- Email: [email protected]
Does Restriction of Public Health Care Dental Benefits Affect the Volume, Severity, or Cost of Dental-Related Hospital Visits?
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DENTOALVEOLAR SURGERY
Does Restriction of Public Health Care Dental Benefits Affect the Volume, Severity, or Cost of Dental-Related Hospital Visits? David Salomon, DDS,* R. Eric Heidel, PhD,y Antonia Kolokythas, DDS, MSc,z Michael Miloro, DMD, MD,x and Thomas Schlieve, DDS, MDk
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Purpose:
On July 1, 2012, the Illinois legislature passed the Save Medicaid Access and Resources Together (SMART) Act, which restricts adult public dental insurance coverage to emergency-only treatment. The purpose of this study was to measure the effect of this restriction on the volume, severity, and treatment costs of odontogenic infections in an urban hospital.
Materials and Methods:
A retrospective cohort study of patients presenting for odontogenic pain or infection at the University of Illinois Hospital was performed. Data were collected using related International Classification of Diseases, Ninth Revision codes from January 1, 2011 through December 31, 2013 and divided into 2 cohorts over consecutive 18-month periods. Outcome variables included age, gender, insurance status, oral and maxillofacial surgery (OMS) consultation, imaging, treatment, treatment location, number of hospital admission days, and inpatient care level. Severity was determined by the presence of OMS consultation, incision and drainage, hospital admission, and cost per encounter. Hospital charges were used to compare the cost of care between cohorts. Between-patients statistics were used to compare risk factors and outcomes between cohorts.
Results:
Of 5,192 encounters identified, 1,405 met the inclusion criteria. There were no significant differences between cohorts for age (P = .28) or gender (P = .43). After passage of the SMART Act, emergency department visits increased 48%, surgical intervention increased 100%, and hospital admission days increased 128%. Patients were more likely to have an OMS consult (odds ratio [OR] = 1.42; 95% confidence interval [CI], 1.11-1.81), an incision and drainage (OR = 1.48; 95% CI, 1.13-1.94), and a longer hospital admission (P = .04). The average cost per encounter increased by 20% and the total cost of care increased by $1.6 million.
Conclusion:
After limitation of dental benefits, there was an increase in the volume and severity of odontogenic infections. In addition, there was an escalated health care cost. The negative public health effects and increased economic impact of eliminating basic dental care show the importance of affordable and accessible preventative oral health care. Ó 2016 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-8, 2016
*Resident, Department of Oral and Maxillofacial Surgery,
Dr Miloro is a consultant to AxoGen, Inc.
University of Illinois, Chicago, IL.
Address correspondence and reprint requests to Dr Schlieve:
yAssistant Professor of Biostatistics, Department of Surgery,
Department of Oral and Maxillofacial Surgery, UT Southwestern
Office of Medical Education, Research, and Development,
Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-
University of Tennessee Graduate School of Medicine, Knoxville,
9109; e-mail: [email protected]
TN. zDepartment Chair, Department of Oral and Maxillofacial
Received January 12 2016 Accepted October 9 2016
Surgery, University of Rochester Medical Center, Rochester, NY.
Ó 2016 Published by Elsevier Inc on behalf of the American Association of Oral
xDepartment Head and Professor, Department of Oral and
and Maxillofacial Surgeons
Maxillofacial Surgery, University of Illinois, Chicago, IL.
0278-2391/16/31028-X
kAssistant Professor, Department of Oral and Maxillofacial
http://dx.doi.org/10.1016/j.joms.2016.10.019
Surgery, UT Southwestern Medical Center, Dallas, TX.
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RESTRICTED PUBLIC HEALTH CARE DENTAL BENEFITS
Most often, dental caries or infection can be easily addressed in an outpatient or ambulatory clinic setting. Nevertheless, the lack of adequate dental care for the economically impoverished and uninsured groups is an issue that has drawn considerable and increasing attention. As an alternative to the desirable preventative medicine paradigm, these patients seek emergency care in hospital or urgent care settings. Because of the lack of trained dental professionals and available resources, these patients very often do not receive appropriate comprehensive treatment and this less than ideal treatment carries an inflated cost. In the United States, there are an average of 738,000 visits to the emergency department (ED) annually for dental complaints, with a disproportionate percentage of Medicaid or self-pay patients compared with those with private insurance.1 In 2006, Nalliah et al2 found that for dental caries alone there were 330,757 visits to the ED for a total estimated cost of $110 million. Unfortunately, for the US health care system, this is an increasing trend.3 Coinciding with this trend, the number of patients hospitalized for odontogenic reasons is increasing.4 Odontogenic infections can progress to extensive multi-space infections requiring surgical intervention and hospitalization and can even result in death from airway compromise or sepsis.5-7 It has been well established that preventive dental treatment in outpatient settings is more effective and cost efficient.1 Griffin et al8 showed that costs for patients admitted to the hospital were more than 10 times greater than those with similar treatment rendered in an outpatient setting. Similarly, Pettinato et al9 found greater expenditures by Medicaid for treatment in the ED compared with the cost to Medicaid for providing routine preventive care. However, there have been very few studies that have accurately analyzed the hospital costs associated with these dental infections.10 In 2012, the Save Medicaid Access and Resources Together (SMART) Act was passed in Illinois, which eliminated nonemergency adult public dental benefits. The law, which went into effect on July 1, 2012, limited covered dental treatment to emergency-only extractions of a single tooth for adults older than 21 years. There is established evidence that a decrease in public dental insurance coverage for adults increases the number of ED visits for dental-related problems.11-13 However, based on the deficiencies in the current literature, the authors sought to approach this public policy change by creating a more accurate and complete study design, one that incorporated ED, operating room, and inpatient data. The purpose of this study was to measure the effect of this restriction on the volume, severity, and treatment costs of odontogenic infections seen in an urban
Illinois hospital. The authors hypothesized that after the limitation of adult dental services in Illinois effective July 1, 2012, increases in the number and severity of dental infections in the ED and hospital settings would be seen. Furthermore, the increased use of hospital-based dental care would increase total health care costs. The specific aims of the study were to measure and compare the change in volume, severity, and total cost before and after the passage of legislation that restricted adult public dental health care in Illinois to emergency-only treatment.
Materials and Methods STUDY DESIGN
This study was approved by the institutional review board of the University of Illinois at Chicago (number 2014-0002). To address the research purpose, the authors designed and implemented a retrospective cohort study. The study population was composed of all patients presenting to the University of Illinois Hospital (UIH) for evaluation and management of dental pain or infection from January 1, 2011 through December 31, 2013. This allowed 36 months of data, which were divided into 2 separate consecutive cohorts of 18 months each. The first 18-month period (cohort 1) occurred immediately before passage of the SMART Act (January 1, 2011 through June 30, 2012). Cohort 2 (July 1, 2012 through December 31, 2013) occurred immediately after. To be included in the study sample, patients had to present to the UIH ED or as a direct transfer from an outside hospital specifically for a nontraumatic odontogenic complaint, such as pain or swelling. Patients were excluded as study subjects if their visit was not related to an odontogenic complaint, such as headache, temporomandibular joint concerns, or folliculitis, or was related to a noninfectious odontogenic process, such as a benign or malignant tumor or postoperative concern. VARIABLES
The primary predictor variable was time. The primary outcome variables of the study were the volume of patients with odontogenic pain or infection (number of included patients), severity of the infection (measured by oral and maxillofacial surgery [OMS] consultation, incision and drainage [I&D], hospital admission, and average cost per ED encounter), and overall cost of treatment based on hospital charges for each variable analyzed. In addition to demographic variables (age, gender, and insurance status), additional variables included OMS consultation, radiographic examination (computed tomography [CT] and Panorex radiography), I&D, treatment in the
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operating room, hospital admission, and inpatient days (intensive care unit [ICU] and floor days).
