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Analyzing Emergency Department Dental Visits: Methods and Data Sources in Oregon

This section outlines the methodologies used to analyze non-traumatic dental visits to emergency departments (EDs) in Oregon. We define what constitutes an ED dental visit based on clinical coding and excluded traumatic cases. Data was sourced from hospital claims and the Oregon All Payer All Claims (APAC) database. We detail how these sources complement each other, the limitations faced, and the demographics of visits. Furthermore, we highlight associated medications and procedures, and how costs are estimated. The study aims to illuminate the unmet need for community dental care.

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Analyzing Emergency Department Dental Visits: Methods and Data Sources in Oregon

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  1. Appendix:StudyMethods Inthissection,weprovidedetailaboutthemethodsusedforthisproject,includingthedefinitionofanEDdentalvisit,datasources,hospitals contributingtotheEDdataset,methodsusedtoidentifydentalEDvisits, methodsusedtodeterminemedicationsandproceduresassociatedwithEDdentalvisits,approachtoestimating costsforEDdentalcare,andmethodsforgeographicanalysesofdentalEDuse. DefininganEDDentalVisit TodefineanEDdentalvisit,weusedpriorresearch2,5,11,13,16–19aswellasthe contentexpertiseofdental health serviceresearchersonourstudyteam.WeidentifiedasetofICD-9discharge codes consistentwith non-traumaticdentalproblems.(AppendixTable1)Wefocusonnon-traumaticdentalproblemsbecauseemergencyphysicianscanrarelyprovidedefinitivecareforthese conditions;thesevisitsreflectanunmetneedfor communitydentalcare. AnEDdentalvisitwasdefinedbypresenceofthese codesastheprimary diagnosisonanEDclaim. Weexcludedtraumaticdentalproblemsasthesemayrepresentacuteinjuries,includingisolateddental injuriesaswellasthoseassociatedwithotherinjuries(e.g.faciallacerations,facialbonefractures, intracranialbleed).TheremaybelimitedalternativesotherthanEDsfortheacuteevaluationofsuchinjuries. Datasources We collected2010datafromtwodatasources:claimsdataobtaineddirectlyfromhospitalsystems,andtheOregon AllPayer AllClaims(APAC)database.Wedescribeeachdatasetandhowthey complementeachother. HospitalClaimsData WerequestedEDclaimsdatadirectlyfromapurposivesampleofOregonhospitals.Weinitiallyidentified 45hospitalsthatwererepresentativeofall58Oregonhospitals,byurban/rurallocation,critical accessdesignation,geographicdistribution,andannualEDvisits.We contactedtheCEOorCMOofalltargetedhospitals,andwesignedDataUseandBusinessUseAgreementswithallparticipatinghospitals. Thestrengthofthesedataistheinclusionofallpayergroupsfortheparticipatinghospitals.WeusedthehospitalclaimsdatatoestimatethefrequencyofEDdentalvisitsandtoidentifypredictorsofEDdental visits. Alimitationofhospitalclaimsdataisthelackofuniformreportingonprocedures,antibiotics,and costs. Inaddition,thesedatamayhavelimitedgeographicgeneralizability. Ofthe45hospitalsthatwereinvitedtoparticipateinthisstudy,24provided2010dataonallEDvisits. AppendixTable2isalistofallOregonhospitalssortedbyparticipantsandnon-participants. AppendixFigure1illustratesthelocationsofparticipantsandnon-participants. AppendixTable3usesdatafromtheAmericanHospitalAssociationSurveyandtheOfficeforOregonHealthPolicyandResearchtoillustratethedifferencesbetweenparticipatingandnon-participatinghospitals.Rural,critical access,andlowvolumehospitalsareunderpresentedinoursampleset.Thus,theanalysesofhospitalclaimsdatamayhavelimited generalizabilitytoexcludedhospitals. In AppendixTable4,wedescribethecharacteristicsofallEDvisitsforbothdentalandnon-dentalproblems. TheprimarydischargediagnosesassociatedwithEDdentalvisitsarepresentedinthemainreport(Table1).Weprovidedescriptivetablesofprimarydiagnoses,stratifiedbybothdischargedandadmittedpatientsin AppendixTables5and6. Part1

