Racial and ethnic disparities in nontraumatic dental-condition visits to emergency departments and physician offices: A study of the Wisconsin Medicaid program

BackgroundNontraumatic dental condition (NTDC) visits occur in emergency departments (EDs) and physician offices (POs), but little is known about factors associated with NTDC visit rates to EDs and POs.MethodsThe authors analyzed all Medicaid dental claims in Wisconsin from 2001 through 2003 to examine factors associated with NTDC visits to EDs and POs. They performed bivariate and multivariable analyses. The independent variables they examined included race/ethnicity, age, sex, dental health professional shortage area (DHPSA) designation and urban influence code for county of residence.ResultsThe authors evaluated 956,774 NTDC visits made during 1,718,006 person-years; 4.3 percent of visits occurred in EDs or POs. Native Americans, African-Americans and enrollees of unknown race/ethnicity had the highest unadjusted ED and PO visit rates for NTDCs. African-Americans, Native Americans, adults and residents in partial or entire DHPSAs had significantly higher adjusted rates of NTDC visits to EDs. The authors observed significantly higher adjusted NTDC visit rates to POs for Native Americans, adults and enrollees residing in entire DHPSAs, and a significantly lower adjusted rate among African-Americans.ConclusionsNative Americans, those residing in entire DHPSAs and adults have significantly higher risks of NTDC visits to EDs and POs. African-Americans are at increased risk of making visits to EDs for NTDCs but at decreased risk of making visits to POs for NTDCs.Clinical ImplicationsReductions in Medicaid visits to EDs and POs and the associated costs might be achieved by improving dental care access and targeted educational strategies among minorities, DHPSA residents and adults.     

Patterns of dental service utilization following nontraumatic dental condition visits to the emergency department in Wisconsin Medicaid

Objectives: To examine patterns of dental service utilization for adult Medicaid enrollees in Wisconsin following nontraumatic dental condition (NTDC) visits to the emergency department (ED). Methods: This is a retrospective, observational study of claims for NTDC visits to the ED and dental service encounters from the Wisconsin Medicaid Evaluation and Decision Support database (2001‐2009). We used competing risk models to predict probabilities of returning to the ED versus obtaining follow‐up care from a dentist. Results: We observed a 43 percent increase in the rate of NTDC visits to the ED, with most of this increase occurring from 2001 to 2005. Within 30 days of an NTDC visit to the ED, ～29.6 percent of enrollees will first visit a dentist office, while ～9.9 percent will return to the ED. Young to middle‐aged adults (18 to <50 years) and enrollees living in counties with a lower supply of dental providers were more likely to return to the ED following a NTDC visit. Among the enrollees that first visited a dental office following an ED visit, 37.6 percent had an extraction performed at this visit. Conclusions: Almost one in five adult Medicaid enrollees will subsequently return to the ED following a previous NTDC visit. The provision of definitive care for these individuals appears to primarily consist of extractions.     

Testing dental quality measures: Emergency department visits for nontraumatic dental conditions and subsequent follow-up dental visits

BackgroundThe goal of this study was to test the feasibility, reliability, and validity of the Dental Quality Alliance’s adult dental quality measures for system-level implementation for ambulatory care sensitive (ACS) emergency department (ED) visits for nontraumatic dental conditions (NTDCs) in adults and follow-up after ED visits for NTDCs in adults.MethodsMedicaid enrollment and claims data from Oregon and Iowa were used for measure testing. Testing included validation of diagnosis codes in claims data through patient record reviews of ED visits and calculations of κ statistic, sensitivity, and specificity.ResultsAdult Medicaid enrollees’ ACS NTDC ED visits ranged from 209 through 310 per 100,000 member-months. In both states, patients in the age category 25 through 34 years and non-Hispanic Black patients had the highest rates of ACS ED visits for NTDCs. Only one-third of all ED visits were associated with a follow-up dental visit within 30 days, decreasing to approximately one-fifth with a 7-day follow-up. The agreement between the claims data and patient records for identification of ACS ED visits for NTDCs was 93%, κ statistic was 0.85, sensitivity was 92%, and specificity was 94%.ConclusionsTesting revealed the feasibility, reliability, and validity of 2 DQA quality measures. Most beneficiaries did not have a follow-up with a dentist within 30 days of an ED visit.Practical ImplicationsAdoption of quality measures by state Medicaid programs and other integrated care systems will enable active tracking of beneficiaries with ED visits for NTDCs and develop strategies to connect them to dental homes.     

