in the public dental sector in Australia. It is also timely to examine Australian guidelines such as those developed by the Australasian Academy of Paediatric Dentistry (AAPD) and published in 2005-06. Development of new guidelines would need to take into account the changing approach to DGA discussed in 10.2.3 - an enhanced child focus in health care generally; increased DGA safety; treatment shifts; and parent demand. Recommendation 5: Update guidelines for DGAs. 227 Workforce imbalance The HWA examination of supply and demand in the oral health workforce concluded that there was generally an excess supply of dentists and paediatric dentists, and a shortage of dental therapists (Health Workforce Australia, 2014) 127 . Professional associations such as the ADA and the AAPD have expressed concern about the oversupply of dentists and paediatric dentists respectively. The Public Health Association of Australia (PHAA) has advocated for a more cost- efficient, flexible and multi-skilled oral health workforce (PHAA policy) 128 , that would be more likely to include more oral and dental health therapists. Oversupply of dental providers can lead to supplier-induced demand as discussed under oral health clinician practice style. High training debts may also influence clinical decision making. Planning the oral health workforce to meet community needs effectively and efficiently is challenging, but essential. Higher education in general, and dental education in particular, face financial pressures. Existing funding arrangements can make it more financially viable for the training institutions to train an inappropriate workforce mix – for example training three times as many dentists as oral health therapists. How can the dental education system be shaped to respond to community oral health needs as in the bicycle model (Figure 30). Section 10.7 outlines further research required in this area. 127 Accessed from the Department of Health website on 19 January 2016 - Figure 30 The oral health education system synchronized to meet oral health needs 129 . DENTAL EDUCATION SYSTEM COMMUNITY ORAL HEALTH NEEDS Training in alternatives to DGA Child-centred and minimum intervention approaches have been shown to reduce the number of children requiring a DGA in two recent Australian projects described in the literature review 130 (Arrow and Klobas, 2015)(2.11). These initiatives provide evidence for techniques that should be emphasised in the training of oral health clinicians. Australian dental school curricula could be strengthened in the areas of child management and MID-ART approaches. The use of fluoride varnish, silver fluoride and Hall crowns could be emphasised. Teaching of these approaches should help address the issue raised in the interviews, that younger dentists may not feel competent to treat children in the dental clinic because they have not had the necessary training and experience . 129 The seat of the bicycle can be considered as ‘community comfort’, the handle bars as 'policy’ for steering, and the pedals as ‘government support’ that is providing power. The source for the model is Wright and Morgan, personal communication, 8 February 2016. 130 Accessed from the Dental Health Services Victoria (DHSV) website on 7 March 2016 - People-centred care The code of conduct for registered health practitioners outlines approaches for people-centred care. The code ‘seeks to assist and support registered health practitioners to deliver effective regulated health services within an ethical framework’ 131 . The code outlines what good care involves, including ‘ not exploiting the vulnerability or lack of knowledge of patients or clients when providing or recommending services’ , ‘providing treatment options based on the best available information and not influenced by financial gain or incentives’ , and ‘supporting the right of the patient or client to seek a second opinion’ . The code highlights the need to recognise ‘that there is a power imbalance in the practitioner– patient/client relationship’ which should not be exploited. Informed consent is considered to be ‘a person’s voluntary decision about healthcare that is made with knowledge and understanding of the benefits and risks involved’ 132 . Recommendation 6: Enhance training of oral health students and providers in: • alternatives to DGAs for children, and • people-centered care as per the code of conduct for registered health practitioners. As outlined earlier, the proportion of Victorian dentists endorsed by the DBA to offer conscious sedation is about seven times less than dentists in New South Wales. There is a need to understand the barriers faced by Victorian dental practitioners to become endorsed. It is likely that training and cost of equipment are key issues. The only course for training dentists in conscious sedation in Australia is in Westmead, Sydney. No course has been available in Victoria since the 1980s. 131 Accessed from the Dental Board of Australia website on 1 May 2015 - Recommendation 7: Review the need to establish a conscious sedation course in Victoria. 10.5.4 Health care system 10.5.4.1 Geographic remoteness and access to primary health services Analysis of VAED Children living in outer regional areas were far more likely to have had a PPDH than children living in major cities. The ratios for 0-4 year olds were about three times in bivariate analysis and twice in multivariate analysis when controlling for access to oral health professionals, access to community water fluoridation, and socioeconomic status (Tables 29 and 30). Children living in outer regional areas were more likely to have relatively lower socioeconomic status, and less access to both oral health professionals and community water fluoridation. Analysis of 2009 VCHWS In the 2009 VCHWS, perceived access to basic health care was measured. The question was whether ‘There is access to basic health services, such as a health centre or medical clinic in this neighbourhood’, and did not specifically mention access to dental care. There were a similar proportion of children whose parents perceived that they had poor access in the overall sample (6.5 per cent), as in the group whose child had been hospitalised for dental reasons (7.3 per cent). The association with PPDH rates was not statistically significant for any of the age groups studied (Tables 33, 34 and 35). That a difference was not found may be because almost all parents perceived they had good access (over 90 per cent) and the question was not sufficiently sensitive to capture differences. Further analysis is required into this finding as other results showed significantly higher dental hospitalisation and PPDH rates in rural areas where, in general, there is less access to health services. 231 General discussion Dental hospitalisation rates in 1-12 year olds in 2009, and PPDH rates in 0-19 year olds for each year from 2001-02 to 2013-14, were higher in rural areas. This is likely to be associated with higher dental caries prevalence due to rural residents’ relatively lower socioeconomic status and less access to community water fluoridation. Relatively greater decreases in rural PPDH rates compared to Melbourne rates among 0-4 year olds from 2001-02 to 2013-14 are likely due to extension of community water fluoridation, and better access to public dental services (10.5.2). Groups with higher PPDH rates include children and young adults with special needs and children with an Aboriginal or Torres Strait Islander background. PPDH rates as a measure of health system performance As mentioned in the literature review, rates of PPH are used in Australia as a measure of health system performance. Using PPDHs for this measure may be more appropriate in younger age groups rather than all age groups. Reducing PPHs is a specific objective in health care reform in Australia to reduce pressure on hospitals and enhance health system efficiency and cost-effectiveness (Katterl et al., 2012). As outlined by Ansari, based on his review of PPHs, changes in PPH rates over time can ‘ help pinpoint gaps in the health system, providing opportunities for targeted public health and health services interventions’ (Ansari, 2007). Rates of PPH can assess the effectiveness of interventions, contribute to improving efficiency, and identify communities with greater problems in accessing primary health care (Ansari, 2007). The major proximal reason for the dental hospitalisation of 0-9 year olds is dental caries. Dental caries is amenable to prevention and generally can be managed in a primary dental care clinic at an early stage. Rates of PPDH for this age group are therefore a useful measure of health system performance. 232 Hospital admission rates for dental caries in children aged 1-4 years are used in England as an indicator of health system performance (Public Health England, 2015a) 133 . In Victoria, PPH rates in five year age groups, commencing for 0-4 year olds, have been collected and reported since 2001-02. As 5-9 year olds have the highest PPDH rates in Victoria and Australia, it would be beneficial to use PPDH rates for 0-9 year olds as an indicator. A combined 0-9 year old rate, as well as rates for 0-4 year olds and for 5-9 year olds, could be monitored. Recommendation 8: Use PPDH rates for 0-9 year olds as a measure of health system performance. The definition of PPDHs excludes treatment of oral health conditions that are not considered to be preventable such as impacted wisdom teeth. However treatments such as the extraction of teeth for orthodontic reasons are included in the PPDH definition. These extractions were previously mostly undertaken in a primary health setting and now more people are choosing to have treatment under DGA. It may be appropriate to review the conditions included within the definition of PPDHs. Use of the current definition is sound for calculating PPDH rates for 0-9 year olds, as over 90 per cent of admissions in this age group are for dental caries. But should, for example, the definition include the extraction of healthy teeth for orthodontic reasons? There may be merit in reviewing the use of PPDHs rates for those 10 years and older as a measure of health system performance. The current definition of what principal diagnoses are considered to be PPDHs could be examined. Classification of all PPDHs as acute conditions could also be reviewed. Any review could consider the socioeconomic profile of PPDHs for older age groups. While there was a social gradient in PPDH rates among 0-9 year olds in 2013- 14, the highest rates for 15-19 year olds were among those living in the most advantaged IRSED quintile. There was no clear social gradient for those 25 years and older. 