  2. Inadditiontothisdescriptivereporting,wecalculatedtheunadjustedrelativeriskratiosfordifferentvalues ofage,gender,race,andpayerthatanEDvisitwouldbeforadental condition.Theresultsoftheserelativeriskanalysesareillustratedinthemainreport (Figure1). FivehospitalswithintheProvidenceHealthSystem(Seaside;St.Vincent;HoodRiver;Newberg;andMedford) providedaggregated,ratherthanencounterlevel,dataonnon-dentalEDvisits.Thesehospitals, accountingfor 20% ofthedata,wereincludedindescriptivereports(AppendixTable3)butexcludedfromtherelativeriskanalysis. Althoughouranalysesfocusedonpatientswithaprimarydiagnosisofanon-traumaticdentalproblem,anadditional3,551 (0.4% ofallEDvisits)EDvisitshadasecondarydiagnosisofanon-traumaticdental problem(AppendixTables7–9).Thethreemost commonassociatedprimarydiagnoseswere“otheracutepain,”“antepartum condition,”and“traumaticwoundoftooth”.Thispopulationlikelyincludesamixtureof patientswithaprimarydentalproblemaswellasthosewithaunrelatedprimaryreasonforanEDvisit. Ourapproachofusingonlyprimarydiagnoses codestodefineanEDdentalvisitreduces contaminationbyEDvisitsprimarilyforanon-dentalproblem;however,itmayresultinanundercountofallEDdentalvisits.Weidentifiedanadditional301hospitalizationswithasecondarydiagnosisofanon-traumaticdentalproblem;thesecasesaredescribedintheResultssectionandin AppendixTable9. TheOregonAllPayerAllClaimsDatabase The AllPayer AllClaims(APAC)database containsstatewideinformationonEDvisitsbypatients coveredbytheOregonHealthPlan, commercialpayers,andMedicaremanagedcare.OurresearchgroupisamongthefirstinOregontoobtainandanalyzetheAPACdata. ThestrengthsandweaknessesofAPACaretheinverseofthehospitalclaimsdata.Strengthsincludeuniqueinformationonprocedures,antibiotics,and costs.APACcanalsobeusedtogeneratestatewideprofilesof EDdentalvisits. ThemajorlimitationofAPACistheexclusionof certainpayergroups.Mostnotably,APAComitsvisitsbytheuninsuredthatrepresentabout 18% ofOregonEDvisits,andtheuninsureddisproportionatelyuseEDsfor non-traumaticdentalproblems.APACalsocurrentlyomitspatientswhoare coveredbyMedicareFee-For-Service(FFS)andfederalinsurance(TRICARE,FEHB).Finally,onemajor commercialpayer(Kaiser) has notyet submitteddatatoAPAC.Therefore,wedonotrelyonAPACtodescribepatientlevelcharacteristicssuchaspayerortoidentifypredictorsofEDdentalvisits. Identifyingmedicationsandprocedures WiththeAPACdatabase,weidentifiedthetop20non-refillprescriptionmedicationclassesthatweredispensedwithin3daysafteranEDdentalvisit(AppendixTable10). AnimportantlimitationtonoteistheinabilitytoverifythattheprescriberandtheEDproviderwerethe same; itispossiblethatsomemedications wereprescribedbynonED-providersandwerenotrelatedtotheEDdentalvisit.However,thefrequent prescribingofpainmedicationsandantibioticsnotedintheAPACdatais consistentwithourclinicalexperience. Weusedbilling codes(CurrentProceduralTerminology[CPT])toidentifyproceduresperformedintheED(AppendixTable11).ThisanalysisexcludesCPT“EvaluationandManagement”codesthatarebasedonthecomplexityofmedicaldecisionmaking. Part1