Emergency department visits for infectious oral conditions in Massachusetts, 2014 through 2018

BackgroundThe authors aimed to measure population-based preventable emergency department (ED) visits related to infectious oral conditions (IOCs) in Massachusetts and to examine the associated sociodemographic factors to support prevention efforts.MethodsA statewide retrospective analysis of ED visits related to IOCs in Massachusetts from 2014 through 2018 was conducted using a Center for Health Information and Analysis database. The authors described patients' characteristics, dental diagnoses frequencies, emergency severity, lengths of stay, associated treatment, and costs. Multilevel logistic regression was used to assess factors associated with IOC visits.ResultsIOC visits in 2014 through 2018 were 1.2% (149,777) of the total ED visits, with an estimated cost of $159.7 million. There was an annual decline in the prevalence of IOC visits from 2014 through 2018. After adjusting for sociodemographic factors, odds of IOC were higher among males (adjusted odd ratio [AOR], 1.26; 95% CI, 1.24 to 1.27), non-Hispanic Blacks compared with non-Hispanic Whites (AOR, 1.03; 95% CI, 1.02 to 1.06), people residing in dental health care professional shortage areas (AOR, 1.06; 95% CI, 1.04 to 1.07), public insurance beneficiaries (AOR, 1.90; 95% CI, 1.87 to 1.93), or uninsured (AOR, 2.60; 95% CI, 2.54 to 2.66) compared with privately insured.ConclusionsThere was an annual decline in the prevalence of IOC visits from 2014 through 2018. Higher odds of IOC visits were associated with young adults, Black patients, uninsured people, public insurance beneficiaries, and people who reside in dental health care professional shortage areas.Practical ImplicationsThe authors provided statewide data to support proposed policies to improve oral health care in Massachusetts. IOCs are mostly preventable, but well-coordinated care between medicine and dentistry is integral for prevention.     

A Comparison of Medical and Dental Outcomes for Medicaid-Insured and Uninsured Medicaid-eligible Children: A U.S. Population–Based Study

BackgroundIn a population-based study of Medicaid-eligible children, the authors described and compared sociodemographic attributes, medical and dental health care utilization, and health status between Medicaid-insured and uninsured Medicaid-eligible children.MethodsThe authors analyzed data from 2,491 poor Medicaid-eligible children 2 to 16 years of age who participated in the 1999–2004 National Health and Nutrition Examination Survey. They quantified the association of medical and dental health care utilization, health status and treatment needs with Medicaid insurance status by using multivariable logistic regression modeling, taking into account the complex survey design and sample weights.ResultsApproximately 40 percent of Medicaid-eligible children were uninsured. Medicaid-insured children were more likely to have an annual physician visit but no more or less likely to have good general or oral health, asthma or dental caries, or treatment needs than were uninsured Medicaid-eligible children. Medicaid-insured older children (9–16 years old) were more likely to have an annual dentist visit than were uninsured Medicaid-eligible older children.ConclusionsChildren with Medicaid coverage were more likely to use health care services but no more or less likely to have good general health, good oral health, asthma treatment needs or dental treatment needs.Practice ImplicationsTo improve health care use, more poor children need to be enrolled in Medicaid.     

The effects of Medicaid expansions on dental services at federally qualified health centers

BackgroundFederally qualified health centers (FQHCs) have become safety-net providers of dental services for low-income patients. The authors examined the effects of the Patient Protection and Affordable Care Act Medicaid expansions, according to level of dental benefits, on the number of visits for dental services at FQHCs.MethodsThe authors used publicly available facility-level data on 1,400 FQHCs across the United States from the 2011 through 2019 Uniform Data System. The authors used an event-study difference-in-difference design to examine the effects of expanding Medicaid in 2014, according to the level of dental benefits, compared with nonexpansion states. Outcomes included the number of dental visits for any dental service and separately for preventive and other services. Regression models adjusted for the demographic characteristics of the FQHC's patient population, county-level factors, and center and year fixed effects.ResultsExpanding Medicaid with extensive dental benefits has increased the number of dental visits provided at FQHCs in 2014 through 2019 from 2013 by 1,329 to 7,647 visits per FQHC on average compared with FQHCs in nonexpansion states. There was an increase in visits for both preventive and other dental services. In contrast, there was no evidence of such an increase from expanding Medicaid with limited or emergency-only dental benefits.ConclusionsExpanding Medicaid eligibility with extensive dental benefits has increased the number of dental visits at FQHCs, including for both preventive and other dental services.Practical ImplicationsAs safety-net providers, FQHCs might be able to provide more oral health care for low-income patients after Medicaid expansions that offer extensive dental benefits.     

