WIP 01 - A Quality Improvement Project to Increase Fluoride Varnish Application in a Primary Care Setting

Publication Number: WIP 01.7593

Connor L. Appelman, Boston Children's Hospital, JAMAICA PLAIN, MA, United States; Corinna Rea, Boston Children's Hospital, Boston, MA, United States; Alexandra Epee-Bounya, Boston Children's Hospital, Boston, MA, United States; Shannon Regan, Boston Children's Hospital, Boston, MA, United States; Wendell Jean, Boston Children's Hospital, waltham, MA, United States; Elizabeth M. Cilento, Children's Hospital, Canton, MA, United States

Background: Topical fluoride varnish application for children ages 1-5 is important for good oral health. According to the CDC, dental caries are the most common chronic disease of childhood in the US and the burden of disease disproportionally affects children from low-income families.

Due to the COVID-19 pandemic and previous supply chain issues, topical fluoride varnish application is no longer a consistent part of the workflow at our three hospital-affiliated primary care clinics. Consequently, rates of fluoride varnish application at well-child visits are low.

Objective: The goal of this quality improvement project is to increase the percentage of well-child visits in which fluoride varnish is applied for primary care patients, ages 1-5, seen in three hospital-affiliated primary care clinics from a current average baseline of 21% to 50% by April 2025. We have also found that White, non-Hispanic children are more likely to receive fluoride varnish than children of other race/ethnicities (p=0.02). We plan to track and narrow this disparity through our project.

Design/Methods: This project qualified as Quality Improvement and therefore did not require IRB approval.

A multi-disciplinary working-group comprised of physicians, nurses and a population health manager formed in March 2024. This group utilized multiple QI process improvement tools including a driver diagram, a cause-and-effect diagram and a process map to evaluate current clinic practices and plan interventions. We began conducting educational talks as an initial intervention. The next interventions will include: clinic signage, an updated nursing policy, EMR reminders and adjustments, updated family education sheets, an updated storage and supply ordering system, and direct provider feedback. We will conduct PDSA cycles to test each intervention.

To monitor improvement, we will utilize statistical process control charts to track the monthly percentage of provider billing for fluoride varnish application in eligible patients. We will track post-well-child visit lab appointment no-show rates as a balancing measure.