133 Accessed via Public Health England website on 19 January 2016 at - Recommendation 9: Review the definition and the use of PPDH rates for people aged 10 years and older as a measure of health system performance. 10.5.4.2 Access to general anaesthetic facilities - admission policy and practice The research identified three key issues related to access to general anaesthetic facilities with potential ramifications for policy. These are general access policies, systems for monitoring adverse events, and the limited number of dental DRGs. Enhanced access to general anaesthetic (GA) facilities for dental care has been proposed as a reason for the increased dental hospitalisation of children in Australia (Jamieson and Roberts- Thomson, 2006) and in New Zealand (Whyman et al., 2014). Data about the influence of access to GA facilities on dental hospitalisation in Victoria were obtained from interviews with key players, a review of the Department of Health & Human Services (DH&HS) policy documents, and review of grey literature such as dental association reports. The main issues identified were: hospital admission policy changes; concern from the dental profession about limited access to GA facilities; general factors that may affect access; and the limited number of dental Diagnostic Related Groups (DRGs). These will now be discussed. Hospital admission policy changes Hospital admission policy changes can markedly impact access. An example was a change in policy by the then Victorian Department of Health in 2011. Patients who attended emergency departments could not be recorded as an admission if they were admitted directly to a public hospital bed. Total public hospital admissions decreased in 2012-13 compared to 2011-12 then increased again in 2013-14 as hospitals established different arrangements for this group 134 . A key player noted that a policy change in New South Wales in 2005 had a considerable impact on PPDH admissions for children in that state. Access to public hospital GA facilities by private 134 Admissions for PPDHs decreased by 11 per cent in 2012-13, followed by an increase of six per cent in 2013-14 (VHISS 2011-12, 2012-13 and 2013-14). 234 dentists and paediatric dentists was restricted. The ‘all services for children free’ policy was stopped and access to theatres required approval by an authorised person. This led to a significant reduction in public dental hospitalisation. Concern from the dental profession about limited access to DGA The lack of access to dental GA facilities has been highlighted as an issue for oral health professionals by paediatric dentists and the Australian Dental Association (ADA). The ADA Victorian Branch (ADAVB) conducted a survey to quantify the problem in 2014. In a 2013 forum to discuss the preparation of Australia’s Oral Health Plan 2015-2024 , paediatric dentists cited limited access to DGA facilities as one of the key oral health issues for children in Australia. The ADA has identified a reduction in private insurance rebates to facilities as one reason for difficulty in dentists being able to access theatres 135 . In 2014, the ADAVB conducted a survey of their members to explore the issue of access to GA facilities. The seven per cent response rate was lower than usual for ADAVB surveys. Most respondents were general dentists (88 per cent), while four per cent were paediatric dentists, three per cent oral and maxillofacial surgeons, and three per cent special needs dentists. Three per cent of respondents indicated that they did not refer patients for treatment under GA because there ‘was no access to GA’ . Some respondents commented that it was difficult to access appropriate DGA for their patients in their area, and so needed to refer patients to other practitioners, requiring patients to travel long distances to receive care. Other respondents commented on the expense to patients admitted to private day procedure facilities which some could not afford. Oral health professionals interviewed noted that only some oral health clinicians complained of lack of access to GA facilities. Interviewees stated that the clinicians who appreciated that private hospitals and day procedure centres needed to make a profit, and so arranged their cases 135 ADA policy statement 2.7.3 Adopted April 2013, accessed via ADA website on 20 March 2016 – There has been a shift to privately funded care over the last 10 years in Victoria. The proportion of total PPDHs admissions to private hospitals increased by 13 per cent from 2004-05 to 2013-14 – from 53 to 60 per cent (5.2.4). Increases in PPDHs have occurred in facilities in outer Melbourne suburbs where a higher proportion of young families live. There has been an increase in the number of private PPDHs in hospitals in higher socioeconomic areas and an increase in public PPDHs in hospitals in more disadvantaged areas. These shifts in PPDH provision may be an indication that the access issue is being overcome by most providers. The low response to the ADAVB survey, the comments from the key players interviewed, and the increase in the number of private PPDHs over the last five years in Victoria, suggests that there may not be a significant issue in access to DGA in the private sector. However, there may be access issues for some people with special needs such as those with an intellectual disability. General access issues A hospital policy officer suggested that the priority of DGA is decreased because public dental waiting times are not a performance measure for which public hospitals are held accountable – ‘If it is not counted (for waiting list reporting) it does not count’ . It was not possible to quantify this factor. Several key players indicated that DGA was perceived by hospitals and day procedure centres as less cost effective for a facility compared to eye (cataracts) or ear (grommets) procedures, and that this limited access to DGA. The impact may vary between the public and private sectors. However an experienced hospital manager said that the WIES price for dental hospitalisation in the public system ‘was not a disincentive’ . 236 The DH&HS undertakes an annual survey in public hospitals to identify the actual costs of procedures. Cost weights are adjusted accordingly. There was a nine per cent increase in the WEIS payment to public hospitals for DRG D40Z (dental extractions and restorations) between 2001-02 and 2013-14 as shown in Table 42. The increase is an indication that actual costs for dental hospitalisations are reviewed, and cost weights adjusted. The impact on dental hospitalisation rates of the price paid to facilities for DGA will depend on the demand for GA facilities from other disciplines and vary in public and private settings. In the private sector, new facilities may be easier to access for DGA than those already established. There is likely to be variation in the public system between busy metropolitan and smaller rural hospitals. Hospital policy managers noted that there may be more scope for dental hospitalisation in smaller rural hospitals because there are not the specialty areas that exist in larger hospitals to compete with dental admissions. The Travis Review, established by the Victorian Government to report on increasing the capacity of the Victorian public hospital system, noted that utilisation of operating theatres is lower in the smaller rural hospitals (Travis, 2015). A large proportion of these hospitals are block funded and so not paid via WIES. Also there can be arrangements for local dentists to have a regular GA ‘list’. There may be pressure to fill the list so that the session is not lost. Recording, monitoring and reporting significant adverse events As outlined in 10.4.3 on monitoring and reporting DGA mortality and morbidity, there have been calls to enhance the systems for recording, monitoring and reporting on significant adverse events in Australian health care services (Jackson et al., 2009), and internationally for events linked to DGA (Wilson and Alcaino, 2011) (Lee et al., 2013). Reporting tools that could be introduced, as well as the importance of seeking feedback from parents and children about DGA and alternatives, are also discussed in 10.4.3 Recommendation 10: Enhance recording, monitoring and reporting of DGA mortality and morbidity. 237 Limited number of Diagnostic Related Groups for oral health The DRGs relevant to hospital based dental procedures are limited in scope and specificity (Healthy Mouths, Healthy Lives, Australia’s National Oral Health Plan 2015-2014 136 ). The major oral health DRG, D40Z, comprised 75 per cent of dental admissions in Australia in 2012- 13 137 . There is wide diversity within this DRG – from extraction of a single tooth to a full mouth treatment with many extractions and/or restorations. DRGs are meant to be a ‘method of classifying patients that have similar clinical conditions and similar level of resource use’ (9.3.1). They should provide a clinically meaningful way of relating the number and type of patients treated in a hospital to the resources required by the hospital. The main DRG, D40Z, cannot adequately reflect the wide diversity of care provided. Recommendation 11: Expand the number of oral health DRGs. Socioeconomic and cultural context of the family 10.5.5 Families’ socioeconomic status and prevention of PPDHs The strong association between socioeconomic status and the dental hospitalisation of children was found in all of the research projects undertaken. Step-wise socioeconomic gradients for PPDHs were steepest for young children, while there was a reverse social gradient among 15-24 year olds with the highest PPDH rates for those living in more advantaged communities (5.2.11). Table 48 shows the results of the research into the seven socioeconomic family factors studied. PPDH rates were found to be higher in children: whose parents held a concession card; who lived in the most disadvantaged areas; whose mothers’ had not completed high school; from 136 Accessed from the Council of Australian Governments (COAG) Health Council web site on 20 March 2016 - < http://www.coaghealthcouncil.gov.au/Publications/Reports/ArtMID/514/ArticleID/81 >. 