Assessing the association between receipt of dental care, diabetes control measures and health care utilization

BackgroundThe literature contains few studies regarding the relationships between receipt of regular dental care and medical outcomes for people with type 2 diabetes.MethodsThe authors compared hemoglobin A_1c (HbA_1c) levels (< 7 percent versus < 7 percent), low-density lipoprotein cholesterol levels (< 100 milligrams/deciliter versus ≥ 100 mg/dL) and diabetes-specific hospital admissions and emergency department (ED) visits (one or more visits versus no visits) in 493 people with type 2 diabetes who received regular dental care (≥ two prophylactic visits, periodontal treatment visits or both during a 12-month period) with measures in 493 people with type 2 diabetes who did not receive any dental care. The authors matched patients, all of whom had private medical and dental insurance benefits during the study period, with regard to age, sex and previous utilization of ED visits and hospital admissions, and they followed them for three years.ResultsThe authors analyzed the data by using multiple logistic regression, which showed that receipt of regular dental care was associated with lower diabetes-specific ED utilization (odds ratio [OR] = 0.61, 95 percent confidence interval [CI] = 0.40–0.92) and hospital admissions (OR = 0.61, 95 percent CI, 0.39–0.95) after they adjusted for age, sex, previous hospital admissions, previous ED utilization, race, baseline HbA_1c values, Charlson comorbidity index score, body mass index status, periodontal risk status and primary care utilization. The authors found no significant association between receipt of dental care and control of HbA_1c levels.ConclusionsThe study results show an association between regular receipt of dental care and reduced diabetes-specific medical care utilization (that is, ED visits and hospital admissions).Clinical ImplicationsAlthough the results of this study could not show causality, they suggest that receipt of dental care may reduce diabetes-specific health care utilization. Prospective studies are needed to better understand the relationship of receipt of dental care with diabetes control and health care utilization measures.     

Hospital-based emergency department visits involving dental conditions: Profile and predictors of poor outcomes and resource utilization

BackgroundUntreated dental conditions may progress to lesions that are severe enough to necessitate emergency visits to hospitals. The authors conducted a study to investigate nationally representative trends in U.S. hospital-based emergency department (ED) visits involving dental conditions and to examine patient-related characteristics associated with ED charges.MethodsThe authors used the Nationwide Emergency Department Sample of the Healthcare Cost and Utilization Project, sponsored by the Agency for Healthcare Research and Quality, for the years 2008 through 2010. They selected all ED visits involving patients with a diagnosis of either dental caries, pulpal or periapical lesions, gingival or periodontal conditions, or mouth cellulitis or abscess. Outcomes examined included post-ED disposition status and hospital ED charges.ResultsDuring the study period, 4,049,361 ED visits involved diagnosis of a dental condition, which is about 1 percent of all ED visits occurring in the entire United States. Uninsured patients made about 40.5 percent of all dental condition–related ED visits. One hundred one patients in the study died in EDs. The mean hospital ED charge per visit was approximately $760 (adjusted to 2010 dollars), and the total ED charges across the entire United States during the three-year study period was $2.7 billion.ConclusionsPatients without insurance are a cohort at high risk of seeking dental care in hospital-based ED settings. A substantial amount of hospital resources are used to treat dental conditions in ED settings. Patients with mouth cellulitis, periodontal conditions and numerous comorbidities are likely to incur higher ED charges.Practical ImplicationsDental conditions can be treated more effectively in a dental office setting than in hospital-based settings.     

