Journal of Public Health Dentistry . ISSN 0022-4006

Analysis of hospital-based emergency department visits for dental caries in the United States in 2008 Andre Walker, PhD1; Janice C. Probst, PhD2,3; Amy B. Martin, Dr.PH2,3; Jessica D. Bellinger, PhD2,3; Anwar Merchant, ScD4 1 2 3 4

Institute for Partnerships to Eliminate Health Disparities, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA South Carolina Rural Health Research Center, Columbia, SC, USA Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA

Keywords dental care delivery; dental service; hospital-emergency service. Correspondence Dr. Andre Walker, Institute for Partnerships to Eliminate Health Disparities, 220 Stoneridge Drive, Suite 208, University of South Carolina, Arnold School of Public Health, Columbia, SC 29208, USA. Tel.: 803-251-2232; Fax: 803-251-6327; e-mail: [email protected]. A. Walker is with the Institute for Partnerships to Eliminate Health Disparities, Arnold School of Public Health, University of South Carolina. Janice C. Probst, Amy B. Martin, and Jessica D. Bellinger are with the Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina and South Carolina Rural Health Research Center. Anwar Merchant is with the Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina. Received: 2/21/2013; accepted: 10/18/2013.

Abstract Objectives: Using nationally representative data, we examined differences in dental care utilization in emergency departments (EDs) among working age adults associated with rural residence and lack of health insurance. Methods: We used data from the 2008 Nationwide Emergency Department Sample, restricted to working age adults (ages 19-64; 16,928,424 observations). The dependent variable was a principal diagnosis of dental caries. The primary independent variable was patient’s area of residence, rural versus urban. The control variables were payer, age, gender, median income, region, and admission timing. Logistic regression analysis was performed to determine the association with residence, payer, and other covariates. Multivariate logistic regression models were estimated. Results: In 2008, there were an estimated 74 million ED visits among working adults ages 19-64 in the United States. Dental caries accounted for between 0.2 percent and 1.0 percent of all visits, depending on patient characteristics. Rural patients were significantly more likely than urban patients to have dental visits. Dental visits were more prevalent among patient with government insurance or self -pay relative to the privately insured. Conclusions: The Affordable Care Act may reduce the proportion of self-pay visits for dental care. Medicaid expansion may not result in improved dental use among Medicaid patients unless dental services are covered and dental practitioners appropriately engaged.

doi: 10.1111/jphd.12045 Journal of Public Health Dentistry 74 (2014) 188–194

Introduction The significance of visits of emergency departments (EDs) for preventable dental conditions was recently highlighted by the Pew Center (1). Patients who lack access and financial resources to procure dental health services are more likely to seek care at hospital ED regarding dental complaints (2,3). An examination using National Hospital Ambulatory Medical Care Survey data estimated that the annual number of dental-related ED visits increased from 1.1 million in 1997/ 1998 to over 2 million in 2007/2008 (4). Visit rates were significantly higher in the 20- to 34-year-old groups compared 188

with all other age groups (4). More recent work done in California suggests that visits for preventable dental conditions are increasing, with many visits being made by patients insured by public programs or uninsured (5). While previous studies (6-11) suggest that dental caries are a highly prevalent dental problem among adults, these studies offer limited reporting of the impact of dental issues on hospital-based ED visits in the United States. Additionally, studies have shown that, compared with other ED visits, patients who reported to the ED were more likely to be working age adults with no insurance (12,13). The American Dental Association asserts the age group most likely to report © 2013 American Association of Public Health Dentistry

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financial difficulty in procuring dental services was working adults (14). In addition, most articles report on specific geographic regions with only gender, age, ethnicity, and insurance status taken into consideration. Few report on characteristics such as median income and geographical location of the patient from the ED. Little research has focused on the volume of ED visits in rural populations attributed to dental caries in the United States. The purpose of the present study was to examine utilization of hospital-based EDs for dental-related care among rural populations and the uninsured. Given the challenges rural populations and the uninsured face with regard to access to adequate health care services, we hypothesized that these populations are more likely to present at the ED seeking dental care.

