P2.268: A Quality Improvement Project to Increase Fluoride Varnish Application in a Primary Care Setting

Purpose/Objectives: Topical fluoride varnish application for children ages 1-5 is an important preventative measure 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 was 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 were low.

The primary 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 an average baseline of 19% 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: 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. Our initial interventions included educational talks, clinic signage, an updated nursing policy as well as EMR reminders and adjustments. PDSA cycles were conducted to test each intervention.

To monitor improvement, we utilized statistical process control charts to track the monthly percentage of fluoride varnish application in eligible patients. We tracked orders for fluoride varnish as a process measure, and post-well-child visit lab appointment completion rates were tracked as a balancing measure.

Results: Interventions implemented during this quality improvement project increased the application of fluoride varnish during well child visits for children aged 1-5 from a baseline of 19% to 35%.

This increase occurred without a reduction in post-well-child visit lab appointments which is demonstrated by an appointment retention percentage that remained above 75% after implementing interventions.

Conclusion/Discussion: A multi-pronged, interdisciplinary improvement effort increased the rates of fluoride varnish application for eligible primary care patients. Increased fluoride varnish treatments have the potential to improve oral health by strengthening tooth enamel and by reducing the risk of dental caries. Future interventions will include updated family education sheets, an updated storage and supply ordering system, continued care team education and direct provider feedback. We also plan to repeat an equity analysis during the maintenance phase of this project which will inform strategies aimed at eliminating racial disparities in fluoride application.