137 D40Z admissions comprised 125,524 admissions out of 167,063 dental admissions. Data accessed from AIHW website on 20 March 2016 - Analysis of VAED In multivariate analysis, controlling for access to fluoridation, PPDH rates for 0-4 year olds were significantly associated with socioeconomic status in 2008-09 and 2012-13. Rates followed a clear socioeconomic gradient by IRSED quintile as shown in Tables 30 and 31. The association between PPDH rates and socioeconomic status was stronger in 2008–09 among children living in quintile 1, the most disadvantaged quintile. These children had PPDH rates 2.5 times higher than children residing in the most advantaged quintile 5. In 2012–13 the multiplier was 1.75 times. Analysis of the 2013-14 VAED found a clear step-wise socioeconomic gradient for PPDH rates in 0-9 year olds. Figure 20 shows the gradient for 0-4 year olds. The gradient was less steep for 5-9 year olds and almost flat for 10-14 year olds. There was a U shaped gradient for 15-24 year olds with the highest rate in the most advantaged quintile (Figure 21). This was the same pattern for 15-19 year olds. For those 25 years and older there was not a clear socioeconomic gradient by IRSED quintile in 2013-14 (Figure 22). However, there had been a reverse gradient for each of the previous 10 years. The implications of these patterns for using PPDH rates as an indicator of health system performance will be discussed in the policy implications section. Analysis of 2009 VCHWS In bivariate analysis, there was a clear socioeconomic gradient for 1-8 year olds with a five-fold difference between children in the most disadvantaged IRSED quintile and the most advantaged (Table 34). The pattern for 9-12 year olds was more U-shaped, with the second highest IRR in the most advantaged quintile (Table 35). In multivariate analysis, adjusting for the other 14 child and family factors, there were no significant differences between IRSED quintiles. The association between ‘level of education of mother’ and dental hospitalisation followed a stronger social gradient in 1-8 year olds in bivariate analysis, as did concession card status, and 239 household income. However these factors were not found to be significant in multivariate analysis when controlling for the other child and family factors. Children from families which had run out of food in the previous year were more likely to have been hospitalised in bivariate analysis, with higher likelihood amongst younger children. Public and private care As mentioned under access to GA facilities (10.5.4.2), there were more dental hospitalisations in the private sector than in the public sector in 2013-14 138 . Young children and rural residents were more likely to be seen in the public sector. While two thirds of all PPDHs (67 per cent) were private in 2013-14, over half of 0-9 year olds attended public hospitals. In rural regions, 56 per cent of PPDH patients attended public hospitals, compared to 34 per cent in metropolitan regions. The age group with the lowest proportion of admission to public hospitals was 15-24 year olds (26 per cent). General discussion The strong association between lower socioeconomic status and higher PPDH rates in young children was evident from the analysis of both the VAED and the 2009 VCHWS. This result was also found in the multivariate analysis of the 2004-05 VAED when household poverty was found to have a strong association with PPDH rates for 0-14 year olds (Department of Human Services, 2007). The socioeconomic gradient shown in children is not evident in PPDHs for over 14 year olds. In 2013-14, there was a U-shaped pattern among 15-24 year olds with no clear socioeconomic gradient for those 25 years and older. Most under 10-year-olds were treated in the public sector, with the reverse for those over 10 years of age. Prevention of oral disease As mentioned at the beginning of the policy implications section, all those interviewed agreed that it was preferable to prevent dental disease, and when there is disease, to manage it through early intervention. Comprehensive prevention of oral disease amongst disadvantaged groups 138 Higher private than public dental admissions were also evident nationally in 2013-14, when 79 per cent of admissions with a procedure of dental services were in the private sector AIHW 2015a. Admiited patient care 2013- 14: Australian hospital statistics. Canberra: Australian Institute of Health and Welfare. This compares with 39 per cent of total admissions in Victorian hospitals that were in the private sector in 2013-14. 240 requires addressing the higher level social determinants of health (Watt et al., 2015, Watt et al., 2016). These determinants are the political, economic and social drivers that were only partially included in this study’s social determinants model for Victoria because of lack of data linked to dental hospitalisations. As discussed when developing the Victorian conceptual model, the framework created by the Commission on the Social Determinants of Health, adapted for oral health (Sheiham et al., 2011) (Watt and Sheiham, 2012, Watt, 2012, Watt et al., 2014, Watt et al., 2015), includes the structural determinants of governance; culture and societal values; and macroeconomic, social and welfare policies (World Health Organization, 2010). Although health professionals can advocate for these structural social determinants to be addressed, and can take some local action (Watt et al., 2014), changing these factors is predominantly beyond the scope of the health system. Best practice oral health promotion includes integrated, multisector, evidence-based common risk factor approaches at local, regional, national and international levels across the Ottawa Charter areas (Watt et al., 2016). The Ottawa Charter areas are to build healthy public policy; create supportive environments; strengthen community action; develop personal skills; and reorient health services 139 . Supportive environments help make the orally healthy choices the easier choices. Action on sugar consumption is important because sugar is the major proximal cause of dental caries (Sheiham and James, 2015). Australian national guidelines recommend that no more than 10 per cent of energy should come from discretionary food and drinks, such as biscuits, snack bars and soft drinks (National Health Medical Research Council, 2013) 140 . In 2015, the WHO 139 The attributes of an ideal Oral Health Care System are considered to be: patient focused (culturally competent, ethical, equitable, empowers individuals and communities); with an emphasis on the prevention of oral disease; effective (evidence-based, continuous quality assessment, cost-effective); and within a quality system (integrated, sustainable, universal, and comprehensive) TOMAR, S. L. & COHEN, L. K. 2010. Attributes of an ideal oral health care system. J Public Health Dent, 70 Suppl 1 , S6-14.. 140 Skinner and colleagues concluded in their study of adolescents in New South Wales, that because sugary drink consumption was associated with dental caries, and given the common risk factors that occur between dental caries, diabetes and obesity, a multi-faceted approach with collaboration among health professionals is required SKINNER, J., JOHNSON, G., BLINKHORN, A. & BYUN, R. 2014. Factors associated with dental caries experience and oral health status among New South Wales adolescents. Aust N Z J Public Health, 38 , 485-9. . 241 released a guideline that strongly recommended that intake of free sugars be less than 10 per cent of total energy intake, and conditionally recommended a further reduction of intake to below 5 per cent (World Health Organization, 2015) 141 . More recently, the Scientific Advisory Committee on Nutrition (SACN) in the United Kingdom has recommended that the average population maximum intake of sugar should not exceed five per cent of total dietary energy (Public Health England, 2015b) 142 . Interventions to reduce sugar consumption include a sugar tax or levy on high sugar products, reducing the advertising of high sugar foods to children, and reducing the amount of sugar in everyday food and drink products (Tedstone et al., 2015). Other evidence-based interventions to prevent dental caries include community water fluoridation (10.5.2), and screening and early intervention (10.5.3). It is also effective to increase the capacity of health, education and welfare professionals to promote oral health (Rogers, 2011). These professionals see children on a regular basis. It has been argued that to reduce the social gradient in health, interventions should be universal, but with an intensity that is proportionate to the level of disadvantage - a proportionate universalism (Marmot, 2010). Recommendation 12: Enhance evidence-based oral health promotion initiatives that prevent dental caries. 