Oregon Health & Science University University of Washington Prepared by: Benjamin Sun, MD, MPP Donald L. Chi, DDS, PhD Emergency Department Visits for Non-Traumatic Dental Problems in Oregon State Part I: Emergency Department Claims Analysis Part II: Qualitative Interview Analysis Report to the Oregon Oral Health Funders Collaborative March 17, 2014 Oregon Health & Science University University of Washington Prepared by: Benjamin Sun, MD, MPP Donald L. Chi, DDS, PhD
Transcript
Oregon Health & Science University
University of Washington
Prepared by:Benjamin Sun, MD, MPPDonald L. Chi, DDS, PhD
1
Emergency Department Visits for Non-Traumatic Dental Problems
in Oregon State
Part I: Emergency Department Claims AnalysisPart II: Qualitative Interview AnalysisReport to the Oregon Oral Health Funders Collaborative
March 17, 2014
Oregon Health & Science University
University of Washington
Prepared by:Benjamin Sun, MD, MPPDonald L. Chi, DDS, PhD
ii
Acknowledgements
The Oral Health Funders Collaborative of Oregon and Southwest Washington determined the need for this study and several funders pooled resources to provide a grant for this work, including The Ford Family Foundation, Kaiser Permanente, Northwest Health Foundation, The Oregon Community Foundation, PacificSource Foundation for Health Improvement, Ronald McDonald House Charities of Oregon and Southwest Washington, Ronald McDonald House Charities Global and Samaritan Health Services.
While the authors accept full responsibility for its contents, we also wish to acknowledge the intellectual as well as the financial support of the Collaborative. Many members reviewed an early draft of this report and provided valuable feedback, as well as support with the logistical challenges of recruiting hospitals and communities to participate in the project.
Oral Health Funders Collaborative
Vision: Outstanding Oral Health for AllThe Oral Health Funders Collaborative of Oregon and Southwest Washington is a partnership of ten regional philanthropic organizations that are coordinating their efforts to identify, advocate and invest in oral health solutions. Steering Committee members include Cambia Health Foundation, Dental Foundation of Oregon, The Ford Family Foundation, Grantmakers of Oregon and Southwest Washington, Kaiser Permanente, Northwest Health Foundation, The Oregon Community Foundation, Providence Health & Services, Ronald McDonald House Charities of Oregon and Southwest Washington and Samaritan Health Services. More information can be found at this website: http://www.oregoncf.org/ocf-initiatives/ohfc
Part I summarizes the analysis of two complementary data sources for the year 2010: data from 24 Oregon hospitals representing 745,348 Emergency Department (ED) visits and statewide data on insured patients’ visits to Oregon hospitals representing 1,587,649 ED visits. We found:
ED visits for dental conditions are common.• Approximately 2% of Oregon ED visits were for non-traumatic dental problems. This condition is the twelfth most common ED discharge diagnosis. Among young adults (ages 20–39 years), it is the second most common discharge diagnosis. Extrapolation to all Oregon hospitals suggests 28,000 annual ED dental visits. Hospital admissions are uncommon (2%) but are associated with potentially serious medical complications.
ED visits for dental conditions reflect lack of access to dental care.• ED visits by uninsured Oregonians were eight times more likely to be for dental problems than were visits by commercially-insured patients. Compared to commercially-insured Oregonians, Oregon Health Plan (OHP) enrollees’ visits were four times more likely to be for dental problems.
• People living closer to hospitals are more likely to seek dental care in EDs, emphasizing the importance of providing access to dental care close to where the need is.
ED visits for dental care are unlikely to cure the patient’s dental problem.• The majority of patients received opioid pain medications and antibiotics, which may reduce pain and potentially prevent progression to uncommon but serious complications.
• Dental procedures are seldom performed in the ED, suggesting that most patients leave the ED still in need of definitive dental care.
• One quarter of Oregonians who sought care in an ED for a dental problem returned to the ED for further dental care.
Failure to provide access to dental care may add cost to the healthcare system.• The mean cost per ED dental visit was $294, greater than the cost for a year’s coverage in an Oregon Dental Care Organization (average annual capitation payment $228). Extrapolation to all Oregon hospitals suggests annual costs as high as $8 million for ED dental visits.
These findings highlight the need for better community resources for oral health. Medicaid expansion as part of the Affordable Care Act, combined with integration of medical and dental benefits through Oregon’s Coordinated Care Organizations, provide unique opportunities to improve oral health and reduce ED dental visits of Oregonians. However, when that care is not available, preserving ED access remains essential to relieve the burden of pain, reduce the risk of infectious complications, and identify uncommon but medically serious conditions associated with dental problems.
POLICY RECOMMENDATION:• Oregon should mandate ED data reporting, similar to requirements in 31 other states. ED claims collection from individual health systems is slow, burdensome, and results in incomplete data. A statewide, mandatory ED dataset will facilitate future health policy analyses.
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Part 2: Executive Summary
Part II summarizes analyses from interviews with 34 stakeholders and 17 patients in 6 Oregon communities. We had three goals: 1) to identify the factors related to ED use for non-traumatic dental conditions (NTDCs); 2) to poll stakeholders on potential solutions that could be implemented to reduce NTDC-related ED use; and 3) to distill research findings into prevention-oriented policy recommendations.
The determinants of NTDC-related ED visits are multilevel and multifactorial• ED visits are related to factors at the health system, community, provider, and patient levels.
• The health system is disjointed and the state Medicaid program, at the time of the interviews, had limited dental coverage for adults.
• At the community level, lack of urgent care clinics, insufficient dissemination of information on dental care resources, and no water fluoridation contributes to NTDC-related ED visits.
• At the provider level, there are few dentists who accept Medicaid, dental office policies are inflexible (particularly in regards to after hours emergencies), and many dentists refer patients directly to the ED.
• Social and economic disadvantage, poor oral health behaviors (e.g., symptom-driven dental care use), dental fears, and lack of a dental home were cited by patients as reasons for individuals utilizing the ED.
• Even with the Affordable Care Act and Coordinated Care Organizations, there will be individuals who do not qualify for dental coverage, leaving some vulnerable individuals susceptible to NTDC-related ED visits.
Stakeholders offered potential solutions to reduce ED use for NTDCs, many of which are un-likely to systematically solve the problem• Train more dentists.
• Open mode dental clinics, including urgent care clinics.
• Increase availability of dentist-on-call within ED.
• Enhance ED-to-dental-office referral system.
• Assign Medicaid enrollees with primary dental care providers and case managers
• Most solutions provided by stakeholders focused predominantly on improving access to dental care, which is unlikely to meaningfully reduce NTDC-related ED visits
Reducing and preventing ED use for NTDCs involves a systematic, multilevel approach• Focus on primary prevention in adolescents to reduce subsequent ED visits by Medicaid enrollees ages 20 and 30
• Develop a statewide surveillance system focusing on adolescents (Smile Survey) and implement metrics to track progress within this high-risk population
• Use the current Medicaid system and work with school nurses within junior and senior high schools to identify and refer adolescents with dental disease and treatment needs
• Educate community about changes in the Oregon Health Plan (Medicaid) and dental benefits
• Distribute free toothpaste and reduce availability of sugar sweetened beverages within schools (pouring rights)
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PART 1
Background
There are an estimated 2 million annual ED visits for non-traumatic dental problems (dental pain and oral disease caused by caries, pulpitis, periodontal disease) in the United States1 and the incidence has increased over the past decade. 2–6 Use of EDs for non-traumatic dental problems generates over $110 million in charges per year in the United States 7. EDs are ill-equipped to provide definitive dental care such as dental restorations or tooth extractions 8–10. Management of non-traumatic dental problems in the ED consists primarily of temporary pain and infection control through prescriptions for analgesics and antibiotics 11.
Elimination of Medicaid dental coverage in Oregon 12 and Maryland 13 led to increases in ED visits for non-traumatic dental problems. Patient surveys identified lack of insurance, lack of money, no existing relationship with a regular dentist, and limited hours of dental care sites as reasons for seeking dental care in an ED 14. Multiple studies 1–7, 9,11–17 have consistently identified lack of insurance, Medicaid insurance, young adult age (18–44 years), and black race as predictors of visiting an ED for dental pain.
Developing interventions to improve dental access in Oregon communities requires state-specific data but little research has been done about dental ED use in our state. This report addresses these knowledge gaps.
A separate report, led by Donald Chi, DDS, PhD of the University of Washington, describes findings from qualitative analyses of dental community stakeholder interviews.