The relationship between diabetes and oral health status,and dental visits among American Indian,Alaska Native,and Native Hawaiian elders

BackgroundAmerican Indian (AI), Alaska Native (AN), and Native Hawaiian (NH) populations report higher rates of diabetes, poorer oral health, and fewer dental visits than their peers. The authors aimed to identify relationships between oral health and dental visits and diabetes diagnosis among AI, AN, and NH elders.MethodsData were obtained from a national survey of AI, AN, and NH elders 55 years and older (April 2014-2017) and included 16,136 respondents. Frequencies and χ² tests were used to assess the relationship between oral health and dental visits, and diabetes.ResultsNearly one-half of the elders reported receiving a diagnosis of diabetes (49.2%). A significantly (P < .01) greater proportion of elders with diabetes reported a dental visit in the past year (57.8%) than those without. Differences (P < .01) were found between reported diabetes and need for extraction, denture work, and relief of dental pain. The authors found lower dental visit rates among elders with diabetes who were low income, older, unemployed, not enrolled in the tribe, lived on the reservation, and had only public insurance.ConclusionsThere is a need to increase oral health literacy and dental visits among elders with diabetes and, more urgently, a need to focus on providing care for subpopulations reporting lower visit rates.Practical ImplicationsDental providers must serve as a referral resource for at-risk elders and must work with and educate about the importance of oral health those who assist tribal elders with diabetes management, including primary care physicians, certified diabetes educators, nutritionists and dietitians, and public health care professionals.     

Disparities in dental health issues and oral health care visits in US children with tobacco smoke exposure

BackgroundThe objective of the authors was to assess the relationships between tobacco smoke exposure (TSE) and dental health and dental care visits among US children.MethodsThe authors examined 2018-2019 National Survey of Children’s Health data on TSE, dental health, and oral health care visits. Children aged 1 through 11 years (N = 32,214) were categorized into TSE groups: no home TSE (did not live with a smoker), thirdhand smoke (THS) exposure (lived with a smoker who did not smoke inside the home), or secondhand smoke (SHS) and THS exposure (lived with a smoker who smoked inside the home). The authors conducted multivariable logistic regression analyses, adjusting for child age, sex, race or ethnicity, prematurity, caregiver education level, family structure, and federal poverty threshold.ResultsChildren with home SHS and THS exposure were at increased odds of having frequent or chronic difficulty with 1 or more oral health problem (adjusted odds ratio [AOR], 1.59; 95% CI, 1.07 to 2.35; P = .022) and carious teeth or caries (AOR, 1.74; 95% CI 1.14 to 2.65; P = .010) than those with no TSE. Compared with children aged 1 through 11 years with no TSE, children with SHS and THS exposure were 2.22 times (95% CI, 1.01 to 4.87; P = .048) more likely to have not received needed oral health care but at decreased odds of having had any kind of oral health care visit (AOR, 0.55; 95% CI, 0.32 to 0.95; P = .032), including a preventive oral health care visit (AOR, 0.60; 95% CI, 0.36 to 0.99; P = .047).ConclusionsTSE in children is associated with caries and inadequate oral health care visits.Practical ImplicationsThe pediatric dental visit is an opportune time to educate caregivers who smoke about dental health to improve their children’s teeth condition and increase oral health care visits.     

Differences in use of dental and medical services by noninstitutionalized children in Ohio

BackgroundThe authors’ aim in this study was to evaluate and compare the use of dental and medical services among Ohio children by using data from the 2008 Ohio Family Health Survey (OFHS).MethodsThe 2008 OFHS data were gathered by means of a random-digit-dial telephone survey of more than 50,000 Ohio residents; they included parental interviews for more than 13,000 Ohio children. The authors compared children across three insurance coverage groups: those covered for the full year by Medicaid, those covered for the full year by private insurance, and those who were covered for only part of the year or who were uninsured. The authors determined differences between groups by means of an adjusted Wald test and analysis of variance. They excluded from the analysis children younger than 1 year.ResultsThe data represented 11,816 responses to questions regarding dental visits, medical visits and the methods used to pay for services for children aged between 1 year and 17 years. The percentages of children who had had a dental visit in the preceding 12 months and had not received needed dental care (as determined by the parent) were statistically significantly lower than percentages of children who had had a medical visit in the preceding 12 months and had not received needed medical care. Furthermore, the percentages of children who never had visited a dental care provider were statistically significantly higher than the percentages of children who never had visited a physician. The authors also observed significant differences in use of dental and medical services among children of different ages. Finally, uninsured children with noncontinuous coverage were the least likely to use health care services.ConclusionsOhio children’s use of medical services was dramatically better than their use of dental services. Although differences in use of medical and dental services are the results of complex, multifactorial factors affecting patients and providers, the robust data from this survey are generalizable to all noninstitutionalized children living in Ohio.     

