The Kansas Chapter of the American Academy of Pediatrics, the Pediatric Department at the University of Kansas Medical Center, the pediatric office of Dr. Dennis Cooley in Topeka and the UMKC School of Dentistry are collaborating on a project to improve the oral health of the most needy children in the Kansas City area. These organizations are experienced at providing health and dental care and information to families. Using their expertise, the project will establish an oral health curriculum in our pediatric residency, provide oral health screenings to the area’s high-risk population, and offer regular treatments with fluoride varnish.
The need for this program is clear. Tooth decay is the most common chronic disease of childhood; it is five times more frequent than asthma. Children living in poverty consistently suffer more tooth decay than other children, yet they have the least access to dental care. In addition, children of all economic circumstances across Kansas have greater access to medical care than dental care; there are only 22 pediatric dentists in the entire state.
The topic of oral health is not well covered in most pediatric curricula. For example, the last issue of PREP mentioned only two topics in the area of dentistry, compared to 20 in the pulmonary division. The KU Pediatric Department implemented a plan to expand the coverage of oral health in the pediatric residency curriculum. A two-hour didactic session has been added, which stresses normal dental findings and explains how to screen infants and toddlers. The previous curriculum, which only stressed abnormal oral pathology, continues as part of this plan. In addition, dental students from UMKC work with our pediatric residents in their continuity clinics, helping to teach and examine patients with the residents. This strengthens the skills of the pediatric residents as well as those of the dental students.
A recent study in Pediatrics documents that after two hours of training in infant oral health, pediatric primary care providers could identify carious lesions with a high level of sensitivity. This suggests that pediatric health providers can benefit from training and can identify those patients needing referral.
The second part of our project is the application of fluoride varnish to low-income children. The varnish obtained FDA approval in 1994. Multiple studies have shown that fluoride varnish is effective in preventing caries and arresting or reversing existing early dental caries. Its use also may result in cost savings. The data currently available applies only to children over the age of three years. However, the varnish is easily applied to infants and toddlers, and can be done at a regular office visit. The “Out of the Mouth of Babes” program in North Carolina was a pilot program studying fluoride varnish application on all primary teeth, and we are modeling our project after their initiative.
In this part of the project we will be measuring the following outcomes: knowledge of oral health by pediatric providers, the referral rate to dentists, the feasibility of the program in private pediatric practices, the number of children who receive fluoride varnish, and parents’ perceptions of the project.
The United Methodist Health Foundation has funded this project, and continues to support efforts to improve oral health care for the people of Kansas.
Chief, Ambulatory Pediatrics
Director, Pediatric Residency Program
The University of Kansas Medical Center Pediatric Clinic and the Kansas City, Kansas Public Schools (USD 500) have worked together since 1998 to provide acute health care services to students in ten schools via telemedicine in the TeleKidcare® program. During the program’s five years of operation, more than 2000 consults have been conducted via telemedicine. Telemedicine is not considered experimental in the setting that has been established in the TeleKidcare® program or in this research project. The purpose of this study was to determine which medical conditions could be accurately diagnosed using telemedicine.
Telemedicine allows a patient and nurse in one location to see and talk to a physician who is at another location, reminiscent of the videophone in a “Jetson’s” cartoon. During a telemedicine visit, the parent, child, nurse and physician can all talk together and see each other. In order to help the physician make a proper diagnosis, the nurse may use such special equipment as a stethoscope that will transmit heart and lung sounds with great clarity to the physician’s headphones, an otoscopic camera to show the child’s ear canal to the physician, or a dermascope to show a skin rash or abrasion. The physician will ask questions and the parent, child, and nurse can provide information. The telemedicine visit is not taped; it can only be seen by the people who are participating in the visit.
To evaluate the telemedicine system it was necessary to conduct parallel examinations both in person and with equipment identical to that used in the schools.
Patients were recruited for the study when they presented to our clinic for an acute care visit. Each patient received two examinations: one in person and one via telemedicine. The “in person” exam took place at the KUMC Pediatric Acute Care Clinic. For the telemedicine exam, the child, parent, and nurse walked down the hall to the telemedicine room in the Developmental Disabilities Center. Each exam took approximately 20 minutes. The order of the examinations was randomized. Each physician determined a diagnosis, filled out a report with treatment recommendations, and completed a post-examination document that included diagnosis and ratings on seven items. One open-ended question asked for “other factors” in making the diagnosis.
The final diagnosis and treatment plan was explained to the family after the attending physician had reviewed the diagnoses provided by each of the examining physicians. If, in the attending physician’s medical judgment, the diagnoses provided did not agree or reached different medical conclusions, the attending performed a second “in person” examination before finalizing a diagnosis and treatment plan.
Patients were categorized by primary diagnosis: ENT, Dermatologic, and Eyes. There was 100% diagnostic agreement between examination methods. Across all groups, diagnostic factors were ranked in the following order: patient history, presenting symptoms, and physical examination. Although their diagnoses were the same, physicians had less confidence in their conclusions with the telemedicine exam compared to the traditional one, and were more satisfied with the traditional exam process.
From the study, we conclude that high diagnostic accuracy can be achieved with telemedicine consultations. A strong working relationship with the nurse involved with the telemedicine exam is critical for success of the consultation. With increased bandwidth and improved instruments with greater visual resolution, diagnostic confidence should improve.
Training residents in the use of telemedicine technology can be a powerful way to improve access to care for many school-age children. Additional training and experience will provide them the increased comfort and expertise in using what promises to be a very useful technological tool.
Chief, Ambulatory Pediatrics
Director, Pediatric Residency Program
Dear pediatric care provider,
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The University of Kansas Medical Center