  3. EstimatingcostsforEDdentalcare Itisimportanttonotethat costisadistinct conceptfromchargeandpayment.Chargeisthebilledamount, variesgreatlybyhospital,andoften has littlerelationshipto cost.Wedidnothave accesstochargedata. APACdoesincludedataonpaymentsbyinsurersandpatients.AccordingtoOregonStateAPACanalysts, paymentdatahavenotbeenverified,andsubmittedOregonHealthPlanpaymentdataarelikelytobe flawed.Therefore,wedonotpresentpaymentdatainthisreport. Toestimatetrue costsreflectingresourcesrequiredtoprovideEDdental services,weappliedthe2010CenterforMedicareandMedicaidServices(CMS)nationalpaymenttablestoallCPT codesassociatedwithanEDdentalvisit.CMSpaymenttablesare commonlyusedtoapproximate actual costofmedical services21. Geographicanalyses WeusedbothhospitalandAPACdatatoillustratewhereOregonianswhouseEDsfordental conditionslive. Weprovidemapsthatillustratefrequency countsbyzip codes. Therearetwoimportantmethodologiclimitationsofourmappingapproachforhospitalclaimsdata.First, ourhospitalclaimsdatadidnotincludeallhospitalsinOregon.Aresidentinagivenzip codemighthavegonetoanearbyEDincludedinourdataortoanothernearbyEDnotincludedinourdata.Toaddressthis limitation,weuseddatafromtheOregonPatientOriginDatasettoidentify,foreachZIP code,themarketshareforallOregonhospitalsin2010.Wethenweightedthe countsineachzip codeto accountformissing data.Forexample,ifourdatasethad500EDdentalvisitsoriginatinginzip code97229butweonlyhad hospitaldatathat accountedfor 50% ofhospitalvisitsoriginatingfromthatzip code,thenwewouldinflatebyafactorof2(foranestimated1000EDdentalvisits)to accountformissingdata.ThisapproachmakestheassumptionthatEDvisitratesaresimilarinmissingdataastheyareinobserveddata. Second,wehadveryfewornoobserveddatafromsomezip codes.Thismayreflecta combinationof missinghospitaldataandlowpopulationdensityinruralareas.Ifazip code countwaszeroorwasmissingmorethan 75% ofhospitalmarketsharedata,thenwe considereddatatobeunreliableforthatzip code. Thisapproachreducestheabilitytomake conclusionsaboutlow-populationareasandareaswhicharepoorlyrepresentedbyourdata. APACdataincludeallOregonEDsbutexcludepatientpopulationsthatarenotrepresentedinAPAC(e.g. uninsured,MedicareFee-For-Service).Despitestatewide coverageofAPAC,therewerenoreportedEDdentalvisitsforasubsetoflow-densityzip codes. Despitedifferencesindata completeness andmethodology,thehospitalandAPACdatashowsimilar geographicpatterns,andpatternsweresimilarforuninsuredandOHP-sponsoredpatients comparedtoall EDpatients.Therobustnessofourgeographicfindingsintwodifferentdatasetsaddstoour confidencein theseresults. BecauseofthesimilaritybetweendifferentmapsofdentalEDvisits,wepresentonlytheAPACmapinthe bodyofthereport (Figure2);theothermapsarepresentedhere(AppendixFigures2-4). Part1

  4. AppendixTable1:ICD-9DischargeCodesforNon-TraumaticDentalProblemsAppendixTable1:ICD-9DischargeCodesforNon-TraumaticDentalProblems Part1

  5. AppendixTable2:ParticipatingandNon-ParticipatingHospitals Part1

  6. AppendixTable2:(continued) Part1

  7. AppendixTable2:(continued) Part1

  8. AppendixFigure1:ParticipatingandNon-ParticipatingHospitals HospitalStudyParticipation Participated DidNotParticipate Part1

  9. AppendixTable3:ComparisonofParticipatingandNon-ParticipatingHospitalsAppendixTable3:ComparisonofParticipatingandNon-ParticipatingHospitals Part1

  10. AppendixTable4:CharacteristicsofEDDentalandNon-DentalVisits Part1

  11. AppendixTable5:Top20PrimaryDentalDiagnoses,DischargedPatientsAppendixTable5:Top20PrimaryDentalDiagnoses,DischargedPatients Part1 20

