P2.K204: Easier than it Seems: Fitting Fluoride Varnish Application into the Pediatric Well-visit

Background: Though largely preventable, dental decay is the most common chronic condition for children. Fluoride varnish (FV) application for young children is a widely recommended evidence-based preventive procedure and is reimbursed in primary care settings by Medicaid/CHIP and private insurance. However, many practices struggle to incorporate that recommendation. Barriers to implementation reported by pediatric practices include the time required and concerns about including in the workflow. Our objective was to rigorously analyze the time required to apply FV in the well-child visit and collect implementable practices that enhanced the efficient delivery of FV in the primary care setting.

Methods: Six varied practices in Georgia currently applying FV during well-child visits were recruited to participate in the study. Videos of FV application were captured and semi-structured interviews with employees (including providers, office managers etc.) were completed. Time study analysis was used to determine times for FV application and factors influencing that time. The updated Consolidated Framework for Implementation Research (CFIR) was used as the framework to collect and analyze interview data. Workflow was examined and suggestions for effective implementation were also collected.

Results: The mean time to apply FV across all practices was 46.5 seconds (95% CI = 37.9,55.1), and 38.5 seconds (95% CI = 30.8,46.3) among more experienced practices. Total time that FV-related activities consumed during a well-child visit totaled 2 minutes and 10 seconds (95% CI = 116.4,143.9 seconds) and 1 minute and 41 seconds (95% CI = 89.3, 112.4 seconds) for more experienced practices. Median times were shorter than means. Estimates for time spent outside of the well-visit related to billing and ordering were less than a minute. Strong facilitators to applying FV were the motivation providers felt from understanding their patient needs and the evidence base of the effectiveness of FV. Similarly important facilitators were provider strategies for engaging their patients, partnerships and connections that introduced them to FV application and integration with their electronic health records. The top barriers were patient resistance, parent's beliefs, and the relative priority of FV compared to other demands during well-visits. Providers and practice managers shared recommendations for engaging their patients and caregivers and for providing education and resources to empower providers. They also shared strategies for ensuring that FV application was remembered and varnish always available to do the procedure – which were the two most common obstacles to successful implementation.

Conclusion: FV application requires approximately 2 minutes during the well-child visit. Practice managers and providers currently applying FV find value in the process. Existing literature and results from this study suggest barriers to FV application during pediatric well-child visits are surmountable, enabling implementation of guidelines.