MethodsIn order to characterize dental ED use throughout the entire State of Oregon as accurately as possible, we obtained emergency department data from two sources. We requested data from a representative sample of Oregon’s 58 hospitals – selected based on urban/rural location, critical access designation, geographic distribution, and annual ED visits. In addition, we obtained data from the Oregon All Payer All Claims (APAC) database, maintained by the Oregon Health Authority’s Office for Oregon Health Policy and Research.
The two data sources complement each other in several ways. Despite its name, the “All Payer All Claims” dataset contains data on ~65–70% of ED visits. It excludes ED visits by the uninsured, as well as ED visits by enrollees in Medicare fee-for-service plans, some other federal programs, and one commercial insurer.
Conversely, the data obtained directly from hospitals includes all ED visits to those hospitals; however, only 24 hospitals provided data. The APAC dataset includes all Oregon EDs, allowing a statewide picture for those payer classes included in the data.
With careful attention to the strengths and limitations of each data source, we are confident in the results presented in this report. Where there are concerns about our ability to provide an accurate statewide picture, we have made those limitations explicit in the Appendix, which provides further detail about the methods used.
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Findings
ED visits for dental conditions are common.There were 745,348 ED visits in 2010 to the 24 participating hospitals. Of these, 15,018 visits (2%) were for non-traumatic dental problems. Dental conditions represent the twelfth most common ED primary discharge diagnosis and are more frequent than headache, pneumonia, and asthma. Among young adults (ages 20–39 years), dental conditions represented the second most common discharge diagnosis.
We describe specific dental diagnoses in Table 1. The most common diagnosis (41% of visits) was “unspecified disorder of the teeth.” The lack of precision in diagnosis may reflect emergency physicians’ inability to definitively diagnose many dental conditions.
Primary Diagnosis ICD9 Code n %*
Unspecified disorder of the teeth and supporting structures 525.9 6232 41.5
Periapical abscess without sinus 522.5 3521 23.45
Dental caries, unspecified 521.00 2958 19.7
Acute apical periodontitis of pulpal origin 522.4 1098 7.31
Other dental caries 521.09 611 4.1
Other dental diagnoses 523.9 563 3.8
*denominator is all ED visits with primary non-trauma ED dental diagnosis (denominator = 15,018)
Table 1: Top Primary Non-Trauma Dental Diagnoses, All Patients
Although only 360 (2%) patients with dental ED visits required hospital admission, these cases illustrate the risks of deferring dental care. Diagnoses included infectious complications of dental conditions, such as cellulitis and abscess of face or oral soft tissues, cellulitis and abscess of the neck, pneumonia, and bacterial endocarditis. Other patients were admitted with uncontrolled diabetes, a condition that can be aggravated by dental infections.
Despite its limitations, the APAC database yields a similar estimate of the total number of dental ED visits in the state. Of the 1,587,649 ED visits in the APAC database, there were 25,683 ED dental visits. Adding the uninsured and the other groups not included in APAC supports the estimate of 28,000 dental ED visits per year obtained from the participating hospitals.
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ED visits for dental conditions reflect lack of access to dental care.ED visits by uninsured Oregonians were eight times more likely to be for dental problems than were visits by commercially-insured patients (Figure 1). Compared to commercially-insured Oregonians, Oregon Health Plan (OHP) enrollees’ visits were four times more likely.
Other predictors of an ED dental visit included young adult age (20–39 years) and male gender. Asians, Hispanics, and “other” race patients were less likely to have an ED dental visit compared to whites.
Gender
Figure 1: Predictors of ED Dental Visits
Insurance
The Y-axis represents the unadjusted relative risk that an individual’s ED visit is for a dental condition, given that they had an ED visit.
Asian Black Hispanic Native Other White Missing American (reference)
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Figure 2. Number of ED Dental Visits by Patient Residential Zip Code (APAC)
Geographic analyses (Figure 2) show that most users of EDs for dental conditions live near hospitals. This finding suggests an opportunity for a solution: Locating dental safety net clinics in communities with high dental ED use could reduce the unmet dental care needs in these high-use communities.
Non-Traumatic ED Dental Visits0/Insufficient Data
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ED visits for dental care are unlikely to cure the patient’s dental problem.The majority of patients received prescriptions for pain medications (56% received opioids and 9% nonsteroidal anti-inflammatory drugs). A significant proportion of patients received antibiotics (36% received penicillins, 16% clindamycin, 2% macrolides, and 2% cephalosporins).
However, dental procedures were seldom performed: 7% of encounters were associated with a facial nerve block (which provides only temporary relief of pain), while only 2% resulted in drainage of a dental abscess. Fewer than 0.04% had a tooth extraction. These findings confirm the perception that EDs lack the proper equipment (e.g. panoramic dental x-ray machines) and personnel to deliver definitive dental care.
Over 25% of patients with an ED dental visit had more than one annual ED encounter for non-traumatic dental problems, suggesting that the problem was not definitively treated on the first visit (Figure 3). The estimate of repeat ED dental visitors is likely an undercount due to the exclusion of uninsured and Medicare Fee-For-Service patients in APAC. These excluded groups are at higher risk of experiencing an ED dental visit.
Failure to provide access to dental care may add cost to the healthcare system.In the APAC population, 25,683 ED dental visits accounted for $7.2 million in costs, at a mean cost of $293 per visit. Extrapolation to all Oregon hospitals suggests annual costs as high as $8 million associated with ED dental visits.
Comparing the cost of ED dental care to the cost of providing an improved dental safety net is beyond the scope of this study. However, it is striking to note that the average annual capitation payment for an Oregon Dental Care Organization is $228, less than the $293 average cost for a single dental ED visit 15.
Figure 3: Number of ED Dental Visits Per Patient
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Conclusions
In summary, ED visits for non-traumatic dental problems are common, especially in patients whose insurance status reduces their access to dental care.
Most ED visits fail to cure the dental condition, and the cost of these visits is substantial. Making available timely and accessible care by a dental practitioner is likely to reduce dental ED use while improving the oral health of vulnerable Oregonians.
However, when that care is not available, preserving access to emergency departments for dental conditions remains essential to relieve the burden of pain, reduce the risk of infectious complications, and identify uncommon but medically serious conditions associated with dental problems.
POLICY RECOMMENDATIONS
Part I of this study focused on describing the extent and impact of ED dental visits, and Part II will describe potential solutions. However, our research team noted that collecting ED data from health systems was slow, laborious (requiring multiple institutional research and business agreement documents), and resulted in incomplete statewide coverage. Thirty one other states have mandatory ED data reporting requirements 20, and similar requirements in Oregon would facilitate health policy analyses.
• Oregon should mandate ED data reporting by hospitals. The state already mandates reporting of inpatient data, and this existing reporting infrastructure could be used to collect ED data.
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Part I: ED Claims Analysis Study Team
Principal Investigator: Benjamin Sun, MD, MPP Associate Professor, Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health and Science University
Co-Investigators:Robert A. Lowe, MD, MPHProfessor, Department of Medical Informatics and Clinical Epidemiology, and Department of Emergency Medicine; Senior Scholar, Center for Policy and Research in Emergency Medicine, Oregon Health and Science University
Eli Schwarz, DDS, MPH, PhD Professor and Chair, Department of Community Dentistry, Oregon Health and Science University
Project Staff:Annick Yagapen, CCRP; Susan Malveau, MPH; Zunqiu Chen, MS and Ben Chan, PhD (OHSU)
Site Recruiters:Sankirtana Danner, MA (OHSU Oregon Rural Practice-based Research Network); Paul McGinnis, MPA (Eastern Oregon CCO); Erin Owen, MPH (Slocum Research & Education Foundation)
Mapping Consultants:Molly Vogt, MS (Metro); Clinton Chiavarini, MS (Metro) and Emerson Ong (Oregon Office of Rural Health)
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Appendix: Study Methods
In this section, we provide detail about the methods used for this project, including the definition of an ED dental visit, data sources, hospitals contributing to the ED dataset, methods used to identify dental ED visits, methods used to determine medications and procedures associated with ED dental visits, approach to estimating costs for ED dental care, and methods for geographic analyses of dental ED use.
Defining an ED Dental VisitTo define an ED dental visit, we used prior research 2, 5, 11, 13, 16–19 as well as the content expertise of dental health service researchers on our study team. We identified a set of ICD-9 discharge codes consistent with non-traumatic dental problems. (Appendix Table 1) We focus on non-traumatic dental problems because emergency physicians can rarely provide definitive care for these conditions; these visits reflect an unmet need for community dental care. An ED dental visit was defined by presence of these codes as the primary diagnosis on an ED claim.
