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We tested the hypothesis that between 2001 and 2008, Americans increasingly relied upon emergency departments (EDs) for dental care.
Data from 2001 through 2008 were collected from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Population-based visit rates for dental problems, and, for comparison, asthma, were calculated using annual US Census Bureau estimates. As part of the analysis, we described patient characteristics associated with large increases in ED dental utilization.
Dental visit rates increased most dramatically for the following subpopulations: those aged 18 to 44 years (7.2–12.2 per 1000, P < .01); Blacks (6.0–10.4 per 1000, P < .01); and the uninsured (9.5–13.2 per 1000, P < .01). Asthma visit rates did not change although dental visit rates increased 59% from 2001 to 2008.
There is an increasing trend in ED visits for dental issues, which was most pronounced among those aged 18 to 44 years, the uninsured, and Blacks. Dental visit rates increased significantly although there was no overall change in asthma visit rates. This suggests that community access to dental care compared with medical care is worsening over time.
Medically underserved patients are increasing their reliance upon emergency departments (EDs) as a safety net provider because of absent or inadequate access to other sources of medical care.1 Many Americans turn to the ED for a variety of health care needs, including dental care, when access to professional dental care is limited.2 Visits to the ED for dental issues have been shown to increase as Medicaid reimbursement declines or is eliminated.3,4 Recent literature has linked the loss of state Medicaid dental benefits along with increases in dental ED use and expenditures to the decrease in utilization of preventive services.5,6 Age-related trends in dental disease may contribute to an overall increased need for dental services over time. Specifically, middle-aged and older adults are experiencing greater rates of tooth retention, thus increasing the demand for care in this cohort.
To date, there are no published reports that quantify temporal trends in national ED utilization patterns for dental issues, although there are several reasons to believe dental care is more difficult to access than medical care. Dental insurance coverage, in addition to provider workforce, health beliefs, and social determinants of health, is one of many important factors in promoting dental care utilization, particularly for vulnerable populations.7–10 First, a greater number of Americans have medical insurance compared with dental insurance, with estimates of as many as 130 million Americans without dental coverage.11 Second, public and private insurance programs tend to cover medical care more extensively than dental care for adults, resulting in higher out-of-pocket cost for dental care.12–14 Medicaid-covered adult dental benefits vary between states but generally are limited to individuals with incomes well below the poverty line and to emergency dental care. Recent state budget cuts have further limited adult dental care options. The majority of low-income adults do not receive basic dental care and experience limited coverage, access, and use of dental care.15 As a result, access to dental care is dependent on both insurance coverage and sufficient discretionary income. Third, although medical care for the uninsured and underinsured is supported by an extensive public health safety net, the dental public health infrastructure is quite limited.16 Federally Qualified Health Centers (FQHCs) and FQHC Look-Alikes (community health centers that resemble FQHCs but do not receive grant funding) serve an increasing role in providing primary care to underserved areas. From 2007 to 2010 the number of FQHCs increased from 1067 (16 050 835 patients) to 1124 (19 469 467 patients).17 The FQHC patient demographic comprises mostly low-income, underinsured patients or those on public insurance programs. FQHCs and Look-Alikes that receive federal grant funding must provide access to dental services for their patients. However, FQHCs face difficulties in recruitment and retention of dental providers.18
In the absence of adequate community-based dental care, another source of dental care for vulnerable populations are EDs, which are staffed by medical providers and rarely employ dentists. Seeking care in the ED for a dental issue often results in temporizing treatment through symptomatic relief (antibiotics and narcotics), which does not definitively treat the underlying disease process.19a Therefore, use of the ED for dental problems is a marker for disparities in dental care quality and access.
We hypothesized that with secular changes over time (e.g., economic downturn, increased unemployment, budget deficits, public program reductions), access to appropriate sources of dental care would decrease, resulting in increased ED utilization for dental problems. The unemployment rate, according to the Bureau of Labor Statistics, was 4.6% before the most recent recession (2006) and peaked at 10.3% (2009).19b We hypothesized that there is a positive relationship between the recent economic recession and higher utilization of EDs for untreated dental problems, which serves as a marker for reduced access to preventive dental care. We also hypothesized that, although similar factors would also impact access to medical care, there would be a more substantial rise in ED dental visits for the reasons discussed above. Therefore, we expected a greater increase in ED dental utilization compared with ED use for ambulatory-care sensitive conditions.
