Does Restriction of Public Health Care Dental Benefits Affect the Volume, Severity, or Cost of Dental-Related Hospital Visits?

PURPOSE: On July 1, 2012, the Illinois legislature passed the Save Medicaid Access and Resources Together (SMART) Act, which restricts adult public dental insurance coverage to emergency-only treatment. The purpose of this study was to measure the effect of this restriction on the volume, severity, and treatment costs of odontogenic infections in an urban hospital. MATERIALS AND METHODS: A retrospective cohort study of patients presenting for odontogenic pain or infection at the University of Illinois Hospital was performed. Data were collected using related International Classification of Diseases, Ninth Revision codes from January 1, 2011 through December 31, 2013 and divided into 2 cohorts over consecutive 18-month periods. Outcome variables included age, gender, insurance status, oral and maxillofacial surgery (OMS) consultation, imaging, treatment, treatment location, number of hospital admission days, and inpatient care level. Severity was determined by the presence of OMS consultation, incision and drainage, hospital admission, and cost per encounter. Hospital charges were used to compare the cost of care between cohorts. Between-patients statistics were used to compare risk factors and outcomes between cohorts. RESULTS: Of 5,192 encounters identified, 1,405 met the inclusion criteria. There were no significant differences between cohorts for age (P = .28) or gender (P = .43). After passage of the SMART Act, emergency department visits increased 48%, surgical intervention increased 100%, and hospital admission days increased 128%. Patients were more likely to have an OMS consult (odds ratio [OR] = 1.42; 95% confidence interval [CI], 1.11-1.81), an incision and drainage (OR = 1.48; 95% CI, 1.13-1.94), and a longer hospital admission (P = .04). The average cost per encounter increased by 20% and the total cost of care increased by $1.6 million. CONCLUSION: After limitation of dental benefits, there was an increase in the volume and severity of odontogenic infections. In addition, there was an escalated health care cost. The negative public health effects and increased economic impact of eliminating basic dental care show the importance of affordable and accessible preventative oral health care.

Oral and Maxillofacial Surgery Foundation Research and Fellowship Awards: A 26-Year Review at Massachusetts General Hospital and Harvard School of Dental Medicine.

PURPOSE: The purpose of this study was to review outcomes of the Oral and Maxillofacial Surgery (OMS) Foundation's funding awards to members of the OMS department at Massachusetts General Hospital (MGH) in terms of projects completed, abstracts presented, peer-reviewed publications, and career trajectories of recipients. MATERIALS AND METHODS: Data were collected from MGH and OMS Foundation records and interviews with award recipients. Primary outcome variables included 1) number of awards and award types, 2) funding amount, 3) project completion, 4) number of presented abstracts, 5) conversion from abstracts to publications, 6) number of peer-reviewed publications, 7) career trajectories of awardees, and 8) additional extramural funding. RESULTS: Eleven Student Research Training Awards provided $135,000 for 39 projects conducted by 37 students. Of these, 34 (87.2%) were completed. There were 30 student abstracts presented, 21 peer-reviewed publications, and a publication conversion rate of 58.8%. Faculty research awards comprised $1,510,970 for 22 research projects by 12 faculty members and two research fellows. Of the 22 funded projects, 21 (95.5%) were completed. There were 110 faculty and research fellow abstracts presented and 113 peer-reviewed publications, for a publication conversion rate of 93.8%. In the student group, 17 of 37 (45.9%) are enrolled in or are applying for OMS residencies. Of the 10 students who have completed OMS training, 3 (30%) are in full-time academic positions. Of the 12 faculty recipients, 9 (75%) remain in OMS academic practice. During this time period, the department received $9.9 million of extramural foundation or National Institutes of Health funding directly or indirectly related to the OMS Foundation grants. CONCLUSIONS: The results of this study indicate that 90.2% of projects funded by the OMS Foundation have been completed. Most projects resulted in abstracts and publications in peer-reviewed journals. These grants encouraged students to pursue OMS careers and aided OMS faculty in developing their research programs.

The relative patient costs and availability of dental services, materials and equipment in public oral care facilities in Tanzania.

BACKGROUND: Patient charges and availability of dental services influence utilization of dental services. There is little available information on the cost of dental services and availability of materials and equipment in public dental facilities in Africa. This study aimed to determine the relative cost and availability of dental services, materials and equipment in public oral care facilities in Tanzania. The local factors affecting availability were also studied. METHODS: A survey of all district and regional dental clinics in selected regions was conducted in 2014. A total of 28/30 facilities participated in the study. A structured interview was undertaken amongst practitioners and clinic managers within the facilities. Daily resources for consumption (DRC) were used for estimation of patients' relative cost. DRC are the quantified average financial resources required for an adult Tanzanian's overall consumption per day. RESULTS: Tooth extractions were found to cost four times the DRC whereas restorations were 9-10 times the DRC. Studied facilities provided tooth extractions (100%), scaling (86%), fillings (79%), root canal treatment (46%) and fabrication of removable partial dentures (32%). The ratio of tooth fillings to extractions in the facilities was 1:16. Less than 50% of the facilities had any of the investigated dental materials consistently available throughout the year, and just three facilities had all the investigated equipment functional and in use. CONCLUSIONS: Dental materials and equipment availability, skills of the practitioners and the cost of services all play major roles in provision and utilization of comprehensive oral care. These factors are likely to be interlinked and should be taken into consideration when studying any of the factors individually.

An audit into the reasons why treatment was not completed as planned under intravenous sedation in an adult oral surgery department, and the cost implications.

This audit aimed to identify the prevalence of, and reasons for failed intravenous conscious sedation in an adult oral surgery department, to develop recommendations to reduce such failures and to identify any cost implications. Data were collected prospectively for three months for all intravenous sedation appointments in the Oral Surgery department. Data were collected for 109 sedation appointments of which 83 were successful (76%). The failure rate (24%) was higher than the acceptable departmental failure rate (10%), and included reasons for failure that should have been avoided by a thorough patient assessment prior to treatment. Of the 26 failures, the most common reasons for failure were: cancellation: 8 patients (30.8%), failure to attend: 6 patients (23.1%), excessively late arrival of patient: 4 patients (15.4%) and failure to cannulate: 3 patients (11.6%). When sedation was unsuccessful, 13 of the 26 patients (50%) had their treatment successfully completed under local anaesthesia alone, 10 patients (38%) were rebooked for sedation and 3 patient. (12%) were rebooked for a general anaesthetic. Identifying and correcting the reasons for failure can result in vast savings in appointment time, clinical resources and cost. That 13 patients subsequently had their treatment completed under local anaesthesia alone opens the debate on how rigorous the patient assessment and allocation of sedation appointments was, and the potential to achieve savings.

Economic evaluation of single-tooth replacement: dental implant versus fixed partial denture.

PURPOSE: This study assessed the cost-effectiveness from a societal perspective of a dental implant compared with a three-unit tooth-supported fixed partial denture (FPD) for the replacement of a single tooth in 2010. MATERIALS AND METHODS: A decision tree was developed to estimate cost-effectiveness over a 10-year period. The survival rates of single-tooth implants and FPDs were extracted from a meta-analysis of single-arm studies. Medical costs included initial treatment costs, maintenance costs, and costs to treat complications. Patient surveys were used to obtain the costs of the initial single-tooth implant or FPD. Maintenance costs and costs to treat complications were based on surveys of seven clinical experts at dental clinics or hospitals. Transportation costs were calculated based on the number of visits for implant or FPD treatment. Patient time costs were estimated using the number of visits and time required, hourly wage, and employment rate. Future costs were discounted by 5% to convert to present values. RESULTS: The results of a 10-year period model showed that a single dental implant cost US $261 (clinic) to $342 (hospital) more than an FPD and had an average survival rate that was 10.4% higher. The incremental cost-effectiveness ratio was $2,514 in a clinic and $3,290 in a hospital for a prosthesis in situ for 10 years. The sensitivity analysis showed that initial treatment costs and survival rate influenced the cost-effectiveness. If the cost of an implant were reduced to 80% of the current cost, the implant would become the dominant intervention. CONCLUSION: Although the level of evidence for effectiveness is low, and some aspects of single-tooth implants or FPDs, such as satisfaction, were not considered, this study will help patients requiring single-tooth replacement to choose the best treatment option.