Table 1. ICD-9 CODES USED TO OBTAIN DATA
ICD-9 Code DATA COLLECTION METHODS
A chart review was completed using electronic health records at the UIH from January 1, 2011 through December 31, 2013. International Classification of Diseases, Ninth Revision (ICD-9) codes possibly associated with odontogenic infectious etiologies (Table 1) were used to collect all patient data for the specified period. A comprehensive and diverse list of ICD-9 codes was used to account for the broad range of codes entered by ED physicians for head and neck infections of odontogenic origin. It has been the authors’ experience that ED physicians select a wide variety of codes when a patient presents with dental pain or swelling. For example, codes for throat pain (784.1) and jaw pain (784.92), although vague, were found to be used by ED physicians as a primary diagnostic code in odontogenic infections. Thus, to capture as many encounters as possible, an extensive list of ICD-9 codes was used and each record was analyzed by the authors to determine inclusion eligibility. Each patient encounter was individually reviewed by the authors to determine eligibility for inclusion. In instances in which more than 1 diagnosis code was used for the same encounter, only 1 encounter was counted. Actual hospital charges for an ED visit, procedure, operating room time, anesthesia, recovery room, medications, imaging, and daily inpatient charges for each level of care were calculated.
521.00 521.01 521.02 521.03 521.04 521.05 521.06 521.07 521.08 521.09 522.0 522.1 522.2 522.3 522.4 522.5 522.6 522.7 522.8 522.9 523.00 523.01 523.10 523.11
DATA ANALYSIS
Descriptive and frequency statistics were calculated for all variables to check for coding errors, describe the sample, and test for statistical assumptions. Skewness and kurtosis statistics were used to test for the assumption of normality, with any statistic above an absolute value of 2.0 denoting a non-normal distribution. The Levene test of equality of variances was used to test the assumption of homogeneity of variance when comparing independent groups. Independentsamples t tests were used to compare the 2 cohorts on continuous outcomes. In the event that a statistical assumption of a t test occurred, nonparametric MannWhitney U tests were used. Associations between the cohorts for categorical risk factors and outcomes were assessed using unadjusted odds ratios (ORs) with 95% confidence intervals (95% CIs). Statistical significance was assumed at an a value of 0.05, unless a Bonferroni correction was used to adjust for multiple comparisons. All analyses were conducted using SPSS 22 (IBM Corp, Armonk, NY).
523.20 523.21 523.22 523.23 523.24 523.25 523.30 523.31 523.32 523.33 523.40 523.41 523.42 523.5 523.6 523.8
Description Unspecified dental caries Dental caries limited to enamel Dental caries extending into dentine Dental caries extending into pulp Arrested dental caries Odontoclasia Dental caries pit and fissure Dental caries of smooth surface Dental caries of root surface Other dental caries Pulpitis Necrosis of the pulp Pulp degeneration Abnormal hard tissue formation in pulp Acute apical periodontitis of pulpal origin Periapical abscess without sinus Chronic apical periodontitis Periapical abscess with sinus Radicular cyst Other and unspecified diseases of pulp and periapical tissues Acute gingivitis, plaque induced Acute gingivitis, non-plaque induced Chronic gingivitis, plaque induced Chronic gingivitis, non-plaque induced Gingival recession, unspecified Gingival recession, minimal Gingival recession, moderate Gingival recession, severe Gingival recession, localized Gingival recession, generalized Aggressive periodontitis, unspecified Aggressive periodontitis, localized Aggressive periodontitis, generalized Acute periodontitis Chronic periodontitis, unspecified Chronic periodontitis, localized Chronic periodontitis, generalized Periodontosis Accretions on teeth Other specified periodontal diseases
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Table 1. Cont’d
ICD-9 Code 523.9 526.4 526.5 528.3 528.9 682.0 682.1 682.8 682.9 784.1 784.92
Description Unspecified gingival and periodontal disease Inflammatory conditions of jaw Alveolitis of jaw Cellulitis and abscess of oral soft tissues Other and unspecified diseases of the oral soft tissues Cellulitis and abscess of face Cellulitis and abscess of neck Cellulitis and abscess of other specified sites Cellulitis and abscess of unspecified sites Throat pain Jaw pain
Abbreviation: ICD-9, International Classification of Diseases, Ninth Revision. Salomon et al. Restricted Public Health Care Dental Benefits. J Oral Maxillofac Surg 2016.
Cost analysis was performed using hospital charges for all patients included in the study. The charges were acquired through the UIH billing department, which supplied a detailed breakdown. The charges were analyzed, categorized, and tabulated for all components of a patient’s hospital stay. These included charges for the ED visit, specific radiology study, OMS consultation, outpatient surgical procedure fees, operating room fees (including equipment, anesthesia charges, and surgical procedure fees), medications, and inpatient daily room charges for a specific level of care. To control for inflation or an increase in the absolute amount charged for the duration of the study, charges were determined based on hospital charges for these components of the encounter at a single time point (the end of cohort 2). In this way, a CT scan at the start of cohort 1 had the same hospital charge as a CT scan at the end of cohort 2.
Results Initially, there were 5,192 patient encounters during the 36-month study period with an ICD-9 diagnosis code corresponding to the predetermined list of diagnosis codes. After a chart review of all encounters, 1,405 (27%) met the inclusion criteria. There were no significant differences between the 2 cohorts for age (P = .28), gender (P = .43), or insurance status (P = .54). The normality assumption was violated for the floor length of stay (LOS) and ICU LOS variables. Nonparametric Mann-Whitney U tests found no signif-
icant main effect for ICU LOS (P = .91), but significance was detected for floor LOS (P = .04). Descriptive statistics for these analyses are presented in Table 2. There was no difference between groups for going to the operating room (P = .34). Cohort 2 was significantly more likely to undergo Panorex radiography (OR = 2.10; 95% CI, 1.59-2.77), undergo CT (OR = 1.73; 95% CI, 1.21-2.48), received an OMS consult (OR = 1.42; 95% CI, 1.11-1.81), and undergo an I&D procedure (OR = 1.48; 95% CI, 1.13-1.94) compared with cohort 1. ORs with 95% CI are presented in Table 3. An increase in the number and overall severity of odontogenic infections was noted in cohort 2 compared with cohort 1 using the increased odds of requiring an OMS consultation, an I&D, and marked increase in floor LOS as a proxy for severity. The number of total patient encounters increased 48%, the number of patients requiring surgical intervention increased 100%, and the number of hospital admission days increased 128%. A complete comparison of the data is presented in Table 4 (cohort 1 vs 2). For financial impact, the total charges related to dental concerns and odontogenic infections in cohort 2 were $3.67 million, whereas the total charges in cohort 1 were $2.08 million. This represents a 77% increase in total charges after passage of the SMART Act. The average charge per ED visit increased from $3,948 to $4,729 (increase, 20%). The complete assessment of total charges for the 2 cohorts is presented in Tables 5 and 6.
Table 2. DESCRIPTIVE STATISTICS FOR BETWEEN-SUBJECTS ANALYSES AND UNADJUSTED ODDS RATIOS WITH 95% CONFIDENCE INTERVALS
Variable Patient encounters Age (yr)* Floor LOS* ICU LOS* Meny Insurancey Location of care (ED)y Panorex radiography CTy Incision and drainagey
Cohort 1
Cohort 2
P Value
567 33.0 (18.2) 0.15 (0.65) 0.06 (0.51) 237 (41.8) 425 (75.0) 526 (93.0) 84 (14.8) 46 (8.1) 101 (17.8)
838 34.0 (17.4) 0.25 (0.93) 0.07 (0.65) 368 (43.9) 615 (73.5) 776 (92.6) 224 (26.7) 111 (13.3) 202 (24.1)
.28 .04z .91 .43 .54 .17 <.001z .003z .004z
Abbreviations: CT, computed tomogram; ED, emergency department; ICU, intensive care unit; LOS, length of stay in days. * Mean (standard deviation). y Frequency (percentage). z Significant (P < .05). Salomon et al. Restricted Public Health Care Dental Benefits. J Oral Maxillofac Surg 2016.
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Table 3. UNADJUSTED ODDS RATIOS (95% CONFIDENCE INTERVALS) FOR COHORTS
Variable
Cohort 1
Cohort 2
P Value
Emergency department Operating room Panorex radiograph CT OMS consult Incision and drainage
Reference
0.78 (0.49-1.25)
.12
Reference Reference
0.40 (0.15-1.05) 2.10 (1.59-2.77)
.51 <.001*
Reference Reference Reference
1.73 (1.21-2.48) 1.42 (1.11-1.81) 1.48 (1.13-1.94)
.003* <.001* .004*
Abbreviations: CT, computed tomogram; OMS, oral and maxillofacial surgery. * Significant (P < .05). Salomon et al. Restricted Public Health Care Dental Benefits. J Oral Maxillofac Surg 2016.