We excluded traumatic dental problems as these may represent acute injuries, including isolated dental injuries as well as those associated with other injuries (e.g. facial lacerations, facial bone fractures, intracranial bleed). There may be limited alternatives other than EDs for the acute evaluation of such injuries.
Data sourcesWe collected 2010 data from two data sources: claims data obtained directly from hospital systems, and the Oregon All Payer All Claims (APAC) database. We describe each dataset and how they complement each other.
Hospital Claims DataWe requested ED claims data directly from a purposive sample of Oregon hospitals. We initially identified 45 hospitals that were representative of all 58 Oregon hospitals, by urban/rural location, critical access designation, geographic distribution, and annual ED visits. We contacted the CEO or CMO of all targeted hospitals, and we signed Data Use and Business Use Agreements with all participating hospitals.
The strength of these data is the inclusion of all payer groups for the participating hospitals. We used the hospital claims data to estimate the frequency of ED dental visits and to identify predictors of ED dental visits.
A limitation of hospital claims data is the lack of uniform reporting on procedures, antibiotics, and costs. In addition, these data may have limited geographic generalizability.
Of the 45 hospitals that were invited to participate in this study, 24 provided 2010 data on all ED visits. Appendix Table 2 is a list of all Oregon hospitals sorted by participants and non-participants. Appendix Figure 1 illustrates the locations of participants and non-participants. Appendix Table 3 uses data from the American Hospital Association Survey and the Office for Oregon Health Policy and Research to illustrate the differences between participating and non-participating hospitals. Rural, critical access, and low volume hospitals are under presented in our sample set. Thus, the analyses of hospital claims data may have limited generalizability to excluded hospitals.
In Appendix Table 4, we describe the characteristics of all ED visits for both dental and non-dental problems. The primary discharge diagnoses associated with ED dental visits are presented in the main report (Table 1). We provide descriptive tables of primary diagnoses, stratified by both discharged and admitted patients in Appendix Tables 5 and 6.
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In addition to this descriptive reporting, we calculated the unadjusted relative risk ratios for different values of age, gender, race, and payer that an ED visit would be for a dental condition. The results of these relative risk analyses are illustrated in the main report (Figure 1).
Five hospitals within the Providence Health System (Seaside; St. Vincent; Hood River; Newberg; and Medford) provided aggregated, rather than encounter level, data on non-dental ED visits. These hospitals, accounting for 20% of the data, were included in descriptive reports (Appendix Table 3) but excluded from the relative risk analysis.
Although our analyses focused on patients with a primary diagnosis of a non-traumatic dental problem, an additional 3,551 (0.4% of all ED visits) ED visits had a secondary diagnosis of a non-traumatic dental problem (Appendix Tables 7–9). The three most common associated primary diagnoses were “other acute pain,” “antepartum condition,” and “traumatic wound of tooth”. This population likely includes a mixture of patients with a primary dental problem as well as those with a unrelated primary reason for an ED visit. Our approach of using only primary diagnoses codes to define an ED dental visit reduces contamination by ED visits primarily for a non-dental problem; however, it may result in an undercount of all ED dental visits. We identified an additional 301 hospitalizations with a secondary diagnosis of a non-traumatic dental problem; these cases are described in the Results section and in Appendix Table 9.
The Oregon All Payer All Claims Database The All Payer All Claims (APAC) database contains statewide information on ED visits by patients covered by the Oregon Health Plan, commercial payers, and Medicare managed care. Our research group is among the first in Oregon to obtain and analyze the APAC data.
The strengths and weaknesses of APAC are the inverse of the hospital claims data. Strengths include unique information on procedures, antibiotics, and costs. APAC can also be used to generate statewide profiles of ED dental visits.
The major limitation of APAC is the exclusion of certain payer groups. Most notably, APAC omits visits by the uninsured that represent about 18% of Oregon ED visits, and the uninsured disproportionately use EDs for non-traumatic dental problems. APAC also currently omits patients who are covered by Medicare Fee-For-Service (FFS) and federal insurance (TRICARE, FEHB). Finally, one major commercial payer (Kaiser) has not yet submitted data to APAC. Therefore, we do not rely on APAC to describe patient level characteristics such as payer or to identify predictors of ED dental visits.
Identifying medications and proceduresWith the APAC database, we identified the top 20 non-refill prescription medication classes that were dispensed within 3 days after an ED dental visit (Appendix Table 10). An important limitation to note is the inability to verify that the prescriber and the ED provider were the same; it is possible that some medications were prescribed by non ED-providers and were not related to the ED dental visit. However, the frequent prescribing of pain medications and antibiotics noted in the APAC data is consistent with our clinical experience.
We used billing codes (Current Procedural Terminology [CPT]) to identify procedures performed in the ED (Appendix Table 11). This analysis excludes CPT “Evaluation and Management” codes that are based on the complexity of medical decision making.
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Estimating costs for ED dental care It is important to note that cost is a distinct concept from charge and payment. Charge is the billed amount, varies greatly by hospital, and often has little relationship to cost. We did not have access to charge data. APAC does include data on payments by insurers and patients. According to Oregon State APAC analysts, payment data have not been verified, and submitted Oregon Health Plan payment data are likely to be flawed. Therefore, we do not present payment data in this report.
To estimate true costs reflecting resources required to provide ED dental services, we applied the 2010 Center for Medicare and Medicaid Services (CMS) national payment tables to all CPT codes associated with an ED dental visit. CMS payment tables are commonly used to approximate actual cost of medical services 21.
Geographic analysesWe used both hospital and APAC data to illustrate where Oregonians who use EDs for dental conditions live. We provide maps that illustrate frequency counts by zip codes.
There are two important methodologic limitations of our mapping approach for hospital claims data. First, our hospital claims data did not include all hospitals in Oregon. A resident in a given zip code might have gone to a nearby ED included in our data or to another nearby ED not included in our data. To address this limitation, we used data from the Oregon Patient Origin Dataset to identify, for each ZIP code, the market share for all Oregon hospitals in 2010. We then weighted the counts in each zip code to account for missing data. For example, if our dataset had 500 ED dental visits originating in zip code 97229 but we only had hospital data that accounted for 50% of hospital visits originating from that zip code, then we would inflate by a factor of 2 (for an estimated 1000 ED dental visits) to account for missing data. This approach makes the assumption that ED visit rates are similar in missing data as they are in observed data.
Second, we had very few or no observed data from some zip codes. This may reflect a combination of missing hospital data and low population density in rural areas. If a zip code count was zero or was missing more than 75% of hospital market share data, then we considered data to be unreliable for that zip code. This approach reduces the ability to make conclusions about low-population areas and areas which are poorly represented by our data.
APAC data include all Oregon EDs but exclude patient populations that are not represented in APAC (e.g. uninsured, Medicare Fee-For-Service). Despite statewide coverage of APAC, there were no reported ED dental visits for a subset of low-density zip codes.
Despite differences in data completeness and methodology, the hospital and APAC data show similar geographic patterns, and patterns were similar for uninsured and OHP-sponsored patients compared to all ED patients. The robustness of our geographic findings in two different datasets adds to our confidence in these results.
Because of the similarity between different maps of dental ED visits, we present only the APAC map in the body of the report (Figure 2); the other maps are presented here (Appendix Figures 2-4).
