Effects of Cuts in Medicaid on Dental-Related Visits and Costs at a Safety-Net Hospital

We used data from Boston Medical Center, Massachusetts, to determine whether dental-related emergency department (ED) visits and costs increased when Medicaid coverage for adult dental care was reduced in July 2010. In this retrospective study of existing data, we examined the safety-net hospital’s dental-related ED visits and costs for 3 years before and 2 years after Massachusetts Health Care Reform. Dental-related ED visits increased 2% the first and 14% the second year after Medicaid cuts. Percentage increases were highest among older adults, minorities, and persons receiving charity care, Medicaid, and Medicare.Emergency department (ED) visits in the United States rose by 32% from 1993 to 2006.1 In the 2010 National Hospital Ambulatory Medical Care Survey,2 there were 42.8 ED visits for every 100 people. Almost one third, 31.4%, of the 2010 ED visits were by people dependent on Medicaid or State Children’s Health Insurance Program,2 17.7% were by people with Medicare, and 16.6% were uninsured.2Cohen et al.3 examined ED use for the treatment of dental problems at the University of Maryland Medical System in 1995. They analyzed dental-related ED use before and after a change in coverage status for poor adults took place (in an attempt to reduce costs, in February 1993, the state of Maryland eliminated Medicaid reimbursement for dental care). After the policy change, the rate of dental visits to the ED by Medicaid recipients increased by 21.8%. Because definitive treatment is not provided in the ED, use of EDs for dental care and associated costs may be repeated because patients are forced to return for treatment of the unresolved condition. The magnitude of this problem is unknown.Lewis et al.4 reported that patients in the United States made about 3 million ED visits for complaints of tooth pain or tooth injury during the 4-year period from 1997 to 2000. Similarly, in a national study based on the National Ambulatory Medical Care Survey, Wall5 found that dental-related ED visits increased from 1.15% to 1.87% between 1997–1998 and 2007–2008. In New Hampshire, overall ED use has been increasing among all age, racial, and ethnic groups. Between 2001 and 2007, Anderson et al.6 found a 14% increase in total ED visits overall and a 47% increase in the visits associated with the nontraumatic dental conditions. Thus, use of EDs for dental care points to an inappropriate use of resources and lack of continuity of dental care.Lowe et al.7 evaluated the effect of the Oregon Health Plan changes on ED use in a representative sample of Oregon EDs before and after the Oregon Health Plan cutbacks in February and March 2003. Multivariate analyses showed that the March 2003 policy change was followed by a 20% (95% confidence interval [CI] = 13%, 28%) increase in the number of uninsured ED visits per month, after they adjusted for seasonal variation and for a secular trend showing an additional increase of 7% per year (95% CI = 4%, 10%).The Massachusetts Medicaid program (MassHealth) reduced its dental coverage for adults in July 2010. The purpose of this study was to analyze the rate of adults (aged 21 years or older) who used the ED at an urban safety-net hospital, Boston Medical Center (BMC) in Massachusetts, for dental problems 3 years before and 2 years after Massachusetts Health Care Reform (July 1, 2007–June 30, 2012).     

Brief Intervention and Follow-Up for Suicidal Patients With Repeat Emergency Department Visits Enhances Treatment Engagement

We implemented an innovative, brief, easy-to-administer 2-part intervention to enhance coping and treatment engagement. The intervention consisted of safety planning and structured telephone follow-up postdischarge with 95 veterans who had 2 or more emergency department (ED) visits within 6 months for suicide-related concerns (i.e., suicide ideation or behavior). The intervention significantly increased behavioral health treatment attendance 3 months after intervention, compared with treatment attendance in the 3 months after a previous ED visit without intervention. The trend was for a decreasing hospitalization rate.Approximately 400 000 to 500 000 US emergency department (ED) visits occur annually for suicide attempts.1,2 The ED is a primary site for the treatment of suicide attempts, and for many patients, ED interventions are the only treatment they receive.3 As many as 60% of suicidal ED patients are stabilized and discharged directly to outpatient care.1,2 Unfortunately, only 50% of these patients follow up on their referrals and attend 1 or more outpatient behavioral health sessions.3 Consequently, costly repeat ED visits and additional suicidal behavior are frequent. As many as 30% of patients presenting to the ED for a suicide-related concern return to the ED for another suicide-related concern within 1 year,4 and 2-year follow-up suicide mortality rates among suicide attempters are estimated at 2%.5 Recurrent suicidal behavior and limited outpatient treatment engagement are similarly significant problems among veterans,6–8 who may be at greater risk for suicide than civilians despite more recent reductions.9,10 Given that the ED is the only place where many suicidal individuals receive care, it could be an important intervention site to increase outpatient treatment engagement and reduce repeat suicidal behavior, ED visits, and hospitalizations.11     

Characteristics of Emergency Department Visits by Older Versus Younger Homeless Adults in the United States

Objectives. We compared the characteristics of emergency department (ED) visits of older versus younger homeless adults.Methods. We analyzed 2005–2009 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative survey of visits to hospitals and EDs, and used sampling weights, strata, and clustering variables to obtain nationally representative estimates.Results. The ED visits of homeless adults aged 50 years and older accounted for 36% of annual visits by homeless patients. Although demographic characteristics of ED visits were similar in older and younger homeless adults, clinical and health services characteristics differed. Older homeless adults had fewer discharge diagnoses related to psychiatric conditions (10% vs 20%; P = .002) and drug abuse (7% vs 15%; P = .003) but more diagnoses related to alcohol abuse (31% vs 23%; P = .03) and were more likely to arrive by ambulance (48% vs 36%; P = .02) and to be admitted to the hospital (20% vs 11%; P = .003).Conclusions. Older homeless adults’ patterns of ED care differ from those of younger homeless adults. Health care systems need to account for these differences to meet the needs of the aging homeless population.The average age of the US homeless population is increasing. Whereas 11% of the homeless population was aged 50 years or older in 1990, this percentage had increased to 32% by 20031 and has continued to rise since then.2 The median age of single homeless adults has increased from 37 years in 19901 to between 49 and 50 years today.2,3 This trend is thought to be because of the aging of individuals born in the second half of the baby boom generation (those born 1954–1965), who have a higher risk of homelessness than do other age cohorts.3 Most homeless adults aged 50 years and older are aged between 50 and 64 years, with adults aged 65 years and older making up less than 5% of the total homeless population.1,3In the general population, adults aged 50 to 64 years are considered middle aged and have lower rates of chronic conditions than do those considered elderly, adults aged 65 years and older.4,5 However, homeless adults aged 50 years and older have rates of chronic illnesses and geriatric conditions similar to or higher than those of housed adults 15 to 20 years older, including conditions often thought to be limited to the elderly, such as falls and memory loss.6,7 Because middle-aged homeless adults face the same geriatric problems as do elderly housed adults, experts consider them to be elderly when aged 50 years, despite their relatively younger age.6,8 Similar patterns of premature aging have been found in other vulnerable populations, including prisoners9 and patients with developmental disabilities.10Despite the growth of the older homeless population, relatively little is known about use of health services among older homeless adults. Homeless health services and research have focused on problems that are common among younger homeless adults, including infectious disease,11 substance use,12 and mental illness.13 The few studies that have focused on older homeless adults found that they have medical problems that differ from those of younger homeless adults, including higher rates of chronic illnesses6,14 and geriatric syndromes6 and lower rates of substance use.15 New frameworks for providing care to the vulnerable and growing older population are needed but cannot be developed until more is known about their use of health services.Homeless adults aged 50 years and older use the emergency department (ED) frequently and at rates nearly 4 times those of the general population.16–18 Knowledge about ED care that older homeless adults receive may allow researchers and clinicians to design interventions to reduce use of the ED and improve ED care for this vulnerable older population. Therefore, we have identified the demographic, clinical, and health services characteristics of ED visits in older versus younger homeless adults, using a nationally representative survey of US ED visits.     