Discussion The purpose of this study was to measure the effect of the restriction of adult public aid dental benefits to emergency-only treatment on the volume, severity,
Table 4. COMPARISON OF COHORTS 1 AND 2
UIH Odontogenic Infection-Related Data Cohort 1* Cohort 2y Change, % Total patient encounters Total ED visits Total Panorex radiographs Total CTs Total OMS consults Total I&D ED I&D OR I&D Total outpatient treatment Total inpatient days Floor or stepdown days ICU days
567
838
48
526 84
776 224
48 167
46 131 101 72 29 497
111 250 202 149 53 723
141 91 100 107 83 45
116 83
264 206
128 148
33
58
76
Abbreviations: CT, computed tomogram; ED, emergency department; I&D, incision and drainage; ICU, intensive care unit; OMS, oral and maxillofacial surgery; OR, operating room; UIH, University of Illinois Hospital, Chicago. * From January 1, 2011 through June 30, 2012, before passage of the Save Medicaid Access and Resources Together Act. y From July 1, 2012 through December 31, 2013, after passage of the Save Medicaid Access and Resources Together Act. Salomon et al. Restricted Public Health Care Dental Benefits. J Oral Maxillofac Surg 2016.
and cost of odontogenic pain and infections seen in an urban Illinois hospital. The authors hypothesized that after the limitation of adult dental services in Illinois effective July 1, 2012, increases in the number and severity of dental infections in the ED and hospital settings would be seen. Furthermore, an increase in the number and severity of odontogenic infections in the hospital setting would increase total health care costs. The specific aims of the study were to measure and compare changes in volume, severity, and total cost before and after the passage of legislation that restricted adult public dental health care in Illinois to emergency-only treatment. During the study period, there was an increase in the absolute number of patients presenting to the ED with odontogenic concerns. Patients in cohort 2 were more likely to have an OMS consult (OR = 1.42; 95% CI, 1.11-1.81) or an I&D procedure (OR = 1.48; 95% CI, 1.13-1.94) and had a statistically significant increase in floor LOS (P = .04). In addition, the average cost per ED encounter increased by 20%, with an overall cost increase of $1.6 million from cohort 1 to cohort 2. The increased cost per ED visit supports an increase in severity under the assumption that, on average, patients in cohort 2 required additional workup and care (laboratory tests, imaging, consultation, and surgery). These findings support the hypothesis that the restriction of adult dental care services to emergency-only treatment by passage of the SMART Act resulted in an increase in the number and severity of odontogenic infections and in an escalation in health care costs at the UIH. It has been well established that preventive dental treatment in outpatient settings is the most effective and cost-efficient management.8,9 However, there have been very few studies that have analyzed the actual hospital charges for these infections. Furthermore, only 3 other studies were found in the literature that specifically cross-checked patient records to determine appropriate inclusion (ie, etiology of odontogenic infections as the primary diagnosis code) other than using ICD-9 codes alone.10,14,15 The overinclusion of data without reviewing patient records for applicability of diagnosis codes can be inaccurate, because the present final data included only 27% of the initial data collected from the codes used. The stringent data collection used in the present study ensures appropriate inclusion criteria (ie, odontogenic etiology) and vastly improves the accuracy of the data. Given the vast array of codes that are used in the hospital setting for odontogenic infections, the codes used to identify patients were purposefully overinclusive to accurately capture all appropriate encounters. For example, ICD-9 code 523.5 (periodontitis) was included to capture these encounters just in case there were some who did
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Table 5. COST ANALYSIS FOR COHORT 1 (BEFORE SMART ACT)*
Table 6. COST ANALYSIS FOR COHORT 2 (AFTER SMART ACT)*
Cohort 1
Cohort 2
Data
Average age (yr) Insured, % Men/women, % Total ED visits Total Panorex radiographs Total CTs Total I&D Total ED I&D Total OR cases Total OMS consults Total floor days Total ICU days Total hospital charges Charge per ED visit
32.98 75 42/58 526 84 46 101 72 29 131 83 33
Total Charge
$947,326.00 $18,564.00 $87,216.00 $47,520.00 $360,992.00 $39,038.00 $230,408.00 $345,840.00 $2,076,904.00 $3,948.49
Average age (yr) Insured, % Men/women, % Total ED visits Total Panorex radiographs Total CTs Total I&D Total ED I&D Total OR cases Total OMS consults Total floor days Total ICU days Total hospital charges Charge per ED visit
Data 34.03 73 44/56 776 224 111 202 149 53 250 206 58
Total Charge
$1,397,576.00 $49,504.00 $210,456.00 $98,340.00 $659,744.00 $74,500.00 $571,856.00 $607,840.00 $3,669,816.00 $4,729.14
Abbreviations: CT, computed tomogram; ED, emergency department; I&D, incision and drainage; ICU, intensive care unit; OMS, oral and maxillofacial surgery; OR, operating room; SMART, Save Medicaid Access and Resources Together. * From January 1, 2011 through June 30, 2012.
Abbreviations: CT, computed tomogram; ED, emergency department; I&D, incision and drainage; ICU, intensive care unit; OMS, oral and maxillofacial surgery; OR, operating room; SMART, Save Medicaid Access and Resources Together. * From July 1, 2012 through December 31, 2013.
Salomon et al. Restricted Public Health Care Dental Benefits. J Oral Maxillofac Surg 2016.
Salomon et al. Restricted Public Health Care Dental Benefits. J Oral Maxillofac Surg 2016.
meet the inclusion criteria but were inappropriately coded. As seen, most were excluded, but there were several encounters that were accurately captured despite an erroneous code being used. All other studies with similar hypotheses used ICD-9 codes but did not individually review each patient record to ensure appropriate coding. Therefore, they included too many extraneous codes, covering a wide spectrum of possible dental, facial, and neck complaints, or were too focused and only included codes for dental caries1 or periapical abscess.4,16 In addition, the costs and charges are likely underestimated in the 3 other studies that actually performed chart review for inclusion criteria, because patients who did not receive treatment in the operating room and who were not admitted were not included.10,14,15 In 2014, Neely et al11 published an article comparing the rate of adults who presented to the ED at the Boston Medical Center (Boston, MA) for dental problems before and after the Massachusetts Medicaid programs decreased dental coverage in 2010. As in the present study, the data were collected by ICD-9 codes retrospectively. They found that dental-related ED visits increased 2 and 14% the first and second years after Medicaid cuts.11 In addition, they found 8% ($8.4 to $9.1 million) and 44% ($8.4 to $12.1 million) increases in total hospital costs for dental-related problems in the first and second years after the Medicaid decreases.11 Mirroring the present
findings, they concluded that ED care for dental problems increased at a major safety-net hospital when Medicaid coverage for dental care for adults was decreased. However, there are several key differences between the work by Neely et al and the present study. As mentioned earlier, there was no cross-referencing of patient records once they were collected by ICD-9 codes. Different ICD-9 codes used in the study by Neely et al were overly inclusive and all dental and oral complaints were compiled together, undoubtedly leading to overinclusion of data. For example, their study included codes for mandibular and maxillary exostosis, acquired tooth loss, and headache. Also, their study did not collect data on operating room treatment, hospital admission, or ICU stay. Similar work was published by Cohen et al12 in a pilot study examining ED visits for dental-related problems before and after the elimination of Medicaid reimbursement for adult emergency dental services in Maryland. Cohen et al13 published a follow-up in 2002 that broadened the data to include the state of Maryland, as opposed to a single hospital, using the original 4-year period in the 1990s. They found that the rate of dental visits to the ED by Medicaid recipients increased by 12% after the policy change.13 The same limitations apply to this study as those mentioned earlier for the study by Neely et al.11 An important additional issue with this study is that up to 2 ICD-9 codes could be submitted; therefore, there are more codes than claims. This also decreases the
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673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728