Caregivers' health literacy and their young children's oral-health-related expenditures.

Caregivers' health literacy has emerged as an important determinant of young children's health care and outcomes. We examined the hypothesis that caregivers' health literacy influences children's oral-health-care-related expenditures. This was a prospective cohort study of 1,132 child/caregiver dyads (children's mean age = 19 months), participating in the Carolina Oral Health Literacy Project. Health literacy was measured by the REALD-30 (word recognition based) and NVS (comprehension based) instruments. Follow-up data included child Medicaid claims for CY2008-10. We quantified expenditures using annualized 2010 fee-adjusted Medicaid-paid dollars for oral-health-related visits involving preventive, restorative, and emergency care. We used descriptive, bivariate, and multivariate statistical methods based on generalized gamma models. Mean oral-health-related annual expenditures totaled $203: preventive--$81, restorative--$99, and emergency care--$22. Among children who received services, mean expenditures were: emergency hospital-based--$1282, preventive--$106, and restorative care--$343. Caregivers' low literacy in the oral health context was associated with a statistically non-significant increase in total expenditures (average annual difference = $40; 95% confidence interval, -32, 111). Nevertheless, with both instruments, emergency dental care expenditures were consistently elevated among children of low-literacy caregivers. These findings provide initial support for health literacy as an important determinant of the meaningful use and cost of oral health care.

Time and cost analysis: pediatric dental rehabilitation with general anesthesia in the office and the hospital settings.

Pediatric dental patients who cannot receive dental care in the clinic due to uncooperative behavior are often referred to receive dental care under general anesthesia (GA). At Stony Brook Medicine, dental patients requiring treatment with GA receive dental care in our outpatient facility at the Stony Brook School of Dental Medicine (SDM) or in the Stony Brook University Hospital ambulatory setting (SBUH). This study investigates the time and cost for ambulatory American Society of Anesthesiologists (ASA) Class I pediatric patients receiving full-mouth dental rehabilitation using GA in these 2 locations, along with a descriptive analysis of the patients and dental services provided. In this institutional review board-approved cross-sectional retrospective study, ICD-9 codes for dental caries (521.00) were used to collect patient records between July 2009 and May 2011. Participants were limited to ASA I patients aged 36-60 months. Complete records from 96 patients were reviewed. There were significant differences in cost, total anesthesia time, and recovery room time (P < .001). The average total time (anesthesia end time minus anesthesia start time) to treat a child at SBUH under GA was 222 ± 62.7 minutes, and recovery time (time of discharge minus anesthesia end time) was 157 ± 97.2 minutes; the average total cost was $7,303. At the SDM, the average total time was 175 ± 36.8 minutes, and recovery time was 25 ± 12.7 minutes; the average total cost was $414. After controlling for anesthesia time and procedures, we found that SBUH cost 13.2 times more than SDM. This study provides evidence that ASA I pediatric patients can receive full-mouth dental rehabilitation utilizing GA under the direction of dentist anesthesiologists in an office-based dental setting more quickly and at a lower cost. This is very promising for patients with the least access to care, including patients with special needs and lack of insurance.

Characteristics of dental clinics in US children's hospitals.