10.5.6 Cultural background The factors related to dental hospitalisation and cultural background that were analysed from the VAED were Aboriginal background and country of birth. The variables analysed from the 2009 VCHWS were the Aboriginal background of the child, and the country of birth of the mother and 141 Accessed from the WHO website on 19 January 2016 - 242 of the child. In addition, key players commented on the influence of cultural background on dental hospitalisation. Analysis of VAED Aboriginal and Torres Strait Islander people PPDHs among Victorians with an Aboriginal background doubled between 2004-05 and 2013- 14 (Table 24)143 . Further analysis is required to determine age-adjusted rates that can be compared with population PPDH rates. Data from the Report on Government Services (RoGS Steering Committee, 2015), sourced from the VAED, show that Victorians with an Aboriginal background have PPDH rates that are 11 per cent higher than Victorians without an Aboriginal background as will be discussed in section 10.3.1. The pattern of hospitalisation of people with an Aboriginal background differs to those of non- Aboriginal background (Table 25). In 2013-14, Aboriginal people admitted for a PPDH were more likely to be rural residents (65 per cent compared to 31 per cent of non-Aboriginal PPDH), young people (54 per cent compared to 28 per cent among 0-9 year olds), and be patients in public hospitals (81 per cent compared to 40 per cent). The Victorian DH&HS reports that Indigenous status data for 2013–14 is of an adequate standard for reporting, but should still be considered to under-count the number of Aboriginal and Torres Strait Islander patients. There is a continued effort to improve the quality of this data element through data validation processes and communication channels (AIHW, 2015a). Country of Birth There was a higher rate of PPDHs among people born in Australia compared to overseas in 2013-14. While approximately 74 per cent of Victorians were Australian born 144 , 85 per cent of 143 In 2004-05, there were 99 people with an Aboriginal background who had a PPDH (comprising 0.7 per cent of total PPDHs). In 2013-14, 196 Aboriginal people had a PPDH (comprising 1.4 per cent of total PPDHs), as presented in 5.2.10. 144 ABS web site accessed 20 March 2016 - PPDHs were of people born in Australia. Further analysis is required to calculate age-adjusted PPDH rates by country of birth. Countries of birth for PPDHs in the top 12 other than Australia were: England; Italy; New Zealand; United Kingdom; India; Germany; Greece; Scotland; South Africa; China; and Vietnam. Only people born in New Zealand had a PPDH rate above the Australian born rate. Analysis of VCHWS 2009 Aboriginal and Torres Strait Islander people There was no difference in dental hospitalisation rates between children with, or without, an Aboriginal background in the 2009 VCHWS. The survey methodology may not have captured a representative sample of children from an Aboriginal background as a general population survey such as the VCHWS is unsuited to data collection for minority population groups. This is discussed under limitations of the 2009 VCHWS in 10.6. Country of Birth Country of birth of the child or of the mother was not found to be associated with higher dental hospitalisation rates in the 2009 VCHWS (Table 29). Less than 10 per cent of children surveyed were born overseas, a lower proportion than in the Victorian population. This underrepresentation is likely to be because of the nature of the VCHWS, as noted for Aboriginal people above. Views of key players Paediatric dentists noted in the interviews that there are cultural variations in parental attitudes toward dental hospitalisation. Reluctance among some parents from an Asian background to have their child hospitalised was mentioned. Interviewees noted that dental hospitalisation rates in children were generally lower in Asian countries than in Australia. General discussion Analysis of the VAED found higher PPDH rates in Australian born compared to those born overseas. Further analysis is required to determine age adjusted rates for children and young adults. Only people born in New Zealand had higher PPDH rates than people born in Australia. 244 Generally the analyses of the VAED and the 2009 VCHWS did not find strong associations between dental hospitalisations of children and cultural factors, possibly due to limitations of the data sets. Further research is required to determine the influence of cultural factors on dental hospitalisation in Victoria. Australian data show poorer oral health and higher DGA rates in children with an Aboriginal or Torres Strait Islander background (AIHW, 2014b). While all-age PPDH rates for 2012-13 show that Victorians with an Aboriginal background have PPDH rates 11 per cent higher than rates of Victorians without an Aboriginal background (RoGS Steering Committee, 2015) (Figure 28), there is no published data on differences for Victorian children. Australian and international research has determined that children from culturally and linguistically diverse backgrounds often have poorer oral health that would predispose them to being hospitalised. At risk groups include recent migrants and children in families where a language other than English is spoken at home (Alcaino et al., 2000, Haubek et al., 2006, Savanheimo et al., 2012). Recommendation 13: Monitor children's PPDH rates, particularly those from high risk groups such as children with an Aboriginal background and children from culturally and linguistically diverse backgrounds. 10.5.7 General parent factors Parent factors associated with dental hospitalisation were investigated through analysis of the 2009 VCHWS and discussion with key players. Analysis of 2009 VCHWS The influence of family socioeconomic status and cultural factors on dental hospitalisation has been discussed. An additional factor found to be significant for 1-8 year olds, was if the family had an ‘unhealthy’ level of functioning. In bivariate analysis, children in these families were 245 twice as likely to have been hospitalised for dental reasons. This factor almost reached significance for 1-8 year olds in multivariate analysis 145 (Table 34). Family function was linked to household type in the 2009 VCHWS. A larger proportion of single parents reported that their household had run out of food in the previous 12 months (16.3 per cent, CI 13.0; 19.6), compared to couple households (3.2 per cent, 2.6; 3.9) (Department of Education and Early Childhood Development, 2009). Views of key players While parents were not interviewed, most of the oral health professionals commented on parental factors that influence the dental hospitalisation of children. Most comments were about push factors likely to increase hospitalisation. Interviewees noted that some parents appreciated the convenience of DGA, compared to multiple sessions in the dental surgery. Parents preferred less time off work and less expense for childcare for their other children. Dental hospitalisation was seen as attractive to parents who are time- poor and asset-rich. A change toward more ‘permissive’ rather than ‘authoritative’ or ‘authoritarian’ parenting approaches was suggested by several interviewees. They suggested this can lead to an increase in dental hospitalisation as parents were less likely to insist that their child behaved in the dental chair. A push factor from parents for dental hospitalisation can be their expectation that the care of their children should be ‘easily and readily accessible and pain-free and result in flawless aesthetics’ (Widmer and Cameron, 2013). Some parents want their children to have white restorations rather than less aesthetic silver crowns so that their dental caries is not as obvious. 145 Overall 6.9 per cent (CI 6.1; 7.8) of Victorian children were found to be from families classified as having unhealthy family functioning in the 2009 VCHWS DEPARTMENT OF EDUCATION AND EARLY CHILDHOOD DEVELOPMENT 2009. Preliminary Findings 2009 Victorian Child Health and Wellbeing Survey. Melbourne Victorian Department of Education and Early Childhood Development.. The frequency was 6.5 per cent (5.6; 7.6) in the families of children who had not been hospitalised for dental reasons, and 8.1 per cent (5.0; 12.9) in the families whose children had been hospitalised. 246 Low levels of parental oral health literacy were also raised by paediatric dentists. Some parents did not appreciate the importance of primary teeth or the preventive impact of fluoride. Two issues were raised about how clinician behaviour can lead to more dental hospitalisations. These were parents being made to feel guilty about their child’s oral health, and the clinician over emphasising DGA over other alternatives. Case studies B and C in section 7.5 are examples of parents’ reluctance to accept a recommendation by an oral health clinician for their child to have a DGA. General discussion Hooley and colleagues reviewed the literature on parental influence and development of dental caries 146 in young children that was published between 2006 and 2011. They concluded that there was no research that explored the possible pathways between the multiple layers of influences (Hooley et al., 2012). Renzaho and de Silva-Sanigorski reviewed the literature that explored social and psychosocial influences on child oral health. They concluded that while potential home environment factors such as parenting stress, maternal self-efficacy, parental locus of control, social desirability, and parent’s sense of coherence have been identified as associated with child oral health, the research has had methodological shortcomings. Shortcomings included small or convenience samples and not controlling for relevant factors such as socioeconomic status. Renzaho and de Silva- Sanigorski suggested that the relationships and pathways involved require further elucidation through longitudinal studies (Renzaho and de Silva-Sanigorski, 2014). More recently, parenting practices and parent-child interactions were found to be associated with childhood caries in two studies in the Netherlands (de Jong-Lenters et al., 2014) (Duijster et al., 2015) 147 . Associations between chronic maternal stress, maternal caretaking behaviours, and child dental caries experience have been reported from the United States (Masterson and Sabbah, 2015). 146 Dental caries is being considered because of the link to dental treatment needs and therefore dental hospitalisation . 147 Effective parenting practices included positive involvement, encouragement and shared problem-solving. 