accuracy of the data compared with the present study in which only 1 code was included per patient encounter. Management of odontogenic infections is not just a major health care issue in the United States. A similar study in Britain reported a 62% increase in patients requiring admission and surgical care for spreading odontogenic infections in the 3 years after the British government changed the system of payment to general practitioners, resulting in fewer dentists accepting government insurance.15 Although this study did cross-reference patient records to ensure odontogenic etiology, it captured only admissions, not outpatient ED visits, and did not analyze the cost of care. As noted in the present study, a large proportion of patients were seen in the ED and discharged home, without hospital admission, which greatly adds to the total hospital costs. Public aid health care coverage plays a critical role in shaping patterns by which patients seek care for dental-related problems.17 In 2005, Shortridge and Moore17 found that states with more generous public aid coverage have slightly less ED usage and that states with less generous coverage treat Medicaid beneficiaries like uninsured patients. Aside from the obvious argument that public aid for dental coverage is a public health and economic benefit, there is evidence that social interventions can be effective in decreasing nonemergency visits to the ED. In 2008, Anantharaman18 examined the impact of social interventions on total ED visits (medical and dental). These included public education, financial disincentives, redirecting to primary health care centers, and use of alternative clinics. During the 12 years of the social interventions, nonemergency ED visits decreased from 57 to 18%.18 This is important because many hospital centers might not have oral and maxillofacial surgeons on staff or nearby, leading to palliative or improper treatment being provided; thus, social interventions can play a crucial role in improving health care usage. To incorporate this concept into the present study, one can look at the reimbursement rates after the restriction of adult dental treatment to emergency care services only. A clinical oral examination fee was set at $16.20, a panoramic radiograph was set at $22.60, and a tooth extraction was set at $39.12, for a total reimbursement of $77.92. When extrapolating these data, if each patient in cohort 2 had an examination, panoramic radiograph, and tooth extraction, then the total cost to the state of Illinois in provider reimbursement would have been $65,296.96 ($77.92 multiplied by 838 patients). Total hospital charges for these same 838 patients were $3,669,816. Although this represents the hospital charges and not the reimbursement rate, this shows a dire need for improved social interventions to direct patients
to the appropriate path for proper diagnosis and treatment. The substantial increase in cost of just 1 urban hospital’s population could be extrapolated to the state level to illustrate a large financial burden. Several strengths of the present study also make it unique. It appears to be the only study that includes outpatient ED visits and hospital operating room and admission data. This results in a more comprehensive dataset and a more accurate impression of the relation between public dental coverage and infection rate, severity, and associated cost. Moreover, this is one of the only studies that reviewed each patient record to ensure appropriate inclusion criteria (primary diagnosis of odontogenic etiology) in contrast to most studies, which use different related codes to generate the dataset without review. An extensive list of ICD-9 codes was used to develop the present dataset to account for coding errors, capture as many dental-related encounters as possible, and improve the reliability of the dataset. In addition, the hospital charges used to determine the cost of care were obtained from a specific period at the end of cohort 2. This controls for inflation or an increase in the amount charged by the UIH across the study period. Furthermore, the attending oral and maxillofacial surgeons on staff at the UIH were unchanged during the time span of this data collection. This controls for differences in surgeon treatment philosophy and judgment when treating odontogenic infections, limiting another potential confounding variable. There are several potential weaknesses to the present study. The retrospective nature does not allow for proof of causation, only correlation. The authors could not control for a trend toward increased ED usage by the community or other variables, such as increased cost of private dental insurance, fewer dentists accepting Medicaid, or decreased funding for oral hygiene and dental care awareness programs that might increase ED usage for dental concerns. Furthermore, a 20% increase in charges per ED encounter likely indicates increased severity, although it could be due to unforeseen reasons independent of infection severity. Another potential weakness of the study is that the type of medical insurance (private vs public) does not capture any information about dental insurance. Unfortunately, there was no feasible way to determine whether dental coverage was offered through each patient’s existing medical insurance. In addition, although the limitation of dental benefits affected only adults older than 21 years, the data included all ages to analyze total patient data. The average age was not significantly different between cohorts (P = .28) and therefore age did not play a role in the differences observed between cohorts. Because these data are derived from 1 urban tertiary care hospital, generalizations must be made with caution. Moreover, it would be preferable to extend this study over a
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RESTRICTED PUBLIC HEALTH CARE DENTAL BENEFITS
longer period. It is probable that at least immediately after the change in Medicaid coverage in Illinois, sufficient time had not passed to see a statistical difference in the severity of odontogenic infections; however, only 18 months of data were available after passage of the SMART Act. In the 21st century, the morbidity and mortality associated with an odontogenic infection should be minimal with appropriate preventative care. Although there were no deaths directly attributed to an odontogenic source in the present study population, the substantial increase in those requiring surgical intervention might be avoidable, or at least minimized, with preventative dentistry. In addition to the direct morbidity associated with a severe odontogenic infection, inpatients are at a much greater risk of indirect morbidity from nosocomial complications, such as pneumonia, urinary tract infections, deep vein thrombosis, and infection with multidrug-resistant organisms. Despite the limitations of previous research and this study, there is convincing evidence from the United States and abroad that decreased public dental insurance coverage increases ED visits11-13 and hospitalizations from odontogenic sources.17 The present findings show an inverse correlation between public dental coverage and dental care being sought in an urban hospital setting. In addition, there was an increase in the severity of odontogenic infections and an increased cost of care after the limitation of public dental coverage. The negative public health effects and increased economic impact of eliminating basic dental care give special importance to affordable, accessible oral health care and valuable social interventions.
References 1. Lewis C, Lynch H, Johnston B: Dental complaints in emergency departments: A national perspective. Ann Emerg Med 42:93, 2003 2. Nalliah R, Allareddy V, Elangovan S, et al: Hospital based emergency department visits attributed to dental caries in the United States in 2006. J Evid Based Dent Pract 10:212, 2010
3. Aston G: Easing the bite on the ED. Hosp Health Netw 87:44, 2013 4. Shah A, Leong K, Lee M, et al: Outcomes of hospitalizations attributed to periapical abscess from 2000 to 2008: A longitudinal trend analysis. J Endod 39:1104, 2013 5. Gann C: Man dies from toothache, couldn’t afford meds. ABC News Medical Unit, September 2, 2011. Available at: http://abcnews.go. com/health/insurance-24-year-dies-toothache/story?id=14438171. Accessed October 2015 6. Owings L. Toothache leads to boy’s death. ABC News Medical Unit, March 5, 2007. Available at: http://abcnews.go.com/ Health/Dental/story?id=2925584&page=1. Accessed October 2015 7. Montoya A: Tooth infection causes blood infection, leads to man’s death. WLWT5, May 8, 2014. Available at: http://www. wlwt.com/article/tooth-infection-causes-blood-infection-leadsto-man-s-death/3542556. Accessed October 2015 8. Griffin SO, Gooch BF, Beltran E, et al: Dental services, costs, and factors associated with hospitalization for Medicaid-eligible children, Louisiana 1996-97. J Public Health Dent 60:21, 2000 9. Pettinato ES, Webb MD, Seale NS: A comparison of Medicaid reimbursement for non-definitive pediatric dental treatment in the emergency room versus periodic preventive care. Pediatr Dent 22:463, 2000 10. Ahmad N, Abubaker AO, Laskin D, et al: The financial burden of hospitalization associated with odontogenic infections. J Oral Maxillofac Surg 71:656, 2013 11. Neely M, Jones J, Rich S, et al: Effects of cuts in Medicaid on dental-related visits and costs at a safety-net hospital. Am J Public Health 104:e13, 2014 12. Cohen LA, Manski R, Hooper FJ: Does the elimination of Medicaid reimbursement affect the frequency of emergency department dental visits? J Am Dent Assoc 127:605, 1996 13. Cohen LA, Manski RJ, Magder LS, et al: Dental visits to hospital emergency departments by adults receiving Medicaid: Assessing their use. J Am Dent Assoc 133:715, 2002 14. Christensen B, Han M, Dillon JK: The cause of cost in the management of odontogenic infections 1: A demographic survey and multivariate analysis. J Oral Maxillofac Surg 71:2058, 2013 15. Burnham R, Bhandari R, Bridle C: Changes in admission rates for spreading odontogenic infection resulting from changes in government policy about the dental schedule and remunerations. Br J Oral Maxillofac Surg 49:26, 2011 16. Nalliah RP, Allareddy V, Elangovan S, et al: Hospital emergency department visits attributed to pulpal and periapical disease in the United States in 2006. J Endod 37:6, 2011 17. Shortridge EF, Moore JR: Use of emergency departments for conditions related to poor oral healthcare: Implications for rural and low-resource urban areas for three states. J Public Health Manag Pract 15:238, 2009 18. Anantharaman V: Impact of health care system interventions on emergency department utilization and overcrowding in Singapore. Int J Emerg Med 1:11, 2008
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DENTOALVEOLAR SURGERY
Does Restriction of Public Health Care Dental Benefits Affect the Volume, Severity, or Cost of Dental-Related Hospital Visits? David Salomon, DDS,* R. Eric Heidel, PhD,y Antonia Kolokythas, DDS, MSc,z Michael Miloro, DMD, MD,x and Thomas Schlieve, DDS, MDk
Q5 Q2
Purpose:
On July 1, 2012, the Illinois legislature passed the Save Medicaid Access and Resources Together (SMART) Act, which restricts adult public dental insurance coverage to emergency-only treatment. The purpose of this study was to measure the effect of this restriction on the volume, severity, and treatment costs of odontogenic infections in an urban hospital.
Materials and Methods:
A retrospective cohort study of patients presenting for odontogenic pain or infection at the University of Illinois Hospital was performed. Data were collected using related International Classification of Diseases, Ninth Revision codes from January 1, 2011 through December 31, 2013 and divided into 2 cohorts over consecutive 18-month periods. Outcome variables included age, gender, insurance status, oral and maxillofacial surgery (OMS) consultation, imaging, treatment, treatment location, number of hospital admission days, and inpatient care level. Severity was determined by the presence of OMS consultation, incision and drainage, hospital admission, and cost per encounter. Hospital charges were used to compare the cost of care between cohorts. Between-patients statistics were used to compare risk factors and outcomes between cohorts.
Results:
Of 5,192 encounters identified, 1,405 met the inclusion criteria. There were no significant differences between cohorts for age (P = .28) or gender (P = .43). After passage of the SMART Act, emergency department visits increased 48%, surgical intervention increased 100%, and hospital admission days increased 128%. Patients were more likely to have an OMS consult (odds ratio [OR] = 1.42; 95% confidence interval [CI], 1.11-1.81), an incision and drainage (OR = 1.48; 95% CI, 1.13-1.94), and a longer hospital admission (P = .04). The average cost per encounter increased by 20% and the total cost of care increased by $1.6 million.
Conclusion:
After limitation of dental benefits, there was an increase in the volume and severity of odontogenic infections. In addition, there was an escalated health care cost. The negative public health effects and increased economic impact of eliminating basic dental care show the importance of affordable and accessible preventative oral health care. Ó 2016 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-8, 2016
*Resident, Department of Oral and Maxillofacial Surgery,
Dr Miloro is a consultant to AxoGen, Inc.
University of Illinois, Chicago, IL.
Address correspondence and reprint requests to Dr Schlieve:
yAssistant Professor of Biostatistics, Department of Surgery,
Department of Oral and Maxillofacial Surgery, UT Southwestern
Office of Medical Education, Research, and Development,
Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-
University of Tennessee Graduate School of Medicine, Knoxville,
9109; e-mail: [email protected]
TN. zDepartment Chair, Department of Oral and Maxillofacial
Received January 12 2016 Accepted October 9 2016
Surgery, University of Rochester Medical Center, Rochester, NY.
Ó 2016 Published by Elsevier Inc on behalf of the American Association of Oral
xDepartment Head and Professor, Department of Oral and
and Maxillofacial Surgeons
Maxillofacial Surgery, University of Illinois, Chicago, IL.
0278-2391/16/31028-X
kAssistant Professor, Department of Oral and Maxillofacial
http://dx.doi.org/10.1016/j.joms.2016.10.019
Surgery, UT Southwestern Medical Center, Dallas, TX.
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RESTRICTED PUBLIC HEALTH CARE DENTAL BENEFITS
Most often, dental caries or infection can be easily addressed in an outpatient or ambulatory clinic setting. Nevertheless, the lack of adequate dental care for the economically impoverished and uninsured groups is an issue that has drawn considerable and increasing attention. As an alternative to the desirable preventative medicine paradigm, these patients seek emergency care in hospital or urgent care settings. Because of the lack of trained dental professionals and available resources, these patients very often do not receive appropriate comprehensive treatment and this less than ideal treatment carries an inflated cost. In the United States, there are an average of 738,000 visits to the emergency department (ED) annually for dental complaints, with a disproportionate percentage of Medicaid or self-pay patients compared with those with private insurance.1 In 2006, Nalliah et al2 found that for dental caries alone there were 330,757 visits to the ED for a total estimated cost of $110 million. Unfortunately, for the US health care system, this is an increasing trend.3 Coinciding with this trend, the number of patients hospitalized for odontogenic reasons is increasing.4 Odontogenic infections can progress to extensive multi-space infections requiring surgical intervention and hospitalization and can even result in death from airway compromise or sepsis.5-7 It has been well established that preventive dental treatment in outpatient settings is more effective and cost efficient.1 Griffin et al8 showed that costs for patients admitted to the hospital were more than 10 times greater than those with similar treatment rendered in an outpatient setting. Similarly, Pettinato et al9 found greater expenditures by Medicaid for treatment in the ED compared with the cost to Medicaid for providing routine preventive care. However, there have been very few studies that have accurately analyzed the hospital costs associated with these dental infections.10 In 2012, the Save Medicaid Access and Resources Together (SMART) Act was passed in Illinois, which eliminated nonemergency adult public dental benefits. The law, which went into effect on July 1, 2012, limited covered dental treatment to emergency-only extractions of a single tooth for adults older than 21 years. There is established evidence that a decrease in public dental insurance coverage for adults increases the number of ED visits for dental-related problems.11-13 However, based on the deficiencies in the current literature, the authors sought to approach this public policy change by creating a more accurate and complete study design, one that incorporated ED, operating room, and inpatient data. The purpose of this study was to measure the effect of this restriction on the volume, severity, and treatment costs of odontogenic infections seen in an urban
Illinois hospital. The authors hypothesized that after the limitation of adult dental services in Illinois effective July 1, 2012, increases in the number and severity of dental infections in the ED and hospital settings would be seen. Furthermore, the increased use of hospital-based dental care would increase total health care costs. The specific aims of the study were to measure and compare the change in volume, severity, and total cost before and after the passage of legislation that restricted adult public dental health care in Illinois to emergency-only treatment.
Materials and Methods STUDY DESIGN
This study was approved by the institutional review board of the University of Illinois at Chicago (number 2014-0002). To address the research purpose, the authors designed and implemented a retrospective cohort study. The study population was composed of all patients presenting to the University of Illinois Hospital (UIH) for evaluation and management of dental pain or infection from January 1, 2011 through December 31, 2013. This allowed 36 months of data, which were divided into 2 separate consecutive cohorts of 18 months each. The first 18-month period (cohort 1) occurred immediately before passage of the SMART Act (January 1, 2011 through June 30, 2012). Cohort 2 (July 1, 2012 through December 31, 2013) occurred immediately after. To be included in the study sample, patients had to present to the UIH ED or as a direct transfer from an outside hospital specifically for a nontraumatic odontogenic complaint, such as pain or swelling. Patients were excluded as study subjects if their visit was not related to an odontogenic complaint, such as headache, temporomandibular joint concerns, or folliculitis, or was related to a noninfectious odontogenic process, such as a benign or malignant tumor or postoperative concern. VARIABLES
The primary predictor variable was time. The primary outcome variables of the study were the volume of patients with odontogenic pain or infection (number of included patients), severity of the infection (measured by oral and maxillofacial surgery [OMS] consultation, incision and drainage [I&D], hospital admission, and average cost per ED encounter), and overall cost of treatment based on hospital charges for each variable analyzed. In addition to demographic variables (age, gender, and insurance status), additional variables included OMS consultation, radiographic examination (computed tomography [CT] and Panorex radiography), I&D, treatment in the
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operating room, hospital admission, and inpatient days (intensive care unit [ICU] and floor days).
Table 1. ICD-9 CODES USED TO OBTAIN DATA
ICD-9 Code DATA COLLECTION METHODS
A chart review was completed using electronic health records at the UIH from January 1, 2011 through December 31, 2013. International Classification of Diseases, Ninth Revision (ICD-9) codes possibly associated with odontogenic infectious etiologies (Table 1) were used to collect all patient data for the specified period. A comprehensive and diverse list of ICD-9 codes was used to account for the broad range of codes entered by ED physicians for head and neck infections of odontogenic origin. It has been the authors’ experience that ED physicians select a wide variety of codes when a patient presents with dental pain or swelling. For example, codes for throat pain (784.1) and jaw pain (784.92), although vague, were found to be used by ED physicians as a primary diagnostic code in odontogenic infections. Thus, to capture as many encounters as possible, an extensive list of ICD-9 codes was used and each record was analyzed by the authors to determine inclusion eligibility. Each patient encounter was individually reviewed by the authors to determine eligibility for inclusion. In instances in which more than 1 diagnosis code was used for the same encounter, only 1 encounter was counted. Actual hospital charges for an ED visit, procedure, operating room time, anesthesia, recovery room, medications, imaging, and daily inpatient charges for each level of care were calculated.
521.00 521.01 521.02 521.03 521.04 521.05 521.06 521.07 521.08 521.09 522.0 522.1 522.2 522.3 522.4 522.5 522.6 522.7 522.8 522.9 523.00 523.01 523.10 523.11
DATA ANALYSIS
Descriptive and frequency statistics were calculated for all variables to check for coding errors, describe the sample, and test for statistical assumptions. Skewness and kurtosis statistics were used to test for the assumption of normality, with any statistic above an absolute value of 2.0 denoting a non-normal distribution. The Levene test of equality of variances was used to test the assumption of homogeneity of variance when comparing independent groups. Independentsamples t tests were used to compare the 2 cohorts on continuous outcomes. In the event that a statistical assumption of a t test occurred, nonparametric MannWhitney U tests were used. Associations between the cohorts for categorical risk factors and outcomes were assessed using unadjusted odds ratios (ORs) with 95% confidence intervals (95% CIs). Statistical significance was assumed at an a value of 0.05, unless a Bonferroni correction was used to adjust for multiple comparisons. All analyses were conducted using SPSS 22 (IBM Corp, Armonk, NY).
523.20 523.21 523.22 523.23 523.24 523.25 523.30 523.31 523.32 523.33 523.40 523.41 523.42 523.5 523.6 523.8
Description Unspecified dental caries Dental caries limited to enamel Dental caries extending into dentine Dental caries extending into pulp Arrested dental caries Odontoclasia Dental caries pit and fissure Dental caries of smooth surface Dental caries of root surface Other dental caries Pulpitis Necrosis of the pulp Pulp degeneration Abnormal hard tissue formation in pulp Acute apical periodontitis of pulpal origin Periapical abscess without sinus Chronic apical periodontitis Periapical abscess with sinus Radicular cyst Other and unspecified diseases of pulp and periapical tissues Acute gingivitis, plaque induced Acute gingivitis, non-plaque induced Chronic gingivitis, plaque induced Chronic gingivitis, non-plaque induced Gingival recession, unspecified Gingival recession, minimal Gingival recession, moderate Gingival recession, severe Gingival recession, localized Gingival recession, generalized Aggressive periodontitis, unspecified Aggressive periodontitis, localized Aggressive periodontitis, generalized Acute periodontitis Chronic periodontitis, unspecified Chronic periodontitis, localized Chronic periodontitis, generalized Periodontosis Accretions on teeth Other specified periodontal diseases
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281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336
337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392
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Table 1. Cont’d
ICD-9 Code 523.9 526.4 526.5 528.3 528.9 682.0 682.1 682.8 682.9 784.1 784.92
Description Unspecified gingival and periodontal disease Inflammatory conditions of jaw Alveolitis of jaw Cellulitis and abscess of oral soft tissues Other and unspecified diseases of the oral soft tissues Cellulitis and abscess of face Cellulitis and abscess of neck Cellulitis and abscess of other specified sites Cellulitis and abscess of unspecified sites Throat pain Jaw pain
Abbreviation: ICD-9, International Classification of Diseases, Ninth Revision. Salomon et al. Restricted Public Health Care Dental Benefits. J Oral Maxillofac Surg 2016.
Cost analysis was performed using hospital charges for all patients included in the study. The charges were acquired through the UIH billing department, which supplied a detailed breakdown. The charges were analyzed, categorized, and tabulated for all components of a patient’s hospital stay. These included charges for the ED visit, specific radiology study, OMS consultation, outpatient surgical procedure fees, operating room fees (including equipment, anesthesia charges, and surgical procedure fees), medications, and inpatient daily room charges for a specific level of care. To control for inflation or an increase in the absolute amount charged for the duration of the study, charges were determined based on hospital charges for these components of the encounter at a single time point (the end of cohort 2). In this way, a CT scan at the start of cohort 1 had the same hospital charge as a CT scan at the end of cohort 2.
Results Initially, there were 5,192 patient encounters during the 36-month study period with an ICD-9 diagnosis code corresponding to the predetermined list of diagnosis codes. After a chart review of all encounters, 1,405 (27%) met the inclusion criteria. There were no significant differences between the 2 cohorts for age (P = .28), gender (P = .43), or insurance status (P = .54). The normality assumption was violated for the floor length of stay (LOS) and ICU LOS variables. Nonparametric Mann-Whitney U tests found no signif-
icant main effect for ICU LOS (P = .91), but significance was detected for floor LOS (P = .04). Descriptive statistics for these analyses are presented in Table 2. There was no difference between groups for going to the operating room (P = .34). Cohort 2 was significantly more likely to undergo Panorex radiography (OR = 2.10; 95% CI, 1.59-2.77), undergo CT (OR = 1.73; 95% CI, 1.21-2.48), received an OMS consult (OR = 1.42; 95% CI, 1.11-1.81), and undergo an I&D procedure (OR = 1.48; 95% CI, 1.13-1.94) compared with cohort 1. ORs with 95% CI are presented in Table 3. An increase in the number and overall severity of odontogenic infections was noted in cohort 2 compared with cohort 1 using the increased odds of requiring an OMS consultation, an I&D, and marked increase in floor LOS as a proxy for severity. The number of total patient encounters increased 48%, the number of patients requiring surgical intervention increased 100%, and the number of hospital admission days increased 128%. A complete comparison of the data is presented in Table 4 (cohort 1 vs 2). For financial impact, the total charges related to dental concerns and odontogenic infections in cohort 2 were $3.67 million, whereas the total charges in cohort 1 were $2.08 million. This represents a 77% increase in total charges after passage of the SMART Act. The average charge per ED visit increased from $3,948 to $4,729 (increase, 20%). The complete assessment of total charges for the 2 cohorts is presented in Tables 5 and 6.
Table 2. DESCRIPTIVE STATISTICS FOR BETWEEN-SUBJECTS ANALYSES AND UNADJUSTED ODDS RATIOS WITH 95% CONFIDENCE INTERVALS
Variable Patient encounters Age (yr)* Floor LOS* ICU LOS* Meny Insurancey Location of care (ED)y Panorex radiography CTy Incision and drainagey
Cohort 1
Cohort 2
P Value
567 33.0 (18.2) 0.15 (0.65) 0.06 (0.51) 237 (41.8) 425 (75.0) 526 (93.0) 84 (14.8) 46 (8.1) 101 (17.8)
838 34.0 (17.4) 0.25 (0.93) 0.07 (0.65) 368 (43.9) 615 (73.5) 776 (92.6) 224 (26.7) 111 (13.3) 202 (24.1)
.28 .04z .91 .43 .54 .17 <.001z .003z .004z
Abbreviations: CT, computed tomogram; ED, emergency department; ICU, intensive care unit; LOS, length of stay in days. * Mean (standard deviation). y Frequency (percentage). z Significant (P < .05). Salomon et al. Restricted Public Health Care Dental Benefits. J Oral Maxillofac Surg 2016.
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Table 3. UNADJUSTED ODDS RATIOS (95% CONFIDENCE INTERVALS) FOR COHORTS
Variable
Cohort 1
Cohort 2
P Value
Emergency department Operating room Panorex radiograph CT OMS consult Incision and drainage
Reference
0.78 (0.49-1.25)
.12
Reference Reference
0.40 (0.15-1.05) 2.10 (1.59-2.77)
.51 <.001*
Reference Reference Reference
1.73 (1.21-2.48) 1.42 (1.11-1.81) 1.48 (1.13-1.94)
.003* <.001* .004*
Abbreviations: CT, computed tomogram; OMS, oral and maxillofacial surgery. * Significant (P < .05). Salomon et al. Restricted Public Health Care Dental Benefits. J Oral Maxillofac Surg 2016.
Discussion The purpose of this study was to measure the effect of the restriction of adult public aid dental benefits to emergency-only treatment on the volume, severity,
Table 4. COMPARISON OF COHORTS 1 AND 2
UIH Odontogenic Infection-Related Data Cohort 1* Cohort 2y Change, % Total patient encounters Total ED visits Total Panorex radiographs Total CTs Total OMS consults Total I&D ED I&D OR I&D Total outpatient treatment Total inpatient days Floor or stepdown days ICU days
567
838
48
526 84
776 224
48 167
46 131 101 72 29 497
111 250 202 149 53 723
141 91 100 107 83 45
116 83
264 206
128 148
33
58
76
Abbreviations: CT, computed tomogram; ED, emergency department; I&D, incision and drainage; ICU, intensive care unit; OMS, oral and maxillofacial surgery; OR, operating room; UIH, University of Illinois Hospital, Chicago. * From January 1, 2011 through June 30, 2012, before passage of the Save Medicaid Access and Resources Together Act. y From July 1, 2012 through December 31, 2013, after passage of the Save Medicaid Access and Resources Together Act. Salomon et al. Restricted Public Health Care Dental Benefits. J Oral Maxillofac Surg 2016.
and cost of odontogenic pain and infections seen in an urban Illinois hospital. The authors hypothesized that after the limitation of adult dental services in Illinois effective July 1, 2012, increases in the number and severity of dental infections in the ED and hospital settings would be seen. Furthermore, an increase in the number and severity of odontogenic infections in the hospital setting would increase total health care costs. The specific aims of the study were to measure and compare changes in volume, severity, and total cost before and after the passage of legislation that restricted adult public dental health care in Illinois to emergency-only treatment. During the study period, there was an increase in the absolute number of patients presenting to the ED with odontogenic concerns. Patients in cohort 2 were more likely to have an OMS consult (OR = 1.42; 95% CI, 1.11-1.81) or an I&D procedure (OR = 1.48; 95% CI, 1.13-1.94) and had a statistically significant increase in floor LOS (P = .04). In addition, the average cost per ED encounter increased by 20%, with an overall cost increase of $1.6 million from cohort 1 to cohort 2. The increased cost per ED visit supports an increase in severity under the assumption that, on average, patients in cohort 2 required additional workup and care (laboratory tests, imaging, consultation, and surgery). These findings support the hypothesis that the restriction of adult dental care services to emergency-only treatment by passage of the SMART Act resulted in an increase in the number and severity of odontogenic infections and in an escalation in health care costs at the UIH. It has been well established that preventive dental treatment in outpatient settings is the most effective and cost-efficient management.8,9 However, there have been very few studies that have analyzed the actual hospital charges for these infections. Furthermore, only 3 other studies were found in the literature that specifically cross-checked patient records to determine appropriate inclusion (ie, etiology of odontogenic infections as the primary diagnosis code) other than using ICD-9 codes alone.10,14,15 The overinclusion of data without reviewing patient records for applicability of diagnosis codes can be inaccurate, because the present final data included only 27% of the initial data collected from the codes used. The stringent data collection used in the present study ensures appropriate inclusion criteria (ie, odontogenic etiology) and vastly improves the accuracy of the data. Given the vast array of codes that are used in the hospital setting for odontogenic infections, the codes used to identify patients were purposefully overinclusive to accurately capture all appropriate encounters. For example, ICD-9 code 523.5 (periodontitis) was included to capture these encounters just in case there were some who did
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Table 5. COST ANALYSIS FOR COHORT 1 (BEFORE SMART ACT)*
Table 6. COST ANALYSIS FOR COHORT 2 (AFTER SMART ACT)*
Cohort 1
Cohort 2
Data
Average age (yr) Insured, % Men/women, % Total ED visits Total Panorex radiographs Total CTs Total I&D Total ED I&D Total OR cases Total OMS consults Total floor days Total ICU days Total hospital charges Charge per ED visit
32.98 75 42/58 526 84 46 101 72 29 131 83 33
Total Charge
$947,326.00 $18,564.00 $87,216.00 $47,520.00 $360,992.00 $39,038.00 $230,408.00 $345,840.00 $2,076,904.00 $3,948.49
Average age (yr) Insured, % Men/women, % Total ED visits Total Panorex radiographs Total CTs Total I&D Total ED I&D Total OR cases Total OMS consults Total floor days Total ICU days Total hospital charges Charge per ED visit
Data 34.03 73 44/56 776 224 111 202 149 53 250 206 58
Total Charge
$1,397,576.00 $49,504.00 $210,456.00 $98,340.00 $659,744.00 $74,500.00 $571,856.00 $607,840.00 $3,669,816.00 $4,729.14
Abbreviations: CT, computed tomogram; ED, emergency department; I&D, incision and drainage; ICU, intensive care unit; OMS, oral and maxillofacial surgery; OR, operating room; SMART, Save Medicaid Access and Resources Together. * From January 1, 2011 through June 30, 2012.
Abbreviations: CT, computed tomogram; ED, emergency department; I&D, incision and drainage; ICU, intensive care unit; OMS, oral and maxillofacial surgery; OR, operating room; SMART, Save Medicaid Access and Resources Together. * From July 1, 2012 through December 31, 2013.
Salomon et al. Restricted Public Health Care Dental Benefits. J Oral Maxillofac Surg 2016.
Salomon et al. Restricted Public Health Care Dental Benefits. J Oral Maxillofac Surg 2016.
meet the inclusion criteria but were inappropriately coded. As seen, most were excluded, but there were several encounters that were accurately captured despite an erroneous code being used. All other studies with similar hypotheses used ICD-9 codes but did not individually review each patient record to ensure appropriate coding. Therefore, they included too many extraneous codes, covering a wide spectrum of possible dental, facial, and neck complaints, or were too focused and only included codes for dental caries1 or periapical abscess.4,16 In addition, the costs and charges are likely underestimated in the 3 other studies that actually performed chart review for inclusion criteria, because patients who did not receive treatment in the operating room and who were not admitted were not included.10,14,15 In 2014, Neely et al11 published an article comparing the rate of adults who presented to the ED at the Boston Medical Center (Boston, MA) for dental problems before and after the Massachusetts Medicaid programs decreased dental coverage in 2010. As in the present study, the data were collected by ICD-9 codes retrospectively. They found that dental-related ED visits increased 2 and 14% the first and second years after Medicaid cuts.11 In addition, they found 8% ($8.4 to $9.1 million) and 44% ($8.4 to $12.1 million) increases in total hospital costs for dental-related problems in the first and second years after the Medicaid decreases.11 Mirroring the present
findings, they concluded that ED care for dental problems increased at a major safety-net hospital when Medicaid coverage for dental care for adults was decreased. However, there are several key differences between the work by Neely et al and the present study. As mentioned earlier, there was no cross-referencing of patient records once they were collected by ICD-9 codes. Different ICD-9 codes used in the study by Neely et al were overly inclusive and all dental and oral complaints were compiled together, undoubtedly leading to overinclusion of data. For example, their study included codes for mandibular and maxillary exostosis, acquired tooth loss, and headache. Also, their study did not collect data on operating room treatment, hospital admission, or ICU stay. Similar work was published by Cohen et al12 in a pilot study examining ED visits for dental-related problems before and after the elimination of Medicaid reimbursement for adult emergency dental services in Maryland. Cohen et al13 published a follow-up in 2002 that broadened the data to include the state of Maryland, as opposed to a single hospital, using the original 4-year period in the 1990s. They found that the rate of dental visits to the ED by Medicaid recipients increased by 12% after the policy change.13 The same limitations apply to this study as those mentioned earlier for the study by Neely et al.11 An important additional issue with this study is that up to 2 ICD-9 codes could be submitted; therefore, there are more codes than claims. This also decreases the
