Determinants of emergency department utilization for non‐traumatic dental conditions in Massachusetts

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use - results of a scoping review

BACKGROUND

Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use.

METHODS

We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the 'Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)' recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered.

RESULTS

Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies.

CONCLUSIONS

Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Utilization of dental care among adult populations: a scoping review of applied models

BACKGROUND

The timely and appropriate utilization of dental health care is essential to the prevention and accurate treatment of oral diseases. Therefore, it is crucial that managers, health professionals and healthcare providers be fully aware of the predictors encouraging the utilization of dental services and reduce social inequalities. In this scoping review, we aimed to analyze the published articles and reports to find out the factors associated with dental services utilization and the comprehensiveness of the applied models among general adult populations.

MATERIALS AND METHODS

This scoping study was based on the 5-steps of Arksey and O'Malley framework. Keywords were selected under two main concepts: determinants of dental care utilization and the concept of the applied models. Searches were conducted in some electronic databses including PubMed, Google Scholar and Scopus with variations, and a combination of the keywords under the two main afore-mentioned concepts. All the relevant articles reporting the utilization of dental care and its potential predictors among adult populations were chosen. No restrictions involving terms of study time, location or methodological aspects of oral health utilization were considered. Using tables and charts mapping, we tried to group the studies based on the year of their publication, geographic distribution, the range of included indices and the type of their measurement. Also, a directed content analysis method was used to investigate the comprehensiveness of the studies in regard to considering the determinant factors at different levels suggested by the Andesen model.

RESULTS

Fifty-two articles were included in the analysis. Thirty-six (69%) had been published between 2016 and 2020. The United States had conducted the most research in this scope. About 30% of studies had mentioned all three domains of demographics, social structure and beliefs, simultaneously. To evaluate the enabling factors, in 84.61% and 59.61% of studies, the income levels and insurance feature were assessed, respectively. 57.69% of the retrieved studies considered the perceived need features and 38.46% referred to the evaluated ones. The dental services utilization, in terms of the last visit during the "past 12 months", was assessed more commonly. Only 11.54% of studies did evaluate the contextual characteristics and about 71.15% of articles were relatively comprehensive.

CONCLUSION

Overall, it seems that in most of the studies, not all of the determinant factors at different levels of the Andersen model have been considered. In order to discover the conceptual linkages and feedback loops of the model, it is essential to conduct more comprehensive research in the future.

The impact of underutilization of preventive dental care by adult Medicaid participants

Objective

To ascertain the financial impact associated with the underutilization of preventive dental care for adults enrolled in Medicaid.

Methods

We used adult claims data for patients aged 21–64 in the IBM Watson Marketscan Medicaid database. Enrollees were included if they had at least one dental claim in 2019 and were continuously enrolled between 2014 and 2019. We then evaluated the costs of their dental care in 2019, based on the number of years of preventive dental care they received between 2014 and 2018. We also assessed Emergency Department (ED) utilization for dental conditions, oral surgeries, and dental‐related opioid prescriptions.

Results

The average Medicaid enrollee with five continuous years of preventive care prior to 2019 experienced 43% lower costs than an individual who received no preventive dental care at all. Most of the savings were a result of fewer oral surgeries. A Medicaid enrollee with no preventive dental visits was eight times more likely to have an ED visit for a nontraumatic dental condition (NTDC), seven times more likely to have oral surgery and six times more likely to receive a dental‐related opioid prescription compared to those who had a dental prevention visit every year in the 5‐year lookback period.

Conclusions

Regular preventive dental care in the lookback period was associated with significant savings in overall dental care costs when compared to dental care costs for those individuals who received no or few preventive visits. Prior preventive dental care was also associated with lower rates of ED‐NTDC utilization, oral surgery, and dental‐related opioid prescriptions.

A state-wide study of dental comorbidities in psychiatric disorders resulting in avoidable emergency department presentations

BACKGROUND

Attendances at emergency departments (EDs) for dental conditions are unnecessary and come at a significant cost to health services.

METHODS

A population-based record-linkage analysis of a retrospective cohort over 2 years across state-based facilities in Queensland. This was to determine if people with mental illness were more likely than the general population to attend EDs for a range of non-traumatic or avoidable dental conditions.

RESULTS

There were 1 381 428 individuals in the linked database, of whom 177 157 (13%) had a psychiatric history and 22 046 (1.5%) had one or more avoidable dental presentations. These were toothache (n = 9619), dental abscesses (n = 8449), caries (n = 1826), stomatitis (n = 1213) and gum disease (n = 939). After adjusting for confounders, psychiatric patients were significantly more likely to present with toothache, dental abscesses and caries but not stomatitis or gum disease. Depending on the dental outcome, other risk factors were male sex, lower income, rurality and Indigenous status.

CONCLUSIONS

Given these findings, possible interventions should include an increased emphasis on assessing oral health in mental health or primary care, especially in non-metropolitan areas, as well as early dental referral. Service planning for this population should including easier navigation of dental services, availability outside normal office hours and free outreach dental clinics.

How Patient-Centered Medical Homes Integrate Dental Services Into Primary Care: A Scoping Review

Integrated care delivery is at the core of patient-centered medical homes (PCMHs). The extent of integration of dental services in PCMHs for adults is largely unknown. We first identified dental-medical integrating processes from the literature and then conducted a scoping review using PRISMA guidelines to evaluate their implementation among PCMHs. Processes were categorized into workforce, information-sharing, evidence-based care, and measuring and monitoring. After screening, 16 articles describing 21 PCMHs fulfilled the inclusion criteria. Overall, the implementation of integrating processes was limited. Less than half of the PCMHs reported processes for information exchange across medical and dental teams, referral tracking, and standardized protocols for oral health assessments by medical providers. Results highlight significant gaps in current implementation of adult dental integration in PCMHs, despite an increasing policy-level recognition of and support for dental-medical integration in primary care. Understanding and addressing associated barriers is important to achieve comprehensive patient-centered primary care.

A systematic review of dental-related emergency department among Medicaid beneficiaries

OBJECTIVES

Dental-related emergency department (ED) visits are a growing public health concern. Dental insurance coverage is a strong predictor of dental service access. The objective of this study was to conduct a systematic review to assess the incidence of dental-related ED visits for Medicaid dental enrollees compared to those with other insurances.

METHODS

PubMed, EMBASE, and Google Scholar were searched for surveillance and observational data published in English from January 1999 to April 2020 to address the following PECOT question: Do patients with nontraumatic dental conditions (NTDC) (P1), or patients with any dental condition (P2) who have Medicaid (E) compared to other insurance status (private insurance, Medicare, no insurance) (C) have a differential incidence of single dental-related ED visits (O) in the literature search results from 1999 to April 2020 (T)? A critical appraisal was performed using a combination of the AXIS tool (for cross-sectional studies with observational data and MetaQAT (for public health evidence).

RESULTS

This systematic review included 32 studies. Overall, risk of bias was low. Due to significant statistical heterogeneity, a synthesis without meta-analysis was conducted. NTDC ED visits ranged from 16.0 percent to 79.8 percent for Medicaid patients and 0.9 percent to 57.2 percent for uninsured patients. The range for any dental visit to the ED was 2.2-63.8 percent for Medicaid patients and 2.9-40.8 percent for uninsured patients.

CONCLUSIONS

The results of this study support expanding insurance coverage in Medicaid programs to reduce ED use for NTDC visits in the United States.

Barriers and facilitators to oral health care utilization in culturally and linguistically diverse mothers: a mixed methods systematic review protocol

OBJECTIVE

The objective of the review is to synthesize existing literature examining the barriers and facilitators to preventive oral health care utilization experienced by culturally and linguistically diverse mothers.

INTRODUCTION

Preventive oral health care in the absence of pain is underutilized in culturally and linguistically diverse groups. Culturally and linguistically diverse mothers experience oral health care utilization barriers compared to their host country counterparts. Much of the current evidence is focused on oral health care knowledge, attitudes, and beliefs of culturally and linguistically diverse groups. To date, it remains unclear as to which barriers or facilitators impact preventive oral health care utilization in culturally and linguistically diverse mothers.

INCLUSION CRITERIA

This review will consider studies that explore oral health care utilization in culturally and linguistically diverse mothers (with children younger than 18 years) who are either born in a different country or who have one parent born in a country that differs culturally and/or linguistically to the host population. Papers that explore barriers and facilitators to oral health care utilization will be included. Quantitative and qualitative studies will be included.

METHODS

A three-step search strategy will be conducted within the following databases: MEDLINE, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, ProQuest Central, and Scopus. The search will be supplemented with gray literature and reference searching from collected articles. No date limitation will be applied. Two reviewers will assess papers against the inclusion criteria. A convergent integrated approach using the JBI mixed methods methodology will be followed for critical appraisal, data extraction, and data synthesis and integration.

Avoidable emergency department presentations for dental comorbidities of psychiatric disorders: A population-based record-linkage analysis

BACKGROUND

Indigenous peoples and those from non-Caucasian, poorer or rural backgrounds are at greater risk of emergency department (ED) presentations for non-traumatic or avoidable dental conditions. There is no information on people with mental illness.