Methods Study design and data source, and population We conducted a cross-sectional study using data from the 2008 Nationwide Emergency Department Sample (NEDS), a component of the Healthcare Cost and Utilization Project (HCUP) sponsored by the Agency for Healthcare Research and Quality (15). NEDS data contain 100 percent of the ED events, whether the patient was admitted or not, from a sample of hospitals in participating states. NEDS contains weighted data from 28 states; it includes information on all ED visits, including those resulting in admission. We restricted the analysis to working age adults, as these individuals are more likely than children or those over 65 to lack health insurance (16). The sample size was 16,928,424 non-weighted observations, representing an estimated 74,200,246 visits by adults between 19 to 64 years of age.

Study variables Dependent variables The dependent variable was a primary diagnosis of dental caries, based on the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes in the primary diagnosis field (Table 1). A maximum of 13 diagnoses were available in each record, coded using the ICD-9-CM (17). The specific ICD-9 codes were selected in consultation with a dental professional to include the dental diagnoses most probably related to dental caries alone and not associated with accidents or trauma, diabetes, human immunodeficiency virus, or any ambulatory sensitive care medical conditions. The diagnostic list used for this work is more restrictive than that of Seu et al. (12), which included all ICD© 2013 American Association of Public Health Dentistry

ED visits for dental care services

Table 1 Dental Caries Related ICD-9-CM Diagnoses Included in Analysis ICD-9 codes

Descriptor

521.0, 521.00, 521.01, 521.02, 521.03, 521.04, 521.05, 521.06, 521.07, 521.08, 521.09 522.0, 522.1

Dental caries

525.13, 525.63, 525.64

527.3

Disease of pulp and periapical tissue Other disease and conditions of the teeth and supporting structures Abscess of salivary gland

ICD-9-CM, International Classification of Diseases, Ninth Edition, Clinical Modification.

9-CM codes in the 520-523.9 range, or Wall (8), which included all codes in the 520.0-526.99 range. Primary independent variables The primary independent variable was the patient’s residence, defined using the NEDS variable PL-NHCS2006; codes 1-4 were classified as “urban” (80 percent of weighted population), while codes 5-6 were classified as “rural” (20 percent of weighted population). Insurance status was derived from the expected primary payer item in the NEDS dataset. Payer status information coded as: a) Medicare; b) Medicaid; c) private including health maintenance organization; d) self-pay; e) no charge; and f) other. Covariates Andersen’s Behavioral Model for Health Services Use served as the conceptual framework for defining covariates that might affect the utilization of hospital-based emergency visits for dental care for rural populations (18). Predisposing characteristics held constant in the analysis included gender and age. Age was grouped into age ranges of 19-26 years, 27-36 years, 37-42 years, and 43 years and older. Enabling characteristics available in the NEDS dataset included median income in the patient’s ZIP code, admission timing, and hospital region. Values for median income were $64,000. Values for hospital region were Northeast, Midwest, South, and West. Values for admission timing were Monday-Friday and Saturday-Sunday, and were coded dichotomously.

Analytical approach All analyses were performed at α level of 0.05 (95 percent confidence level) using SAS version 9.2 and Sudaan (11.0.1; SUDAAN, Research Triangle Park, NC, USA) to account for 189

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the complex sample design (19,20). Statistical analyses included descriptive analyses with frequencies, percentages, and selected measures of association. The study was approved by the University of South Carolina’s Institutional Review Board.

Results Table 2 describes the demographic characteristics of adult patients in our study (n = 16,928,424 visits). Rural patients made 21.1 percent of all visits. More than half (56.5 percent) of visits were made by females. Approximately 60 percent of visits involved patients less than 43 years of age. Approximately 23.9 percent of all ED visits were self-pay. Examining

ecological variables, 33 percent of patients lived in areas with median incomes below $38,999 annually and 40.2 percent lived in the South. Over 71 percent of hospital-based ED visits occurred on a weekday. Dental caries was not a common reason for visit, accounting for between 0.2 percent and 1.0 percent of all visits (Table 2). The proportion of visits attributable to caries was higher among men than women, among younger adults, and in regions outside the West. Generally, the proportion of visits associated with caries was higher among vulnerable population such as: persons whose visit was identified as self-pay or government insured and those not living in areas with high median income. Income in the ZIP code of residence and mode of insurance were closely related. For example, while