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ICD-9 Discharge Codes For Non-Traumatic Dental Problems
Non-Traumatic Dental Problems
520.0–520.9: Disorders of tooth development and eruption
521.0–521.9: Diseases of the hard tissue of teeth
522.0–522.9: Diseases of pulp and periapical tissues
523.0–523.9: Gingival and periodontal diseases
525.0–525.9,excluding 525.11:
Other diseases and conditions of the teeth and supporting structures
Appendix Table 1: ICD-9 Discharge Codes for Non-Traumatic Dental Problems
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Participating Hospital Name Health System Region Rural/
UrbanCritical Access
ED Annual
Visits
Yes Blue Mountain Hospital self/none known NE Oregon rural Yes 2989
Yes Cottage Grove Community Hospital PeaceHealth SW Oregon rural Yes 11378
Yes Grande Ronde Hospital self/none known NE Oregon rural Yes 12306
Yes Kaiser Sunnyside Medical Center Kaiser Portland urban No 52508
Yes Lake District Hospital Lake Health District
Cascades East rural Yes 3502
Yes Legacy Emanuel Hospital & Health Center Legacy Portland urban No 46485
Yes Legacy Good Samaritan Hospital Legacy Portland urban No 28440
Yes Legacy Meridian Park Hospital Legacy Portland urban No 30735
Yes Legacy Mount Hood Medical Center Legacy Portland urban No 40138
Yes McKenzie-Willamette Medical Center
CommunityHealth Systems SW Oregon urban No 26803
Yes Mercy Medical Center Catholic Health SW Oregon rural No 40577Yes OHSU Hospital OHSU Portland No 40268Yes Peace Harbor Hospital PeaceHealth SW Oregon rural Yes 7667
Yes Providence Hood River Memorial Hospital Providence NE Oregon rural Yes 9341
Yes Providence Medford Medical Center Providence SW Oregon urban No 28892
Yes Providence Milwaukie Hospital Providence Portland urban No 35955
Yes Providence Newberg Hospital Providence Pacific rural No 18308
Yes Providence Portland Medical Center Providence Portland urban No 67874
*denominator is all ED visits with primary non-trauma ED dental diagnosis who were admitted (denominator = 59)
Appendix Table 6: Top Primary Dental Diagnoses, Admitted Patients
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Secondary Dental Diagnosis ICD9 Code n %*
Unspecified disorder of the teeth and supporting structures 5259 1014 34.14
Dental caries, unspecified 52100 911 30.67
Periapical abscess without sinus 5225 517 17.41
Acute apical periodontitis of pulpal origin 5224 229 7.71
Acquired absence of teeth, unspecified 52510 222 7.47
Partial edentulism, unspecified 52550 166 5.59
Other dental caries 52109 91 3.06
Chronic gingivitis, plaque induced 52310 84 2.83
Teething syndrome 5207 74 2.49
Other specified disorders of the teeth and supporting structures 5258 62 2.09
Disturbances in tooth eruption 5206 36 1.21
Complete edentulism, unspecified 52540 32 1.08
Other specified periodontal diseases 5238 23 0.77
Cracked tooth 52181 19 0.64
Chronic periodontitis, unspecified 52340 12 0.4
Acute gingivitis, plaque induced 52300 11 0.37
Unspecified gingival and periodontal disease 5239 10 0.34
Erosion, unspecified 52130 6 0.2
Other loss of teeth 52519 5 0.17
Other and unspecified diseases of pulp and periapical tissues 5229 3 0.1
*denominator is all ED visits with NO primary non-trauma dental diagnosis AND any secondary non-trauma dental diagnosis (denominator = 2,970)
Appendix Table 7: Top 20 Secondary Dental Diagnoses, All Patients
This table includes patients who had a non dental primary diagnosis but with a secondary diagnosis consistent with a non-traumatic dental problem.
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Primary Diagnosis ICD9 Code n %*
Other acute pain 33819 324 10.91
Other current conditions classifiable elsewhere of mother, antepartum condition or complication
64893 139 4.68
Open wound of tooth (broken) (fractured) (due to trauma), without mention of complication
87363 115 3.87
Headache 7840 94 3.16
Cellulitis and abscess of face 6820 83 2.79
Swelling, mass, or lump in head and neck 7842 70 2.36
Other acute postoperative pain 33818 69 2.32
Unspecified disease of the jaws 5269 53 1.78
Acute pharyngitis 462 49 1.65
Other and unspecified diseases of the oral soft tissues 5289 42 1.41
Issue of repeat prescriptions V681 42 1.41
Fever, unspecified 78060 40 1.35
Otalgia, unspecified 38870 40 1.35
Acute upper respiratory infections of unspecified site 4659 37 1.25
Unspecified otitis media 3829 36 1.21
Unspecified essential hypertension 4019 31 1.04
Open wound of lip, without mention of complication 87343 29 0.98
Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus
34690 29 0.98
Syncope and collapse 7802 27 0.91
Nausea with vomiting 78701 26 0.88
*denominator is all ED visits with NO primary non-trauma dental diagnosis AND any secondary non-trauma dental diagnosis (denominator = 2,970)
Appendix Table 7: (continued)
This table includes patients who had a non dental primary diagnosis but with a secondary diagnosis consistent with a non-traumatic dental problem.
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Secondary Dental Diagnosis ICD9 Code n %*
Unspecified disorder of the teeth and supporting structures 5259 975 36.06
Dental caries, unspecified 52100 848 31.36
Periapical abscess without sinus 5225 443 16.38
Acquired absence of teeth, unspecified 52510 214 7.91
Acute apical periodontitis of pulpal origin 5224 195 7.21
Partial edentulism, unspecified 52550 158 5.84
Other dental caries 52109 80 2.96
Chronic gingivitis, plaque induced 52310 74 2.74
Teething syndrome 5207 72 2.66
Other specified disorders of the teeth and supporting structures 5258 50 1.85
Disturbances in tooth eruption 5206 33 1.22
Complete edentulism, unspecified 52540 22 0.81
Cracked tooth 52181 17 0.63
Other specified periodontal diseases 5238 14 0.52
Chronic periodontitis, unspecified 52340 11 0.41
Acute gingivitis, plaque induced 52300 10 0.37
Erosion, unspecified 52130 6 0.22
Unspecified gingival and periodontal disease 5239 5 0.18
Other loss of teeth 52519 4 0.15
Anodontia 5200 2 0.07
*denominator is all ED visits with NO primary non-trauma dental diagnosis AND any secondary non-trauma dental diagnosis AND patient discharged (denominator = 2,704)
Appendix Table 8: Top 20 Secondary Dental Diagnoses, Discharged
This table includes patients who had a non dental primary diagnosis but with a secondary diagnosis consistent with a non-traumatic dental problem.
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Primary Diagnosis ICD9 Code n %*
Other acute pain 33819 324 11.98
Other current conditions classifiable elsewhere of mother, antepartum condition or complication 64893 139 5.14
Open wound of tooth (broken) (fractured) (due to trauma), without mention of complication 87363 115 4.25
Headache 7840 94 3.48
Other acute postoperative pain 33818 68 2.51
Swelling, mass, or lump in head and neck 7842 68 2.51
Cellulitis and abscess of face 6820 67 2.48
Unspecified disease of the jaws 5269 53 1.96
Acute pharyngitis 462 49 1.81
Issue of repeat prescriptions V681 42 1.55
Other and unspecified diseases of the oral soft tissues 5289 41 1.52
Otalgia, unspecified 38870 40 1.48
Fever, unspecified 78060 38 1.41
Acute upper respiratory infections of unspecified site 4659 37 1.37
Unspecified otitis media 3829 36 1.33
Unspecified essential hypertension 4019 30 1.11
Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus 34690 29 1.07
Open wound of lip, without mention of complication 87343 28 1.04
Hemorrhage complicating a procedure 99811 25 0.92
Nausea with vomiting 78701 25 0.92
*denominator is all ED visits with NO primary non-trauma dental diagnosis AND any secondary non-trauma dental diagnosis AND patient discharged (denominator = 2,704)
Appendix Table 8: (continued)
This table includes patients who had a non dental primary diagnosis but with a secondary diagnosis consistent with a non-traumatic dental problem.
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Secondary Dental Diagnosis ICD9 Code n %*
Periapical abscess without sinus 5225 74 27.82
Dental caries, unspecified 52100 63 23.68
Unspecified disorder of the teeth and supporting structures 5259 39 14.66
Acute apical periodontitis of pulpal origin 5224 34 12.78
Other specified disorders of the teeth and supporting structures 5258 12 4.51
Other dental caries 52109 11 4.14
Complete edentulism, unspecified 52540 10 3.76
Chronic gingivitis, plaque induced 52310 10 3.76
Other specified periodontal diseases 5238 9 3.38
Partial edentulism, unspecified 52550 8 3.01
Acquired absence of teeth, unspecified 52510 8 3.01
Unspecified gingival and periodontal disease 5239 5 1.88
Disturbances in tooth eruption 5206 3 1.13
Teething syndrome 5207 2 0.75
Cracked tooth 52181 2 0.75
Dental caries extending into pulp 52103 2 0.75
Loss of teeth due to caries 52513 2 0.75
Acute periodontitis 52333 1 0.38
Other and unspecified diseases of pulp and periapical tissues 5229 1 0.38
Chronic periodontitis, unspecified 52340 1 0.38
*denominator is all ED visits with NO primary non-trauma dental diagnosis AND any secondary non-trauma dental diagnosis AND patient admitted (denominator = 266)
Appendix Table 9: Top 20 Secondary Dental Diagnoses, Admitted
This table includes patients who had a non dental primary diagnosis but with a secondary diagnosis consistent with a non-traumatic dental problem.