Effects of Early Dental Office Visits on Dental Caries Experience

Objectives. We determined the association between timing of a first dentist office visit before age 5 years and dental disease in kindergarten.Methods. We used North Carolina Medicaid claims (1999–2006) linked to state oral health surveillance data to compare caries experience for kindergarten students (2005–2006) who had a visit before age 60 months (n = 11 394) to derive overall exposure effects from a zero-inflated negative binomial regression model. We repeated the analysis separately for children who had preventive and tertiary visits.Results. Children who had a visit at age 37 to 48 and 49 to 60 months had significantly less disease than children with a visit by age 24 months (incidence rate ratio [IRR] = 0.88; 95% confidence interval [CI] = 0.81, 0.95; IRR = 0.75; 95% CI = 0.69, 0.82, respectively). Disease status did not differ between children who had a tertiary visit by age 24 months and other children.Conclusions. Medicaid-enrolled children in our study followed an urgent care type of utilization, and access to dental care was limited. Children at high risk for dental disease should be given priority for a preventive dental visit before age 3 years.Early childhood caries, or tooth decay in children younger than 6 years, is the most common chronic disease among children. Its prevalence increased to 28% among 2- to 4-year-old children between 1988 to 1994 and 1999 to 2004, and its impact on children is becoming better known.1,2 Tooth decay can impair young children’s overall health, speech, growth, and school performance; it can also negatively affect families’ quality of life.2–6Because of concern about the impact of dental disease on overall health and the stagnant rate of dental care use over the past decade, Healthy People 2020 identified the annual use of dental care for every person aged 2 years and older as 1 of 24 leading health indicators.7 Dental use was selected from as many as 1200 objectives as a high-priority health issue.Early childhood tooth decay is preventable and largely reversible in its early stages through self-care, use of professional services, and exposure to community interventions such as water fluoridation.8,9 During dental visits, children can receive an assessment for disease risk, early detection and treatment services, preventive care such as fluoride therapy, and anticipatory guidance.8,10–12 To ensure exposure to prevention early in life, professional organizations recommend that children have a dental home by 12 months of age.10,12–14 North Carolina Medicaid, along with Medicaid in most other states, also recommends a first dental visit by age 12 months; however, North Carolina Medicaid does not require a visit until age 3 years because of a limited supply of dentists.Despite evidence that professional preventive dental care leads to good oral health outcomes, no strong evidence indicates the most effective age for the first visit. A previous study found no difference in the severity of disease at age 6 to 7 years between children whose first dental visit occurred before age 2 years and those who were aged 2 to 5 years at their first visit.15 Another study found that early dentist visits that included prevention were associated with fewer treatments from the time the children were aged zero to 5 years.16 Three studies found no relationship between early visits and dental costs or treatment use,17–19 but one found that children with existing disease who received preventive services earlier had fewer subsequent treatments and expenditures.19Previous studies on the age of the first dental visit have primarily focused on treatment and cost outcomes, with conflicting results. It is unclear from studies on treatment outcomes whether children with early visits have differences in disease status. Unlike medical claims, dental claims do not include diagnosis codes, so the extent of disease cannot be determined from claims files alone. We combined claims files with public health surveillance files of oral health status to estimate the effect of the timing of the first dental visit on dental disease history and untreated disease in kindergarten students in North Carolina.     

Effects of a Brief Case Management Intervention Linking People With HIV to Oral Health Care: Project SMILE

Objectives. Although people with HIV experience significant oral health problems, many consistently identify oral health as an unmet health care need. We conducted a randomized controlled trial to evaluate the impact of a dental case management intervention on dental care use.Methods. We evaluated the intervention according to self-reported dental care use at 6-, 12-, and 18-month follow-ups. Multivariable logistic models with generalized estimating equations were used to assess the effects of the intervention over time.Results. The odds of having a dental care visit were about twice as high in the intervention group as in the standard care group at 6 months (adjusted odds ratio [OR] = 2.52; 95% confidence interval [CI] = 1.58, 4.08) and 12 months (adjusted OR = 1.98; 95% CI = 1.17, 3.35), but the odds were comparable in the 2 groups by 18 months (adjusted OR = 1.07; 95% CI = 0.62, 1.86). Factors significantly associated with having a dental care visit included frequent physician visits and dental care referrals.Conclusions. We demonstrated that a dental case management intervention targeting people with HIV was efficacious but not sustainable over time. Barriers not addressed in the intervention must be considered to sustain its use over time.In the era of antiretroviral therapy, people with HIV are living longer and the treatment of associated medical and oral manifestations of the disease has shifted to a chronic disease model.1 Previous studies have shown that a person living with HIV/AIDS is more likely than a person without the disease to experience oral health problems.2–5 Furthermore, the oral health problems of individuals with HIV can be more severe and difficult to treat than those of the general population and may also contribute to the onset of opportunistic infections.5The oral health complications associated with HIV are well documented,2–6 and oral manifestations are increasingly being recognized as markers for monitoring treatment efficacy and predicting treatment failure.7 Oral manifestations, including Kaposi’s sarcoma, necrotizing ulcerative periodontitis, oral hairy leukoplakia, and candidiasis, may be present in up to 50% of people with HIV and 80% of people diagnosed with AIDS,5,6 and may predict low CD4 counts.8 In addition, individuals living with HIV/AIDS may experience difficulty in maintaining adequate salivary flow, which affects chewing, swallowing, and the ability to take medication.4 Chronic use of highly active antiretroviral therapy can also contribute to diminished salivary flow as well as an increased risk of oral candidiasis and oral hairy leukoplakia.9Throughout the 1990s, a series of study findings highlighted the unmet needs for dental care among people with HIV infection.10–14 This gap in oral health care services was corroborated by findings from the oral health component of the HIV Cost and Services Utilization Study,15 which demonstrated that unmet dental needs were twice as common as unmet medical needs among HIV-positive adults16,17 and led to a national call to action to improve access to oral health care.18 That study also showed that approximately half of people living with HIV had dental insurance, and those without dental insurance had greater unmet needs for dental services.17,19,20Recently published findings suggest that an unmet need still persists. One example is an initiative, funded by the Health Resources and Services Administration, that included 2469 people living with HIV who had not received dental care during the preceding year. Nearly half of these individuals (48%) reported an unmet dental need since their HIV diagnosis, 52% had not seen a dentist in more than 2 years, and 63% rated the health of their teeth and gums as fair or poor.21,22 An earlier investigation involving baseline data from the study presented here showed that oral health problems and symptoms were very prevalent among our study population, with 63% of participants having experienced an oral health impact very often or fairly often in the preceding 4 weeks.23Barriers to dental care use among individuals living with HIV include fear of dental care, HIV-specific stigma, fear of disclosing their HIV status to health care providers, perceived cost barriers, and poor adherence to medical guidance.20,22,24–31 Compounding patient access barriers, dental care providers may be reluctant to treat patients with HIV owing to fears of HIV transmission and associated stigma.32–36Previous research conducted in Florida revealed that more than one third of people with HIV do not discuss oral health with their primary care providers.37 Although clinical guidelines recommend that HIV care providers examine the oral cavity during initial and interim physical examinations of people living with HIV, this still may not be a regular clinical practice.37 To address underuse of oral health care services among individuals with HIV, we evaluated the efficacy of an intervention that linked individuals to dental care. The sample comprised a population of HIV-positive individuals in south Florida who had received HIV primary care but had not received oral health services in the preceding 12 months.     

