Rural Veterans’ Dental Utilization, BRFSS, 2014

Abstract

Introduction

The U.S. Department of Veterans Affairs estimates that there are 21.68 million Veterans; 9.11 million of whom are enrollees in the Veterans Health Administration (VHA).¹ There are 150 VHA medical centers, and approximately 1,400 community-based outpatient clinics in the U.S.² Although the VA provides a medical, dental, and social care safety net, many Veterans may not, cannot, or do not wish to take advantage of the services. Some Veterans have faced difficulty in receiving needed care^3,4 and/or receiving information about Veterans’ services.⁵ Travel, distance, and age are also barriers which impede access to care for some Veterans.^6,7

People living in urban areas often have several healthcare resources and options from which to choose. Researchers indicated that overall, Veterans living in urban areas were less likely to use VHA services, whereas, Veterans who were black, or had a higher VHA priority (ie., who were evaluated to have a higher rating of Veteran benefit need/service-connected disability) were more likely to use VHA services.⁵ Nevertheless, many healthcare needs of Veterans go unmet,⁸ particularly for rural Veterans.⁹ Researchers indicated that there were significantly more prevalent diseases in rural settings compared to urban settings and the odds ratios persisted upon adjustment for sociodemographic factors.¹⁰ Additionally, health-related quality of life was lower for rural Veterans than for suburban or urban-dwelling Veterans.¹¹

It is difficult to provide a complete array of medical services in a rural setting due to the expense of some of the technologies, reluctance of some physicians in selecting a rural practice, and the financial considerations of the limited number of people needing specialized services to make a specialized practice successful in a rural setting.¹² As a result, people living in rural areas, even with insurance, may not have access to essential services and may substitute emergency department care for routine care.¹³

Among the many healthcare services which are needed by Veterans are oral health-related services. Neglected oral health maintenance often results in the need for additional restoration of natural dentition, implant placement,¹⁴ extractions, or fabrication of removable dental prostheses. Failures in patient recall, failures in professional maintenance, and failures in at-home maintenance are risk factors for failure of tooth and implant-borne restorations.¹⁵ Recent clinical practice guidelines for recall and maintenance of patients with tooth-borne dental restorations re-affirmed routine patient recalls and professional maintenance at least every 6 months as a lifelong regimen.¹⁵ Although, a set of VA researchers conducted a systematic review to address recall interval for periodontal maintenance and concluded that any specific recall interval, such as 3 or 6 months, is not beneficial leading to the thought that “one size does not fit all” with clinical need driving recall timeframes.¹⁶ None-the-less, poor oral health and lack of recall or maintenance can lead to periodontal disease and impact glycemic control; both have been associated with increased mortality in individuals with diabetes.^17,18

Veterans have extremely limited dental health coverage, in fact, they must be 100% disabled, be a former prisoner of war, or have a service-related injury to their mouths to qualify for services.¹⁹ VHA dental health services are limited to residents of VA domicilaries, VA Community Living Centers, hospitalized patients with a dental need which could impact medical care, or hospital discharged patients who had care VHA dental initiated in the hospital, humanitarian emergency dental care, and outpatient Veterans who are Class I-VI beneficiaries.¹⁹ If clinic capacity is available, dental care may be provided to inpatient active duty personnel or retirees in VA facilities as per VA Department of Defense or TRICARE agreements and designated inpatients and outpatients as per approved sharing agreements.¹⁹ There are over 200 VHA dental centers across the U.S.¹⁹ Each state has at least one VHA dental center; the states with the most dental centers are: Texas, with 15 centers; California with 16 centers; and Florida with 19 centers.¹⁹ Despite these programs, the Veteran must be enrolled for VA services; over 400,000 veterans are receiving dental services each year in the VA.²⁰