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Primary Diagnosis ICD9 Code n %*
Cellulitis and abscess of face 6820 16 6.02
Cellulitis and abscess of oral soft tissues 5283 9 3.38
Syncope and collapse 7802 7 2.63
Coronary atherosclerosis of native coronary artery 41401 5 1.88
Diabetes with ketoacidosis, type I [juvenile type], uncontrolled 25013 4 1.5
Bipolar I disorder, most recent episode (or current) depressed, unspecified 29650 4 1.5
Pneumonia, organism unspecified 486 4 1.5
Other chest pain 78659 4 1.5
Other and unspecified noninfectious gastroenteritis and colitis 5589 3 1.13
Iron deficiency anemia secondary to blood loss (chronic) 2800 3 1.13
Cellulitis and abscess of neck 6821 3 1.13
Cellulitis and abscess of oral soft tissues 528.3 3 1.13
Neutropenia, unspecified 28800 3 1.13
Other bipolar disorders 29689 3 1.13
Acute systolic heart failure 42821 3 1.13
Major depressive affective disorder, recurrent episode, severe, without mention of psychotic behavior 29633 2 0.75
Acute and subacute bacterial endocarditis 4210 2 0.75
Poisoning by antiallergic and antiemetic drugs 9630 2 0.75
Hyposmolality and/or hyponatremia 2761 2 0.75
Fever, unspecified 780.6 2 0.75
*denominator is all ED visits with NO primary non-trauma dental diagnosis AND any secondary non-trauma dental diagnosis AND patient admitted (denominator = 266)
Appendix Table 9: (continued)
This table includes patients who had a non dental primary diagnosis but with a secondary diagnosis consistent with a non-traumatic dental problem.
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Appendix Table 10: Prescription Medications Dispensed After ED Dental Visit
Medication Class Frequency % ED Visits*
Analgesics - Opioid 14348 56%
Penicillins 9254 36%
Clindamycin 4120 16%
Analgesics - Anti-Inflammatory 2242 9%
Antidepressants 678 3%
Antihistamines 671 3%
Mouth/Throat/Dental Agents 618 2%
Antianxiety Agents 520 2%
Macrolides 513 2%
Cephalosporins 462 2%
Anticonvulsants 399 2%
Ulcer Drugs 347 1%
Antiemetics 290 1%
Antiasthmatic and Bronchodilator Agents 283 1%
Musculoskeletal Therapy Agents 279 1%
Antipsychotics/Antimanic Agents 272 1%
Antihypertensives 237 1%
Corticosteroids 204 1%
Beta Blockers 157 1%
Analgesics - Nonnarcotic 151 1%
* denominator is 25,683 ED dental visits identified in APAC
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Appendix Table 11: Procedures Associated With ED Dental Visits
CPT Code Description Frequency % ED Visits*
64400 Facial Nerve Block 1794 7%
85025 Blood Test: Cell Count 1239 5%
96375 Drug Injection- Subsequent Intravenous Push 867 3%
96372 Drug Injection- Subcutaneous or Intramuscular 843 3%
80053 Blood Test: Metabolic Panel 837 3%
96374 Drug Injection- Initial Intravenous Push 649 3%
96365 Intravenous Infusion 635 2%
36415 Vein Puncture 565 2%
J1170 Hydromorphone Injection 488 2%
J2405 Ondansetron Injection 481 2%
41800 Drainage of Dental Abscess from Dental Structure 478 2%
70450 Computed Tomography of Head or Brain 471 2%
* denominator is 25,683 ED dental visits identified in APAC
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Appendix Figure 2: Number of ED Dental Visits in 2010 by Patient Residential Zip Code, Oregon Health Plan Beneficiaries (APAC)
Non-Traumatic OHP ED Dental Visits0/Insufficient Data
1 - 3
4 - 12
13 - 33
34 - 264
Hospitals LocationsHospital Locations
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Appendix Figure 3: Number of ED Dental Visits in 2010 by Patient Residential Zip Code, All Payers (Hospital Data)
Non-Traumatic ED Dental Visits (Weighted)0/Insufficient Data
1 - 6
7 - 23
24 - 104
105 - 868
Hospitals LocationsHospital Locations
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Appendix Figure 4: Number of ED Dental Visits in 2010 by Patient Residential Zip Code, Oregon Health Plan Beneficiaries and Uninsured (Hospital Data)
Non-Traumatic OHP/Uninsured ED Dental Visits (Weighted)0/Insufficient Data
1 - 5
6 - 20
21 - 92
93 - 778
Hospitals LocationsHospital Locations
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References
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2. Hong L, Ahmed A, McCunniff M, Liu Y, Cai J, Hoff G. Secular trends in hospital emergency department visits for dental care in Kansas City, Missouri, 2001–2006. Public Health Rep. Mar–Apr 2011;126(2):210–219.
3. Ladrillo TE, Hobdell MH, Caviness AC. Increasing prevalence of emergency department visits for pediatric dental care, 1997–2001. J Am Dent Assoc. Mar 2006;137(3):379–385.
4. Lee HH, Lewis CW, Saltzman B, Starks H. Visiting the emergency department for dental problems: trends in utilization, 2001 to 2008. American journal of public health. Nov 2012;102(11):e77–83.
5. Anderson L, Cherala S, Traore E, Martin NR. Utilization of Hospital Emergency Departments for non- traumatic dental care in New Hampshire, 2001–2008. Journal of community health. Aug 2011;36(4):513–516.
6. Wall T. Recent trends in dental emergency department visits in the United States:1997/1998 to 2007/2008. Journal of public health dentistry. Summer 2012;72(3):216–220.
7. Nalliah RP, Allareddy V, Elangovan S, Karimbux N. Hospital based emergency department visits attributed to dental caries in the United States in 2006. The journal of evidence-based dental practice. Dec 2010;10(4):212–222.
8. Pennycook A, Makower R, Brewer A, Moulton C, Crawford R. The management of dental problems presenting to an accident and emergency department. Journal of the Royal Society of Medicine. Dec 1993;86(12):702–703.
9. Pajewski NM, Okunseri C. Patterns of dental service utilization following nontraumatic dental condition visits to the emergency department in Wisconsin Medicaid. Journal of public health dentistry. Aug 8 2012.
10. Davis EE, Deinard AS, Maiga EW. Doctor, my tooth hurts: the costs of incomplete dental care in the emergency room. Journal of public health dentistry. Summer 2010;70(3):205–210.
11. Hocker MB, Villani JJ, Borawski JB, et al. Dental visits to a North Carolina emergency department: a painful problem. North Carolina medical journal. Sep–Oct 2012;73(5):346–351.
12. Wallace NT, Carlson MJ, Mosen DM, Snyder JJ, Wright BJ. The individual and program impacts of eliminating Medicaid dental benefits in the Oregon Health Plan. American journal of public health. Nov 2011;101(11):2144–2150.
13. Cohen LA, Manski RJ, Hooper FJ. Does the elimination of Medicaid reimbursement affect the frequency of emergency department dental visits? J Am Dent Assoc. May 1996;127(5):605–609.
14. Dorfman DH, Kastner B, Vinci RJ. Dental concerns unrelated to trauma in the pediatric emergency department: barriers to care. Archives of pediatrics & adolescent medicine. Jun 2001;155(6):699–703.
15. Oregon Health Plan Medicaid Demonstration. Capitation Rate Development. Dental Care Organizations Remaining During Transition to Coordinated Care Organizations. In: Actuarial Service Unit OHA, ed2013:1–49.
16. Cohen LA, Manski RJ, Magder LS, Mullins CD. Dental visits to hospital emergency departments by adults receiving Medicaid: assessing their use. J Am Dent Assoc. Jun 2002;133(6):715–724; quiz 768.
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17. Lewis C, Lynch H, Johnston B. Dental complaints in emergency departments: a national perspective. Annals of emergency medicine. Jul 2003;42(1):93–99.
18. Lowe RA. Dental and mental conditions in rural Oregon emergency departments. 23rd Annual Oregon Rural Health Conference. Newport, Oregon2006.
19. Mullins CD, Cohen LA, Magder LS, Manski RJ. Medicaid coverage and utilization of adult dental services. J Health Care Poor Underserved. Nov 2004;15(4):672–687.