Socioeconomic Status,Food Security,and Dental Caries in US Children: Mediation Analyses of Data From the National Health and Nutrition Examination Survey, 2007–2008

Objectives. We examined associations of household socioeconomic status (SES) and food security with children’s oral health outcomes.Methods. We analyzed 2007 and 2008 US National Health and Nutrition Examination Survey data for children aged 5 to 17 years (n = 2206) to examine the relationship between food security and untreated dental caries and to assess whether food security mediates the SES–caries relationship.Results. About 20.1% of children had untreated caries. Most households had full food security (62%); 13% had marginal, 17% had low, and 8% had very low food security. Higher SES was associated with significantly lower caries prevalence (prevalence ratio [PR] = 0.77; 95% confidence interval = 0.63, 0.94; P = .01). Children from households with low or very low food security had significantly higher caries prevalence (PR = 2.00 and PR = 1.70, respectively) than did children living in fully food-secure households. Caries prevalence did not differ among children from fully and marginally food-secure households (P = .17). Food insecurity did not appear to mediate the SES–caries relationship.Conclusions. Interventions and policies to ensure food security may help address the US pediatric caries epidemic.Tooth decay (dental caries) is the most prevalent disease worldwide and the most common pediatric disease in the United States.1,2 From 1999 to 2004, the prevalence of untreated tooth decay was 24.5% for children aged 6 to 11 years and 19.6% for adolescents aged 12 to 19 years.3 Untreated tooth decay can lead to difficulties eating and sleeping, pain, the need for invasive restorative treatment, emergency department visits and inpatient hospitalizations, poor quality of life, systemic health problems, and, in rare cases, death.4–7 To date, most public health efforts aimed at addressing the pediatric caries epidemic have focused on tooth-level interventions (e.g., topical fluorides, dental sealants). Although disparities in oral health are considered a measure of social injustice,8 comparatively less research has been conducted on the social determinants of pediatric oral health.9Low socioeconomic status (SES), one of the strongest determinants of caries in children,10–12 is associated with food insecurity,10–17 defined as inadequate access to food resulting in food shortages, disrupted eating patterns, and hunger.18 Food insecurity, in turn, is associated with oral health–related behaviors, including increased fermentable carbohydrate intake,19,20 a risk factor for dental caries.21,22 The American Dietetic Association recognizes the link between nutrition and oral health,23 and numerous studies have drawn associations between dietary factors and disparities in dental caries.24 Collectively, these studies suggest that food insecurity is related to caries and is a potential mechanism linking SES and caries, but these relationships have not yet been evaluated empirically. We used nationally representative data from the United States to test 3 hypotheses: (1) food insecurity is positively associated with untreated dental caries, (2) food insecurity mediates the SES–caries relationship, and (3) food insecurity mediates the SES–caries relationship differentially for children from higher- versus lower-SES households.     

Health Literacy: A Pathway to Better Oral Health

Objectives. We examined whether health literacy was associated with self-rated oral health status and whether the relationship was mediated by patient–dentist communication and dental care patterns.Methods. We tested a path model with data collected from 2 waves of telephone surveys (baseline, 2009–2010; follow-up, 2011) of individuals residing in 36 rural census tracts in northern Florida (final sample size n = 1799).Results. Higher levels of health literacy were associated with better self-rated oral health status (B = 0.091; P < .001). In addition, higher levels of health literacy were associated with better patient–dentist communication, which in turn corresponded with patterns of regular dental care and better self-rated oral health (B = 0.003; P = .01).Conclusions. Our study showed that, beyond the often-reported effects of gender, race, education, financial status, and access to dental care, it is also important to consider the influence of health literacy and quality of patient–dentist communication on oral health status. Improved patient–dentist communication is needed as an initial step in improving the population’s oral health.Oral health status is inexorably linked with general health,1 as evidenced by the association between poor oral health and chronic diseases, such as diabetes,2 cardiovascular disease,3 and respiratory disease.4 Among US adults, the burden of oral disease falls heaviest on vulnerable population groups,5–7 particularly those living in rural areas.8 Although improving oral health is named as one of the top 5 health priorities in Rural Healthy People 2010,9 little progress has been made in establishing public health programs to address this priority area. To achieve the goal of improved oral health, it is essential to study the risk factors associated with the oral health status of individuals residing in rural areas and to understand the relationships among these risk factors.The association between low dental care utilization and poor oral health outcomes has been proposed as a partial explanation for urban–rural disparities in oral health status.10–13 The rate of dental care utilization is lower among US rural than general populations, and dental visits tend to be problem—rather than prevention—oriented.14–17 Low levels of financial security and a lack of dental providers in rural areas are cited as major reasons for the low utilization rates in rural populations.12,18,19 However, evidence that individuals with dental insurance benefits choose to forgo regular preventive dental care suggests the presence of additional determinants in dental care utilization.20Previous research showed that communication between dentists and their patients plays an important role in the use of dental services.21–24 Effective patient–dentist communication increases utilization of dental services by lessening dental anxiety and, as a result, increasing patient perceptions of provider competence.25 Conversely, deficient communication skills, on either side of the patient–provider equation, are likely to increase dental anxiety and overall dissatisfaction with care.Health literacy deficits can interfere with effective patient–dentist communication. Individuals with low health literacy skills often have difficulty describing dental problems to their dentist and understanding dental conditions described by the dentist.26 Rozier et al. surveyed about 2000 dentists in the United States regarding the use of the 5 domains of communication techniques: interpersonal communication, teach-back method, patient-friendly materials and aids, assistance, and patient-friendly practice.27 Findings revealed low routine use by dentists of each communication technique, including those thought to be most effective with patients who demonstrate low health literacy.The association between low health literacy and poor health outcomes is well established.28–30 However, in the context of oral health, the literature offers few studies identifying the relationship between health literacy and oral health outcomes. It has been suggested that those with low health literacy are at highest risk for oral diseases and problems31 and that low health literacy may be associated with barriers to accessing care and with oral health behaviors such as seeking preventive care.32 Furthermore, rural residents have lower health literacy skills than urban residents.33 However, how health literacy is related to oral health status among rural populations remains an unanswered question.Frequently acknowledged risk factors for poor oral health include gender (male), race (Black), educational attainment (low), financial status (low), and access to dental care (none). We controlled for these factors in an examination of the effects of health literacy, patient–dentist communication, and dental care patterns on self-rated oral health status. In addition, we tested mediational pathways between health literacy and self-rated oral health. We hypothesized that greater health literacy would be associated with better patient–dentist communication, and in turn, that better patient–dentist communication would be associated with an increased likelihood of seeking regular dental care, ultimately leading to better self-rated oral health.     

Prevalence of Undiagnosed Acute and Chronic HIV in a Lower-Prevalence Urban Emergency Department

Objectives. We estimated the seroprevalence of both acute and chronic HIV infection by using a random sample of emergency department (ED) patients from a region of the United States with low-to-moderate HIV prevalence.Methods. This cross-sectional seroprevalence study consecutively enrolled patients aged 18 to 64 years within randomly selected sampling blocks in a Midwestern urban ED in a region of lower HIV prevalence in 2008 to 2009. Participants were compensated for providing a blood sample and health information. After de-identification, we assayed samples for HIV antibody and nucleic acid.Results. There were 926 participants who consented and enrolled. Overall, prevalence of undiagnosed HIV was 0.76% (95% confidence interval [CI] = 0.30%, 1.56%). Three participants (0.32%; 95% CI = 0.09%, 0.86%) were nucleic acid–positive but antibody-negative and 4 (0.43%; 95% CI = 0.15%, 1.02%) were antibody-positive.Conclusions. Even when the absolute prevalence is low, a considerable proportion of undetected HIV cases in an ED population are acute. Identification of acute HIV in ED settings should receive increased priority.HIV screening is recommended by the US Centers for Disease Control and Prevention as an essential component of the nation’s HIV prevention effort.1,2 Emergency departments (EDs) are particularly emphasized as venues for HIV screening.3–5 Emergency departments serve more than 100 million patients annually, readily accessing vulnerable populations with a high prevalence of undetected HIV.1,4–8To date, most attention has been focused on detection of HIV in the chronic phase, after seroconversion, by assay for antibodies. Yet identification of patients during acute HIV infection could have a significant impact on further transmission.9,10 Testing for acute HIV infection is accomplished by assays that detect viral proteins or viral genetic material before antibody detection is possible. This testing is more expensive, complex, or may delay results compared with antibody testing.9,11,12 Despite these disadvantages, screening for acute HIV is increasingly suggested by various authors.9,13–19 Acute HIV infection is thought to contribute disproportionately to HIV incidence because of high viral replication and increased infectiousness during this phase.15,20–22 Diagnosis prompts many individuals to reduce transmission behaviors,23 and partner notification efforts may be more successful.24 There is also renewed interest in treatment during acute HIV infection, to lower infectiousness and improve long-term patient health outcomes.21,25–27 In light of these benefits, screening for acute HIV infection may ultimately be cost-effective and worthy of increased logistical challenges.9,28Unfortunately, the controversies and implementation barriers in HIV screening have yet to be fully resolved,29–35 particularly in ED settings where patient volumes exceed capacity and acute stabilization takes precedence over preventive health.36–38 Screening in the ED for acute HIV infection will be even more challenging than screening for chronic HIV if it entails additional complexity and expense. Motivation to surmount such barriers is likely to be less in regions of lower HIV prevalence, in which disease incidence would also be presumed lower. Improving our understanding of acute HIV epidemiology in ED settings is fundamental for guiding potential implementation of ED screening interventions targeting acute HIV infection. We estimated the seroprevalence of both acute and chronic HIV infection by using a random sample of ED patients from a low-to-moderate HIV prevalence region of the United States.     