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accuracy of the data compared with the present study in which only 1 code was included per patient encounter. Management of odontogenic infections is not just a major health care issue in the United States. A similar study in Britain reported a 62% increase in patients requiring admission and surgical care for spreading odontogenic infections in the 3 years after the British government changed the system of payment to general practitioners, resulting in fewer dentists accepting government insurance.15 Although this study did cross-reference patient records to ensure odontogenic etiology, it captured only admissions, not outpatient ED visits, and did not analyze the cost of care. As noted in the present study, a large proportion of patients were seen in the ED and discharged home, without hospital admission, which greatly adds to the total hospital costs. Public aid health care coverage plays a critical role in shaping patterns by which patients seek care for dental-related problems.17 In 2005, Shortridge and Moore17 found that states with more generous public aid coverage have slightly less ED usage and that states with less generous coverage treat Medicaid beneficiaries like uninsured patients. Aside from the obvious argument that public aid for dental coverage is a public health and economic benefit, there is evidence that social interventions can be effective in decreasing nonemergency visits to the ED. In 2008, Anantharaman18 examined the impact of social interventions on total ED visits (medical and dental). These included public education, financial disincentives, redirecting to primary health care centers, and use of alternative clinics. During the 12 years of the social interventions, nonemergency ED visits decreased from 57 to 18%.18 This is important because many hospital centers might not have oral and maxillofacial surgeons on staff or nearby, leading to palliative or improper treatment being provided; thus, social interventions can play a crucial role in improving health care usage. To incorporate this concept into the present study, one can look at the reimbursement rates after the restriction of adult dental treatment to emergency care services only. A clinical oral examination fee was set at $16.20, a panoramic radiograph was set at $22.60, and a tooth extraction was set at $39.12, for a total reimbursement of $77.92. When extrapolating these data, if each patient in cohort 2 had an examination, panoramic radiograph, and tooth extraction, then the total cost to the state of Illinois in provider reimbursement would have been $65,296.96 ($77.92 multiplied by 838 patients). Total hospital charges for these same 838 patients were $3,669,816. Although this represents the hospital charges and not the reimbursement rate, this shows a dire need for improved social interventions to direct patients
to the appropriate path for proper diagnosis and treatment. The substantial increase in cost of just 1 urban hospital’s population could be extrapolated to the state level to illustrate a large financial burden. Several strengths of the present study also make it unique. It appears to be the only study that includes outpatient ED visits and hospital operating room and admission data. This results in a more comprehensive dataset and a more accurate impression of the relation between public dental coverage and infection rate, severity, and associated cost. Moreover, this is one of the only studies that reviewed each patient record to ensure appropriate inclusion criteria (primary diagnosis of odontogenic etiology) in contrast to most studies, which use different related codes to generate the dataset without review. An extensive list of ICD-9 codes was used to develop the present dataset to account for coding errors, capture as many dental-related encounters as possible, and improve the reliability of the dataset. In addition, the hospital charges used to determine the cost of care were obtained from a specific period at the end of cohort 2. This controls for inflation or an increase in the amount charged by the UIH across the study period. Furthermore, the attending oral and maxillofacial surgeons on staff at the UIH were unchanged during the time span of this data collection. This controls for differences in surgeon treatment philosophy and judgment when treating odontogenic infections, limiting another potential confounding variable. There are several potential weaknesses to the present study. The retrospective nature does not allow for proof of causation, only correlation. The authors could not control for a trend toward increased ED usage by the community or other variables, such as increased cost of private dental insurance, fewer dentists accepting Medicaid, or decreased funding for oral hygiene and dental care awareness programs that might increase ED usage for dental concerns. Furthermore, a 20% increase in charges per ED encounter likely indicates increased severity, although it could be due to unforeseen reasons independent of infection severity. Another potential weakness of the study is that the type of medical insurance (private vs public) does not capture any information about dental insurance. Unfortunately, there was no feasible way to determine whether dental coverage was offered through each patient’s existing medical insurance. In addition, although the limitation of dental benefits affected only adults older than 21 years, the data included all ages to analyze total patient data. The average age was not significantly different between cohorts (P = .28) and therefore age did not play a role in the differences observed between cohorts. Because these data are derived from 1 urban tertiary care hospital, generalizations must be made with caution. Moreover, it would be preferable to extend this study over a
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longer period. It is probable that at least immediately after the change in Medicaid coverage in Illinois, sufficient time had not passed to see a statistical difference in the severity of odontogenic infections; however, only 18 months of data were available after passage of the SMART Act. In the 21st century, the morbidity and mortality associated with an odontogenic infection should be minimal with appropriate preventative care. Although there were no deaths directly attributed to an odontogenic source in the present study population, the substantial increase in those requiring surgical intervention might be avoidable, or at least minimized, with preventative dentistry. In addition to the direct morbidity associated with a severe odontogenic infection, inpatients are at a much greater risk of indirect morbidity from nosocomial complications, such as pneumonia, urinary tract infections, deep vein thrombosis, and infection with multidrug-resistant organisms. Despite the limitations of previous research and this study, there is convincing evidence from the United States and abroad that decreased public dental insurance coverage increases ED visits11-13 and hospitalizations from odontogenic sources.17 The present findings show an inverse correlation between public dental coverage and dental care being sought in an urban hospital setting. In addition, there was an increase in the severity of odontogenic infections and an increased cost of care after the limitation of public dental coverage. The negative public health effects and increased economic impact of eliminating basic dental care give special importance to affordable, accessible oral health care and valuable social interventions.
References 1. Lewis C, Lynch H, Johnston B: Dental complaints in emergency departments: A national perspective. Ann Emerg Med 42:93, 2003 2. Nalliah R, Allareddy V, Elangovan S, et al: Hospital based emergency department visits attributed to dental caries in the United States in 2006. J Evid Based Dent Pract 10:212, 2010
3. Aston G: Easing the bite on the ED. Hosp Health Netw 87:44, 2013 4. Shah A, Leong K, Lee M, et al: Outcomes of hospitalizations attributed to periapical abscess from 2000 to 2008: A longitudinal trend analysis. J Endod 39:1104, 2013 5. Gann C: Man dies from toothache, couldn’t afford meds. ABC News Medical Unit, September 2, 2011. Available at: http://abcnews.go. com/health/insurance-24-year-dies-toothache/story?id=14438171. Accessed October 2015 6. Owings L. Toothache leads to boy’s death. ABC News Medical Unit, March 5, 2007. Available at: http://abcnews.go.com/ Health/Dental/story?id=2925584&page=1. Accessed October 2015 7. Montoya A: Tooth infection causes blood infection, leads to man’s death. WLWT5, May 8, 2014. Available at: http://www. wlwt.com/article/tooth-infection-causes-blood-infection-leadsto-man-s-death/3542556. Accessed October 2015 8. Griffin SO, Gooch BF, Beltran E, et al: Dental services, costs, and factors associated with hospitalization for Medicaid-eligible children, Louisiana 1996-97. J Public Health Dent 60:21, 2000 9. Pettinato ES, Webb MD, Seale NS: A comparison of Medicaid reimbursement for non-definitive pediatric dental treatment in the emergency room versus periodic preventive care. Pediatr Dent 22:463, 2000 10. Ahmad N, Abubaker AO, Laskin D, et al: The financial burden of hospitalization associated with odontogenic infections. J Oral Maxillofac Surg 71:656, 2013 11. Neely M, Jones J, Rich S, et al: Effects of cuts in Medicaid on dental-related visits and costs at a safety-net hospital. Am J Public Health 104:e13, 2014 12. Cohen LA, Manski R, Hooper FJ: Does the elimination of Medicaid reimbursement affect the frequency of emergency department dental visits? J Am Dent Assoc 127:605, 1996 13. Cohen LA, Manski RJ, Magder LS, et al: Dental visits to hospital emergency departments by adults receiving Medicaid: Assessing their use. J Am Dent Assoc 133:715, 2002 14. Christensen B, Han M, Dillon JK: The cause of cost in the management of odontogenic infections 1: A demographic survey and multivariate analysis. J Oral Maxillofac Surg 71:2058, 2013 15. Burnham R, Bhandari R, Bridle C: Changes in admission rates for spreading odontogenic infection resulting from changes in government policy about the dental schedule and remunerations. Br J Oral Maxillofac Surg 49:26, 2011 16. Nalliah RP, Allareddy V, Elangovan S, et al: Hospital emergency department visits attributed to pulpal and periapical disease in the United States in 2006. J Endod 37:6, 2011 17. Shortridge EF, Moore JR: Use of emergency departments for conditions related to poor oral healthcare: Implications for rural and low-resource urban areas for three states. J Public Health Manag Pract 15:238, 2009 18. Anantharaman V: Impact of health care system interventions on emergency department utilization and overcrowding in Singapore. Int J Emerg Med 1:11, 2008
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