Dynamics of Dental Care for the Population of the Ryazan Region in COVID-19 Pandemic

全文:

LIST OF ABBREVIATIONS

CHI — compulsory health insurance

CNСDs — chronic non-communicable diseases

СOVID-19 — Corona Virus Disease 2019

MCQE — medical care quality examination

ICD-10 — International Statistical Classification of Diseases and Related Health Problems, 10^th revision

MEE — medical and economic examination

PHC — primary health care

RR — Ryazan region

TP — territorial program

INTRODUCTION

The task of protecting the health of citizens of the Russian Federation cannot be solved without reducing the prevalence of dental pathology [1]. In the evidence-based medicine, a reliable connection has been established between diseases of the liver, gastro-intestinal tract, chronic non-communicable diseases (CNCDs) including cardiovascular diseases, and diseases of teeth and oral cavity [2–4]. Taking into account the fact that the targets and indicators of the ‘Healthcare’ national project include the reduction of premature mortality from cardiovascular diseases, diseases of digestive organs, etc. [5], of increasing importance for reducing premature mortality of the populationare prevention and treatment of diseases of teeth and oral cavity [6, 7].

The study of the dynamics of dental morbidity parameters is also of high medical and social importance due to frequent progressive course of dental diseases, chronification of the processleading to the risk of developing various non-infectious diseases and comorbid conditions in a patient.

Forecasting dental morbidity and the needs of the region's population for medical care for competent resource planning and distribution of compulsory health insurance (CHI) funds between medical organizations, is aimed at increasing the accessibility and quality of medical care, including ensuring the rights of insured persons by monitoring the amount, timing, quality and conditions of providing medical care in the field of compulsory medical insurance.

The relevance of this scientific research has increased in the special conditions of the pandemic of the new coronavirus infection (Corona Virus Disease 2019, COVID-19) and changes in the geopolitical situation, when important adjustments were made to the compulsory medical insurance system, which permitted to more effectively organize the system of provision of and payment for medical care inthe territorial program (TP) of compulsory medical insurance.

The aim of this study to the structure and dynamics of provision of dental care in the period 2018–2021 (pre-pandemic and the period of the new coronavirus infection pandemic) based on the amountof dental care paid for in the compulsory health insurance system provided for citizens of the Ryazan region (RR).

МАТЕРИАЛЫ И МЕТОДЫ

An analysis of completed cases of treatment of insured persons with dental diseases has been conducted based on the data from registers of bills submitted for payment by medical organizations of the region in the period 2018–2021 with control and expert measures taken into account.

Groups (n = 4) were formed depending on the year of turning for dental care. Each group includes subgroups based on the following criteria:

- nosological form:

• caries (codes in the International Statistical Classification of Diseases and Related health Problems, 10^th revision (ICD-10): К02–К02.9),
• diseases of pulp and periapical tissues (ICD-10 codes: К04–К04.9),
• periodontal diseases (ICD-10 codes: К05–К05.6),
• other dental diseases and dental examination cases;

- aim of visiting medical organizations by patients:

• visits for preventive and other purposes;
• visits for dental disease;
• emergency visits.

Planning, organization, control of rendering care and of payment for the primary healthcare (PHC) of all profiles including dental care, were performed at the regional level taking into account the results of monitoring the implementation of the territorial program of compulsory health insurance (TP CHI) and in accordance with the standards and procedures of rendering medical care.

To assess the quality of dental care for the insured population of the RR, an analysis of the results of control and expert activities was carried out for 2018–2021. It should be noted that during the period under study, major changes occurred in the compulsory health insurance system: on January 1, 2021, amendments to the Federal Law on No. 326-FL dated November 29, 2010 [8] came into force, which approved the transfer of the function of medical and economic control to territorial compulsory medical insurance funds [9]. At the same time, the interests of patients continue to be protected by the insurance companies that issued them compulsory medical insurance policies, by, among other things, conductingmedical and economic examinations (MEEs) and medical care quality examinations (HCQEs) [10, 11].

