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Performance Measure: Dental and Medical History

National Quality Forum #: None

Description: Percentage of oral health patients1 with a diagnosis of HIV who had a dental and medical health history2 (initial or updated) at least once in the measurement year

Numerator: Number of oral health patients with a diagnosis of HIV who had a dental and medical health history2 (initial or updated) at least once in the measurement year

Denominator: Number of oral health patients with a diagnosis of HIV who received a clinical oral evaluation3 at least once in the measurement year

Patient Exclusions:

  1. Patients who had only an evaluation or treatment for a dental emergency in the measurement year4
  2. Patients who were <12 months of age

Data Elements:

  1. Does the patient have a diagnosis of HIV? (Y/N)
    1. If yes, did the patient have a clinical oral evaluation3 at least once in the measurement year? (Y/N)
      1. If yes, did the patient have a dental and medical health history (initial or updated) in the measurement year? (Y/N)

Data Sources:

  • Data reports required by HRSA/HAB, such as the Ryan White HIV/AIDS Program Services Report (RSR)
  • Electronic Health Record/Electronic Medical Record
  • Sample of oral health services, patient records
  • Provider billing systems (Note: This will be dependent on the completeness and accuracy of coding of the procedures of interest.)

National goals, targets, or benchmarks for comparison

The HIV Quality Measures (HIVQM) Module is a tool within the Ryan White HIV/AIDS Services Report portal. It allows recipients to enter aggregate data specific to HRSA HAB Performance Measures. The HIVQM Module allows recipients to conduct point-in-time benchmarking across Ryan White HIV/AIDS Programs that use the module.

Basis for selection

To develop an appropriate treatment plan, the oral health care provider should obtain complete information about the patient's health and medication status.5 The American Dental Association (ADA) Guidelines for Practice Success include accurate documentation of medical/dental health history as vital, "especially since certain medications can influence treatment decisions."6

Department of Health and Human Services Clinical Practice Guidelines

None

References/notes

1 "Patient" includes all patients aged 12 months or older.

2 Dental and medical history should include medications and predisposing conditions that may affect the prognosis, progression, and management of oral health condition. See Footnote 6.

3 Clinical oral evaluations include evaluation, diagnosis, and treatment planning. Pertinent ADA CDT codes may include the following: D0120-Periodic Oral Evaluation-established patient; D0150Comprehensive oral evaluation, new or established patient; D0160-Detailed and Extensive Oral Evaluation-problem focused by report; D0170-Re-evaluation, limited, problem focused (established patient; not post-operative visit); and D0180-Comprehensive Periodontal Evaluation-new or established patient.

4 Pertinent ADA CDT codes for patient exclusion may include the following: D9110-Palliative (emergency) treatment of dental pain-minor procedure; and D0140-Limited Oral Evaluation-Problem Focused; however, the diagnostic and treatment procedures associated with emergency evaluation and treatment encounters (including those using these or other ADA CDT codes, as well as other procedures which may not be coded) should be considered when identifying patients for exclusion.

5 New York State Department of Health. Oral health care for people with HIV infection. New York (NY): New York State Department of Health; 2001 Dec: 3.

6 American Dental Association. Medical/Dental Health History. Available online. Accessed August 2023.

Date Last Reviewed: