Methods in Assessing Non-Traumatic Dental Care in Emergency Departments



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Outcomes of Interest

General Dental Access and ED Utilization


As with other aspects of ED dental care research, study outcomes varied widely. Some researchers have conducted general studies of ED use and access to regular dental care, without specifically looking at ED use for dental problems.(26, 54, 73, 85, 90-92) Newacheck and Kim explored health and dental care access and expenses with a focus on CSHCN.(27) Romaire et al. used MEPS data to explore healthcare access and expenses, including ED visits and dental visits, in subsets of children aged 0 to 17 years in one study and CSHCN children 0 to 17 years in another study.(41, 42) Flores and Tomany-Korman analyzed 2003-2004 National Survey of Children’s Health to examine racial/ethnic disparities in health and dental care among children, exploring many measures of oral and medical health status, access, and utilization, including perceived oral health status, dental insurance, preventive dental care in the past year, and ED visits, though the investigation did not include ED visits specifically for oral problems.(43) Stevens et al. interviewed older patients (aged 65+) presenting at a southeastern US ED to ascertain frequency of ten health care access problems, including difficulty in obtaining dental care.(76) McCormick, D et al. investigated health care access issues, including delayed dental care or not getting dental care among ED patients in an investigation of health care access impacts of health care reform in Massachusetts.(71) Wallace et al. assessed changes among Oregon Medicaid patients in unmet dental needs, utilization of preventive services, and ED dental visit rates and associated costs associated with the elimination of dental benefits.(56) Lee et al. investigated dental care access and ED visits with a primary diagnosis of caries through Medicaid claims as the outcome, comparing North Carolina Medicaid children participating in WIC compared to those not participating in WIC.(53) Martin et al. also used Medicaid data to investigate outcomes of preventive dental visits, receipt of preventive dental procedures, dental home status, and access to ED or medical offices for dental care.(46) Patel et al. interviewed and examined all patients presenting at the Hennepin County Medical Center ED to determine the proportions of patients with early or urgent dental care needs, independent of the patients’ reason for visiting the ED.(75) Authors and general dental access and ED utilization outcomes studied are summarized in Table 7.
Table 7: Authors and General Dental Access and ED Utilization Outcomes Studied

Authors

General Dental Access and ED Utilization Outcomes Investigated

Newacheck and Kim(27)

Health and dental care access and expenses with a focus on CSHCN

Romaire et al.(41)

Healthcare access and expenses, including ED visits and dental visits, in children aged 0 to 17

Romaire et al.(42)

Healthcare access and expenses, including ED visits and dental visits, in CSHCN children aged 0 to 17

Flores and Tomany-

Korman(43)



Racial/ethnic disparities among children in oral and medical health status, access, and utilization, including perceived oral health status, dental insurance, preventive dental care in the past year, and ED visits

Stevens et al.(76)

Frequency of ten health care access problems, including difficulty in obtaining dental care among older patients (aged 65+)

McCormick, D et al.(71)

Health care access issues, including delayed dental care or not getting dental care among ED patients in Massachusetts

Wallace et al.(56)

Changes among Oregon Medicaid patients in unmet dental needs, utilization of preventive services, and ED dental visit rates and associated costs

Lee et al.(53)

Dental care access and ED visits with a primary diagnosis of caries

Martin et al.(46)

Preventive dental visits, receipt of preventive dental procedures, dental home status, and access to ED or medical offices for dental care

Patel et al.(75)

Proportions of patients with early or urgent dental care needs, independent of the patients’ reason for visiting the ED


ED Utilization for Dental Care and NTDC Care – Rates and Factors Affecting Rates


More basic outcomes specifically related to ED utilization for dental care generally, or more specifically for NTDCs, include simple assessments of counts of ED visits for dental care or NTDCs, proportions of populations using EDs for dental care or NTDCs in the past year,(85) proportions of total ED visits that are for dental care or NTDCs, costs or charges associated with ED visits for dental care or NTDCs, and possibly trends of these measures over time. Wall analyzed 1997-2008 NHAMCS data to determine national rates and trends of ED dental visits.(29) Wall and Vujicic analyzed the latest NEDS data in 2015 to determine national rates and costs of ED visits for dental reasons.(24) Shortridge and Moore used 2005 SEDD data from Utah, Vermont, and Wisconsin to assess and compare ED visit rates in three states for dental care in general, for preventable dental diagnoses, and for dental diagnoses considered to have low severity.(57) Nalliah et al. analyzed 2006 NEDS data to investigate national counts, rates, and costs specifically for caries related ED visits.(23) Walker et al. analyzed 2008 NEDS data to determine predictors of ED visits with caries diagnoses among working age adults.(37) Lewis et al. investigated overall rates of ED use for dental complaints focusing on toothache as the primary visit complaint in NHAMCS data,(30) and then followed up with another NHAMCS data study with a focus on comparing similar outcomes and trends in ED use for young adults compared to other ED users (with specific comparisons to ED use for back pain).(31)