The concern for oral health in rural Veterans is significant. The VHA Office of Rural Health was established in an effort to improve the access to care for rural Veterans. Rural Veterans have challenges involving distance to care, travel concerns due to road conditions and weather, and wait time for appointments.¹⁹ Often receiving care requires financial burdens associated with the cost of gasoline, overnight stays in hotels, and most significantly, loss of income. While people living in rural areas value health, they recognize these challenging circumstances intrinsically as part of living in an area which is not densely populated. Additionally, health services provided by some VA sites are limited in scope and may not include dental services. As a result, oral care may be neglected by many Veterans. Rural residents are overrepresented in the military,¹³ therefore there is a need to identify rural Veteran healthcare utilization. There are two purposes of this study: 1) to determine if there is an association between rural dwelling and Veteran utilization of dental services; and, 2) to determine if there is an association between rural dwelling and the oral health outcome of missing teeth. Our research hypotheses are that rural Veterans will be less likely to have utilized dental services within the previous year and that rural Veterans will be more likely to have missing teeth than non-rural Veterans.

Methods

This study received West Virginia University Institutional Review Board study acknowledgement (protocol number 1602007654). Strengthening the reporting of observational studies in epidemiology (STROBE) guidelines were followed in this study. The theoretical framework used was the Andersen Model of Health Service Use. In the model, predisposing characteristics, enabling resources, personal health practices and need are factors which influence health service utilization.²²

Findings

There were 36,594 participants in the study; 24,537 lived in metropolitan areas (79.3%) and 12,057 (20.7%) lived in rural areas. There were 17,520 metropolitan participants (70.2%) who had a dental visit within the past year and 7,676 rural participants (62.6%) who had a dental visit during the past year. For participants who lived in metropolitan areas, there were 37.5% who had no missing teeth, 34.7% who had 1 to 5 missing teeth, 18.9% who had 6 or more (but not all) missing teeth, and 8.9% who had all of their teeth missing. The respective percentages for participants who lived in rural areas were 31.6%, 33.2%, 21.8%, and 13.3%. There were no significant differences in the sample distribution between metropolitan or rural participants in the categories of sex, age, marital status, health insurance, body mass index, and with missing data. The sample had fewer rural Latino and African American participants than metropolitan participants. Rural participants were less likely to have attended college, to exercise, and to have a usual source of health than metropolitan participants; however, they were less likely to have activity limitations than metropolitan participants. Rural participants were more likely to smoke and to have no alcohol use than metropolitan participants. Details are presented in Table 1.

Table 2 has the Chi Square results of participants who responded “yes” to having a dental visit within the past year. Overall, participants living in metropolitan areas were more likely to have dental visits in the previous year than participants living in rural areas (70.2% versus 62.6%). Other significant factors associated with having dental visits in the past six months for metropolitan Veterans over rural Veterans were with sex, white, black, age categories from 45 and older, marital status, education, health insurance, usual source of care, body mass index, physical activity, smoking, and no or moderate alcohol use.

Several logistic regression models were created to compare rural/metropolitan Veteran dental visits during the past year (Table 3). In the adjusted analysis, rural Veterans were less likely to have a dental visit during the past year as compared with metropolitan Veterans (Odds Ratio = 0.69, 95% Confidence Interval, 0.63, 0.76). Five models were presented and the relationships remained significant throughout. In sensitivity analyses with missing data included, the results remained the same (When sex, age, race, marital status, education, health insurance, employment, income, usual source of care, health status, and personal healthcare practices were added, the adjusted odds ratio was 0.86 [95% Confidence Interval, 0.78, 0.96]).

The positive results of the bivariate Chi Square analyses of missing teeth and rural/metropolitan status are presented in Table 4. There were significantly more metropolitan participants who had all of their teeth than rural participants (37.5% versus 31.6%). Other significant associations with participants who had all of their teeth were with sex, race/ethnicity, age, marital status, education, usual source of care, activity limitation, body mass index, physical activity, smoking, and alcohol use.