During the COVID-19 pandemic, the Government of the Russian Federation decided to suspend the planned MEEs and ECMQs (Resolution of the Government of the Russian Federation on No. 432 dated April 03, 2020 [12], according to which expert measures for controlling the quality of dental care were completely suspended in 2020, with the exception of cases of complaints from insured citizens (or their representatives) of a medical organization or of poor-quality dental care)) [13].

Statistical analysis of the obtained data was carried out using the Excel analysis package (Microsoft, USA). Descriptive statistical results were mean ± standard error (M ± SD) for quantitative data. The statistical significance of the differences was assessed based on the calculation of χ2-criterion and Student's test. Differences were considered significant at p ˂ 0.05.

RESULTS

Based on the analysis of statistical reporting form No. 30 ‘Information about a medical organization’ for 2018–2021, by ranking through 10 basic medical specialties (profiles) involved in rendering PMC in the RR, a masscharacter of seeking dental servicesby the population was established — doctors of dental profile ranked third in turning of the population for medical care (Table 1). A share of visits to dentists made 7.40% of the total number of visits to doctors of all other specialties.

 

Тable 1. Ranking of Specialties (Profiles) by Average Number of Visits in Provision of Dental Care in Outpatient Setting in the Ryazan Region (2018–2021)

Profile	Average Number of Visits per Year, M ± SD	Rank
Physicians including:	7852445.50 ± 498660.05	–
therapists	2002227.25 ± 122170.81	1
pediatricians	1057124.00 ± 71489.40	2
dentists	581348.00 ± 37964.75	3
obstetricians-gynecologists	555172.75 ± 28861.58	4
dermatovenerologists	497210.50 ± 11229.68	5
ophthalmologists	398475.50 ± 28267.10	6
neurologists	357829.25 ± 25917.20	7
surgeons	319550.75 ± 32298.71	8
ENT specialists	266820.25 ± 24654.72	9
psychiatrists-addiction therapists	238730.00 ± 13836.03	10

 

During the implementation of TPCHIin part of the primary dental care, a ‘variegated picture’ of the annual fulfilmentof plan goals was detected, which was associated withrestricting measures in conditions of COVID-19: in 2020, there was a decrease in the amount of planned medical care (visits for preventive and other purposes and visits for diseases) and in the labor intensity of manipulations performed on visits to specialists (Figure 1, Table 2).

 

Fig. 1. Dynamics of the number of completed cases of treatment in the provision of dental care to the population of the Ryazan region within the framework of the territorial compulsory health insurance program in 2018–2021, depending on the purpose of the visit.

 

Тable 2. Dynamics of Amount of Dental Care Performed within Territorial Program of Compulsory Health Insurance in 2018–2021

Year, Parameter	Parameters
	Preventive Visits	Visits for Diseases	Emergency Visits	Total
Primary dental care
2018: n	157086	293408	16379	466873
2019: n increment rate (±), %	143354 - 8.74	290464 - 1.00	19585 + 19.57	453403 - 2.89
2020: n increment rate (±), %	132882 - 7.30	253358 - 12.77	20755 + 5.97	406995 - 10.24
2021: n increment rate (±), %	156090 + 17.47	265652 + 4.85	19121 - 7.87	440863 + 8.32
Labor intensity of work of dentists, thousand rel. units
2018: n	486.97	1734.69	73.03	2294.69
2019: n increment rate (±), %	481.33 - 1.16	1572.50 - 9.35	75.98 + 4.05	2129.81 - 7.19
2020: n increment rate (±), %	460.38 - 4.35	1461.15 - 7.08	84.33 + 10.99	2005.86 - 5.82
2021: n increment rate (±), %	571.31 + 24.01	1593.32 + 9.05	90.91 + 7.81	2255.54 + 12.45

 

When monitoring TP CHI, the main forms of dental pathology in the structure of dental morbidityof the RR population were caries (К02–К02.9), diseases of the pulp and periapical tissues (К04–К04.9),periodontal diseases (К05–К05.6) (Figure 2). At the same time, in the period from 2018 to 2020, in the structure of dental morbidity (based on visits), a significant reduction of caries (р < 0.02) and diseases of periapical tissues (р < 0.01) was revealed; during the study period of periodontal diseases (р < 0.02, Table 3). In the structure of dental morbidity (based on visits), caries made 37.19 ± 1.95%, diseases of the pulp and periapical tissues 48.26 ± 1.07%,periodontal diseases5.05 ± 1.06%. There was found a tendencyto reduction of visits for periodontal diseases by 1.91 times, and forother dental diseases (with the exception for caries, diseases of the pulp, periapical tissues and periodontal diseases) by 1.30 times.