Posttraumatic Stress Disorder and Incident Heart Failure Among a Community-Based Sample of US Veterans

Objectives. We investigated the association between posttraumatic stress disorder (PTSD) and incident heart failure in a community-based sample of veterans.Methods. We examined Veterans Affairs Pacific Islands Health Care System outpatient medical records for 8248 veterans between 2005 and 2012. We used multivariable Cox regression to estimate hazard ratios and 95% confidence intervals for the development of heart failure by PTSD status.Results. Over a mean follow-up of 7.2 years, veterans with PTSD were at increased risk for developing heart failure (hazard ratio [HR] = 1.47; 95% confidence interval [CI] = 1.13, 1.92) compared with veterans without PTSD after adjustment for age, gender, diabetes, hyperlipidemia, hypertension, body mass index, combat service, and military service period. Additional predictors for heart failure included age (HR = 1.05; 95% CI = 1.03, 1.07), diabetes (HR = 2.54; 95% CI = 2.02, 3.20), hypertension (HR = 1.87; 95% CI = 1.42, 2.46), overweight (HR = 1.72; 95% CI = 1.25, 2.36), obesity (HR = 3.43; 95% CI = 2.50, 4.70), and combat service (HR = 4.99; 95% CI = 1.29, 19.38).Conclusions. Ours is the first large-scale longitudinal study to report an association between PTSD and incident heart failure in an outpatient sample of US veterans. Prevention and treatment efforts for heart failure and its associated risk factors should be expanded among US veterans with PTSD.Posttraumatic stress disorder (PTSD) is a psychiatric illness that affects approximately 7.7 million Americans aged older than 18 years.1 PTSD typically results after the experience of severe trauma, and veterans are at elevated risk for the disorder. The National Vietnam Veterans Readjustment Study reported the prevalence of PTSD among veterans who served in Vietnam as 15.2% among men and 8.1% among women.2 In fiscal year 2009, nearly 446 045 Veterans Administration (VA) patients had a primary diagnosis of PTSD, a threefold increase since 1999.3 PTSD is of growing clinical concern as evidence continues to link psychiatric illnesses to conditions such as arthritis,4 liver disease,5 digestive disease,6 and cancer.6 When the postwar health status of Vietnam veterans was examined, those with PTSD had higher rates of diseases of the circulatory, nervous, digestive, musculoskeletal, and respiratory systems.7The evidence linking PTSD to coronary heart disease (CHD) is substantial.8–10 Veterans with PTSD are significantly more likely to have abnormal electrocardiograph results, myocardial infarctions, and atrioventricular conduction deficits than are veterans without PTSD.11 In a study of 605 male veterans of World War II and the Korean War, CHD was more common among veterans with PTSD than among those without PTSD.12 Worldwide, adults exposed to the disaster at Chernobyl experienced increased rates of CHD up to 10 years after the event,13 and studies of stressors resulting from the civil war in Lebanon found elevated CHD mortality.14,15Although the exact biological mechanism by which PTSD contributes to CHD remains unclear, several hypotheses have been suggested, including autonomic nervous system dysfunction,16 inflammation,17 hypercoagulability,18 cardiac hyperreactivity,19 altered neurochemistry,20 and co-occurring metabolic syndrome.16 One of the hallmark symptoms of PTSD is hyperarousal,21 and the neurobiological changes brought on from sustained sympathetic nervous system activation affect the release of neurotransmitters and endocrine function.22 These changes have negative effects on the cardiovascular system, including increased blood pressure, heart rate, and cardiac output.22,23Most extant literature to date examining cardiovascular sequelae has shown a positive association between PTSD and coronary artery disease.8–10 Coronary artery disease is well documented as one of the most significant risk factors for future development of heart failure.24 Despite burgeoning evidence for the role of PTSD in the development of coronary artery disease, there are few studies specifically exploring the relationship between PTSD and heart failure. Limited data suggest that PTSD imparts roughly a threefold increase in the odds of developing heart failure in both the general population5 and in a sample of the elderly.25 These investigations, however, have been limited by cross-sectional study design, a small proportion of participants with PTSD, and reliance on self-reported measures for both PTSD and heart failure.5,25 Heart failure is a uniquely large public health issue, as nearly 5 million patients in the United States are affected and there are approximately 500 000 new cases each year.26 Identifying predictors of heart failure can aid in early detection efforts while simultaneously increasing understanding of the mechanism behind development of heart failure.To mitigate the limitations of previous investigations, we undertook a large-scale prospective study to further elucidate the role of prevalent PTSD and development of incident heart failure among veterans, while controlling for service-related and clinical covariates. Many studies investigating heart failure have relied on inpatient records; we leveraged outpatient records to more accurately reflect the community burden of disease.     

Neighborhood Social Capital,Neighborhood Attachment,and Dental Care Use for Los Angeles Family and Neighborhood Survey Adults