In multinomial logistic regression with the categories of tooth loss on rural/metropolitan status, rural Veterans were more likely to have missing teeth than were metropolitan Veterans in unadjusted analysis. Similar results remain in the provided adjusted analyses (Table 5). In cases where all teeth were missing, rural Veterans had an adjusted odds ratio of 1.81 (95% Confidence Interval, 1.56, 2.09). When sex, age, race/ethnicity, marital status, education, health insurance, employment, income, usual source of care, and health status were included, the adjusted odds ratio was 1.38 (95% Confidence Interval, 1.17, 1.63)

Discussion and Policy Implications

The results of this study were that there is an association between rural Veterans and the decreased likelihood of having a dental visit during the previous year as compared with Veterans who lived in metropolitan areas (the association remained in the presence of the known individual factors that explain dental utilization). Additionally, rural Veterans were more likely to have missing teeth than metropolitan Veterans. There have been few dental studies of national scope specifically on utilization by U.S. Veterans,^32,22 and data and studies concerning rural Veteran dental utilization similar to this study (i.e. public use data) are not available in the current literature with which to compare results. There is a persistence of a dearth of knowledge concerning rural Veterans and dental needs.

However, in a study evaluating factors considered to impact dental utilization in older Veterans, researchers showed that “need” factors accounted for the greatest degree of explained variance in use of dental services (R²= .15).³⁴ Healthcare was studied in rural Veterans living in Alabama and 33.5% reported a delay for dental care services among delays with other services.³⁵ There is a need for more studies concerning Veteran oral health, particularly that of rural veterans. The need for this knowledge has been a concern for administrators of the VHA for over two decades: why do eligible Veterans not utilize dental care; what are the needs; what is optimal care; are cost-efficient programs in place; and what is the best setting for the provision of dental care?³⁶ In 2007, the VA established the Office of Rural Health. The VHA Office of Rural Health administrators are working to adequately reach out to rural Veterans and establish/improve rural Veterans’ access to care, including dental care. Additionally, the Veterans Access, Choice and Accountability Act of 2014 has improved access by permitting qualified Veterans to utilize community health care facilities’ services.³⁷ This Act provides Veterans who are enrolled in VA health care (i.e. meaning they meet the general eligibility criteria) with a Veterans Choice Card. With this card, Veterans who are unable to schedule a visit not more than 30 days from the date on which a veteran requests an appointment or the clinically appropriate date, or due to the distance from their place of residence (i.e. more than 40 miles) to a VA program for care to choose to receive care from eligible non-VA health care/private care entities or providers.³⁸ Given that our data came from BRFSS 2014, Veterans may now be accessing more non-VA care sources for dental care in the years later than 2014 than we found in the current study.

This study has several limitations. We were focused on the utilization of dental services by Veterans, but the BRFSS data set is limited in that we could identify veterans but we were unable to distinguish Veterans eligible and enrolled for VA-based dental care versus Veterans who were not eligible. Eligibility and enrollment status would need to be assessed using a VA dataset, but then we would miss the Veterans who are not enrolled in the VA for services. Thus, this is a limitation in our study, however we were still able to characterize utilization by Veterans as whole in the community regardless of care system. Furthermore, we were limited by the choice of questions posed in the BRFSS data set. Also, there were a significant number of participants who did not have data concerning rural/metropolitan status. However, the study has several strengths as well. The sample size is large. The sample is nationally representative and many variables were used in the analyses. Sensitivity analyses were conducted to identify the impact (which was negligible) of missing rural/metropolitan status. We evaluated individual factors which had the potential to impact the rural/metropolitan relationship with dental visit during the previous year as well as the relationship with tooth loss and determined that those individual factors did not further explain the relationship. Research is needed to determine if community or cultural influences are factors. Also, research is needed to determine if rural status is a proxy for the number of available dentists.

The VA develops policies for establishing centers for care for enrolled Veterans. The policy development should take into consideration that rural Veterans are not as likely as urban Veterans to utilize dental services¹² and since rural Veterans are overrepresented in current conflicts there is a need to reach out to these Veterans. Rural Veterans are a priority for the VA and we believe this study has shed some light on oral health care for Veterans overall, and not just the ones who receive care within a VA setting.

Acknowledgments

References