 

Fig. 2. Dynamics of the amount of dental care (treatment cases) provided to the populationof the Ryazan region in the territorial programof compulsory health insurance in 2018–2021 by nosological groups.

 

Тable 3. Comparative Analysis of Amount of Dental Care (by Nosological Groups) Provided in the Ryazan Region under Territorial Program of Compulsory Health Insurance

Parameter	2018	2019	2020	2021
	1	2	3	4
Caries (К02–К02.9), n	123499	116128	102892*	114715
increment (decrement) rate, %	-	-5.97	-11.40	+11.49
Illustrative aspect	100.0	94.03	83.31	95.89
Diseases of pulp and periapical tissues (К04–К04.9), n	174357	138483**	136251***	146336
increment (decrement) rate, %	-	-20.58	-1.61	+7.40
Illustrative aspect	100.0	79.42	78.14	83.93
Periodontal diseases (К05–К05.6), n	23363	14562****	13071*	12247*****
increment (decrement) rate, %	-	-37.67	-10.24	-6.30
Illustrative aspect	100.0	62.33	55.95	52.42
Other dental diseases, n	35498	27594	26899	27351
increment (decrement) rate, %	-	-22.27	-2.52	+1.68
Illustrative aspect	100.0	77.73	75.78	77.05
TOTAL completed cases including those with preventive purposes	466873	453403	406995	440863
increment (decrement) rate, %	-	-2.89	-10.24	+8.32
Illustrative aspect	100.0	97.11	87.17	94.43

Notes: *— р < 0.02, comparison between groups 3 and 1; ** — р < 0.01, comparison between groups 2 and 1; ***— р < 0.01, comparison between groups 3 and 1;**** — р < 0.02, comparison between groups 2 and 1; ***** — р < 0.02, comparison between groups 4 and 1

 

At the next stage of the study, ranking of the ten most common main nosological forms was performed, according to the average number of completed treatment cases per year for the period 2018–2021 (Table 4).

 

Тable 4. Ranking of Main Nosological Forms Most Often Encountered when Seeking Dental Care by Population of the Ryazan Regionin 2018–2021

ICD-10 Codes	Section ofICD-10	Average Number of Visits, M ± SD	Ranking Position	Increment/Decrement Rate for 4 Years, %
Z01.2	Encounter for dental examination	128070.25 ± 5061.97	1	+12.48
K02.1	Caries of dentin	74084.00 ± 1231.42	2	-1.42
K04.5	Chronic apical periodontitis	61027.25 ± 2548.16	3	-8.56
K04.0	Pulpitis	50939.00 ± 2025.22	4	-4.98
K04.7	Periapical abscess without sinus	23292.00 ± 580.76	5	+2.61
K02.8	Other dental caries	21917.50 ± 341.89	6	+0.12
K05.3	Chronic periodontitis	9495.00 ± 513.66	7	-12.24
K02.2	Caries of cementum	8945.25 ± 422.88	8	-7.74
K07.3	Anomalies of tooth position	7601.25 ± 304.64	9	-5.98
К02.9	Dental caries, unspecified	6394.00 ± 84.51	10	+1.44

Note: ICD-10 — the International Statistical Classification of Diseases and Related health Problems, 10^th revision

 