Objectives. We tested the hypothesis that neighborhood-level social capital and individual-level neighborhood attachment are positively associated with adult dental care use.Methods. We analyzed data from the 2000–2001 Los Angeles Family and Neighborhood Survey that were linked to US Census Bureau data from 2000 (n = 1800 adults aged 18–64 years across 65 neighborhoods). We used 2-level hierarchical logistic regression models to estimate the odds of dental use associated with each of 4 forms of social capital and neighborhood attachment.Results. After adjusting for confounders, the odds of dental use were significantly associated with only 1 form of social capital: social support (adjusted odds ratio [AOR] = 0.85; 95% confidence interval [CI] = 0.72, 0.99). Individual-level neighborhood attachment was positively associated with dental care use (AOR = 1.05; 95% CI = 1.01, 1.10).Conclusions. Contrary to our hypothesis, adults in neighborhoods with higher levels of social capital, particularly social support, were significantly less likely to use dental care. Future research should identify the oral health–related attitudes, beliefs, norms, and practices in neighborhoods and other behavioral and cultural factors that moderate and mediate the relationship between social capital and dental care use.Oral health is an indicator of general health and social justice.1,2 Common dental diseases such as tooth decay and gum disease are linked to chronic health conditions, including cardiovascular disease, stroke, diabetes, obesity, and kidney disease.3–7 When left untreated, dental diseases can lead to difficulties chewing food, pain, systemic infections, hospitalization, and, in rare cases, death. Less visible are the social consequences of poor oral health, such as lost work hours,8 functional limitations,9,10 and poor quality of life.11A comprehensive strategy for optimal oral health involves exposure to topical fluorides (e.g., in optimally fluoridated water, toothpaste), limited fermentable carbohydrate intake, tobacco use prevention, and regular dental visits.12 Professional dental care is particularly important because dentists have opportunities to assess a patient’s risk level for oral health problems, provide diagnostic and preventive care as well as needed restorative care, deliver patient-centered anticipatory guidance, and screen for systemic health conditions.13–16 However, not all individuals in the United States have equal access to dental care.17Most dental utilization studies focus on children younger than 18 years and seniors aged 65 years and older, even though data from the National Health and Nutrition Examination Survey indicate a decline in dental care use for US adults aged 18 to 64 years.18 Between 1988 and 1994 and 1999 and 2004, there were significant drops in the proportions of adults who had an annual dental visit for those aged 20 to 34 years (from 63.5% to 54.6%) and those aged 35 to 49 years (from 69.0% to 62.5%).18 The factors related to these declines are unknown.The 2008 World Health Organization report Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health calls for policies and interventions targeting the social determinants of health to reduce and eliminate health disparities.19 Social determinants of health are the structural and environmental conditions that shape human welfare and well-being,20 with health inequalities attributed to unequal distribution of and access to power, money, and resources.21 Although social factors contribute to disparities in dental care use,22 relevant studies focus mostly on individual-level determinants.23–37 There has been less emphasis on the area-level social determinants of adult dental care use.Social capital is an important health determinant38–41 and is defined as the material, affective, and informational resources inherent in social networks. Most health research has focused on social capital in neighborhoods. Neighborhood-based social capital can be operationalized into 4 forms: (1) social support (provisions that help residents cope with everyday challenges), (2) social leverage (sharing information on health- and non–health-related issues), (3) informal social control (maintenance of safety and norms), and (4) neighborhood organization participation (organized efforts that address community quality of life and personal well-being).42 Social capital has direct and interactive associations with a range of positive and negative health-related outcomes.43,44 In some cases, these resources may not help individuals pursue a desirable health outcome or may inhibit an individual’s efforts through negative influences in the community.45Although investigators have examined social capital and access to health care services,46 fewer oral health–related studies have focused on social capital. In 2 multilevel studies of elderly persons in Japan, number of teeth was positively associated with higher levels of neighborhood friendship networks47 and a higher prevalence of neighborhood peer group activities.48 Neighborhood social capital also moderated the relationship between income inequality and self-reported oral health but not the number of teeth present among the Japanese elderly.49 A study of Japanese students aged 18 to 19 years found that poor self-reported oral health was associated with lower levels of neighborhood trust and with higher levels of neighborhood informal social control.50 Among Brazilians aged 14 to 15 years, a 5-dimension measure showed that social capital (social trust, social control, empowerment, neighborhood security, and political efficacy) was inversely associated with odds of dental injury.51Although social capital was not the primary focus, there are 2 relevant US publications. The first reported positive associations between neighborhood social capital and self-reported oral health for children younger than 18 years.52 In the second, neighborhood social capital was identified as a potential source of oral health disparities between Black children and White children aged 3 to 17 years (measured as having a dental problem and poor self-reported oral health) but not for disparities in preventive dental care use.53 Collectively, these studies suggest that neighborhood social capital is an important determinant of oral health.54–56 However, they have 2 main limitations: (1) none of the operationalizations of social capital considered the extent of neighborhood social ties, the resources linked to these ties, or unequal access to resources42; and (2) none focused on dental care use for adults aged 18 to 64 years, a US population subgroup that has exhibited declines in dental care use.18We addressed previous limitations by adopting a multilevel conceptual model of social capital42,43,45 to examine how neighborhood social capital is associated with dental care use for US adults (Figure 1). We operationalized neighborhood-level social capital as the 4 forms identified earlier (social support, social leverage, informal social control, and neighborhood organization participation). Individual-level neighborhood attachment is the extent to which an individual knows and socializes with neighbors42–44; this moderates the effects of social capital.57 On the basis of this model, we tested 3 hypotheses: (1) higher levels of each form of neighborhood social capital are associated with greater odds of dental use, (2) neighborhood attachment is associated with greater odds of dental care use, and (3) there are interactions between social capital and neighborhood attachment. This study represents an important first step in understanding the social determinants of an important oral health behavior. Our long-term goal is to develop and test neighborhood-based interventions and policies aimed at improving the oral health of individuals at greatest risk for disparities in dental care use.Open in a separate windowFIGURE 1—Conceptual model and proposed study hypotheses tested using data from the Los Angeles Family and Neighborhood Survey, 2000–2001.Note. H1 = hypothesis 1 (there is a direct relationship between the 4 social capital forms and adult dental care use); H2 = hypothesis 2 (there is a direct relationship between neighborhood attachment and adult dental care use); H3 = hypothesis 3 (in modeling adult dental care use, there is an interaction between the four forms of social capital and neighborhood attachment).     

Visiting the Emergency Department for Dental Problems: Trends in Utilization, 2001 to 2008

Objectives. We tested the hypothesis that between 2001 and 2008, Americans increasingly relied upon emergency departments (EDs) for dental care.Methods. 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.Results. 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.Conclusions. 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.18In 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.     

Caregivers Who Refuse Preventive Care for Their Children: The Relationship Between Immunization and Topical Fluoride Refusal

Objectives. The aim of this study was to examine caregivers’ refusal of preventive medical and dental care for children.Methods. Prevalence rates of topical fluoride refusal based on dental records and caregiver self-reports were estimated for children treated in 3 dental clinics in Washington State. A 60-item survey was administered to 1024 caregivers to evaluate the association between immunization and topical fluoride refusal. Modified Poisson regression models were used to estimate prevalence rate ratios (PRRs).Results. The prevalence of topical fluoride refusal was 4.9% according to dental records and 12.7% according to caregiver self-reports. The rate of immunization refusal was 27.4%. In the regression models, immunization refusal was significantly associated with topical fluoride refusal (dental record PRR = 1.61; 95% confidence interval [CI] = 1.32, 1.96; P < .001; caregiver self-report PRR = 6.20; 95% CI = 3.21, 11.98; P < .001). Caregivers younger than 35 years were significantly more likely than older caregivers to refuse both immunizations and topical fluoride (P < .05).Conclusions. Caregiver refusal of immunizations is associated with topical fluoride refusal. Future research should identify the behavioral and social factors related to caregiver refusal of preventive care with the goal of developing multidisciplinary strategies to help caregivers make optimal preventive care decisions for children.The 2013 Institute of Medicine report Childhood Immunization Schedule and Safety: Stakeholder Concerns, Scientific Evidence, and Future Studies provides an up-to-date review of immunization safety for children.1 This report, along with numerous other publications, indicates that childhood immunizations are safe, have decreased morbidity and mortality by reducing the incidence of serious diseases, and play an important role in population-based disease prevention.2–4 Similarly, topical fluoride is safe, effective, and prevents dental caries,5 the most common disease worldwide.6 However, as is the case with all drugs and preventive therapies, immunizations and topical fluoride are not completely risk-free, which can lead to concerns among caregivers regarding preventive care for children.Most children in the United States receive immunizations as recommended, but immunization hesitancy and refusal among caregivers are growing problems. According to a recent study, 20% of children 6 to 23 months of age did not receive recommended immunizations.7 Another study reported an increase in the percentage of immunization-hesitant caregivers from 2.5% to 9.5% between 2006 and 2009.8 Overall immunization refusal rates range from 1.6% to 2.4%, and they are known to cluster geographically within school districts, communities, and counties.9,10More than 90% of pediatricians and 60% of family medicine physicians report having treated at least 1 child whose caregiver had previously refused immunizations.11 Reasons for immunization hesitancy or refusal include concerns about safety and side effects, religious objections, and philosophical or personal beliefs.12–20 The public health consequences of immunization refusal include outbreaks of life-threatening diseases (e.g., measles, pertussis, rubella), hospitalizations, and threats to herd immunity.21–27The dental caries process begins with intake of dietary fermentable carbohydrates, which are metabolized by intraoral bacteria. Over time, these bacteria produce acids that demineralize tooth structure. Topical fluorides are defined as any fluoride source (e.g., fluoridated drinking water, toothpaste, mouth rinses) that promotes remineralization and inhibits demineralization on the tooth surface. Regular exposure to topical fluorides helps to prevent tooth decay.28Inadequate or irregular exposure to topical fluorides leads to increased risk of dental caries (cavities), which requires dental treatments such as fillings, crowns, or extractions. When left untreated, dental caries can lead to pain, infection, hospitalization, and, in rare cases, death. The social and economic consequences span the life course and include missed school days, poor grades, and teasing or bullying at school among children and underemployment and lower earnings among adults.29–32Low levels of fluoride are found in drinking water, toothpastes, and mouth rinses. Individuals at increased risk for dental caries who lack access to fluoridated water can be prescribed fluoride tablets or drops that are taken daily at home.33 High-risk individuals may periodically have higher levels of fluoride applied to their teeth in the form of fluoride gels, foams, and varnishes during dental or medical visits.Relatively few studies have addressed fluoride hesitancy and refusal among caregivers. One study examined predictors of fluoride varnish refusal but focused on child behaviors and provider factors as correlates of refusal by children.34 A number of investigations have identified caregiver concerns regarding fluoride safety, particularly among caregivers of children with autism spectrum disorders.35–37 Most studies focus on opposition to community water fluoridation.38–40Concerns about topical fluoride may stem from the handful of cases of accidental hyperfluoridation of community water,41–49 which is extremely rare and most commonly results in temporary nausea and vomiting. Since the 1980s, there have been fewer than 20 incidents of hyperfluoridation across community water systems, which serve 72.4% of the US population.50 However, 1 documented death related to water fluoridation was reported in Hooper Bay, Alaska, in 1992. This incident was caused by insufficient system monitoring and an equipment malfunction,47 highlighting the importance of proper training and oversight of water hygienists responsible for fluoridating water.Dental fluorosis, in which the teeth exhibit diffuse, whitish mottling, is a more prevalent side effect associated with fluoride overexposure.51–53 Fluorosis occurs with chronic intake of low levels of fluoride during early childhood, particularly when young children brush their teeth unsupervised and ingest fluoridated toothpaste in excess of the amount needed to prevent dental caries.54 Topical fluorides provided during dental visits are not known to cause dental fluorosis.54Immunizations and topical fluorides are front-line preventive strategies in pediatric medicine and dentistry. As such, the growing number of caregivers who refuse preventive care for children is a significant public health concern. The links between medical care and dental care use among children55–57 suggest that caregivers’ refusal of immunizations and refusal of fluoride are related behaviors; however, to my knowledge, no investigations to date have examined this relationship. In this study, the goals were to estimate the prevalence of caregiver refusal of topical fluoride through chart review and survey data and to evaluate the association between immunization and topical fluoride refusal. Such work has important public health implications for developing clinical strategies that can be deployed by medical, dental, and public health professionals to help caregivers make optimal preventive care decisions for children.     

The individual and program impacts of eliminating Medicaid dental benefits in the Oregon Health Plan

Objectives. We determined how elimination of dental benefits among adult Medicaid beneficiaries in Oregon affected their access to dental care, Medicaid expenditures, and use of medical settings for dental services.Methods. We used a natural experimental design using Medicaid claims data (n = 22 833) before and after Medicaid dental benefits were eliminated in Oregon in 2003 and survey data for continuously enrolled Oregon Health Plan enrollees (n = 718) covering 3 years after benefit cuts.Results. Claims analysis showed that, compared with enrollees who retained dental benefits, those who lost benefits had large increases in dental-related emergency department use (101.7%; P < .001) and expenditures (98.8%; P < .001) and in all ambulatory medical care use (77.0%; P < .01) and expenditures (114.5%; P < .01). Survey results indicated that enrollees who lost dental benefits had nearly 3 times the odds (odds ratio = 2.863; P = .001) of unmet dental need, and only one third the odds (odds ratio = 0.340; P = .001) of getting annual dental checkups relative to those retaining benefits.Conclusions. Combined evidence from both analyses suggested that the elimination of dental benefits resulted in significant unmet dental health care needs, which led to increased use of medical settings for dental problems.Dental coverage is considered optional under Medicaid, and 22 states have either no coverage (6 states) or emergency-only coverage (16 states) that does not cover preventive services.¹ Moreover, recent budget shortfalls have caused many states to consider eliminating Medicaid dental benefits for adults. In response to budget shortfalls, California recently eliminated dental benefits for its Medicaid program.² The optional status of dental coverage under Medicaid and the varied uptake and uncertain maintenance of these benefits by the states suggest that they are not perceived to be as effective or valuable as other coverage. However, having dental insurance is associated with receipt of regular preventive dental care^3–6 and subsequently with improved overall oral health.⁶Although improved oral health is arguably an important outcome in itself, recent research has also demonstrated important relationships between oral health and other physical health. Specifically, periodontal disease has been found to be associated with cardiovascular and cerebrovascular disease,^7–10 diabetes mellitus,¹¹ and adverse pregnancy outcomes.^12–16 Moreover, among patients with diabetes mellitus who have periodontal disease, treatment of periodontal disease can actually improve glycemic control.¹⁷Despite the clear links between dental coverage and oral health, and the additional linkage between oral and physical health, oral diseases have been called the “neglected epidemic.”^18(pS82) As such, the importance of improving access to oral health care has been emphasized as an objective in Healthy People 2010.³ Access to dental care is particularly important for vulnerable populations, for whom Medicaid is often the primary opportunity for dental coverage, as they often have the greatest need of dental care^3,4,19–21 and the poorest access to oral health care services.^22–24Two prior studies have examined the elimination of dental benefits in state Medicaid programs. A Massachusetts study found that after the elimination of Medicaid dental benefits, adult enrollees were less than half as likely to receive dental services, with 24% receiving services before the cuts and only 11% receiving services afterwards.²⁵ Moreover, findings from focus groups conducted with enrollees of Mass-Health (Massachusetts''s Medicaid program) suggested that nearly all respondents interviewed were living with “ongoing, serious pain from untreated dental problems” as well as diminished self-esteem.^25(p3) Another study, conducted in Maryland, found that the elimination of reimbursements to dentists for dental-related emergencies resulted in a 12% increase in dental-related emergency department visits.²⁶ That study also found an 8% decrease in dental-related primary care visits during the same time period.²⁷In early 2003, changes made to Oregon''s Medicaid Program resulted in the elimination of specific benefits, including dental coverage, and the imposition of copayments on the remaining covered care for one segment of the adult Medicaid population. These changes created an ideal natural experiment for examining the impacts of eliminating dental benefits on low-income adults. Specifically, dental benefits were eliminated, along with other discrete coverage (e.g., mental health outpatient care), and copayments were imposed for Oregon Health Plan Standard (OHP Standard) enrollees. OHP Standard enrollees, known as Oregon''s expansion population, include adults and couples eligible for OHP solely on the basis of incomes below 100% of the federal poverty level as established by the US Department of Health and Human Services. Oregon Health Plan Plus (OHP Plus) enrollees, which include individuals eligible for OHP on the basis of federal statutory criteria such as enrollment in the Temporary Aid to Needy Families (TANF) program or presence of a disabling condition, had no changes to their Medicaid benefits and retained their dental coverage.We compared those who lost dental benefits (OHP Standard enrollees) with those who retained benefits (OHP Plus enrollees) to examine the impact of eliminating dental coverage from an individual consumer and Medicaid program perspective. We assessed the impact of dental benefit cuts from an individual consumer perspective using self-report of unmet dental needs and receipt of annual dental exams. We assessed the impact of the benefit cuts on the Medicaid program through expenditures and use of outpatient medical settings and emergency departments for dental problems within the Medicaid program.     