20. Agency for Healthcare Research and Quality. Overview of the State Emergency Department Databases. Accessed 2/20/14. https://www.hcup-us.ahrq.gov/seddoverview.jsp
21. Muennig P. Cost-Effectiveness Analysis in Health: A Practical Approach. San Francisco: John Wiley & Sons; 2008.
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PART 2
Background
Recent U.S. data suggest significant increases in the number of patients utilizing the ED for treatment of non-traumatic dental conditions (NTDCs) (Lee et al. 2012; Okunseri et al 2012). Studies have identified various factors related to NTDC-related ED use (e.g., low-income, racial/ethnic minority status, being insured by Medicaid, having no insurance, and living in a Health Professional Shortage Area) (Hong et al. 2011; Okunseri et al. 2008). Young adults ages 20 to 30 years appear to use the ED for NTDCs at higher rates than other individuals (Chi et al. 2014). No studies to date have used qualitative methods to examine stakeholder and patient perspectives on NTDC-related ED use and to identify possible strategies to reduce and prevent ED visits.
The goals of this study were to identify the multilevel determinants of NTDC-related ED use, poll stakeholders on potential solutions that could be implemented to reduce NTDC-related ED use, generate a preliminary conceptual model on ED use, and distill research findings into prevention-oriented policy recommendations aimed at preventing ED use for NTDCs. We achieved these goals by collecting qualitative interview data from a sample of community stakeholders and patients in Oregon. This study will help our team plan future studies that test interventions that reduce and prevent NTDC-related ED use.
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Data
Location and Study ParticipantsWe focused on 6 communities in Oregon State (5 rural and 1 urban). These communities had a history of participating in research through the Oregon Rural Practice-based Research Network (ORPRN). From these communities, we recruited a purposive sample of community stakeholders (N=34) and individuals with a history of ED use for NTDCs (N=17) (Table 1). Community stakeholders were recruited through hospitals and local dental societies. We used snowball techniques to identify additional stakeholders. The stakeholder group included ED staff (physicians, nurses, and managers), hospital administrators, dental society leaders and dentists, non-profit health program executives, and other relevant stakeholders. Patients were recruited from hospitals and safety net dental clinics.
Data CollectionWe generated preliminary 12-item interview scripts for stakeholders and ED utilizers. Cognitive interviewing methods were used to pre-test the scripts with representative stakeholders and patients. The scripts were modified to improve clarity and flow. The scripts were used to train three interviewers. Study participants were consented and received a $25 gift card as an incentive. Each interview was conducted in person or by phone and digitally recorded. The study was approved by the University of Washington institutional review board.
Data Management and AnalysesThe digital data were transcribed by a professional medical transcription service. Each transcribed interview was compared to the digital file to ensure accuracy. A codebook was created that included three main domains: 1) perceptions of NTDC-related ED use as a problem; 2) determinants of NTDC-related ED use; and 3) potential solutions to reduce and prevent NTDC-related ED use. Stakeholder and patient data were analyzed separately. For the stakeholder data, three trained Research Assistants coded a random sample of three stakeholder transcripts to establish inter-coder agreement through subjective assessment, a standard practice in qualitative methods. Discrepancies between the coders were discussed with a fourth coder and resolved. The remaining 31 transcripts were divided among the three coders. Each transcript was individually read and coded by two different coders using NVivo 8® qualitative data analysis software (QSR International Pty Ltd, Victoria, Australia) to assign thematic codes to segments of the transcript text. The two coded versions of each transcript were merged. An identical process was used to code the patient transcripts. Based on the findings, we generated a preliminary conceptual model of NTDC-related ED use.
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Main Findings
NTDC-Related ED Visits are a ProblemA number of ED health care providers and hospital administrators stated that NTDC-related ED visits were not a problem. The main reason was the few number of patients presenting with NTDCs. It appears that some hospital EDs see a low volume of NTDCs and “less dental pain than we used to.” However, there were noted inconsistencies within communities. One potential reason is that EDs do not typically track the number of NTDCs. In response to an ED health provider’s complaints about NTDCs, a regional medical center CEO recently looked into “how many dental charges I was doing and in one year discovered it was $750,000 out of a 25-bed hospital…that was astounding. I had no idea…We just hadn’t noticed.”
Other interviewees, including a community organizer, saw NTDC-related ED visits as a “big problem.”One female ED patient reported that the ED physician who treated her commented on how “there are more and more people coming into the emergency room for teeth problems.” A Registered Nurse with eight years of clinical experience in the ED estimated that three to ten patients with NTDCs would present to the ED each day. She commented that NTDCs can “really screw up your flow of getting patients in and taking care of them.” An ED Director noted that triaged patients with NTDCs can cause problems in the waiting areas, particularly when patients have been waiting “for up to six hours. They become unhappy with the situation and are vocal about it, so anybody else who is waiting [starts to develop] a negative overtone.” With the exception of occasional “[drug] seekers” in the ED who present “with the excuse of dental pain” but “nothing wrong” in the mouth, patients with NTDCs “really do have problems with their teeth.”
All ED staff and local dentists agreed that care provided in the ED is non-definitive, usually a combination of administering a dental nerve block and prescribing analgesics and/or antibiotics. A number of patients reported that “a lot of times [the treating provider doesn’t] won’t even really look in your mouth” and one patient recalled her ED physician “was annoyed at the fact that I was there for my teeth.” ED clinicians reported not having sufficient training, space, or equipment to treat NTDCs. While one ED clinic manager stated that ED patients “need to take responsibility for their own healthcare, which includes their dental care”, most ED staff were sympathetic. An ED Nurse Manager stated that “it is a struggle to treat [patients with NTDCs]…you want to treat their pain.” An ED physician admitted that “we are not getting at the heart of the issue”, which leads to repeat ED visits over time by the same patient, also known as “frequent flyers.”
A young mother who reported visiting the ED two or three times for NTDCs commented that the ED staff “…don’t really know what they’re doing with teeth…or I don’t think they really want to deal with it…I think they have more pressing matters”. Another mother of two children, who recently went to the ED with an NTDC as a “last option”, recalled that
Through the years, [dentists] have told me that [tooth decay] can fester into a bad infection and then it can actually kill you. So…if you are that bad you need to go to the ER [emergency room]. But, then you get to the ER and they don’t know what to do. “Okay, we’ll give her something for pain, that’s all we can do.” They don’t even refer you somewhere. “Just go to the dentist.” That’s all they say. That’s pretty much going in circles. Going around and around. It’s like I can’t [go to a dentist] ‘cause I can’t afford it.
The determinants of NTDC-related ED visits are multilevel and multifactorialHealth SystemAccording to a patient who has utilized the ED multiple times in the past five years, one reason for NTDC-related ED visits is federal legislation that ensures access to emergency health care services regardless of an individual’s ability to pay. This retired, uninsured father of a 5-year old child said “…the person that needs the help doesn’t have money to pay for the [dental] care. The problem with the emergency room is that I know
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that if I have an emergency… they have to give me care. They can’t deny me. There is a law… whether I have money or not”.
Stakeholders believed that a disjointed medical and dental care system prompted many patients to seek care in the ED. “It is not an integrated health solution. It [oral health] is a separate health issue. It is like your mouth is somehow…different…than the rest of your body so I see it is as being treated separately...Dentistry [is] an afterthought”.
Interviewees specifically raised problems with the Oregon Medicaid program, particularly in terms of dental service coverage. A non-profit executive said that Medicaid in Oregon “is a mirage benefit”. A dental society president who practices at a corporate dental clinic said “…you just get emergency. That’s it. They will not cover fillings. They…only cover emergencies”. A dental clinic coordinator stated that Medicaid “…will pay a visit to a provider or to an ER for a dental-related problem, but not pay for the visit to the dentist’s office to have that problem taken care of”. Similarly, a general dentist working at a community health center stated
As soon as that emergency is treated, they won’t cover other things which can help prevent the problems from happening in the first place.
A quote from an ED manager, who mistakenly believed that the Oregon Health Plan covered dental care for adults, illustrates that some providers are confused about dental coverage and may “blame the victim,” the patient who does not have access to dental care:
…[most of] our patients…are on Medicaid. I don’t think they understand that they have dental coverage, so some of them have emergency dental coverage. Some of them have regular dental coverage where they can go and get cleanings and things like this and I think they just are undereducated on what kind of coverage they have and who to contact.
In the broader context of federal health care and state-level Medicaid reforms, a hospital director pointed out that problems with dental provider shortages:
…about 16,000 new patients [in my region]…will be eligible for the Oregon Health Plan…Before it was just emergency care for dental services…and now [enrollees] will be eligible for exams, extractions, fillings, and cleanings annually. So, who’s going to be taking care of all these patients if you have a dentist shortage already and how are the Dental Care Organizations preparing for that?...Who is going to care for them and how many dentists do we have that we are going to be able to provide this coverage? It’s a big job.