As a result, the most common cause of seeking medical care in the studied periodwas encounter for dental examination (Z01.2) 29.06 ± 2.42%; the indicator increased by 30.46% over 4 years, and by 8.46% in the structure of appeal ability. The second cause was caries of dentin (К02.1) 16.75 ± 0.12% with a constant share in the structure of dental care; appeal ability decreased by 5.41%. The third cause was chronic apical periodontitis (К04.5) 13.75 ± 0.80%; appeal ability decreased by 25.43%, and by 3.39% in the structure of overall dental morbidity. Pulpitis (K04.0) took the 4^th ranking position, amounting to 11.50 ± 0.73% in the structure of dental care; the appeal ability decreased by 18.62%, and by 1.84% in the morbidity structure. Periapical abscess without sinus (K04.7) occupied the 5^th ranking position in the structure of dental care 5.29 ± 0.33%; and insignificantly increased in the structure of morbidity by 0.54%. The 6^th ranking position was taken by other dental caries (K02.8). This code is assigned to secondary recurrent caries of a devitalized tooth. The frequency of this pathology decreased by 1.18%, its share in the structure of dental morbidity increased by 0.23%. Chronic periodontitis (K05.3) occupied the 7^th ranking position 2.14 ± 0.18% of the total amount of medical care provided by dentists; appeal abilitydecreased significantly by 34.08%, share by 0.80%. Caries of cementum (K02.2) 8^th ranking position, 2.01 ± 0.14% of the amount of dental care, appeal abilitydecreased by 25.47% and the share in the structure of dental morbidity by 0.49%. Anomalies of tooth position (K07.3) 9^th ranking position, 1.72 ± 0.11%; with a decrease in the appeal ability by 20.58% and decrease in the share in the structure of total morbidity by only 0.32%. Dental caries, unspecified (K02.9) 10^th ranking position, 1.45 ± 0.05% of theamount of medical care; the accessibility increased by 3.59%, and the share in the morbidity structure increased by 0.14%.

According to the data of medical insurance organizations involvedin the implementation of TP CHI of the RR, for the period 2018–2021, 73,049 MEEs and 1,626 MCQEs were conducted, and 1,966 violations were found (1,316 by the results of MEE sand 650 by the results of MCQEs) on the part of medical workers. The vast majority of them concerned non-observance of the medical care standards and clinical recom-mendations (Table 5).

 

Тable 5. Monitoring of Control and Expert Measures of Dental Care Delivery to Population of the RR under Territorial Program of Compulsory Health Insurance in 2018–2021

Year	Completed Treatment Case, n	Number of Examinations, n	Number of Examinations with Identified Defects, n (%)	Coverage of Treatment Cases by Examination, %	Share of Cases of Identified Violations from the Overall Cases of Dental Care, %
Medical and Economic Examination
2018	466873	17953	138 (0.77)	3.85	0.03
2019	453403	52878	664 (1.26)	11.66	0.15
2020	406995	986	294 (29.82)	0.24	0.07
2021	440563	1232	220 (17.86)	0.28	0.05
Итого	1767834	73049	1316 (1.80)	4.13	0.07
Medical Care Quality Examination
2018	466873	8	5 (62.50)	0	0
2019	453403	520	14 (2.69)	0.11	0
2020	406995	572	273 (47.73)	0.14	0.07
2021	440563	526	358 (68.06)	0.12	0.08
Итого	1767834	1626	650 (39.98)	0.09	0.04

 

The analysis of the MEE results revealed a change in the structure of the identified violations. Thus, in 2018–2020 in the vast majority of cases, financial sanctions were applied to medical organizations for non-submitting the primary medical documentation confirming the fact of medical care providedto an insured person in a medical organization, without objective reasons (76.09% in 2018, 52.11% in 2019, 68.03% in 2020). In 2021, such violations were detected only in 19.55%. The absence of the primary documentation forinformed voluntary consent (or refusal) of the insured person to medical intervention was identified in 13.77% of cases in 2018, in 36.75% in 2019. In 2020, no facts of absence of informed consent wereestablished by medical insurance organizations, in 2021 such violations were identified in 1.82% of examinations. Noteworthy is the fact that inclusion of payment for medical care/service in the bill in the absence of information in the medical document confirming the fact of deliveryof medical care/serviceto the patient, was considered by experts as the ground for application of financial sanctions in 5.72% of the MEEs in 2019, in 14.97% in 2020, and already in 72.73% in 2021.

CMQEs were performed in0.09 ± 0.03% of cases of dental care provided. It should be noted that medical insurance organizations approached the selection of cases for CMQEs quite rationally, as evidenced by the proportion of identified violations on average, every second examination revealed defects in the quality of medical care (45.25 ± 14.82%, Table 5).