Many studies have gone beyond reporting levels of ED dental utilization to explore predictive factors. Sun et al. used a combination of 2010 claims data from 45 of Oregon’s 60 hospitals (including all payer groups) and the Oregon Payer All Claims file (which includes procedure, prescription, repeat ED visits, and costs data not available in hospital supplied data), and also interviewed purposive samples of ED dental visitors and community stakeholders in six counties to determine rates, costs, and predictors of ED use for NTDCs and possible interventions.(44) Hom et al. studied individuals younger than 18 years in North Carolina visiting hospital EDs to assess whether the proportion of people accessing EDs for oral problems varied by hospital population insurance mix.(45) Hong et al. studied the Kansas City, Missouri population to determine number and rates of ED use for dental care and to identify predictive factors for ED dental visits.(82, 83) Waldrop et al. conducted a chart review of all patients presenting with dental complaints during the period from 1987 to 1995 at a Baton Rouge, Louisiana hospital ED to determine rates, and trends of ED use for dental complaints and severity of dental conditions, finding increasing rates over the time period, and that half of the cases were non-emergent and could have been treated at dental offices during normal business hours.(70) Roghmann and Goldman studied the geographic area and hospitals of Rochester, New York to explore if a neighborhood health center providing continuous dental care reduced the number of ED dental emergency visits.(84) Nakao et al. assessed NTDC related ED visit rates and costs, and compared overall rates and costs to those for people with autism spectrum disorder.(40)



Okunseri et al., in several NTDC ED treatment studies, investigated a variety of outcomes. In one study they assessed rates of ED and physician office care for NTDCs in the Wisconsin Medicaid population, with a focus on racial and ethnic differences.(50) In another study of national NHAMCS data, they assessed rates and trends of ED visits for NTDCs, evaluating different predictive factors. One of their studies evaluated ED waiting times for treatment of NTDCs.(32) Another study evaluated rates of ED use by time of day and weekends vs. weekdays.(33) Authors and ED dental care utilization rate related outcomes studied are summarized in Table 8.

Table 8: Authors and ED Dental Care Utilization Rate Related Outcomes Studied

Authors

ED Dental Care Utilization Rate Related Outcomes

Feinglass et al.(85)

Proportions of populations using EDs for dental care or NTDCs in the past year

Wall(29)

National rates and trends of ED dental visits

Wall and Vujicic(24)

National rates and costs of ED visits for dental reasons

Shortridge and Moore(57)

Compare ED visit rates in three states for dental care in general, for preventable dental diagnoses, and for dental diagnoses considered to have low severity

Nalliah et al.(23)

National counts, rates, and costs specifically for caries related ED visits

Walker et al.(37)

ED visits with caries diagnoses among working age adults

Lewis et al.(30)

Overall rates of ED use for dental complaints focusing on toothache as the primary visit complaint

Lewis et al.(31)

Outcomes and trends in ED use for young adults compared to other ED users (with specific comparisons to ED use for back pain)

Sun et al.(44)

Rates, costs, and predictors of ED use for NTDCs and possible interventions

Hom et al.(45)

Proportion of people (younger than 18 yrs) accessing EDs for oral problems compared by hospital population insurance mix

Hong et al.(82, 83)

Numbers and rates of ED use for dental care

Waldrop et al.(70)

rates, and trends of ED use for dental complaints and severity of dental conditions

Roghmann and

Goldman(84)



Reduction in the number of ED dental emergency visits

Nakao et al.(40)

NTDC related ED visit rates and costs, comparing the overall population to people with autism spectrum disorder

Okunseri et al.(50)

Rates of ED and physician office care for NTDCs in the Wisconsin Medicaid population, with a focus on racial and ethnic differences

Okunseri et al.(32)

ED waiting times for treatment of NTDCs

Okunseri et al.(33)

