Dental-Related Emergency Department Visits on the Increase in the United States
Authors: Thomas Wall, M.A., M.B.A.; Kamyar Nasseh, Ph.D.
- Emergency department (ED) visits for dental conditions are increasing, driven primarily by a larger share of dental visits taking place in EDs rather than dental offices.
- Decreases in private dental insurance coverage among young adults combined with significant reductions in adult dental Medicaid programs have created a financial barrier that could have led to a substitution of dental ED visits for dental office visits.
- Unfortunately, the Affordable Care Act does not address increased dental utilization in EDs or generate effective solutions to increase access to dental care in office settings.
- Several programs have demonstrated success in reducing ED use for non-traumatic dental conditions. These programs should be expanded.
- Without further interventions from policy makers, dental ED visits are likely to increase in the future, straining the health care system and increasing overall health care costs.
A number of studies based on individual hospitals, cities or states have reported an increase in dental-related emergency department (ED) visits in the U.S. Studies have also shown that, for the U.S. as a whole, per-capita dental ED visits have been increasing, and that dental ED visits are growing as a percentage of all ED visits.
Most dental ED visits are for non-traumatic dental conditions, and in most cases, ED healthcare providers provide prescriptions for pain or antibiotics for infections. For example, a 2009 study based on the National Emergency Department Sample (NEDS) reported that dental caries were the principle diagnosis for 41.8% of all ED visits for dental conditions. Patients who present at an ED with a non-traumatic dental condition would be better served in a dental office setting due to the availability of definitive care and the likelihood of continuity of care.
The number of ED visits also has grown. According to one study, between 1997 and 2007, the increase in per-capita ED visit rates was almost double of what would be expected from population growth. This
increase in ED visits has coincided with a decrease in the number of Emergency Departments nationwide.
Thus, EDs nationwide are under pressure to provide care for more patients. Inappropriate and continuous use of EDs for non-traumatic dental visits strain the health care system, contribute to overcrowding, increased care costs and longer wait times for patients with urgent health conditions.
Nationally, dental ED visits have been growing faster than overall ED visits and understanding the factors behind this trend is important. In this research brief, we have three objectives. First, we develop a simple framework to identify key components that drive dental ED visits. Second, we use various data sources to
identify which factors are most important in explaining the increase in dental ED visits. Finally, we discuss the policy implications of our findings.
Data & Methods
In this analysis, we used annual dental utilization data from the Medical Expenditure Panel Survey (MEPS), which is managed by the Agency for Healthcare Research and Quality (AHRQ). The MEPS is a nationally representative survey of the noninstitutionalized U.S. population. Data contained in the MEPS includes information on demographics, health conditions, health status, health expenditures, access to care, health insurance coverage, family income, employment status and utilization of medical services. We focused on the period 2000 to 2010, the most recent year for which data are available. The MEPS is recognized as the most reliable data source for dental care utilization at the national level.
For information regarding the annual number of dentalrelated ED visits, we analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), which is based on a national probability sample of visits to EDs of nonfederal general and short-stay hospitals in the United States. A dental ED visit was defined as those ED visits with a primary diagnosis ICD-9 code in the following range: 520.0 to 526.9.
These codes correspond to Clinical Software Classification category 136 – disorders of the teeth and jaw. Estimates of the U.S. population were based on census and inter-census estimates of the U.S. residential population from the U.S. Census Bureau.
We defined total dental visits for each year as the sum of visits to a dentist (MEPS) plus dental ED visits (NHAMCS). We also estimated the percent of ED visits that were related to dental conditions for each year.
This annual percentage is determined by (1) the percentage of all dental visits that took place in an ED, (2) the percentage of the population with any dental visit (i.e., dental office or ED) in a given year and (3)
percentage of the population that had an ED visit.
The percent of ED visits that were related to dental conditions was defined as the number of dental ED visits divided by the number of total ED visits based on a NHAMCS file for a given year. The percentage of all dental visits that took place in an ED was defined as the total number of dental ED visits estimated from the NHAMCS divided by the total number of dental visits estimated from the MEPS and the NHAMCS. The percentage of the population with any dental visit was defined as the total number of dental visits estimated from the MEPS and the NHAMCS divided by an estimate of the U.S. civilian population. The percentage of the population that had an ED visit was defined as the total number of ED visits estimated from the NHAMCS divided by an estimate of the U.S. civilian population.
We then analyzed these components to determine what factor could be driving the increase in dental ED visits. We used a chi-square test to test for a significant difference in dental ED visits as a percent of total ED visits between 2000 and 2010.
According to the NHAMCS, the number of dental ED visits in the U.S. increased from 1.1 million in 2000 to 2.1 million in 2010. As shown in Figure 1, dental ED visits as a percent of total ED visits increased from 1.06% in 2000 to 1.65% in 2010 and this change was statistically significant. Twice during this period of time (i.e., 2002 to 2004 and 2006 to 2008) growth in dental ED visits as a percent of total ED visits appears to have leveled off, only to be followed by further increases.
Figure 2 summarizes trends across time in each of the components that factored into the increase in dental ED visits as a percent of total ED visits. To illustrate the relative importance of each component, we indexed all variable values to 100 in the year 2000.
The indexed trend lines in Figure 2 show that the increase in dental ED visits as a percentage of all ED visits was driven primarily by an increase in dental ED visits as a percentage of total dental visits. From 2004 to 2006, and again from 2008 to 2010, dental ED visits grew at a faster absolute rate than total dental visits.
Figure 3 shows trends in dental ED visits as a percentage of total dental visits, by patient age. It is clear that young adults 21 to 34 accounted for most of the overall increase in the percentage of dental visits that took place in an ED setting. The percentage of dental ED visits to total dental visits did not change among other age groups.
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