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A p p endix: S tudy M etho ds

A p p endix: S tudy M etho ds.

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A p p endix: S tudy M etho ds

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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

  24. References CentersforDiseaseControl.NationalHospital AmbulatoryMedicalCareSurvey:2010EmergencyDepartmentsummaryTables.2012;http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf.Accessed Dec26,2013. HongL, Ahmed A, McCunniffM,LiuY,CaiJ,HoffG.Seculartrendsinhospitalemergencydepartment visitsfordentalcareinKansasCity,Missouri,2001–2006.PublicHealthRep.Mar–Apr2011;126(2):210–219. LadrilloTE,HobdellMH,CavinessAC.Increasingprevalenceofemergencydepartmentvisitsforpediatricdentalcare,1997–2001.J AmDentAssoc.Mar2006;137(3):379–385. LeeHH,LewisCW,SaltzmanB,StarksH.Visitingtheemergencydepartmentfordentalproblems:trendsinutilization,2001to2008. Americanjournalofpublichealth.Nov2012;102(11):e77–83. AndersonL,CheralaS,TraoreE,MartinNR.UtilizationofHospitalEmergencyDepartmentsfornon-traumaticdentalcareinNewHampshire,2001–2008.Journalofcommunityhealth. Aug2011;36(4):513–516. WallT.RecenttrendsindentalemergencydepartmentvisitsintheUnitedStates:1997/1998to2007/2008.Journalofpublichealthdentistry.Summer2012;72(3):216–220. NalliahRP, AllareddyV,ElangovanS,KarimbuxN.HospitalbasedemergencydepartmentvisitsattributedtodentalcariesintheUnitedStatesin2006.Thejournalofevidence-baseddentalpractice. Dec2010;10(4):212–222. Pennycook A, MakowerR,Brewer A, MoultonC,CrawfordR.Themanagementofdentalproblems presentingtoan accidentandemergencydepartment.JournaloftheRoyalSocietyofMedicine. Dec1993;86(12):702–703. PajewskiNM, OkunseriC.Patternsofdental serviceutilizationfollowingnontraumaticdental conditionvisitstotheemergencydepartmentinWisconsinMedicaid.Journalofpublichealthdentistry. Aug82012. DavisEE,DeinardAS,MaigaEW.Doctor,mytoothhurts:the costsofincompletedentalcareintheemergencyroom.Journalofpublichealthdentistry.Summer2010;70(3):205–210. HockerMB,VillaniJJ,BorawskiJB,etal.DentalvisitstoaNorthCarolinaemergencydepartment:apainfulproblem.NorthCarolinamedicaljournal.Sep–Oct2012;73(5):346–351. WallaceNT,CarlsonMJ,MosenDM,SnyderJJ,WrightBJ.Theindividualandprogramimpactsof eliminatingMedicaiddentalbenefitsintheOregonHealthPlan. Americanjournalofpublichealth.Nov2011;101(11):2144–2150. CohenLA,ManskiRJ,HooperFJ.DoestheeliminationofMedicaidreimbursementaffectthefrequency ofemergencydepartmentdentalvisits?J AmDentAssoc.May1996;127(5):605–609. DorfmanDH,KastnerB,VinciRJ.Dental concernsunrelatedtotraumainthepediatricemergencydepartment:barrierstocare. Archivesofpediatrics & adolescentmedicine.Jun2001;155(6):699–703. OregonHealthPlanMedicaidDemonstration.CapitationRateDevelopment.DentalCareOrganizationsRemainingDuringTransitiontoCoordinatedCareOrganizations.In:ActuarialServiceUnit OHA,ed2013:1–49. CohenLA,ManskiRJ,MagderLS,MullinsCD.DentalvisitstohospitalemergencydepartmentsbyadultsreceivingMedicaid:assessingtheiruse.J AmDentAssoc.Jun2002;133(6):715–724;quiz768. Part1

  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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