Table 2 Characteristics of Hospital-Based Emergency Department Visits, 2008 Nationwide Emergency Department Sample (NEDS), by Primary Dental Caries Diagnosis versus Other Primary Diagnosis; Adults 19-64 Years of Age (All Percents Weighted to Reflect Sampling Design) Dental primary diagnosis

Total population Unweighted observations n = 16,928,424 Total estimated visits Characteristics Personal characteristics Residence Rural Urban Gender Female Male Age group 19-26 27-36 37-42 43+ Primary payer Medicare Medicaid Priv. including HMO Self-pay No charge Other Ecological characteristics Median income (ZCTA) >$64,000 $49,000-$63,999 $39,000-$48,999 $1.00-38,999 Hospital region Northeast Midwest South West Admission timing Monday-Friday Saturday-Sunday

Other primary diagnosis

74,200,246 Percent (%)

SE

92,370 (%)

SE

74,107,876 (%)

SE

21.1 79.9

0.66 0.66

0.7 0.5

0.03 0.03

99.3 99.5

0.03 0.03

56.5 43.5

0.19 0.19

0.5 0.6

0.02 0.03

99.5 99.4

0.02 0.03

23.3 23.9 13.3 39.6

0.14 0.09 0.04 0.19

0.8 0.8 0.5 0.3

0.04 0.04 0.02 0.01

99.2 99.2 99.5 99.7

0.04 0.04 0.02 0.01

9.1 19.9 39.5 23.9 1.1 6.5

0.14 0.38 0.61 0.51 0.30 0.28

0.3 0.7 0.2 1.0 1.0 0.3

0.02 0.04 0.01 0.05 0.20 0.03

99.7 99.3 99.8 98.0 99.0 99.7

0.02 0.04 0.01 0.05 0.20 0.03

16.2 21.0 30.0 32.8

0.82 0.67 0.78 1.03

0.3 0.5 0.6 0.7

0.03 0.03 0.03 0.04

99.7 99.5 99.4 99.3

0.03 0.03 0.03 0.04

19.6 23.4 40.2 16.6

1.00 1.00 1.14 0.75

0.4 0.7 0.6 0.3

0.06 0.07 0.04 0.02

99.6 99.3 99.4 99.7

0.06 0.07 0.04 0.02

71.6 28.4

0.06 0.06

0.5 0.6

0.02 0.03

99.5 99.4

0.02 0.03

P value 0.01

0.01

0.01

0.01

0.01

0.01

0.01

HMO, health maintenance organization; SE, standard error; ZCTA, ZIP Code Tabulation Areas.

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only 10.95 percent of all visits involved persons living in the highest income quartile, 59.19 percent of privately insured patients lived in the top income quartile. Conversely, while 39.73 percent of all ED visits involved patients who lived in the lowest income quartile, 43.69 percent of Medicaidinsured visits involved these patients (P = 0.000; data not in the table). Visits were more likely on a weekend day than on a weekday. In adjusted analysis (Table 3), certain factors emerged as key to the likelihood of a visit for dental caries. Rural residence was associated with increased odds of a dental caries

Table 3 Adjusted Odds of Hospital-Based Emergency Department Visits with Primary Dental Caries Diagnosis versus Other Primary Diagnosis; Adults 19-64 Years of Age, 2008 Nationwide Emergency Department Sample (NEDS) Adjusted analysis Odds ratio Unweighted observations n = 16,928,424 Total estimated visits: 74,200,246 Personal characteristics Residence Urban Rural Gender Female Male Age group 19-26 27-36 37-42 43+ Primary payer Priv. Ins. Medicaid Medicare Self-pay No charge Other Ecological characteristics Median income >64,000 $49,000-$63,999 $39,000-48,999 $1.00-38,999 Hospital region Northeast Midwest South West Admission timing Monday-Friday Saturday-Sunday

95% CI

OR

LCL

UCL

Reference 1.16

Ref. 1.14

Ref. 1.18

Reference 1.29

Ref. 1.27

Ref. 1.31

2.52 2.77 1.85 Reference

2.47 2.71 1.80 Ref.