247 Lower levels of family function were found to be associated with higher dental hospitalisation rates. Children, 1-8 years of age, from families that had a lower level of functioning were twice as likely to have been hospitalised for dental reasons. A strong link between family function and disadvantage was found in the 2009 VCHWS (Department of Education and Early Childhood Development, 2012). Two key parent factors that affected whether a DGA was conducted were convenience for income-rich and time-poor families, and low levels of oral health literacy. Poor understanding of the importance of primary teeth and the preventive impact of fluoride were reported. A concerning trend was the observed increase in the use of herbal rather than fluoride toothpaste. Another element of health literacy reported by interviewees was that there was often considerable information asymmetry between parents and dental providers, particularly in relation to treatment options for their children. While enhancing the oral health literacy of all age groups is important to prevent oral disease, addressing the information asymmetry between the community and dental providers is particularly relevant to support fully informed decisions about DGA. Recommendation 14: Increase parents’ and young adults’ oral health literacy about prevention and alternative options to DGA. There is a link with recommendation 6 regarding people-centred care, as it is part of the clinician’s responsibility under the code of conduct to discuss ‘the available healthcare options, including their nature, purpose, possible positive and adverse consequences, limitations and reasonable alternatives wherever they exist’. Better knowledge will allow parents to make an informed choice about treatment options for their children. Gaps in oral health literacy can be identified through qualitative research such as Aljafari and colleagues’ study in England with parents and children (Aljafari et al., 2014). 248 Child intermediary determinants 10.5.8 Age Analysis of VAED In 2013-14, there was a higher PPDH rate among 0-19 year olds (4.2 per 1,000 population) than among people aged 20 years and older (2.2 per 1,000 population). 0-4 year olds The article in the Melbourne Age on 14 October 2015, stating that ‘toddlers as young as 18 months are having rotten teeth pulled out’ in Victoria, was based on an interview with a local paediatric dentist with a long experience with DGA. In 2013-14, 75 one year olds, 193 two year olds, and a total of 1,421 0-4 year olds were admitted for a PPDH, predominantly for treatment of dental caries. Children 0-4 years of age admitted for a PPDH are more likely to live in a disadvantaged area (10.5.5), that does not have community water fluoridation (10.5.2), or good access to oral health professionals (10.5.3.1). Most (90 per cent) PPDH were for the treatment of dental caries in 2013-14. A majority (58 per cent) of PPDH were in public hospitals. The PPDH rate in 0-4 year olds significantly reduced between 2001-02 and 2013-14, as mentioned in 10.2.3.1 on access to dental services 148 . Rates in older age groups have mostly been stable or increased. 5-9 year olds This age group had the highest rates of PPDHs in 2013-14, a total of 2,746 children, with a rate of 7.9 per 1,000 population. This is similar to the 2001-02 rate of 8.0 per 1,000 population. Most (95 per cent) PPDHs were for the treatment of dental caries in 2013-14. A majority (52 per cent) of PPDHs were in public hospitals. 148 The decrease in PPDH rates in 0-4 year olds between 2001-02 and 2013-14 (from 7.9 to 3.9 per 1,000 population). The decrease has been greater in rural areas, 59 per cent compared to 43 per cent in metropolitan Melbourne. 249 The peak age for PPDHs has increased from four years in 2004-05 to five years in 2013-14. As detailed in 10.5.5, the social gradient among 5-9 year olds was not as steep as for 0-4 year olds in 2013-14. 10-19 year olds Rates of PPDH for 10-19 year olds increased by 63 per cent from 2001-02 to 2013-14 but from a lower base than 0-9 year olds (1.6 per 1,000 population in 2001-02 to 2.6 per 1,000 population in 2013-14). The increase was higher in metropolitan Melbourne, 86 per cent, compared to rural areas, 34 per cent. The socioeconomic gradient for 10-14 year olds was flat, while there was a reverse gradient for 15-19 year olds. In the older age group, the highest PPDH rates were in the most advantaged IRSED quintiles. Analysis of 2009 VCHWS Over half (57 per cent), of the 250 children hospitalised for dental reasons in the 2009 VCHWS were 9-12 year olds, 40 per cent were 5-8 year olds, and three per cent were 1-4 year olds. The significance of associations between factors and dental hospitalisation varied by age. While dental treatment needs and rural residence remained strongly associated across the age groups, the most significant third factor in the modelling was ‘child needing services’ for 1-12 year olds (Table 37), socioeconomic status (concession card holding) for 1-8 year olds (Table 38), and being male for 9-12 year olds (Table 39). AIHW hospital statistics The highest rates of dental hospitalisations were for 15-24 year olds as detailed in the literature review (Figure 1). In 2013-14, this age group comprised 40 per cent of all oral health admissions that involved a DGA. Their dental hospitalisation rate was 16.9 per 1,000 population, compared to the overall rate of 5.7 per 1,000 population (AIHW: et al., 2016). 250 General discussion The differences between age groups in PPDH presentations have been summarised in 10.2.2.7 and Table 48. Variations exist in: PPDH rates; changes between 2001-02 and 2013-14; metropolitan – rural changes; proportion of admissions for dental caries; and proportion of public admissions. The social gradient in PPDH rates in 0-9 year olds, and the U-shaped gradient among 15-19 year olds have been discussed in 10.5.5. The high DGA rates among 15-24 year olds, particularly among females, for extraction of impacted and embedded teeth will be discussed in 10.5.10. Public health policy analysts have questioned whether the high rates of extraction of asymptomatic wisdom teeth in particular in this age group constitute a public health problem in Australia (Jamieson and Roberts-Thomson, 2006) (George et al., 2011) (Anjrini et al., 2014), and in the United States (Friedman, 2007). Further research is required to develop best practice guidelines. The considerable variation in rates in England and Western Australia (Anjrini et al., 2014) may be a natural experiment that could assist to determine the impact of the lower frequency of extraction of asymptomatic wisdom teeth. Recommendation 15: Develop Australian guidelines for the removal of asymptomatic wisdom teeth. 10.5.9 Gender There have not been large gender differences in dental hospitalisation rates in Victoria and Australia except for 15-24 year olds. Analysis of VAED A higher proportion of males were in younger age groups (53 per cent of 0–9 year-olds) in 2013- 14 (5.2.2). There were more females in most of the older age groups. Overall, 52 per cent of PPDH admissions were females. 251 Analysis of 2009 VCHWS A higher proportion of boys in the survey (55 per cent) had a dental hospitalisation, but the difference was not statistically significant (Table 32). AIHW hospital statistics In 2011-12, 56 per cent of separations for oral health procedures involving GA were females (Chrisopoulos and Harford, 2013). As was the case for PPDHs in Victoria in 2013-14, males comprised a higher proportion of separations for 0-9 year olds, and there were more females aged ten years and over. In 2011-12, the DGA rate per 1,000 population was 20.6 for females in 15-24 year olds, 62 per cent higher than the 12.7 rate for males. As will be discussed in the next section, the main reason for hospitalisation for 15-24 year olds was for the removal of embedded and impacted teeth. 10.5.10 Dental treatment needs Dental hospitalisation admission and treatment data were obtained from the VAED and AIHW hospital data sets. Two factors in the 2009 VCHWS that are linked to dental needs were analysed. Analysis of VAED and AIHW data sets In 2013-14 there were 39,196 dental hospitalisations in Victoria. The highest admission rate was for 15-24 year olds, predominantly for extraction of teeth. These extractions were to create more space for orthodontic reasons, to remove embedded and impacted teeth, and to remove non- impacted wisdom teeth. The second highest age group was 5-9 year olds, predominantly for treatment (extractions, fillings or preventive care) of dental caries. Analysis of VCHWS The two factors in the 2009 VCHWS that indicated dental treatment needs were whether a child ‘ever had a toothache’ and/or ‘ever had a tooth extracted’. In multivariate analysis, adjusting for the 13 other child and family factors examined, the associations with dental hospitalisation were 252 highly significant for these treatment related factors (Table 33). In modelling, controlling for rural dwelling and ‘child needs services’, ‘ever had a toothache’ was the most significant factor associated with dental hospitalisation (Table 37). Views of key players All but one of the paediatric dentists interviewed said that dental treatment needs of Victorian children appeared to have increased since 2000. Interviewees could not quantify the trend and acknowledged that they see a non-representative sample of children. The other paediatric dentist had ‘not observed much change’ . General discussion Emergency admissions The proportion of PPDH that were emergency admissions has been relatively low, but has been increasing for children and adults. As outlined in 5.2.7, the rate of emergencies increased in 0-4 year olds from 2.5 per cent of PPDHs in 2004-05 to 4.8 per cent in 2013-14. The proportion for those 15 years and over increased from 5.8 to 10.3 per cent. The common emergency presentation in children is toothache and a swollen face due to an infected tooth (facial cellulitis). Often intravenous antibiotics and an emergency GA are required. While a low proportion of total admissions, it is a concern that over 150 children a year in Victoria require emergency admission. After examining pathways taken prior to emergency dental care at the Royal Children’s Hospital Melbourne, Tran and colleagues noted that, given tooth decay is preventable – ‘it is disappointing that children still experience such episodes of acute treatment which are associated with not only economic but also health, social and emotional costs’ (Tran et al., 2010). Admissions of 15-24 year olds and extraction of asymptomatic wisdom teeth Rates of extraction of embedded and impacted teeth are significantly higher in Australia than in England (Anjrini et al., 2014). As noted under the sections on age and gender, extraction of 253 embedded and impacted teeth is the major total procedure provided under GA for 15-24 year olds. Availability of data Significant research findings in were that children were more likely to have been hospitalised for dental care if they had a tooth extracted or had a toothache. Despite stable PPDH rates among 0- 9 year olds since 2001-02, there was an increase in children admitted for emergency dental care between 2004-05 and 2013-14. There is limited population-wide, representative data on the dental treatment needs of Victorian children and young people. While the Victorian component of the National Survey of Adult Oral Health 2004-06 provided data for people over 15 years of age, there are little data for younger age groups . Information on oral health status is collected on people visiting public dental services but these data are not representative of all Victorians. Recommendation 16: Enhance oral health status surveillance systems. 