  12. AppendixTable6:TopPrimaryDentalDiagnoses,AdmittedPatients Part1

  13. AppendixTable7:Top20SecondaryDentalDiagnoses,AllPatients This tableincludespatientswhohadanondentalprimarydiagnosisbutwithasecondarydiagnosisconsistentwithanon-traumaticdentalproblem. Part1

  14. AppendixTable7:(continued) This tableincludespatientswhohadanondentalprimarydiagnosisbutwithasecondarydiagnosisconsistentwithanon-traumaticdentalproblem. Part1

  15. AppendixTable8:Top20SecondaryDentalDiagnoses,Discharged This tableincludespatientswhohadanondentalprimarydiagnosisbutwithasecondarydiagnosisconsistentwithanon-traumaticdentalproblem. Part1

  16. AppendixTable8:(continued) This tableincludespatientswhohadanondentalprimarydiagnosisbutwithasecondarydiagnosisconsistentwithanon-traumaticdentalproblem. Part1

  17. AppendixTable9:Top20SecondaryDentalDiagnoses,Admitted This tableincludespatientswhohadanondentalprimarydiagnosisbutwithasecondarydiagnosisconsistentwithanon-traumaticdentalproblem. Part1

  18. AppendixTable9:(continued) This tableincludespatientswhohadanondentalprimarydiagnosisbutwithasecondarydiagnosisconsistentwithanon-traumaticdentalproblem. Part1

  19. AppendixTable10:PrescriptionMedicationsDispensedAfterEDDentalVisitAppendixTable10:PrescriptionMedicationsDispensedAfterEDDentalVisit Part1

  20. AppendixTable11:ProceduresAssociatedWithEDDentalVisits Part1

  21. AppendixFigure2:NumberofEDDentalVisitsin2010byPatientResidentialZipCode,OregonHealthPlanBeneficiaries(APAC)AppendixFigure2:NumberofEDDentalVisitsin2010byPatientResidentialZipCode,OregonHealthPlanBeneficiaries(APAC) Non-TraumaticOHP ED DentalVisits 0/InsufficientData 1- 3 4- 12 13- 33 34- 264 HosHospitalLocations pitals Locations Part1 30

  22. AppendixFigure3:NumberofEDDentalVisitsin2010byPatientResidentialZipCode,AllPayers(HospitalData)AppendixFigure3:NumberofEDDentalVisitsin2010byPatientResidentialZipCode,AllPayers(HospitalData) Non-Traumatic EDDental Visits(Weighted) 0/InsufficientData 1- 6 7- 23 24- 104 105- 868 HospitalLocations Hospitals Locations Part1

  23. AppendixFigure4:NumberofEDDentalVisitsin2010byPatientResidentialZipCode,OregonHealthPlanBeneficiariesandUninsured(HospitalData)AppendixFigure4:NumberofEDDentalVisitsin2010byPatientResidentialZipCode,OregonHealthPlanBeneficiariesandUninsured(HospitalData) Non-TraumaticOHP/UninsuredEDDentalVisits(Weighted) 0/InsufficientData 1 - 5 6 - 20 21- 92 93- 778 HospitalLocations Hospitals Locations Part1

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  25. LewisC,LynchH,JohnstonB.Dental complaintsinemergencydepartments:anationalperspective. Annalsofemergencymedicine.Jul2003;42(1):93–99. LoweRA. Dentalandmental conditionsinruralOregonemergencydepartments.23rd AnnualOregonRuralHealthConference.Newport,Oregon2006. MullinsCD,CohenLA,MagderLS,ManskiRJ.Medicaidcoverageandutilizationofadultdental services. JHealthCarePoorUnderserved.Nov2004;15(4):672–687. AgencyforHealthcareResearchandQuality.OverviewoftheStateEmergencyDepartmentDatabases. Accessed 2/20/14.https://www.hcup-us.ahrq.gov/seddoverview.jsp MuennigP.Cost-EffectivenessAnalysisinHealth:APracticalApproach.SanFrancisco:JohnWiley&Sons;2008. Part1

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