2.57 2.82 1.90 Ref.

Reference 2.87 1.70 3.43 3.68 1.06

Ref. 2.80 1.64 3.36 3.50 1.02

Ref. 2.93 1.76 3.50 3.87 1.11

Reference 1.33 1.39 1.37

Ref. 1.29 1.36 1.33

Ref. 1.37 1.43 1.40

Reference 1.40 1.18 0.58

Ref. 1.37 1.15 0.58

Ref. 1.43 1.20 0.60

Reference 1.18

Ref. 1.16

Ref. 1.20

P value

0.01

0.01

0.01

0.01

0.01

0.01

0.01

CI, confidence interval; LCL, Lower Confidence Limit; UCL, Upper Confidence Limit.

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visit. Male gender and age less than 43 years continued to be associated with visits for dental caries, while persons living in the West had lower odds for a dental caries visit than those living in the Northeast. With the exception of “other,”all payer categories were associated with higher odds for a dental visit compared with those covered by private insurance. Area income, significantly associated with dental visits in unadjusted analysis, was not significant in a model that included payer type.

Discussion Rural patient residence was associated with an increased likelihood that an ED visit would involve a diagnosis of dental caries, exclusive of other dental diagnoses, in both raw and adjusted analysis. This finding parallels that of Seu and colleagues (12); it extends their descriptive work by determining that the greater likelihood of ED visits for dental caries among rural adults remains even after population characteristics are held statistically equal. Differences between our findings and those of Shortridge and Moore (21) may be related to the larger geographic scope of the present study (28 states versus 3 states). Other patient characteristics were associated with a dental caries diagnosis in ways noted by previous research (13,14). Patients without insurance or with government insurance were more likely to present to the ED for primary dental caries-related diagnoses than were those with private insurance. Dental care is not a mandated benefit for adults who receive Medicaid, and adult dental care services have been downsized or eliminated in a number of states (22,23). Cohen and colleagues found that when Maryland eliminated Medicaid reimbursement to dentists for adult emergency coverage services at outpatient clinics, the policy change resulted in a 12 percent increase in ED claims for dentalrelated complaints (24). Pryor and Monopoli reported similar findings in Massachusetts where they observed reduced dental Medicaid coverage and subsequent decline in utilization, which eventually led to negative oral health outcomes, as cost for care shifted to the patient (25). Observed negative outcomes included steady decline in Medicaid acceptance of by private dentists, increased dependence on tooth extraction over restorative procedures, diminished selfesteem, and chronic tooth pain (25). In addition, the reluctance of dental care providers to accept Medicaid patients may have a role in ED utilization (26,27). Low Medicaid reimbursement rates and administrative issues are chief concerns among health care providers. Some states provide limited oral health care services to Medicaid beneficiaries, which may influence their likelihood of seeking care at a dentist’s office rather than the ED. For example, those patients between 19 to 21 years of age may be covered under the State Children’s Health Insurance Program, which provides dental coverage. This population 191

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would be less likely to visit the ED because of their ability to obtain financial access to dentists. Medicare beneficiaries have no dental benefits, and treatment from a dentist would require out-of-pocket cost. However, Medicare covers ED visits for a primary diagnosis for a dental-related problem (28). Care of dental conditions in EDs is often limited to prescribing antibiotics and analgesics, rather than definitive correction of the problem (12). Whether patients actually sought appropriate dental care after their ED visit remains an unanswered question. A number of patients, particularly those lacking private dental insurance, may not be able to access dental care soon after their visit to the ED. There are a number of factors that could potentially contribute to this problem, including access issues related to affordability of care and the dental workforce shortage in low income areas (14). In the absence of appropriate restorative care, these patients may return to the ED as untreated dental issues result in pain.