Maternal Allostatic Load,Caretaking Behaviors,and Child Dental Caries Experience: A Cross-Sectional Evaluation of Linked Mother–Child Data From the Third National Health and Nutrition Examination Survey

Objectives. We evaluated the associations between chronic maternal stress measured by allostatic load (AL), maternal caretaking behaviors, and child dental caries experience. We also assessed the role of socioeconomic status in these associations.Methods. We used data from the Third National Health and Nutrition Examination Survey (1988–1994). We included children aged 2 to 6 years who linked to a maternal record (n = 716 maternal–child pairs). The main exposure was maternal AL index (0, 1, or ≥ 2). The primary outcome of interest was child dental caries experience (none or any). We evaluated the association between maternal AL and (1) maternal caretaking behaviors, and (2) child caries status and the role of socioeconomic status in these relationships.Results. Children of mothers with an AL index of at least 2 were significantly more likely to have not been breastfed and to have dental caries than were children of mothers with a normal AL before adjusting for measures of socioeconomic status.Conclusions. Maternal chronic stress, indicated by elevation in markers of AL, has an important role in child caretaking behaviors and in children’s oral health.Childhood dental caries are among the most studied dental conditions. Several studies have addressed the behavioral and biological risk factors1–7 and the socioeconomic determinants of dental caries among preschool children.1,8,9 Fewer studies have specifically examined the particular pathways that may link socioeconomic status (SES) with pediatric dental caries. One potential pathway for the SES–pediatric caries relationship—which has not been specifically evaluated—is maternal stress. It is important to better understand the dynamics of the persistent SES–dental caries association to develop and target effective public health programs and interventions.The association between SES and stress has been documented in the literature.10,11 Frequent exposure over time to adverse life events induces biological responses to cope with these events, leading to wear and tear on the autoimmune, cardiovascular, metabolic, and nervous systems. This exposure is primarily marked by elevated adrenaline and cortisol levels in the body, a phenomenon known as allostatic load (AL).10,12–14 Several biological changes have been depicted as markers of AL, including changes in high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, plasma glucose, C-reactive protein, fibrinogen, waist circumference, blood pressure, and triglycerides.11,12 Several studies have examined the elevation of AL as a marker of chronic stress—the outcome of cumulative adverse events over the life course—and established its relationship with various chronic conditions,10,12,15 including clinical measures of oral health.11,16Chronic exposure to stressful events also affects behavior, because individuals tend to adopt unhealthy habits such as smoking, drinking, and comfort eating.17 Evidence suggests that frequent exposure to adverse life events may also alter maternal caretaking behaviors, which in turn may influence the well-being of their children.2,18,19 Maternal anxiety, self-efficacy, sense of coherence, and depression have been linked to child caries.1,2,20–22 Maternal stress has also been linked to health-related behaviors that affect children’s general health, including poorer patterns of feeding children,23 poorer child-rearing behaviors, and child abuse.18,19,24 However, the relationship between SES, chronic maternal stress, maternal caretaking behaviors, and pediatric dental caries has not been jointly examined.25 We set out to evaluate whether a mother’s chronic stress indicated by individual and aggregate markers of AL is associated with (1) maternal caretaking behaviors (including breastfeeding,4 dental visits,26 and eating breakfast daily27), and (2) the dental caries experience of her child. We also assessed the role of SES in these relationships.     

Influenza and Seasonal Patterns of Hospital Use by Older Adults in Long-Term Care and Community Settings in Ontario,Canada

Objectives. We compared seasonal influenza hospital use among older adults in long-term care (LTC) and community settings.Methods. We used provincial administrative data from Ontario to identify all emergency department (ED) visits and hospital admissions for pneumonia and influenza among adults older than 65 years between 2002 and 2008. We used sentinel laboratory reports to define influenza and summer seasons and estimated mean annual event rates and influenza-associated rates.Results. Mean annual pneumonia and influenza ED visit rates were higher in LTC than the community (rate ratio [RR] for influenza season = 3.9; 95% confidence interval [CI] = 3.8, 4.0; for summer = 4.9; 95% CI = 4.8, 5.1) but this was attenuated in influenza-associated rates (RR = 2.4; 95% CI = 2.1, 2.8). The proportion of pneumonia and influenza ED visits attributable to seasonal influenza was 17% (15%–20%) in LTC and 28% (27%–29%) in the community. Results for hospital admissions were comparable.Conclusions. We found high rates of hospital use from LTC but evidence of lower impact of circulating influenza in the community. This differential impact of circulating influenza between the 2 environments may result from different influenza control policies.Influenza has been identified as among the top 10 infectious agents that are causes of health burden,1 and it continues to create significant morbidity and mortality among older adults. Individuals older than 65 years, in particular those with preexisting chronic conditions, are at increased risk for hospitalization2,3 and death4,5 associated with influenza. The Canadian province of Ontario first introduced universal influenza immunization in 2000, granting all provincial residents aged 6 months or older the option for annual immunization without out-of-pocket cost. Although immunization coverage in the general population remains relatively low, levels are highest among community-dwelling adults older than 65 years, with coverage exceeding 70%.6For residents of long-term care (LTC) facilities, also known as nursing homes, immunization coverage generally exceeds 90% in Ontario7 and 80% in other jurisdictions, mainly because of concerted efforts to reach this group.8,9 LTC residents are a particularly vulnerable segment of the older population, with an average age of 80 years, significant cognitive and physical impairments, and a high burden of complex chronic conditions, including cardiovascular and respiratory illnesses. Despite high immunization coverage in residents, influenza continues to cause significant burden. Influenza has been associated with increased rates of functional decline and pressure ulcers in this group.10 It is also among the most common reasons for transfer to the hospital and accounts for a significant proportion of mortality in this population.11–13A single study reported that rates of hospitalization for influenza were 3 times as high among LTC as among community residents, both during and before the identified influenza season.14 In addition to their heightened vulnerability, LTC residents face other risk factors for infection, including congregate living and shared bedrooms, that community residents do not experience. Because of this, LTC is targeted for strong infection prevention and control (IPC) measures, including staff immunization. Although evidence from Ontario suggests that LTC staff immunization rates are generally higher than 70%,7 well above that reported in hospitals, other evidence points to generally poor compliance with other IPC practices.15To date, little is known about the burden of influenza in LTC and how it compares to that in the community. Our objectives were to compare the burden of influenza, as measured by hospital use, both emergency department (ED) visits and inpatient admissions, among older adults in LTC and community settings.     

Relationship Between Medical Well Baby Visits and First Dental Examinations for Young Children in Medicaid

Objectives. We examined the relationship between preventive well baby visits (WBVs) and the timing of first dental examinations for young Medicaid-enrolled children.Methods. The study focused on children born in 2000 and enrolled continuously in the Iowa Medicaid Program from birth to age 41 months (n = 6322). The main predictor variables were number and timing of WBVs. The outcome variable was timing of first dental examination. We used survival analysis to evaluate these relationships.Results. Children with more WBVs between ages 1 and 2 years and ages 2 and 3 years were 2.96 and 1.25 times as likely, respectively, to have earlier first dental examinations as children with fewer WBVs. The number of WBVs before age 1 year and the timing of the WBVs were not significantly related to the outcome.Conclusions. The number of WBVs from ages 1 to 3 years was significantly related to earlier first dental examinations, whereas the number of WBVs before age 1 year and the timing of WBVs were not. Future interventions and policies should actively promote first dental examinations by age 12 months at WBVs that take place during the first year of life.The 2011 Institute of Medicine report Improving Access to Oral Health Care for Vulnerable and Underserved Populations highlighted the persistent disparities in dental care access that affect young children.1 Fewer than 5% of children have a dental examination by age 12 months as recommended by the American Academy of Pediatrics and the American Academy of Pediatric Dentistry.2–5 A cornerstone in prevention, dental examinations provide dentists the opportunity to deliver risk-based anticipatory guidance to caregivers, allow for less invasive restorative interventions when disease is already present, and are a source of preventive care provided throughout childhood.6,7Dental examinations are part of a comprehensive strategy to prevent early childhood caries, a type of tooth decay that affects children aged younger than 6 years.8 Early childhood caries is the most common pediatric disease in the United States and is a public health problem that disproportionately affects low-income children.9–11 A 70% increase occurred in the prevalence of untreated early childhood caries among low-income children aged 2 to 5 years between 1988 to 1994 and 1999 to 2004.12 Thus, it is a growing problem. Untreated early childhood caries can lead to pain, infection, hospitalization, and in rare cases death13–15 and is associated with subsequent tooth decay in the permanent teeth, poor school attendance, and low quality of life—consequences that have deleterious effects throughout the life course.16–18From a public health perspective, earlier first dental examinations are likely to help prevent early childhood caries among low-income children enrolled in state Medicaid programs.19 One study reported that earlier first dental examinations for Medicaid-enrolled children reduce the need for invasive restorative treatments and are cost effective.2 The barriers to early first dental examinations include dentists’ unwillingness to treat young children, limited caregiver knowledge of when to take their child to a dentist, medical provider uncertainty of when to refer young children, and low Medicaid reimbursement.20–22Although few children have a first dental examination by age 12 months, most have multiple well baby visits (WBVs) by this age.23 Previous studies have reported associations between preventive medical and dental care use as well as between preventive medical care use and the timing of first dental visits for Medicaid-enrolled children aged 3 to 8 years.24–26 However, no study has focused on the relationship between WBVs and first dental examinations for young Medicaid-enrolled children younger than 3 years, with an emphasis on how the frequency and timing of WBVs are related to the timing of first dental examinations.In this study, we adapted a sociocultural oral health disparities model presented by Patrick et al.27 to test 3 hypotheses: (1) young children with more WBVs are more likely to have earlier first dental examinations than those with fewer WBVs, (2) young children with earlier first WBVs are more likely to have earlier first dental examinations, and (3) other social and behavioral factors are associated with earlier first dental examinations. We focused on WBVs because of the conceptual link between medical and dental care use.24–26 These first 2 hypotheses are based on the premise that WBVs are proxies for health-related behaviors and beliefs influenced by the motivations, values, and personal preferences for earlier first dental examinations by caregivers.27 The third hypothesis is based on the premise that factors at the system, community, and family level make up the milieu in which decisions are made by caregivers to seek dental care for their child.27 The information gleaned from this study could help identify specific points in the WBV periodicity schedule at which future population-based interventions aimed at getting infants to the dentist earlier for their first dental examination could be implemented.     