Rates of ED use by time of day and weekends vs. weekdays


Other Outcomes Related to ED Utilization for Dental Care


Other factors related to ED visits for dental care have been studied. An important outcome related to basic ED dental care utilization is the rate of same subject return visits to EDs for the same oral problem (if that can be determined), which has an obvious direct impact on total ED related costs for NTDCs. Davis et al. investigated costs and frequency of return visits in Minneapolis-St. Paul area hospitals.(77) In addition to basic findings on number and costs of ED visits for dental care, DeLia et al. took investigation of return visits a step further and identified “high users” as subjects accessing EDs four or more times during the study period of 2008-10.(93) They explored differences of “high users” in terms of primary dental diagnoses and secondary diagnoses, and also found that “high users” often accessed multiple hospitals in their repeat visits. They also found that young adults, non-Hispanic blacks, and medically uninsured were over-represented among “high users.” Likewise, Hardie et al. analyzed 2012 ED admission data from a rural Maryland hospital to characterize frequents users of the ED, finding multiple distinct diagnoses correlated with number of ED admissions, and that many of the return visits involved dental diagnoses.(69) A variation on investigation of return visits to EDs as an outcome was conducted by Hayes et al., comparing the return rates of patients with infections (including dental infections) receiving medications vs. those receiving prescriptions.(74)

Another somewhat commonly evaluated outcome is dental related ED visits resulting in hospital admission. Nalliah et al., in analyzing 2006 NEDS data, found that 158 hospital admissions occurred out of 330,757 caries related ED visits.(23) Cohen et al. found that 2% of Medicaid related ED visits for dental reasons resulted in hospital admissions with a mean associated claims cost of $5,793.(49) Laurence et al. also explored the outcome of hospital admission using NEDS data to assess if patients with sickle cell disease and patients with pneumonia had increased probability of hospital admission from EDs if they also had dental infections.(38, 39) Authors and ED dental care utilization related outcomes studied are summarized in Table 9.



Table 9: Authors and ED Dental Care Utilization Related Outcomes Studied

Authors

ED Dental Care Utilization Related Outcomes

Davis et al.(77)

Costs and frequency of return visits in Minneapolis-St. Paul area hospitals

DeLia et al.(93)

Identified “high users” as subjects accessing EDs four or more times over a three year period

Hardie et al.(69)

Frequent users of the ED in terms of multiple distinct diagnoses, including dental

Hayes et al.(74)

Return rates of patients with infections (including dental infections) receiving medications vs. those receiving prescriptions

Nalliah et al.(23)

Proportion of hospital admissions out of all caries related ED visits

Cohen et al.(49)

Proportion and costs of hospital admissions among Medicaid related ED visits for dental reasons

Laurence et al.(38, 39)

Hospital admission among patients with sickle cell disease and patients with pneumonia who also had dental infections


Care Related Outcomes


Many investigations have explored the care received for NTDCs in EDs. Virtually all formal and informal reports find that in EDs where no dental personnel or dental clinics are present, care primarily is provided in the form of prescriptions for pain and antibiotics. While Cohen found that subject demographics were related to where care was sought, and care varied depending on whether care was sought at EDs, dental offices, or MD offices, the services provided at these different site categories did not vary by subjects’ incomes or race/ethnicity.(48)

Two studies conducted by Okunseri et al. focusing specifically on dental related ED prescriptions evaluated national rates and trends of medications prescribed at EDs for NTDCs, one looking at analgesics and antibiotics in general,(34) and the other assessing rates and trends of opioid, non-opioid, and combination analgesics.(36) Related to ED prescribing is the issue of DSB, more specifically the seeking of opioid prescriptions with oral pain given as the chief complaint. Fox et al. conducted chart reviews in a two-hospital system to study the effects of an instituted prescribing guideline on opioid prescribing for patients with oral pain complaints, finding the rate of opioid prescribing dropped, as well as the rate of ED visits for oral pain.(78) In the Grover et al. chart review studies, DSB was studied related to ED patient behaviors and complaints, including oral pain complaints.(80, 81) Weiner studied consistency of emergency providers’ impressions using objective criteria from a state prescription drug monitoring program to identify drug seeking behavior among patients presenting at two hospital EDs with a chief complaint of back pain, dental pain, or headache.(79)

Another outcome of interest is whether those presenting at an ED with NTDCs had follow-up care with a dentist. Cohen et al. found in their Maryland phone survey that 96% of those having gone to an ED for a NTDC contacted a dentist after their ED visit.(48) Pajewski and Okunseri found in an analysis of Wisconsin Medicaid data that among adults, 30% visited a dentist within 30 days; 42% visited a dentist within 180 days; 10% returned to the ED within 30 days; and 18.3 percent returned to the ED within 180 days.(51) Of the patients visiting a dentist following an ED NTDC related visit, 38% had a tooth extraction.