10.5.11 Child behavioural and ability factors Analysis of 2009 VCHWS Child behavioural and ability factors found to be significantly associated with dental hospitalisation were, in bivariate analysis for 1-12 year olds: ‘child needs more medical care, mental health or educational services than is usual for most children of the same age’; ‘child has had a functional limitation for 12 months or more’; and ‘child has emotional, developmental or behavioural problems for which he or she needs or gets treatment or counselling’. Children hospitalised for dental care were about twice as likely to have had the three conditions as shown by the unadjusted incident rate ratios (IRR) (Table 33). As expected, the factors were significantly correlated. Almost a fifth of children who ‘needed more services’ were hospitalised 254 for dental care. ‘Functional limitations’ affected 11 per cent, and ‘emotional, developmental or behavioural problems’ affected 18.6 per cent of children hospitalised 149 . In multivariate analysis, controlling for the other child and family factors (shown in Tables 33, 34 and 35), only the ‘need for services’ in 1-8 year olds was significant 150 . Under Model 1 for 1- 12 year olds, when controlling for ‘male’, ‘ever toothache’, ‘ever extraction’, and ‘rural dwelling’, ‘need for services’ was significantly associated with dental hospitalisation. In the final model for 1-12 year olds, controlling for ‘ever extraction’ and ‘rural dwelling’, ‘need for services’ was also significant (Table 37). Analysis of interviews with key players A key finding from interviews was an increase in ‘child focus’ across all medical disciplines over the last 20 years in Victoria. This is evident in dental provider behaviour with less acceptance of ‘rough and tumble’ in the dental chair. It is possibly a driver of dental hospitalisation as discussed under dental care system factors, 10.5.3.2. General discussion Children with behavioural or ability issues were about twice as likely to have been hospitalised for dental care. Significant associations were found for children who needed more services than is usual for most children of the same age; children who had a functional limitation for 12 months or more; and children who had emotional, developmental or behavioural problems. In multivariate analysis, controlling for the other 14 child and family factors, the ‘need for services’ in 1-8 year olds was significant. The perception of interviewees that ‘child focus’ has increased across all health disciplines over the last 20 years in Victoria has been discussed in 10.2.3. The study did not include talking to children. There would be benefit in doing so in order to improve children’s experience and outcomes. A recent study in northern England did include asking children to describe their experience of dental hospitalisation (Rodd et al 2014). 149 The prevalence of the three conditions in the children who were not hospitalised for dental reasons was about half: 11.1 per cent compared with 19.9 per cent, 5.4 per cent compared to 11.2 per cent, and 9.6 per cent compared to 17.6 per cent respectively. 150 This factor almost reached significance for 1-12 year olds (IRR 1.55, p<0.051 ). 255 Rodd and colleagues sought to gain a greater understanding of the physical and psychological impacts from a child’s perspective. Impacts reported were similar to parent reports, such as nausea, bleeding and tiredness. In addition, children mentioned hunger, being scared and experiencing discomfort from the IV cannula. Positive outcomes were also reported including attention and rewards from family members and satisfaction that their dental problems were fixed. 256 Section 6 10.6 Strengths and limitations of the research The strengths of the study were that mixed methods were used and a wide range of databases were accessed. The two large databases that were analysed, the VAED and the 2009 VCHWS, provided a comprehensive picture of factors relating to dental hospitalisation in Victoria. The VAED contains information on all PPDHs in the public and the private sector in Victoria. The 2009 VCHWS was a representative sample of Victorian children aged birth to 12 years. Data were also obtained from the National Coronial Information Service and nine other databases. A limitation was that data from the VAED and VCHWS are cross sectional, not longitudinal, thus limiting the ability to ascribe causality. The analysis of the VAED was conducted at the postcode level, a smaller geographic level than previously published analyses that examined the impact of community water fluoridation and socioeconomic status on dental hospitalisation. While analyses at this small geographic level allows for a more fine-grained analysis, there is a resultant increase in variability. An associated issue was that oral health professionals were recorded as practicing from their postcode of registration, which did not account for the fact that their clientele might live in other postcodes. Analysis on a larger geographic area, such as local government catchments, would overcome this limitation to some extent and is worth exploring. The IRSED measure of socioeconomic disadvantage is an area rather than an individual or family level measure of disadvantage. Therefore it is not possible to determine the impact of more advantaged people living in a disadvantaged area and vice versa. This disadvantage was overcome to some extent by undertaking analysis at the smallest geographic area level possible (postcodes) with the available data. In relation to a child’s access to community water fluoridation, the data are a point in time measure and do not give an indication of the child’s life time exposure to community water fluoridation. As such, correlation to PPDH rates can underestimate the impact of community 257 water fluoridation. A child, for example, may have recently moved from a non-fluoridated into a fluoridated area and not have benefited from fluoridation from birth. A general population survey such as the 2009 VCHWS is unsuited to data collection for minority population groups or minority problems or experiences. Its strength was that overall it was a representative sample of Victorian children because of its size (5,000 children) and high participation rate (75 per cent). There are possible limitations with the mortality data because of issues with sources as outlined in section 10.4.1. The quality and consistency of data may vary between each jurisdiction and there are also differences between jurisdictions as to legislation governing the reporting of a death to a coroner. The type of surgery an individual has undergone prior to their death is not routinely recorded in the NCIS, so there is a possibility of under-reporting. The strength of the qualitative research approach employed was that a detailed exploration of the contributing factors impacting on DGA was possible. A more comprehensive understanding of decision making contexts related to DGA was obtained, particularly for factors that are difficult to quantify. The interviews allowed participants to describe their individual decision making strategies and to identify the range of drivers they face concerning DGA. Combining these data with the quantitative data allowed a greater appreciation of the complex issues involved and an opportunity to cross-verify information. The paediatric dentists that were interviewed had the most experience of dental hospitalisation in the Victorian public sector. The use of open ended questions allowed generation of a greater richness of data than if closed questions had been used. Participants were able to provide their views and examples of key factors that they saw as relevant to DGA. Provision of quantitative data helped to focus the interviews. Interviews were not audio recorded and transcribed which risked loss of data. However it was possible to create a more collegial tone between the researcher and those interviewed without audio recording, which allowed in-depth discussion about sensitive issues such as the potential 258 for supplier-induced demand. The researcher took notes which were compiled and provided to the interviewees to check accuracy. Verbatim quotes were checked in this way. 10.7 Research required Information is required in the following areas – • The impact of DGA from the child’s and parent’s points of view to help identify what is people-centred best practice. • Systems for recording impacts of DGA. • Effects of general anaesthesia on young children’s neuro-development 151 . • Influence of factors such as cultural background, social cohesion and social capital on dental hospitalisation. • Access to DGA for people from high risk groups such as children from an Aboriginal background and children from culturally and linguistically diverse backgrounds. • Cost benefit analysis of DGA and alternatives. • Appropriateness of using PPDH rates for adolescents and adults as a measure of health system performance. • Education and workforce issues – for example, How can the dental education system be shaped to respond to community oral health needs? What impact does student debt have on the models of care that graduates adopt? • Impact of funding systems on treatment provided under DGA. 151 Nelson and Xu have recently commented on the state of research in this area. They note that studies in humans have revealed conflicting conclusions, with some showing long-term deficits in learning and behaviour and others not. Nelson and Xu comment that this is a difficult area of study with significant challenges in resourcing and study design. They conclude that it is likely to be many years before it is possible to determine the impact with confidence, so that when considering sedation or DGA for children, ‘Parents should be informed of procedural risks and benefits, and sedation must only be employed when a significant benefit to the patient can be expected’ NELSON, T. M. & XU, Z. 2015. Pediatric dental sedation: challenges and opportunities. Clin Cosmet Investig Dent, 7, 97-106. 