Clustering of Midlife Lifestyle Behaviors and Subsequent Cognitive Function: A Longitudinal Study

Objectives. We examined the association between individual and clustered lifestyle behaviors in middle age and later in cognitive functioning.Methods. Middle-aged participants (n = 2430) in the Supplémentation en Vitamines et Minéraux Antioxydant study self-reported their low physical activity, sedentary behavior, alcohol use, smoking, low fruit and vegetable consumption, and low fish consumption. We assessed cognition 13 years later via 6 neuropsychological tests. After standardization, we summed the scores for a composite cognitive measure. We estimated executive functioning and verbal memory scores using principal component analysis. We estimated the mean differences (95% confidence intervals [CIs]) in cognitive performance by the number of unhealthy behaviors using analysis of covariance. We identified latent unhealthy behavior factor via structural equation modeling.Results. Global cognitive function and verbal memory were linearly, negatively associated with the number of unhealthy behaviors: adjusted mean differences = −0.36 (95% CI = −0.69, −0.03) and −0.46 (95% CI = −0.80, −0.11), respectively, per unit increase in the number of unhealthy behaviors. The latent unhealthy behavior factor with low fruit and vegetable consumption and low physical activity as main contributors was associated with reduced verbal memory (RMSEA = 0.02; CFI = 0.96; P = .004). No association was found with executive functioning.Conclusions. Comprehensive public health strategies promoting healthy lifestyles might help deter cognitive aging.Noncommunicable diseases with notable lifestyle components are the leading causes of death worldwide.1,2 There is also growing evidence of the critical role of different midlife health and risk behaviors in cognitive aging.3–7 Because lifestyles are inherently modifiable and no treatment of cognitive decline is available, such findings argue for the paramount importance of prevention.8,9Current data support a deleterious effect of alcohol abstinence or abuse (compared with moderate alcohol consumption),10 smoking,7 low fruit and vegetable intake,11 low fish intake,12 and low physical activity (PA) levels13 on cognitive aging. However, it has been widely documented that lifestyle factors are strongly correlated with each other, forming a cluster of healthy or unhealthy behaviors.14 Traditionally, such interrelations have been accounted for by statistical adjustment; however, it is of major public health interest to consider the cumulative and combined effect of the various lifestyle behaviors on health by using multidimensional strategies.14Research that examines the combined effect of lifestyle factors on mortality is plentiful, and data have been colligated in a recent meta-analysis.15 These authors reported a 66% reduction in mortality risk by comparing adherence to 4 or more healthy lifestyle behaviors versus engagement in any number of unhealthy behaviors.The combined effect of lifestyle factors has also been explored in relation to cardiovascular diseases,16–18 cancer,18–22 diabetes,18,23 memory complaints,24 and dementia25–27; however, very few studies have reported findings regarding cognition.28,29 Despite heterogeneity in the definition of a healthy lifestyle, study design, and residual confounding, available, but scarce, data support a critical, protective role of healthy lifestyles in cognitive health through their beneficial properties via oxidative, inflammatory, vascular, and other neuroprotective pathways.30–33Our objectives in this study were to examine the association between individual and clustered lifestyle behaviors and later cognitive functioning. We employed traditional and innovative techniques (structural equation modeling) in our epidemiological pursuit.     

The Cost-Effectiveness of School-Based Eating Disorder Screening

Objectives. We aimed to assess the value of school-based eating disorder (ED) screening for a hypothetical cohort of US public school students.Methods. We used a decision-analytic microsimulation model to model the effectiveness (life-years with ED and quality-adjusted life-years [QALYs]), total direct costs, and cost-effectiveness (cost per QALY gained) of screening relative to current practice.Results. The screening strategy cost $2260 (95% confidence interval [CI] = $1892, $2668) per student and resulted in a per capita gain of 0.25 fewer life-years with ED (95% CI = 0.21, 0.30) and 0.04 QALYs (95% CI = 0.03, 0.05) relative to current practice. The base case cost-effectiveness of the intervention was $9041 per life-year with ED avoided (95% CI = $6617, $12 344) and $56 500 per QALY gained (95% CI = $38 805, $71 250).Conclusions. At willingness-to-pay thresholds of $50 000 and $100 000 per QALY gained, school-based ED screening is 41% and 100% likely to be cost-effective, respectively. The cost-effectiveness of ED screening is comparable to many other accepted pediatric health interventions, including hypertension screening.Eating disorders (EDs), including anorexia nervosa, bulimia nervosa, and binge-eating disorder, are prevalent among adolescents.1 Approximately 3.8% of females and 1.5% of males aged 13 to 18 years have an ED,2 and 16.3% of US 9th to 12th graders report engaging in disordered eating behaviors such as fasting or vomiting to lose weight.3 Although efficacious treatments for EDs exist,4 services for these conditions are underused.5 Seventy-eight percent to 88% of adolescents with EDs have contact with a health provider; of these youths, however, only 3% to 28% received treatment specifically for eating problems.1 Left untreated, EDs can significantly affect the length and quality of adolescent lives.6,7 ED medical complication, hospitalization, and mortality rates are the highest of any psychiatric disorder.8–11 Like many other chronic mental heath disorders, EDs can be costly to treat and place a considerable burden on patients and their caregivers. Estimates of the annual impact of EDs on health care costs and economic productivity in Australia and England range from US $1.8 billion to $19.2 billion.12–14 With early diagnosis and timely treatment, we may be able to decrease the economic and health burden of EDs.The American Academy of Pediatrics suggests that schools are a viable setting for health screening.15 Scoliosis, hearing, body mass index, and other health screenings are currently conducted in US public schools or required for enrollment.16 Policies designed to identify secondary school students with ED have been introduced in several states (Figure A, available as a supplement to the online version of this article at http://www.ajph.org). As of September 2013, only 1 state passed legislation aimed at improving detection of EDs, requiring schools to educate parents on how to recognize symptoms of an ED. Three states are currently considering ED-related legislation and ED screening legislation has failed in 2 states (Taryn O’Brien, written communication, September 2013).The impact of school-based screening on ED diagnosis and treatment duration is unknown. No studies have evaluated the health or economic impact of screening for EDs in school-based settings. Given the high proportion of EDs that remain undetected and the fact that no states currently mandate ED screening, experimentally evaluating the benefits of such screening programs in the real world would be resource intensive and may underestimate the potential benefits of screening. However, simulation models can be used to estimate the cost-effectiveness of screening with few constraints.17 We used a decision-analytic simulation model to evaluate the cost-effectiveness of a theoretical school-based ED screening program.