This hospital director went on to explain that dental insurance reform is not likely to completely eliminate NTDC-related ED visits.
…even with the Affordable Care Act and insurance exchanges, you are…going to have a population of uninsured people who will not qualify for coverage that are going to be coming to our emergency departments to get dental needs met…There are going to be families who don’t meet the eligibility requirement…We need to make certain we are ready to handle that.
CommunityThere were three community-level factors stakeholders reported as being related to NTDC-related ED visits. The first was the absence of urgent care clinics. In one community, an ED charge nurse noted “…a lot that could be treated at an urgent care…end up coming to the emergency room…Frequently these patients have no other alternative”. However, an ED manager in another community believed that urgent care clinic practices may lead to ED visits for NTDCs:
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I don’t particularly like what we have done in our urgent care clinics because if you can’t pay, you don’t get seen, so guess where they go, the ER, which is really dumb. Because the visit in urgent care is $100 and the visit in the ED is $600 and if you don’t have your copay over there, they won’t see you.
The second was insufficient dissemination of information about available resources in the community. A general dentist who works part-time in a community dental clinic said
We see patients all the time at our clinic that don’t know of our program. We have tried to get the word out in all the emergency rooms, public health clinics, homeless shelters…but still we hear of patients that don’t know about [our clinic] until they go to the emergency room…I would say that is key: getting the word out of what resources there are. We don’t turn people away because we can’t see them.
The third was the absence of community water fluoridation. An ED physician and medical director has observed that most ED patients “…do not live in areas with fluoridated water…If you grow up without fluoridated water, you are much more vulnerable to dental disease which put[s] you at risk of having problems that would lead you to deciding to come to an emergency department”.
ProvidersCommon reasons cited by patients for their ED visits were inflexible dental office policies and referrals to the ED by dentists. Patients reported that dentists are unavailable to provide emergency dental treatment during evenings and weekends. In addition, emergency appointments with dental offices were difficult to schedule during business hours. A 28-year-old female described the process of turning to the ED after attempting to seek care from her dentist:
They said they couldn’t get me in…if the pain is that bad and I [couldn’t] wait [for] an appointment to go ahead [and] go to the hospital.
Most dentists freely admitted that NTDC-related ED visits were a problem. A private practice dentist cited overburdened dentists as a reason why patients end up in the ED:
There is a lack of OHP [Medicaid] providers in these communities…There are a few providers taking the lion’s share of OHP, which overburdens them…doesn’t allow for care to be delivered in a timely fashion and…leads to patient dissatisfaction, provider dissatisfaction…[It] is a fairly broken system that limps along.
Dentists also cited potential legal liabilities associated with treating non-patients of record with NTDCs. A private practice general dentist commented:
We have a lot of narcotic seekers, they shop from doctor to doctor, so you are very reticent in just giving narcotics over the phone. You will send them to the emergency room because if we give narcotics, then it is our license that is at risk. We have no history with the patient knowing if they are actually shopping for doctors and then we suddenly get hit as giving out drugs. There goes your practice, you’re dead in the water. So they do defensive dentistry and send them to the emergency room because they have the liability coverage to be able to do that.
PatientsSocial and economic disadvantage were common reasons cited for why individuals present to the ED with NTDCs. A common observation was that ED utilizers have no alternatives. A physician and medical officer at a Coordinated Care Organization commented that NTDC-related ED utilizers are more likely to be “impoverished…We are seeing an increased rate of dental caries in the lower socioeconomic range”. An executive at a non-profit health collaborative described findings from a recent community health survey she administered that “asked about social determinants of health and financing issues, do you have enough money for housing, do you have enough money for food, do you have problems with transportation, do you
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have someone to talk to, do you have literacy issues? The number one issue by a long shot was not having enough money to pay for a dentist.” She went onto to say that “vulnerable individuals have high, high, high stress in their lives…on a chronic basis”.
Health-related culture and values were also mentioned as patient-level factors related to ED visits. A nurse manager observed that “…people who have been on Medicaid for years and years and years, they just use the ER. It is the easiest to thing to do. I can go anytime I want. I don’t have to have an appointment”.Another nurse manager similarly noted that ED utilizers “…are not forward thinking. They don’t try and make appointments. They are not engaged in their own care and so they come to the ER because it is an easy, fast thing to do. It doesn’t require any accountability, making an appointment, follow-up, anything”. A general dentist attributed it to “lack of responsibility”.
Other themes were oral health-related behaviors, including symptom-driven dental care use, inconsistent visits to the dentist, lack of oral hygiene, and poor diet. One patient who went to the ED after breaking her tooth on a Friday night stated that “I don’t really feel the need [to seek regular dental care]…although I think if I was flush with cash, I wouldn’t be going to the dentist necessarily. It’s not one of my habits…I’m the type that I tend to not go unless…I had no option”. Many believed these behaviors lead to repeat ED visits for NTDCs. “I think part of that is if they get antibiotics and pain medication, their symptoms resolve temporarily and they think they are fine”. An ED nurse manager echoed these observations: “You see…frequent flyers that come in over and over and over with dental problems…We are treating their infection and treating their pain and then once the infection is better, they don’t have pain anymore, but then it’s going to come back down the road…We call back all of our patients…post visit…and very frequently [we] ask Were you able to make a follow-up appointment? They don’t have the money for it. They are not following up”.
Interviewees mentioned a number of possible reasons for lack of follow up and symptom-driven dental care use. The first is the lack of a dental home. An ED physician and hospital medical director noted that “…the majority of patients who present to the emergency department for non-traumatic dental emergencies do not have an established relationship with a dentist”. One ED patient explained the difference between a place to go for emergency care versus a dental home. “With the health department [as a place to go for dental care], I mean it helps, it’s cheap, but you don’t have an actual doctor. He’s not your doctor…and I just wanted to get everything done from a real dentist [versus a different dentist each time]”.
The second is dental fears. A young female dentist in private practice explained that “A lot of people have a really substantial amount of fear…of the unknown. Fear of if look you are going to find something and I just don’t want to acknowledge it’s there. Fear of pain, especially people who have a history of drug use…seem to be…sensitized to any kind of pain” like a toothache or a needle. A number of patients confirmed these observations. A young male cancer survivor admitted being “really, really deathly scared of the dentist” and a young female acknowledged emotionally “I’m scared of the dentist…I have not had very good experiences at the dentist. They are rough”.
Other reasons included not being able to take time off from work, lack of transportation, and no money or insurance. ED clinicians mentioned drug seeking as a common reason for ED visits for NTDCs.
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Selected Patient NarrativesPatient 1
I want to eat without feeling pain in my mouth. There are some times it hurts so bad I develop like a constant migraine and stuff and it just kills me…I was just in such pain, I kind of wasn’t even thinking right. I actually took off walking [to the ED] because I couldn’t find a ride. I was hurting that bad and I hitchhiked, somebody picked me up and took me there and actually brought me back…
Patient 2It was giving me such excruciating pain that I decided the emergency room would be next best place to go and they basically told me you need to see a dentist. It was kind of playing tag.
Patient 3I can’t [go to the dentist] because I can’t afford it. With a job or without, I can’t afford it. Don’t get me wrong, I love my smile, I like to smile and when I don’t have a smile, who would want to get a job, who would want to hire you, because you have bad teeth. You don’t have that confidence anymore because your teeth are bad and that is a problem, too. I have seen it.
Patient 4[Going to the ED] did not solve [my dental problem]. [Afterwards, the pain] would always come back, sometimes even worse and I would have to go to the dentist. I would have to borrow and save and collect cans whatever I had to do to get the money to get my dental work done. But the more I get done, the more cavities come and the more issues happen…I have been suffering and I don’t like pain. Pain is just too much, overwhelming. I am not going to pull all my teeth and walk around with nothing in my mouth. I just can’t see myself doing that. So I want to keep them as long as I possibly can. I just can’t see myself walking around like most people I’ve seen with no teeth. They smile and it’s like, wow. Some people won’t even smile or they will turn their head and talk, no confidence. It is just sad and I don’t want to be like that.
Patient 5INTERVIEWER: How you do decide to go to the emergency room with a dental problem?
Basically, if I can’t make it through the pain until the nerve burns out, then I will try to acquire antibiotics on the street and deal with it that way. Or, if I know a friend that has one or something like that. I know, you’re not supposed to, but it seems to work. Another trick is I can go to the coop and buy Terramycin for animals and you can take that for yourself. Put it in caplets. It says not for human consumption, but it seems to work.