In the structure of cases of dental care depending on the nosology, for which CMQEswere conducted, the largest share was taken by cases of treatment of caries (K02–K02.9) and of diseases of the pulp and periapical tissues (K04–K04.9) 39.84 ± 11.06 % and 33.10 ± 11.05%, respectively; followed by cases of dental examination (18.95 ± 2.50%). Every second case of treatment of pulpitis that was subject to examination was considered defective (53.91 ± 20.92%). Similar results were obtained in CMQEs of treatment of caries (46.51 ± 15.65%), slightly better results in CMQEs of dental examinations (35.27 ± 21.83%).

A comparative analysis of the applied codes of defective cases subjected to CMQE showed that most cases (64.28 ± 12.18%) were non-fulfilment, untimely or improper fulfilment of requireddiagnosticand/or therapeutic measures orof surgical interventions in accordance with the procedures of rendering medical care, clinical recommendations and medical care standards, recommendations for methods of prevention, diagnosis, treatment and rehabilitation, by medical workers of national medical research centers during consultations/case conferences with use of telemedicine technologies that had no effect on the health condition of the insured person. Non-fulfilment, untimely or improper fulfilment ofneeded by the patient diagnosticand/or therapeutic measuresthat led to impairment of health condition of the insured person or created risk for progression of the existing disease, or for development of a new disease, were found in 21.91 ± 11.11% of CMQEs.

DISCUSSION

A significant increase in the number of MEEs was found in 2019 relative to 2018, when 11.66% cases of dental care were subjected to control measures.To this end, of all the conducted examinations, violations were found in only 1.26% of cases, which made 0.15% of the total number of treatment cases. In 2020–2021, due to introduced restrictions, MEEs were conducted in 0.24%–0.28% of rendered dental care cases, violations were identified in 29.82%–17.86% of cases, respectively. The highest number of MEEs was conducted in cases of treatment of diseases of pulp and periapical tissues (К04–К04.9) and caries (К02–К02.9), which shared the leading positionsin different yearsand made 41.24 ± 11.28% and 37.95 ± 6.68%, respectively.The third position was taken by cases of dental examinations with the share of 8.70 ± 4.49%.To note, in 2018-2019, violations were found only in 0.77%–0.99% of MEEsof cases of treatment of caries and 0.66%–1.32% of MEEs of cases of treatment of pulpitis. In 2020-2021, the number of defects identified in examinations, significantly increased: in 31.60% of MEEs of this pathology in 2020 and 22.07% in 2021; in 26.77% of MEEs of cases of treatment of pulp diseases in 2020 and 10.74% in 2021. Based on the results of MEE of dental examination cases, violations in provision of medical care were established in 6.11% in 2018, 6.15% in 2019, 44.86% in 2020, 21.34% in 2021.

The authors note a direct correlation between changes in the structure of identified violationsand changes in the regulatory and legal frameworkgoverning the control procedure in CHI system. Thus, since theentry of the Order of Health Ministry of Russia on No. 108n dated February 28, 2019 (registered in the Ministry of Justice of Russia on No. 54643 dated May 17, 2019) [14] into force, one of the groundsfor applying financial sanctions to a medical organization in full volume was non-submission of the primary medical documentation, which was the basis for reduction of payment by 100% of the cost of case and for additional imposition of fine at the full cost of the case, which was actively used by medical insurance companies without actually assessing the medical care quality. In the mid-2021, amendments were introduced into the CHI Rules [15], which cancelled fines for such violations, but retained the possibility to with draw the case from payment and apply fine sanctions in the amount of the cost of the case if a medical service was included in a bill in the absence of information confirming the fact of rendering a medical service to the patient, in the medical document.

Undoubtedly, the quality of medical care can only be ensured on condition that constant monitoring of compliance with the established procedures, clinical recommendations and methods of their implementation is provided. Increasing the amount of expertise of the quality of medical care with an increase in appeal ability by insured citizens during the period of decreasing intensity of the new coronavirus infection, is aimed at providing high-quality medical care, among other things, by conducting regular analysis of the results obtained,which will permitto increase efficiency and accessibility.