Impact of Medicaid dental coverage expansion on self-reported tooth loss in low-income adults

BackgroundLow-income adults delay oral health care due to cost more than any other health care service. These delays lead to caries, periodontal disease, and tooth loss. Expanding Medicaid dental coverage has increased dental visits, but the potential impact on previously unmet oral health needs is not well understood.MethodsIn this analysis, the authors estimated the association between Medicaid dental expansion and tooth loss. Data on self-reported tooth loss among adults below 138% federal poverty guideline were obtained from the Behavioral Risk Factor Surveillance System. A difference-in-differences regression was estimated. Additional analyses stratified according to age and separated extensive and limited dental benefits.ResultsExpanding Medicaid dental coverage is associated with increased probability of total tooth loss of 1 percentage point in the total sample, representing a 20% relative increase from the pre-expansion rate. This increase was concentrated in states offering extensive dental benefits and was largest (2.5-percentage-point greater likelihood) among adults aged 55 through 64 years for whom both extensive and limited dental benefits were associated with total tooth loss.ConclusionsMedicaid expansion with extensive dental benefits was associated with increased total tooth loss among low-income adults. This finding suggests that greater access to oral health care addressed previously unmet oral health needs for this population.Practical ImplicationsAs public dental coverage continues to expand, dental care professionals may find themselves treating a greater number of patients with substantial, previously unmet, oral health needs. Additional research to understand the long-term effects of Medicaid dental insurance for adults on their oral health is needed.     

Racial and ethnic variations in waiting times for emergency department visits related to nontraumatic dental conditions in the United States

BackgroundResearchers have documented an association between waiting times in emergency departments (EDs) and quality of care for medical conditions, but little is known about trends and factors associated with waiting times for ED visits related to nontraumatic dental conditions (NTDCs). The authors examined trends in waiting time and associated factors for NTDC-related ED visits in the United States.MethodsThe authors analyzed data from the National Hospital Ambulatory Medical Care survey for 1997 to 2007, excluding 2001 and 2002 owing to lack of information about waiting times. The authors used a survey-weighted linear regression of log-transformed waiting-time model to determine the waiting time for NTDC-related visits.ResultsThe geometric mean (standard error) waiting times for NTDC- and non–NTDC-related visits were 29 (1.0) and 25 (0.6) minutes, respectively (P < .01). The geometric mean waiting time for NTDC-related visits increased by 6 percent annually and from 20 minutes in 1997 to 37 minutes in 2007. Compared with whites, Hispanics and African Americans had significantly longer waiting times for NTDC-related visits (adjusted fold-difference [R] = 1.2, 95 percent confidence interval [CI] = 1.13–1.31) and [R] = 1.3, [CI] = 1.29–1.38). Age, payer type, reason for visit and triage category were significant predictors of waiting time (R = 2.3 and 2.4 for NTDC-related visits in the triage categories of more than one to two hours and more than two to 24 hours, respectively).ConclusionNationally, waiting times in EDs for NTDC-related visits increased over time. Compared with whites, Hispanics and blacks waited longer to receive care for NTDCs in EDs.Practical ImplicationsProlonged waiting times associated with NTDC-related ED visits reinforce the need for dental professionals to continue to advise patients regarding the need to implement oral health preventive strategies and to avoid the use of the ED for preventable common dental conditions.     