259 Chapter 11 Conclusion The number of people being admitted to hospital for dental care has increased over the last 15 years in Victoria, Australia and other high income countries. Most of these hospitalisations involve treatment under general anaesthesia and many are considered to be preventable. While these procedures are considered necessary for some people with severe oral disease, behavioural problems or medical/physical complications, they are costly for families and the community. They also involve some risk. The rates of both dental general anaesthetics (DGAs) and Potentially Preventable Dental Hospitalisations (PPDHs) have increased in children and young adults in Victoria since 2001-02. Rates have varied by age group. Overall, the PPDHs rate increased until 2008-09 and then decreased to 2013-14 when there were 15,652 PPDHs out of almost 40,000 (39,196) dental admissions. Between 2001-02 and 2013-14, rates for 0-4 year olds decreased, rates for 5-9 year olds were stable, and rates for 10-24 year olds increased. The aim of the study was to research the dental hospitalisation of children and young people in Victoria to answer three principal questions. Prevalence and trends between 2001-02 and 2013- 14 were analysed, and associations between dental hospitalisation and a broad range of potentially contributing factors were investigated using a mixed methods approach (Table 4) within a social determinants model (Figure 6). The impact of dental hospitalisation on mortality, morbidity and cost was investigated, and policy implications and recommendations made. Although PPDH rates in under 25 year old Victorians have decreased, these admissions were the highest cause of all Potentially Preventable Hospitalisations (PPHs) in 2013-14. Emergency dental cases in Victorian children have increased from 2004-05 (10.5.2). These are predominantly presentations to hospital emergency departments by children in distress with a swollen face because of a dental abscess. 260 Mortality and morbidity related to DGAs have decreased with improvements in anaesthetic drugs and techniques (10.4.2). Mortality rates for DGAs appear very low in Australia. A single DGA related death was identified between 2000 and 2012 by the National Coronial Information Service (NCIS), a period when there were over one million DGAs undertaken. This rate should be considered indicative because of the limitations of the NCIS database. Morbidity is relatively common and may have decreased, but is not well documented. Enhanced monitoring and reporting of morbidity is required. Costs of dental hospitalisation are significant for families and the health system (10.4.4). The direct cost was estimated at approximately $570 million a year in Australia. If indirect costs are included the total cost is in the order of $1.43 billion. A complex interaction of many factors influence whether a child or young adult will experience a dental hospitalisation. The study found that factors could be considered within a social determinants framework (Figure 29). Three overarching categories were used: environmental structural determinants, the socioeconomic and cultural context of the family, and child intermediary determinants. Key factors for PPDHs in Victorian 0-4 year olds were found to be access to community water fluoridation, access to primary dental services, and socioeconomic status. All three were independently associated with higher PPDH rates in 2008-09 and 2012-13 when controlling for the other two factors (10.2.1.1). In addition, high dental treatment needs and a child requiring more services were found to be significant predictors of dental hospitalisation in children in 2009 (10.2.1.3). Associations between PPDHs and socioeconomic status vary by age group. In 2013-14, there was a steep social gradient among 0-4 year olds and a less steep gradient for 5-9 year olds. Among 15-19 year olds there was a reverse gradient with a flat pattern for most other age groups (Table 48). Young Victorians from families with lower socioeconomic status have higher PPDH rates because of their higher dental treatment needs. These needs are predominantly because of higher rates of dental caries. 261 Over the past 15 years, social, technical and dental provider influences have changed attitudes to the dental hospitalisation of children and young adults. There has been an enhanced child focus in health care generally, with an emphasis on not stressing the child. Within dentistry, parents and dental providers have become less accepting of ‘rough and tumble in the chair’. Parents, particularly those who are time-poor and asset-rich, appreciate the convenience of a DGA over having to make more visits to a dental clinic with their child. Younger dentists are possibly not as confident to treat children, because they have not had the necessary training and experience plus there are more paediatric dentists for referral. In addition, it is likely that more extraction of teeth for orthodontic reasons occurs under DGA. These factors, as well as the increased safety of DGA, may help explain the shift to private care over the last 15 years. While young children are more likely to be treated in public hospitals, older age groups utilise private hospitals or day procedure centres. Further factors that can influence dental hospitalisation rates are aspects of the dental and health care systems, and general parent factors. Dental care system factors (10.5.3) include: need for updated dental hospitalisation guidelines; workforce balance (oversupply of dentists and paediatric dentists, undersupply of dental and oral health therapists); high costs of training; and possible supplier induced demand. The latter can be a push factor because of the pressures of workforce over supply and the need to repay high tuition fees. Health care system factors (10.5.4) include: admission policy for access to GA facilities, pricing systems, and the limited number of Diagnostic Related Groups (DRGs) for oral health care. It was concluded that PPDH rates for 0-9 year olds are an appropriate indicator of health system performance. Review of the definition and use of PPDH rates for people aged 10 and over is recommended. A general parent factor that is likely to be associated with dental hospitalisation is low oral health literacy (10.5.7). The information asymmetry between parents and dental providers needs to be 262 reduced for better people-centred care. This includes parents being able to provide truly informed consent for dental treatment plans for their children. While there is debate within the dental profession about the indications for dental hospitalisation for children, there is general agreement that it is preferable to prevent dental disease in the first place and, when there is disease, to prevent a dental hospitalisation through earlier intervention when the problem is less severe. Progress has been made in reducing PPDHs in Victoria, particularly for 0-4 year olds. Victoria now has lower rates for children than other jurisdictions (9.1). However, there is scope to further reduce PPDHs by preventing oral disease. Extensive prevention of oral disease amongst disadvantaged groups requires addressing the social determinants of health. These are the ‘upstream’, ‘causes of causes’, the political and economic drivers (Watt et al., 2016). Although health professionals can advocate for the social determinants to be addressed, and can take some local action (Watt et al., 2014), changing these factors is predominantly beyond the scope of the health system. The environments in which people live, work and play should ideally be health promoting to help make the orally healthy choices the easier choices (10.5.6). Initiatives to reduce the consumption of sugar are essential. Community water fluoridation should be extended as it is a safe and cost effective way to prevent dental caries for all ages. Further initiatives include using non-oral health professionals to screen young children’s mouths and to apply fluoride varnish; enhancing access to primary dental care for young children; and increasing access to alternatives to DGAs. There is some evidence that PPDH rates are lower in countries where there is universal access to oral health care for young children. The high rates of DGA among 15-24 year olds have prompted calls to review whether this is a public health issue (10.5.8). These admissions are primarily for removal of embedded or impacted teeth such as wisdom teeth, many of which are asymptomatic. There is a need to develop Australian guidelines for removal of asymptomatic wisdom teeth. Policy implications in the form of 16 recommendations have been identified from the research findings (Table 49). 263 Table 49 Policy implications of the research findings – key recommendations with relevant section for further details R1. Extend community water fluoridation to communities with a population of over 1,000 people. 10.5.2 R2. Establish programs to extend the preventive effects of fluoride to families in small communities or 10.5.2 living off the water grid. R3. Enhance screening of young children by primary health care workers to facilitate early 10.5.3.1 intervention and referral to dental services, particularly for disadvantaged children. R4. Continue delivery of the CDBS through the public and private sectors 152 . 10.5.3.1 R5. Update guidelines for DGAs. 10.5.3.2 R6. Enhance training of oral health students and providers in: 10.5.3.2 • alternatives to DGA for children and • 153 people centered care . R7. Review the need to establish a conscious sedation course in Victoria. 