In general, the readiness of medical organizations to work in emergency situations, while maintaining the provision of quality medical care, has been confirmed.

CONCLUSION

During the pandemic of the new coronavirus infection, a significant reduction of completed cases of treatment of dental diseases was registered when providing primary medical specialized care in outpatient setting (р < 0.02).

The main cause for seeking medical care of dentistry profile by the population remains theneed for examination. The leader in the structure of dental diseases during the entire study period was caries of dentin, the second position was taken by chronic apical periodontitis, third by pulpitis. Increase in the number of completed cases of treatment of pulpitis and periapical abscess without sinus in the structure of dental morbidity was identified in 2020 as compared to 2019, with thegeneral reduction inthe amount of dental care. The situation changed in 2021 in the period of decline of the new coronavirus infection with increase in turning of the population for dental care due to increase in the incidence of dentalpathology.

Owing to the order of the health Ministry of the Russian Federation on No. 231n dated March 19, 2021 obliging medical organizations to conduct control and expert measures in each medical organization in a certain portion of payable cases of dental care, the number of examinations increased, and, as a consequence, the number of violations afforded by medical organizations.

ADDITIONALLY

Funding. The authors declare that there is no funding for the study.

Conflict of interests. The authors declare no conflicts of interests.

Contribution of the authors: S. V. Yurina — concept and design of the study, statistical processing, analysis and interpretation of data, writing the text; E. V. Manukhina — concept and design of the study, editing; I. V. Uspenskaya — concept of the study, editing; P. P. Yurin — statistical processing, analysis and interpretation of data; L. N. Tishkina — collection and processing of material, statistical processing. The authors confirm the correspondence of their authorship to the ICMJE International Criteria. All authors made a substantial contribution to the conception of the work, acquisition, analysis, interpretation of data for the work, drafting and revising the work, final approval of the version to be published and agree to be accountable for all aspects of the work

Финансирование. Авторы заявляют об отсутствии внешнего финансирования при проведении исследования.

Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов.

Вклад авторов: Юрина С. В. ― концепция и дизайн исследования, статистическая обработка, анализ и интерпретация данных, написание текста; Манухина Е. В. ― концепция и дизайн исследования, редактирование; Успенская И. В. ― концепция исследования, редактирование; Юрин П. П. ― статистическая обработка, анализ и интерпретация данных; Тишкина Л.Н. — сбор и обработка материала, статистическая обработка. Авторы подтверждают соответствие своего авторства международным критериям ICMJE (все авторы внесли существенный вклад в разработку концепции, проведение исследования и подготовку статьи, прочли и одобрили финальную версию перед публикацией).

作者简介

Svetlana Yurina

Ryazan State Medical University; Territorial Compulsory Health Insurance Fund of the Ryazan Region

编辑信件的主要联系方式.
Email: s.urina@mail.ru
ORCID iD: 0000-0002-5107-3379
SPIN 代码: 2731-5534

MD, Cand. Sci. (Med.)

俄罗斯联邦, Ryazan; Ryazan

Elena Manukhina

Ryazan State Medical University; Territorial Compulsory Health Insurance Fund of the Ryazan Region

Email: manuxina.ev@tfoms-rzn.ru
ORCID iD: 0000-0001-9784-9454
SPIN 代码: 5924-6540

MD, Cand. Sci. (Med.), Associate Professor

俄罗斯联邦, Ryazan; Ryazan

Irina Uspenskaya

Ryazan State Medical University

Email: irinauspenskaya1958@yandex.ru
ORCID iD: 0000-0002-3163-5688
SPIN 代码: 6094-2737

MD, Dr. Sci. (Med.), Professor

俄罗斯联邦, Ryazan

Pavel Yurin

Ryazan Dental Implantation Center

Email: yurin.pashan@gmail.com
ORCID iD: 0000-0002-3684-2619
俄罗斯联邦, Ryazan

Larisa Tishkina

Dental Clinic No. 1

Email: loratishkina@mail.ru
ORCID iD: 0000-0003-4021-3695
SPIN 代码: 8698-4018
俄罗斯联邦, Ryazan

参考

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