Methods in Assessing Non-Traumatic Dental Care in Emergency Departments



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Summary of Findings


  1. Investigations varied widely in terms of target populations of interest. Target populations ranged from national, state, and local levels down to a single hospital or ED. Some target populations were further defined by limiting the study population to those with specific demographic or other characteristics, or by specific aspects of patient care processes or outcomes.

  2. Investigation outcomes of interest varied widely, including general access to dental care and ED use, counts and rates of ED general dental and NTDC usage, rates of ED return visits, rates of hospital admission for dental conditions, and trends or changes in rates of ED utilization for dental care.

  3. Predictive factors investigated varied widely. Though some basic demographic and insurance status predictors were commonly investigated, other factors included urban/rural status and other environmental factors, psychological factors, other concurrent conditions, and changes in insurance coverage or policy (e.g., adult Medicaid coverage).

  4. Data sources for investigations varied widely, though some national and state data systems were commonly used. Some studies (e.g., local hospital studies) used different sources of data but had similar variable content in the datasets.

  5. Specific sets of diagnosis codes used to define dental care, or more specifically, NTDCs, varied. Few investigators used exactly the same sets of codes. Some investigators used similar codes with slight variations, while other investigators used very different sets of codes to define the same dental care category (e.g., NTDCs).

  6. While there have been many investigations of the use of EDs for dental care that explored different aspects of the issue, the variation in studies and the methods employed have resulted in inconsistent data that often are not comparable. This does not allow for effective standardized surveillance of ED dental care at the state and local levels.

  7. Standardized research protocols, including data collection, analysis and reporting methods need to be developed and promoted, particularly at the state level, to ensure reliable comparable data sufficient for tracking and comparing state trends.



Recommendations Summary





  • Specifically define study populations of interest, assess usability of data sources, and follow good investigation protocol in assessing ED dental care and planning interventions.

  • Develop sets of codes and analysis methods, including important predictive factors that will most appropriately answer research questions with the underlying motivation of standardizing methods to the extent possible to allow for comparison to other studies on other populations.

  • Encourage specific research on ED use for NTDCs, which includes the majority of unnecessary visits and costs and could most effectively be addressed in the primary dental care setting.

  • Develop and promote standardized sets of codes and analysis methods providing appropriate basic ED dental use data for state oral health surveillance systems and for state data submission to a national data repository for tracking national ED dental care, allowing for comparability across states. Additional optional data analyses can be conducted by states as desired.


Introduction

There is increasing attention given to the use of hospital emergency departments (EDs) for oral problems, when care could more appropriately and less expensively be provided in primary dental care settings. Many investigators and organizations have reported the numerous concerns associated with this phenomenon.(1-4) The primary concern is that EDs generally provide only palliative care for oral problems (e.g., antibiotics and pain medication). Interestingly, Cohen et al., in a focus group study of Maryland low income white, black and Hispanic adults, found that toothache pain was the most common dental reason for visits to physicians or EDs, and financial constraints were most commonly cited as the reason for not seeking care from dentists. Of particular note is that participants in this study were aware that they were likely to only get prescriptions and would need to seek follow-up care with a dentist.(5) While there has been some attention to the potentially increasing role of non-dental professionals in providing dental care to certain population groups such as low-income and minority populations(6), currently dental care in EDs primarily addresses symptoms. ED care that only addresses symptoms, without definitive care to alleviate the cause of oral problems, results in patients often returning to EDs multiple times for the same problem. ED visits, especially when repeated for the same problem, generate high costs to patients, insurance companies, and taxpayers, depending on the patients’ means to pay.


Many investigators have assessed data on the use of emergency departments for oral problems, and more specifically, non-traumatic dental conditions (NTDCs) at the local, state, and national levels. Particularly at the state level, the general thinking is that if states were to adopt policies that support increased access to dental care in dental offices or clinics, there would be significant cost savings and better oral health outcomes. Though many states have started to look at data on dental related ED visits, there currently is no standardized protocol for collection and analysis of these data. Therefore, data interpretation and comparability of data between studies are in question.
Concerns related to lack of data comparability with past reports include the different sources of the data, the content of the data used, the way the data were analyzed, and the way the data were reported. The lack of comparability between reports can cause frustration. This lack of standardization impacts the ability of local, state, and national policy makers to make informed decisions that address the economic and quality of life impact of the use of EDs for NTDCs. Development of a standardized protocol for the collection, analysis, and reporting of ED data will allow local, state and national policy makers to make informed policy decisions that will result in more efficient use of scarce resources and promote better quality of life for individuals with improved access to “dental homes.”
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