Determinants of dental care visits among low-income African-American children

BACKGROUND: The objective of the authors' analysis was to investigate the determinants of dental care visits among young, low-income African-American children. METHODS: Trained researchers interviewed a representative sample of low-income black families (caregivers and children aged 0 through 5 years) in Detroit to assess their dental visit history, dental insurance status and oral health behaviors. Dental examinations were conducted using the International Caries Diagnosis Assessment System (ICDAS). Of the 1,021 families who completed an interview and examination, a subset of the 552 children aged 3 to 5 years (and their primary caregivers) was the focus of this analysis. RESULTS: Children with private dental insurance had four times higher odds of having visited a dentist compared with those who had no dental insurance, and the odds for children receiving Medicaid were about 1.5 times higher. A child's age and a caregiver's educational attainment were positive and significant determinants of child dental visits. Caregivers who visited a dentist for preventive reasons were five times more likely to have taken their children to visit the dentist. Visiting a dentist was associated with an increased mean number of filled or missing tooth surfaces, but it was not significantly associated with the mean number of untreated decayed teeth. CONCLUSION: Children's dental insurance status was a significant determinant of their having visited a dentist. Even after the authors accounted for insurance status and other risk indicators, they found that children of caregivers who reported visiting a dentist for preventive care had a higher number of dental care visits. Determinants of caregivers' preventive dental visits must be identified and encouraged to improve the percentage of low-income children who visit dentists.     

Wisconsin Medicaid enrollees' recurrent use of emergency departments and physicians' offices for treatment of nontraumatic dental conditions

BackgroundMedicaid enrollees experience a number of barriers that prevent them from seeking care in dental offices, leading some to repeatedly seek treatment for nontraumatic dental conditions (NTDCs) in emergency departments (EDs) and physicians’ offices (POs). The authors examined the rate of return visits to EDs and POs for treatment of NTDCs among Wisconsin Medicaid enrollees and sought to characterize frequent and typical users of such care in this population.MethodsThe authors conducted a retrospective analysis of all Wisconsin Medicaid dental claims for NTDCs to EDs and POs from 2001 through 2003. They used finite mixture models, allowing for covariate dependence, to model separate rates of return for NTDC-related visits corresponding to typical and frequent users of EDs and POs.ResultsOverall, 23,999 enrollees had made NTDC-related visits to EDs and POs, with 6.5 percent estimated to be frequent users of such care. Typical and frequent users had a mean (± standard error) rate of return visits of 0.2 ± 0.01 and 4.0 ± 0.08 per year, respectively. Male enrollees and people aged 19 to 42 years were more likely to be frequent users, with African American and Hispanic enrollees having lower odds of being frequent users than did white enrollees. The effect of living in an area with a shortage of dental health care professionals did not affect the likelihood of being a frequent user of EDs and POs for such care.ConclusionsMale and middle-aged enrollees were significantly more likely to be frequent users of EDs and POs for treatment of NTDCs. Compared with white enrollees, African American and Hispanic enrollees were less likely to be frequent users and had lower rates of recurrent visits for NTDCs among typical users.Clinical ImplicationsImproved access to dental care for Medicaid enrollees that is best managed by dental care providers should reduce the rates of recurrent NTDC-related visits to EDs and POs.     

Assessing Patterns of Restorative and Preventive Care Among Children Enrolled in Medicaid,by Type of Dental Care Provider

BackgroundThe authors investigate the relationship of preventive dental treatment to subsequent receipt of comprehensive treatment among Medicaid-enrolled children.MethodsThe authors analyzed Medicaid dental claims data for 50,485 children residing in Wayne County, Mich. The study sample included children aged 5 through 12 years in 2002 who had been enrolled in Medicaid for at least one month and had had at least one dental visit each year from 2002 through 2005. The authors assessed dental care utilization and treatment patterns cross-sectionally for each year and longitudinally.ResultsAmong the Medicaid-enrolled children in 2002, 42 percent had had one or more dental visits during the year. At least 20 percent of the children with a dental visit in 2002 were treated by providers who billed Medicaid exclusively for diagnostic and preventive (DP) services. Children treated by DP care providers were less likely to receive restorative and/or surgical services than were children who were treated by dentists who provided a comprehensive mix of dental services. The logistic model showed that children who visited a DP-care provider were about 2.5 times less likely to receive restorative or surgical treatments than were children who visited comprehensive-care providers. Older children and African-American children were less likely to receive restorative and surgical treatments from both types of providers.ConclusionsThe study results show that the type of provider is a significant determinant of whether children received comprehensive restorative and surgical services. The results suggest that current policies that support preventive care–only programs may achieve increased access to preventive care for Medicaid-enrolled children in Wayne County, but they do not provide access to adequate comprehensive dental care.