INTERVIEWER: What does the Terramycin do, is it a painkiller?
PATIENT: No, it’s an antibiotic for horses. If you live on a farm and you raise animals, you know it.
INTERVIEWER: Why don’t you go to the dentist?
PATIENT: Money, plain and simple. Plain and simple reason, money. I have a 5-year-old daughter that I’ve got to take care of and other bills to pay and survive. It is hard enough to… if the pain is so bad that I have to come up with it, then I will come up with it…. Maybe one month, I might not pay the power bill…so I can go to the dentist, but the next month I have to pay it off or go on a payment plan. It all depends on how it goes. Hand to mouth. Feast or famine.
PATIENT: If I went [to the ED] with a knife in my back and they said, well here’s some painkillers and some antibiotics, go see your doctor on Monday to take the knife out of your back, I might get a little concerned. Although it is [what] they do with teeth really. It is obviously broken. It is obviously a problem. Come on.
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Stakeholders offered potential solutions to reduce ED use for NTDCs, many of which are un-likely to systematically solve the problemInterviewees suggested a number of possible solutions that could help to reduce NTDC-related ED visits. While not all of these may be effective, some of them merit further consideration.
Health system
• Assignment of a Primary Dental Care Provider to Medicaid enrollees
• Assignment of a Dental Case Worker for Medicaid enrollees
…case workers [could] call them [and ask] did you make your appointment? Did you go? You can’t go, you need a ride, I will come get you and take you.
• Electronic Benefit Transfer for dental care
…if you give [patients with NTDCs] money, they are going to spend it on other things than their teeth. Giving them money to fix their teeth won’t work. Maybe something along the lines of the Oregon Trail Card except it is only for dental work. Everybody…would try to find a way to get around this. They even tried to do it with Oregon Trail Card. They will try to trade the Oregon Trail Card…50 cents on the dollar. It used to be with food stamps they would do that. The black market creates avenues for everything. There is not going to be a way for you to take an Oregon Dental Card into a dentist and say you are somebody different to get teeth work. It would be impossible to defraud that card. The biggest problem with anything the government gives us, like money or food stamps or benefits or anything like that is that they find a way to exploit it and trade it for drugs or stuff on the street. The biggest challenge is to prevent that.
• Make dental services available in urgent care clinics
NTDCs are “an urgent care problem…not an emergency department” problem.
There is this mental thing of, if I go to the ED, it’s free. I don’t particularly like what we have done in our urgent care clinics because if you can’t pay, you don’t get seen, so guess where they go, the ER. Because the visit in urgent care is $100 and the visit in the ED is $600 and if you don’t have your copay over there, they won’t see you. It is like we are offloading the nonpaying participants to the highest level of care which is really silly.
• Development of appropriate dental clinic policies on after-hour dental emergencies
Providers• Train more dentists
• Open mode dental clinics, including urgent care clinics
• Continuing education for ED staff
• Increase availability of dentist-on-call within ED
Preliminary Conceptual Model On NTDC-Related ED Use
Based on the data provided by stakeholders and patients, we developed a preliminary conceptual model that describes initial and repeat ED use for NTDCs, both of which future interventions will need to prevent and reduce (Figure 1).
The model incorporates health system and community factors as important contextual influences on the triangulated relationship between patients, dentists, and the ED.
Initially (at time 0), patients may seek care from a dentist for NTDCs. However, various barriers to dental care exist. Dental offices do not provide care after hours or may not be able to schedule emergency patients during the day. As a result, dentists refer patients with NTDCs to the ED. While ED care may be “free” to patients, the ED is equipped to provide only palliative care, which temporarily addresses acute symptoms associated with NTDCs. ED clinicians refer patients to a dentist, but barriers to dental care have not been eliminated. Subsequently (at time 1), patients come to rely on the ED for palliative care, leading to repeat ED use for NTDCs.
Various intervention points exist at the health system, community, provider, and patient levels.
44Part 2
Policy Recommendations
Based on findings from Aim 1 and the potential solutions proposed by stakeholders in Aim 2, we draw the following multilevel policy recommendations that we believe will systematically reduce and prevent ED use for NTDCs.
Target Population• Medicaid enrollees are at high risk for NTDC-related ED use
• NTDC-related ED use is primarily a problem of young adults ages 20 and 30, which means that all of these individuals were likely to have treatable dental disease during adolescence
• Medicaid-enrolled adolescents have comprehensive dental benefits, which offers an opportunity to target these high risk individuals, treat disease, and reinforce oral health behaviors (toothbrushing with fluoride toothpaste, healthy diet, regular visits to the dentist) that prevent NTDC-related ED use later in life.
Multilevel Solutions• Develop a statewide surveillance system focusing on adolescents (Smile Survey) and implement metrics to track progress within this high-risk population
• Assemble community planning groups consisting of adolescents to help develop feasible interventions aimed at adolescent oral health promotion
• Use the current Medicaid system and work with school nurses within junior and senior high schools to identify and refer adolescents with dental disease and treatment needs
• Reinforce primary care dental providers and case management for adolescents in Medicaid
• Educate community about changes in the Oregon Health Plan (Medicaid) and dental benefits
• Distribute free toothpaste and reduce availability of sugar sweetened beverages within schools (pouring rights)
• Develop community-based strategies to promote and protect community water fluoridation
Additional Solutions• Encourage interprofessional collaborations between dentists and pharmacists and implement oral health education interventions within pharmacies, which patients who require prescription medications will visit
• Use denturists to provide removable prosthodontic care (partial dentures) for patient requiring tooth extractions
• Provide continuing education courses for dentists on appropriate management of NTDCs to take advantage of chemotherapeutic management of dental disease including topical fluoride, povidone iodine, and diammine silver fluoride.
• Deliver continuing education courses for ED staff on appropriate prescribing of antibiotics to reduce costs to Medicaid
45Part 2
Conclusions
There was agreement among interviewed stakeholders and patients that the ED does not have the trained staffs, equipment, or space to deliver definitive dental care. As a result, EDs are only able to provide palliative care (e.g., antibiotics, analgesics). Patients described overwhelming social, economic, and behavioral barriers to preventive and restorative dental care that might help to prevent NTDCs and use of the ED, including repeat ED visits for unresolved NTDCs.
The determinants of ED use for NTDCs are multilevel and multifactorial. Future strategies aimed at reducing and preventing NTDC-related ED use will require systematic multilevel interventions that focus on high risk adolescents. Such interventions will need to modify patient oral health-related behaviors, involve medical and dental care providers, incorporate community-level solutions like water fluoridation, and reform existing programs and policies aimed at vulnerable populations, including Medicaid.
46Part 2
AIM 2 Study Team
University of WashingtonDonald L. Chi, DDS, PhD, Principal Investigator
Peter Milgrom, DDS, Co-Investigator
Erin Masterson, MPH, Lead Data Analyst
Christopher Shyue, BA, Data Analyst
Hilary Chen, BS, Data Analyst
Zoljargal Bayarsaikhan, Data Analyst
Oregon Rural Practice-based Research Network (ORPRN)Sankirtana Danner, MFT, Lead Research Coordinator
Jillian Currey, MPH, CCRP, Research Coordinator
Molly DeSordi, BS, Research Coordinator
Mark Remiker, MA, Research Coordinator
47Part 2
References
1. Chi DL, Masterson EE, Wong J. Emergency department use for non-traumatic dental conditions for individuals with intellectual and developmental disabilities. Intellect Dev Disabil. 2014. Accepted for publication.
2. Hong L, Ahmed A, McCunniff M, Liu Y, Cai J, Hoff G. Secular trends in hospital emergency department visits for dental care in Kansas City, Missouri, 2001–2006. Public Health Rep. 2011 Mar–Apr;126(2):210–9.
3. Lee HH, Lewis CW, Saltzman B, Starks H. Visiting the emergency department for dental problems: trends in utilization, 2001 to 2008. Am J Public Health. 2012 Nov;102(11):e77–83.
4. Okunseri C, Okunseri E, Thorpe JM, Xiang Q, Szabo A. Patient characteristics and trends in nontraumatic dental condition visits to emergency departments in the United States. Clin Cosmet Investig Dent. 2012 Jan 16;4:1–7.
5. Okunseri C, Pajewski NM, Brousseau DC, Tomany-Korman S, Snyder A, Flores G. Racial and ethnic disparities in nontraumatic dental-condition visits to emergency departments and physician offices: a study of the Wisconsin Medicaid program. J Am Dent Assoc. 2008 Dec;139(12):1657–66.