Limitations As a secondary data analysis, our study has multiple limitations. Study limitations include the absence of information on race/ethnicity, data limited to median income by ZIP code rather than person-specific information, and the lack of information about any follow-up care obtained after the ED visit. Because the data source does not provide a single patient identifier across episodes, we could not observe whether the patients return to the ED for dental complaints multiple times during the course of the year. Finally, the providers coding the data reported in the HCUP may not be familiar with oral health complaints, and hospitals may code dental complaints differently.

Implications Despite limitations, our study provides useful evidence to inform policy debates regarding how best to increase access to dental care among low income populations. Options include a) increasing or expanding access to dental care services; b) increasing scopes of practice to allow allied dental professionals to treat patients; and c) establishing dental care networks to address patience compliance issues. Regrettably, the Affordable Care Act (ACA) failed to extend dental coverage to adults, and most health insurance plans offered to most states exchanges will exclude dental benefits packages (29). Additionally, recent research has shown that the ACA will not substantially increase access to dental benefits for adults through Medicaid expansion, nor will it have a greater impact regarding providing adults private insurance (30). Thus, it does not appear that expanded financial access to dental services for adults is likely to occur over the next several years. 192

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Several institutions are implementing ED diversion programs to connect patients who have dental-related complaints to appropriate safety net providers as a way of improving access. Dental safety net providers include dental services provided in hospitals, dental schools, and federally qualified health center (FQHC)/community health centers (31). In 2010, over 70 percent of FQHCs offered dental services; these centers assisted over 3 million patients who presented with dental concerns (32). In addition to linking with FQHCs, hospitals have compiled lists of local dentists willing to accept a sliding fee scale, providing the emergency room with an alternative to which to refer low income patients (33). Diversion of dental ED patients to specialty clinic within the hospital has also proven to be effective at reducing both initial and return ED visits (34). These solutions, however, are limited in scope to the institutions that implement them. Modifying scope of practice laws could address the workforce shortages in underserved areas. Allied dental professionals are trained in preventive practices and educating patients about appropriate dental health behavior. Eight states, through special licensing, promote the provision of dental hygienist services in safety net settings; an additional 13 states allow hygienists to provide services in safety net settings without direct supervision (35). In addition, proactive approaches from the federal and state governments to increase the number of practicing dentists could improve access to oral health service in rural and other underserved areas where disparities are more pronounced (37). Areas identified as dental health professional shortage areas could qualify for various federal assistance programs, including dentists assigned to work in those areas and a variety of financial incentives to encourage new dentists to establish dental practices in those underserved areas (37). Finally, networking and cooperation among safety net dental providers can improve irregular dental attendance and compliance issues among patients in vulnerable populations (36). Many people elect not to visit a dentist because of lack of the perceived value associated with the service. Formal dental care networks, which have been tried in Europe (36), would allow private dentists to work collaboratively with social workers, physicians, or public hospitals in efforts to provide care to socially disadvantaged patients. Additionally, dental care networks are patient centered, which implies an educational component, and all health care providers pool their competencies to give care adapted to the social and health needs of specific patient groups (36). Dental care networks could be very important in emphasizing preventive care and personal behavioral practices such as frequent tooth brushing and dental regular visits. Further research is needed to determine whether such an approach would work in the United States. Our study illustrated the use of hospital-based EDs for diagnoses indicative of dental decay, particularly among © 2013 American Association of Public Health Dentistry

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those without insurance. Inappropriate use diverts ED providers, who may not be the best qualified to address oral health complaints, from less avoidable health problems. ED care that does not include appropriate dental services may lead to additional visits and corrective procedures, adding more strain on the health care system and attributing to a more fragmented pattern of care among patients seeking care for their dental needs. Future studies are needed to better understand the patterns and risk factors for dental visits within EDs.

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13.

14.

15.

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Analysis of hospital-based emergency department visits for dental caries in the United States in 2008.

Using nationally representative data, we examined differences in dental care utilization in emergency departments (EDs) among working age adults assoc...
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