OBJECTIVE

To compare avoidable dental ED admissions in psychiatric patients with those of the general population over 2 years.

METHODS

A population-based record-linkage analysis across state-based facilities in Queensland, Australia. Avoidable dental ED presentations were defined using ICD10 codes K02.9, K04.7, K05.0, K08.8 and K12.

RESULTS

There were 1,381,428 individuals in the linked database, of whom 657,933 (47.6%) were male. Of the sample, 177,157 (13%) had a history of contact for mental health problems and 22,046 (1.5%) had at least one avoidable dental presentation. The most two common were unspecified disorders of teeth or supportive structures (n = 10,184) and periapical abscesses (n = 7970). After adjusting for confounders, those who had ever needed psychiatric treatment were 72% more likely to experience an avoidable dental presentation (95% = 1.65-1.79; p < 0.0001). Other significant independent risk factors were lower income, rurality and Indigenous status. Within the inpatient psychiatric group, those with substance use or personality disorders had the highest risk of avoidable presentations.

CONCLUSIONS

In common with other marginalised groups, psychiatric patients have increased avoidable presentations. Possible clinical interventions could include an increased emphasis on oral health assessment in primary health care and early dental referral. Dental education and service planning should consider this population's needs including easier navigation of services, availability outside normal office hours, and free outreach dental clinics.

Antibiotic and opioid prescribing for dental-related conditions in emergency departments: United States, 2012 through 2014

BACKGROUND

Patients visiting the emergency department (ED) for nontraumatic dental conditions usually receive nondefinitive health care and are referred to treatment elsewhere. This may lead to potentially avoidable antibiotic and opioid use.

METHODS

A retrospective study was conducted in IBM MarketScan Research Databases in Treatment Pathways from 2012 through 2014. This study included patients with commercial insurance or enrolled in Medicaid. Patients receiving a diagnosis of a dental condition in the ED with no secondary diagnosis warranting an antibiotic prescription were included. Patients were stratified on the basis of the primary payer and available demographics, as well as on the basis of repeat visits to the ED.

RESULTS

A higher proportion of Medicaid beneficiaries (280,410, 4.9%) had dental-related visits compared with the commercially insured (159,066, 1.3%). The most common diagnoses were similar for both groups and included caries. In both cohorts, the 18- through 34-year age group had the highest rate of dental-related ED visits. Within 7 days of a dental-related ED visit, 54.9% of Medicaid beneficiaries and 55.0% of commercially insured beneficiaries filled a prescription for an antibiotic and 39.6% of Medicaid patients and 42.0% of commercially insured patients filled an opioid prescription.

CONCLUSIONS

Antibiotics and opioids are frequently prescribed during ED visits for dental conditions. Access to preventive and acute oral health care for routine dental symptoms, such as caries, may reduce unnecessary prescriptions in both the commercially insured and Medicaid beneficiary populations.

PRACTICAL IMPLICATIONS

Treatment of dental conditions in the ED often indicates a lack of access to preventive or acute oral health care. Data-driven solutions, such as guideline implementation, could improve oral health access, reduce medication-related harms, and avert health care expenditures.

Emergency department revisits for nontraumatic dental conditions in Massachusetts

BACKGROUND

Inadequate access to oral health care and palliative care provided in the emergency department (ED) creates a pattern of repeat nontraumatic dental condition (NTDC) ED visits. The authors examined NTDC ED revisits and assessed the determinants associated with these visits in Massachusetts.

METHODS

The authors examined NTDC ED revisits in Massachusetts during 2013 using the Massachusetts All-Payer Claims Database. The authors report patient characteristics of those who made a single NTDC ED visit and of those who made NTDC ED revisits within 30 days of the index NTDC ED visit. The authors used a multilevel logistic regression model to examine the determinants associated with NTDC ED repeat visits.

RESULTS

In 2013, 21.5% of NTDC ED visits were revisits. Men from 26 through 35 years of age who were enrolled in Medicaid and who did not make an outpatient dental office visit within 30 days of the index NTDC ED visit had increased odds of repeat visits.

CONCLUSIONS

The sizable proportion of NTDC ED repeat visits indicates that certain patients in Massachusetts experience consistent and systematic barriers in accessing appropriate and timely oral health care.

PRACTICAL IMPLICATIONS

Prioritizing young adults and Medicaid enrollees for ED diversion programs and setting up a formal referral process via connecting patients to dental offices and community health centers after an NTDC ED visit may reduce NTDC ED revisits and provide appropriate oral health care to these patients.