Many other outcomes have been investigated in relation to ED dental care. Cohen et al., in their state telephone interview study, included an assessment of dentist, physician, and ED visits for dental care that resulted in a health literacy related problem in caregiver-patient interactions.(47) Authors and ED dental care related outcomes studied are summarized in Table 10.



Table 10: Authors and ED Dental Care Related Outcomes Studied

Authors

ED Dental Care Related Outcomes

Cohen(48)

Care provided at EDs, dental offices, or MD offices, and comparisons by patient income and race/ethnicity

Okunseri et al.(34)

National rates and trends of NTDC related ED visit analgesic and antibiotic prescriptions

Okunseri et al.(36)

Rates and trends of NTDC related ED visit opioid, non-opioid, and combination analgesics

Fox et al.(78)

Effects of an instituted prescribing guideline on opioid prescribing for patients with oral pain complaints

Grover et al.(80, 81)

Drug seeking behavior related to ED patient behaviors and complaints, including oral pain complaints

Weiner(79)

Consistency of emergency providers’ impressions using objective criteria from a state prescription drug monitoring program to identify drug seeking behavior among patients with a chief complaint of back pain, dental pain, or headache

Cohen et al.(48)

Percentage of those having gone to an ED for a NTDC contacting a dentist after their ED visit

Pajewski and Okunseri(51)

Percentage visiting a dentist (and procedures provided) or returning to an ED within 30 days and 180 days of a dental related ED visit

Cohen et al.(47)

Dentist, physician, and ED visits for dental care resulting in a health literacy related problem in caregiver-patient interactions


Trends or Changes in Dental ED Utilization


While many researchers have studied point in time associations of different ED dental care outcomes with different predictors, some investigators have also explored changes between two points in time or trends in ED use for oral problems over time. Lee et al. determined an increasing trend in ED dental visits over the years 2001 to 2008 in data from the NHAMCS.(28) Pajewski and Okunseri, in their analysis of Wisconsin 2001-2009 Medicaid data focusing on follow-up treatment after NTDC ED visits among adult Medicaid patients, found a 43% increase in NTDC visits to EDs over the nine years of data.(51)Hong et al. found increased ED use for dental complaints over a six-year period from 2001 to 2006 in ER discharge data for Kansas City, Missouri hospital EDs.(82)

Other studies have investigated trends or changes in dental ED utilization related to specific care factors. Kempe et al. explored changes in care and access for general health, dental health, and ED care for Colorado residents before and one year after enrollment in Colorado’s CHP+ program.(52) Lave et al. investigated changes over the first year in health care access, including having a regular dentist, access to dental care when needed, and proportion having visited an ED, among new enrollees in Western Pennsylvania health insurance programs for low-income uninsured residents.(86) McCormick et al., in addition to determining basic ED dental usage rates and costs, also analyzed changes in these rates, costs, and repeat ED visits after instituting a program to divert patients with dental complaints to an urgent dental care clinic in the oral and maxillofacial surgery department of the hospital.(67) Likewise, Neely et al. explored dental related ED visit rates and costs, but specifically explored changes in rates and costs 3 years before and 2 years after Massachusetts health care reform.(68) Singhal et al. assessed rates and trends of ED dental visits over the time period from 2006 to 2011, before and after a July, 2009 Medicaid policy change in California eliminating adult dental benefits, and compared these rates and trends to those for other ambulatory care-sensitive conditions.(55) Authors and ED dental care trend or change related outcomes studied are summarized in Table 11.



Table 11: Authors and ED Dental Care Trend/Change Outcomes Studied

Authors

ED Dental Care Trend/Change Related Outcomes

Lee et al.(28)

National trend in ED dental visits over the years 2001 to 2008

Pajewski and Okunseri(51)

State trend in Medicaid NTDC visits to EDs over nine years

Hong et al.(82)

City trend in ED use for dental complaints over a six-year period

Kempe et al.(52)

Changes in care and access for general health, dental health, and ED care for state residents before and one year after enrollment in CHP+ program

Lave et al.(86)

Changes in health care access, including having a regular dentist, access to dental care when needed, and proportion having visited an ED over the first year among new enrollees in Western Pennsylvania health insurance programs for low-income uninsured residents

McCormick et al.(67)

Changes in ED dental usage rates, costs, and repeat ED visits after instituting a diversion program

Neely et al.(68)

Changes in dental related ED visit rates and costs 3 years before and 2 years after state health care reform

Singhal et al.(55)

Trends of ED dental visit rates over five years, before and after state Medicaid policy change eliminating adult dental benefits, and comparison to trends for other ambulatory care-sensitive conditions


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