10.5.3.2 R8. Use PPDH rates of 0-9 year olds as a measure of health system performance. 10.5.4.1 R9. Review the use and definition of PPDH rates for people aged 10 years and over as a measure of 10.5.4.1 health system performance. R10. Enhance recording, monitoring and reporting of DGA mortality and morbidity. 10.5.4.2 R11. Expand the number of oral health DRGs. 10.5.4.2 R12. Enhance evidence -based oral health promotion initiatives that prevent dental caries . 10.5.5 R13. Increase parents’ and young adults’ oral health literacy about prevention and alternatives to 10.5.7 DGA. R14. Monitor children's PPDH rates, particularly those from high risk groups such as children from an 10.5.9 Aboriginal background and children from culturally and linguistically diverse backgrounds. R15. Develop Australian guidelines for the removal of asymptomatic wisdom teeth. 10.5.8 R16. Enhance oral health status surveillance systems. 10.5.10 152 Child Dental Benefits Schedule (CDBS). 153 Train to the Australian Health Professional Registration Agency (AHPRA) code of conduct standards for health professionals. 264 In conclusion, the results of the study indicate that dental hospitalisation is an important issue for Victoria and Australia. Other high-income countries are also facing similar problems. The direct and indirect costs are high and while mortality is low, side effects are common. Some improvements have been made for young children in Victoria. There are now fewer preschool children undergoing a DGA for extraction of their teeth, but the rate can be lowered further through more active prevention of dental caries. The rate of extraction of impacted and embedded teeth in Australian young adults is considerably higher than in England where national guidelines are followed. Appropriate guidelines are required in Australia. Implications for action The sixteen policy implication recommendations can be consolidated into six key implications for actions: 1. Extend evidence-based prevention initiatives that prevent dental caries 154 . 2. Develop Australian guidelines for DGA including for the removal of asymptomatic wisdom teeth. 3. Use PPDH rates of 0-9 year olds as a measure of health system performance and review the appropriateness of using this measure for older age groups. 4. Enhance training of oral health students and providers in alternatives to DGA for children and people centered care. 5. Increase parents’ and young adults’ oral health literacy about prevention and alternatives to DGA. 6. Enhance DGA oral health status surveillance systems including recording, monitoring and reporting of mortality and morbidity. 154 Including community water fluoridation, creation of health promoting settings, targeted programs for high risk groups, and screening and early intervention. 265 Appendices 266 Appendix 1 Plain language statement Potentially preventable dental hospitalisation of Victorian children Dear Colleague You are invited to participate in the above research project, which is being conducted by Professor Mike Morgan (supervisor), A/Professor Fredrick (Clive) Wright, A/Professor Kaye Roberts-Thomson and Dr John Rogers (PhD student) of the Melbourne Dental School at The University of Melbourne. You have been asked to participate because of your understanding of admission policies for dental reasons in Victoria. This project will form part of Dr Rogers’ PhD thesis, and has been approved by the University of Melbourne’s Human Research Ethics Committee. The aim of this study is to analyse the distribution and determinants of potentially preventable dental hospitalisation of Victorian children over the period 2001-02 and 2012-13, and to identify options for prevention. Should you agree to participate, you would be asked to participate in an interview of about 20 - 30 minutes, so that we can get a more detailed picture of factors related to potentially preventable dental hospitalisation. The results of this study will be reported as group data only. Your individual information will not be identifiable in the report. To further protect your confidentiality and anonymity, we will store your name and contact details in a separate, locked cabinet from the data you supply. All computer files will be accessible to the researchers only, and will be password protected. You should note that these measures are only able to guarantee confidentiality within the limits of the law. Once the thesis arising from this research has been completed, a brief summary of the findings will be available to you if you wish. It is also possible that the results will be presented at academic conferences. The data will be kept securely in the Melbourne Dental School for five years from the date of publication, before being destroyed. Please be advised that your participation in this study is completely voluntary. Should you wish to withdraw at any stage, or to withdraw any unprocessed data you have supplied, you are free to do so without prejudice. If you would like to participate, please indicate that you have read and understood this information by signing the accompanying consent form and returning it in the envelope provided. The researchers will then contact you to arrange a mutually convenient time for an interview. Should you require any further information, or have any concerns, please do not hesitate to contact either of the researchers; Dr John Rogers on 041763847 or Professor Mike Morgan on 93411546. Should you have any concerns about the conduct of the project, you are welcome to contact the Executive Officer, Human Research Ethics, The University of Melbourne, on ph: 8344 2073, or fax: 9347 6739. 267 Appendix 2 Consent form MELBOURNE DENTAL SCHOOL Consent form for persons participating in a research project PROJECT TITLE: Potentially preventable dental hospitalisation of Victorian children Name of participant: Name of investigators: Dr John Rogers, Professor Mike Morgan, A/Professor Fredrick (Clive) Wright, A/Professor Kaye Roberts-Thomson 1. I consent to participate in this project, the details of which have been explained to me, and I have been provided with a written plain language statement to keep. 2. I understand that after I sign and return this consent form it will be retained by the researcher. 3. I understand that my participation will involve an interview and I agree that the researcher may use the results as described in the plain language statement. 4. I acknowledge that: (a) the possible effects of participating in the interview have been explained to my satisfaction; (b) I have been informed that I am free to withdraw from the project at any time without explanation or prejudice and to withdraw any unprocessed data I have provided; (c) the project is for the purpose of research; (d) I have been informed that the confidentiality of the information I provide will be safeguarded subject to any legal requirements; (e) I have been informed that with my consent the interview details will be stored at University of Melbourne and will be destroyed after five years; (f) I have been informed that a copy of the research findings will be forwarded to me, should I agree to this. I wish to receive a copy of the summary project report on research findings □ yes □ no (please tick) Participant signature: Date: 268 Appendix 3 Hospitalisations for dental procedures The relevant dental conditions are as defined by the following Australian Classification of Health interventions (ACHI) 6 th edition block numbers and procedure codes: 457 Nonsurgical removal of tooth; 458 Surgical removal of tooth; 462 Pulp treatment; 463 Periradicular surgery; 465 Metallic restoration; 466 Tooth-coloured restoration; 468 Inlay, onlay, indirect; 469 Other restorative dental service; 470 Crown; 471 Bridge; 472 Other dental service on crown and bridge; 97241 −00 Tooth root resection, per root; 97387−00 Replantati on and splinting of tooth; 97388 −00 Transplantation of tooth or tooth bud; 97445 -00 Exploration or negotiation of calcified root canal, per canal; 97455-00 Irrigation and dressing of root canal system;97457-00 Obturation of resorption defect or perforation; 97458 -00 Interim therapeutic root filling; 97772 −00 Provision of resin splint, indirect; 97773−00 Provision of metal splint, indirect; 97778-00 Metallic inlay for denture tooth. Data for 2013–14 are defined using ICD-10-AM 8th edition. (AIHW: et al., 2016) . 269 Appendix 4 Potentially preventable dental hospitalisations by Diagnosis Related Group by age group, Victoria, 2013–14 Table 5.9 Potentially preventable dental hospitalisations by Diagnosis Related Group by age group, 2013–14 DRG version W20VICDRG 0–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 D04B 0 3 10 13 21 20 10 31 D14Z 34 61 49 59 85 70 64 66 D40Z 1,259 2,535 633 784 707 424 373 375 D67A+B 96 58 47 77 97 100 141 91 Other 19 11 9 13 15 12 13 20 Total 1,408 2,668 748 946 925 626 601 583 DRG version W20VICDRG 40–44 45–49 50–54 55–59 60–64 65–69 75–79 80–84 85+ Total D04B 44 54 71 108 86 75 9 1 1 589 D14Z 94 130 148 146 155 149 60 30 18 1,496 D40Z 454 467 533 568 440 402 232 188 216 10,874 D67A+B 158 131 139 142 118 135 74 31 31 1,768 Other 26 23 37 26 43 26 12 6 7 332 Total 776 805 928 990 842 787 387 256 273 15,059 Source: VAED 2013-14. 270 References AIHW 2014a. 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Community Dent Oral Epidemiol, 43 , 550-9. 282 Minerva Access is the Institutional Repository of The University of Melbourne Author/s: Rogers , John Gordon Title: Dental hospitalisation of Victorian children and young adults - prevalence, determinants, impacts and policy implications Date: 2016 Persistent Link: http://hdl.handle.net/11343/120191 File Description: Dental hospitalisation of Victorian children and young adults - prevalence, determinants, impacts and policy implications Terms and Conditions: Terms and Conditions: Copyright in works deposited in Minerva Access is retained by the copyright owner. The work may not be altered without permission from the copyright owner. Readers may only download, print and save electronic copies of whole works for their own personal non-commercial use. Any use that exceeds these limits requires permission from the copyright owner. Attribution is essential when quoting or paraphrasing from these works.