To examine these hypotheses, we compared ED visit rates over the period of 2001 to 2008 for dental issues versus asthma using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS); the study period was chosen because it included the most recent economic recession (2008 was the most recent data available at the time of our analyses). NHAMCS is an annual, national-probability sample survey of US hospital EDs conducted by the National Center for Health Statistics. The survey excludes federal, military, and Veterans Administration hospitals and uses multistage probability sampling methods to collect nationally representative data from US emergency departments. A patient visit is the basic sampling unit for NHAMCS. Trained interviewers, over a 4-week period on an annual basis, visit a nationally-representative sample of EDs in adult and pediatric noninstitutional hospitals (general and short-stay) and collect data.
A patient record form is completed for each visit and includes information on patient demographic characteristics; patient’s complaint; time, day of week, and mode of arrival; whether the visit was injury-related and cause of injury; categories of diagnostic tests and procedures performed; discharge diagnoses; medications prescribed; and disposition. Up to 3 reason-for-visit codes and 3 discharge diagnoses are possible for each visit. Diagnoses are coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Methodological details of NHAMCS have been described in detail elsewhere.20,21 Use of these data were exempt from review by the institutional review board of the University of Washington.
ED visits for dental care were identified using the NHAMCS “reason for visit” variable and included: symptoms of teeth and gums (NHAMCS code: 1500.0); toothache (code: 1500.1); gum pain (code: 1500.2); and bleeding gums (code: 1500.3). Reason for visit codes were chosen over ICD-9 codes because we are particularly interested in the phenomenon of patients using the ED for a perceived dental problem. Some patients may present to the ED for multiple reasons, including both medical and dental issues; use of discharge diagnosis to identify ED dental care might introduce a bias toward individuals seeking care primarily for medical problems and incidentally reporting a nonurgent dental issue at the time of visit. Additionally, the use of ICD-9 codes for dental issues is problematic because there is limited coding for dentistry and its use by physicians is typically nonspecific and inadequate.3,22 We selected ED visits for asthma as the comparison condition because asthma affects individuals across the age spectrum, as do dental problems, and represents an ambulatory-care sensitive condition. Asthma visits were identified using the ICD-9 code of 493 (asthma). The reason-for-visit variable was not used to identify asthma exacerbation because the respiratory codes for shortness of breath, dyspnea, and wheezing are nonspecific and could also represent other cardiopulmonary diseases.
We estimated ED dental visit rates by age, gender, race/ethnicity (non-Latino White [“White”], non-Latino Black [“Black”], and Latino), US Census geographic region, and insurance status (private, Medicare, Medicaid/State Children’s Health Insurance Plan [SCHIP], uninsured). Insurance status categories were created using the “PAYTYPE” variable. NHAMCS assigned the primary expected source of payment to the “PAYTYPE” variable using a hierarchical ranking (Medicaid, Medicare, private insurance, worker’s compensation, self-payment, and no charge, in decreasing order). From 2005 to 2007, patients who were dually eligible for Medicare and Medicaid were assigned Medicaid as the primary expected source of payment. Beginning in 2008, dually eligible patients have Medicare classified as their primary expected payment source. The uninsured category was compiled from visits that were identified as “self-pay,” “no charge,” or “charity.” ED dental and asthma visit rates per 1000 people were based on the weighted number of visits (weights provided by NHAMCS) divided by estimates of the civilian, non-institutionalized US population as reported by the US Census Bureau.
To test the hypothesis that secular changes had an impact on ED dental visit rates, we compared the national unemployment rate to the ED dental visit rates over the time period studies. The most recent recession, according to the Bureau of Economic Research, occurred from December 2007 to June 2009. For simplicity and because we did not have 2009 data, we regarded 2008 as the year of the economic recession. The unemployment rate is considered a coincident indicator of the economy. Coincident economic indicators measure aggregate economic activity and thus rise and fall in concordance with fluxes in the economy.23 The national unemployment rate was derived from the Bureau of Labor Statistics using the seasonally adjusted rates reported for the civilian labor force in December of each year.24
We have presented unweighted NHAMCS visit counts, weighted national estimates, and 95% confidence intervals based on survey visit weights and standard errors provided by NHAMCS. We created population-based overall ED and dental and asthma ED visit rates for each age, race/ethnicity, and insurance-specific stratum using the national weighted ED visit estimates and dividing by the corresponding stratum-specific US Census Bureau population estimates. Relative rates were calculated by dividing each of the year- and diagnosis-specific visit rates (between and including 2002 and 2008) by their baseline rates in 2001. We assessed the change in ED visit rates over time by using weighted linear regression models fitted to estimates from all years between and including 2001 and 2008. All analyses were performed using STATA 11 (STATA Corp, College Station, TX).
Utilization of EDs for dental care increased from 2001 to 2008. This increase was disproportionate to the increase in ED visits for all conditions (all cause ED visits). National estimates for total ED visits for all conditions increased approximately 13% from 2001 to 2008, while the number of ED dental visits increased over 41% in the same time period (Table 1). When population-based ED visits rates were considered, the ED dental visit rates increased from 3.7 to 5.9 visits per 1000 people (P < .01; Figure 1). Year-to-year variability in ED dental visit rates occurred in all subpopulations, but the greatest overall increase in ED dental visit rates occurred among those aged 18 to 44 years (Figure 1a), Blacks (Figure 1b), and uninsured subpopulations (Figure 1c), with the greatest increase observed those aged 18 to 44 years.
Grossly comparing the trend in the national unemployment rate to the ED dental visit rates, there does not appear to be any correlation between the 2 (Figure 2). From 2001 to 2008, the ED dental visit rates increased in a nearly parallel fashion despite decreasing unemployment rates from 2002 to 2006.
ED visit rates for dental issues increased by about 59% over the study period. This increase in the rate of visits was significantly different from asthma visit rates, which showed no change in the relative rate of visits from 2001 to 2008 (Figure 3).
We found that dental visits increased at a more rapid rate than did all cause and asthma ED visits, and that the rise in ED dental rates has been ongoing rather than associated with economic downturn. This is the first study, to our knowledge, that estimates trends in national-level utilization of EDs for dental problems over recent years. Our findings support the hypothesis that utilization of EDs for dental problems has increased. ED dental visit rates increased significantly between 2001 and 2008, and at a faster rate than ED visit rates for all conditions. This increase was most pronounced among younger adults (aged 18–44 years), the uninsured, and Blacks.
ED dental-visit rates among the pediatric and elderly population remained relatively stable throughout the study period. Such results for children are likely explained at least in part by the existence and expansion of public programs (SCHIP/Medicaid), which covers dental care under EPSDT (Early and Periodic Screening, Diagnosis, and Treatment). The disproportionate rise in ED visits among those aged 18 to 44 years may have resulted in part when state funds were shifted from adult Medicaid dental programs to support dental care for the increasing numbers of SCHIP-insured children. Age-related edentulism might explain stable visit rates among the elderly population. Approximately 24% of those aged 65 to 74 years and 31% of those aged 75 years or older are edentulous, thus limiting their perceived need for dental care.25 Additionally, retired individuals’ incomes and dental insurance status are less subject to fluctuations in the economy or state budget cuts; since its establishment, Medicare has never covered dental care.
Although the ED dental visit rate did not appear to increase dramatically during the economic recession year of 2008, it is difficult to discount the recession’s impact on ED dental-visit rates. It is possible that periods of economic downturn are reflected, years later, in outcomes that represent decreased access to care. It is perhaps more concerning that ED dental visit rates increase regardless of secular changes in the economy. This finding might indicate that the problems with our health system that contribute to inappropriate access to dental care extend beyond employment status and are worsening. Other factors that might explain increased ED visit rates include the rise in prescription-narcotic addiction, which may contribute to the rise in ED visits for any pain symptoms, including toothache.
The changes in dental visit rates, compared with the relatively stable asthma visit rates, support the hypothesis that access to dental care was affected to a greater degree than was access to medical care over the study’s time period. Asthma exacerbation is one of several conditions identified by the Agency of Health-care Research and Quality as a prevention quality indicator (PQI). PQIs are a set of measures that identify “ambulatory care sensitive conditions” that are “conditions for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease.”26 However, although PQIs do not exist for dental care, reliance on the ED for dental problems can, for the most part, be viewed as a marker of diminished availability of affordable dental care within the community. This study’s findings of (1) the increasing reliance upon EDs for dental care and (2) the disparity in trends between ED dental and asthma care visit rates indicate that dental visits to the ED should be considered as a PQI.
Given the limitations in the dental public health safety net, EDs have become the de facto safety net providers of dental care. However, EDs are an inadequate and expensive mechanism for delivery of dental care. Even when individuals resort to dental care at EDs, previous research indicates primarily temporizing (antibiotics or pain medications) treatment of dental pain is delivered in the ED.19a The etiology of poor oral health is multifactorial and includes inadequate access to care, social determinants of health, and varying health beliefs. The consequences of poor oral health may extend beyond the mouth. Previous literature has identified associations between oral disease, medical conditions, and quality of life measures (e.g., pain, sleep disturbances, glycemic control for type 2 patients with diabetes, and lost days of work and school).7,27–29 Considering the role of access to care in the development of poor oral health, inadequate dental care secondary to poor insurance coverage or other barriers can lead to increased oral-disease burden, ED utilization, and overall costs.30–36 Improving access to appropriate dental care, thereby reducing the reliance on EDs, could be achieved in several ways:
This study has several limitations. First, we are unable to evaluate how rates of ED dental visits are changing in concert with utilization of and access to dental care outside of hospital settings. ED dental visits should be interpreted as insufficient quality of or access to primary dental care, irrespective of utilization of dental care elsewhere in the community. Second, NHAMCS is an estimation of ED visits that have been unlinked from patient-level identifiers. This makes it impossible to evaluate the number of unique individuals who are utilizing EDs for dental care. Thus, the sample includes patients with single or repeat visits to the same ED; repeat visits by the same individuals may overestimate the rate of ED dental use. Finally, we may have missed some proportion of dental care that was delivered during the course of an ED visit but not stated as the primary reason for the visit; we attempted to mitigate this by identifying ED dental visits according to the patient’s reason for the visit instead of discharge diagnoses via ICD-9 codes as most physicians code dental problems as “Dental Disorder Unspecified.”3
This work (1) establishes that there is an increasing overall trend of ED visits for dental issues; (2) identifies that this rise in ED dental visits seems most pronounced among adults between the ages of 18 and 44 years, the uninsured, and Blacks; and (3) suggests that the dental ED visits are increasing at a faster rate than are overall ED visits or asthma visits. Although we did not find a direct correlation between ED dental visit rates and the national unemployment rates, increasing ED use for dental issues has been an ongoing and disproportionate phenomenon. These findings suggest that, until fundamental changes in delivery of preventive dental care to vulnerable populations occur, the upward trend in ED dental visits will likely continue.
Certain strategies may help to alleviate the disparity between access to dental care and medical care for vulnerable populations, and include increasing availability of dental providers to underserved populations. Increasing collaborations between safety net providers (EDs, community health centers, and dental schools and residencies), as well as novel approaches to provider shortages (teledentistry) may increase the delivery of appropriate dental care to vulnerable populations. Health care systems that integrate dental providers within their medical delivery systems, including EDs, should be studied.
H. H. Lee is funded by the National Institutes of Health (grant T32GM086270 Department of Anesthesiology and Pain Medicine, University of Washington).
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ContributorsH. H. Lee and C. W. Lewis conceptualized the study idea. H. H. Lee and B. Saltzman conducted primary data management and analysis with assistance from C. W. Lewis and H. Starks. H. H. Lee was the primary writer with assistance from B. Saltzman, C. W. Lewis, and H. Starks.
An abstract of these data were presented at Academy Health’s 2011 Annual Research Meeting in Seattle, WA.
Human Participant Protection
Institutional review board approval was not needed to conduct this study.
Helen H. Lee, Department of Anesthesiology, University of Washington, Seattle.
Charlotte W. Lewis, Department of Pediatrics, University of Washington.
Babette Saltzman, Craniofacial Center, Seattle Children’s Hospital, Seattle, WA.
Helene Starks, Department of Bioethics and Humanities, University of Washington.