PURPOSE: This study's purpose was to describe the workforce, patient, and service characteristics of dental clinics affiliated with US children's hospitals belonging to the National Association of Children's Hospital and Related Institutions (NACHRI). METHODS: A 2-stage survey mechanism using ad hoc questionnaires sought responses from hospital administrators and dental clinic administrators. Questionnaires asked about: (1) clinic purpose; (2) workforce; (3) patient population; (4) dental services provided; (5) community professional relations; and (5) relationships with medical services. RESULTS: Of the 222 NACHRI-affiliated hospitals, 87 reported comprehensive dental clinics (CDCs) and 64 (74%) of CDCs provided data. Provision of tertiary medical services was significantly related to presence of a CDC. Most CDCs were clustered east of the Mississippi River. Size, workload, and patient characteristics were variable across CDCs. Most were not profitable. Medical diagnosis was the primary criterion for eligibility, with all but 1 clinic treating special needs children. Most clinics (74%) had dental residencies. Over 75% reported providing dental care prior to major medical care (cardiac, oncology, transplantation), but follow-up care was variable. CONCLUSIONS: Many children's hospitals reported comprehensive dental clinics, but the characteristics were highly variable, suggesting this element of the pediatric oral health care safety net may be fragile.

Doctor, my tooth hurts: the costs of incomplete dental care in the emergency room.

OBJECTIVES: This study aims to examine the charges and frequency of return visits for treating dental health problems in hospital emergency rooms (ERs) in order to provide a basis for policy discussion concerning cost-effective and appropriate treatment for those without access to private dental services. METHODS: Records were abstracted from hospital administrative data systems for dental-related ER visits from five major hospital systems in the Minneapolis-St. Paul metropolitan area during a 1-year period. Data on the number of visits and charges were analyzed by age and type of payor (public or private). Similar data were obtained from records for a commercially insured population from a single large employer. RESULTS: There were over 10,000 visits to ERs for dental-related problems with total charges reaching nearly $5 million in 1 year, mainly charged to public programs and reimbursed at about 50 percent. The frequency of repeat visits suggests that while acute pain and infection were treated by the ER physicians, the underlying dental problem often was not resolved. In contrast, a population with commercial dental insurance rarely used hospital ERs for dental problems. CONCLUSIONS: Access to preventive and restorative dental care is a critical public health problem in the United States, particularly for those without insurance and those covered by public programs. Public health policy initiatives such as the use of dental therapists should be expanded to improve access and to provide alternatives that offer more complete and less costly care for oral health problems than do hospital ERs.

Retrospective audit of Taranaki children undergoing dental care under general anaesthetic from 2001 to 2005.

A retrospective audit of trends in day-stay treatment for dental caries at a New Zealand hospital dental unit showed that demand for treatment has risen. The annual number of children undergoing a GA increased by over 13%, although the average waiting time after the initial consultation decreased. The cost of treatment also dramatically increased with time, as the numbers and complexity of cases increased. The type of treatment under GA changed over the five years, with more extractions occurring over the course of the audit. Restorations were still the most common treatment item provided, although the use of SSC trebled in 2004 and 2005. Socio-economic status, sex and ethnic differences were observed, with more boys and Maori receiving GA care and having a higher number of extractions. These children were identified as being high users of other hospital services (such as the Emergency Department).

Estimating unit costs for dental service delivery in institutional and community-based settings in southern Thailand.

In this cross-sectional study, the cost of different dental services was estimated and the unit costs of dental services for schoolchildren were compared between 2 settings: hospital-based and community-based mobile dental clinics. Heads of all departments in a selected community hospital were invited to attend 2 workshops to collect relevant data. Unit costs of different dental services varied from 41 to 2693 baht, with services falling into 4 unit cost groups: very high, high, moderate, and low. The very-high-unit-cost services included rehabilitative dental services. The high-unit-cost services covered removal of an impacted tooth, root canal treatment, and tooth-color fillings. The moderate-unit-cost group included a wide range of other dental services, with screening and oral hygiene instruction in community-based dental clinics falling into the low-unit-cost group. Generally, services provided in the community-based mobile clinic had lower unit costs than the same services provided in the hospital dental clinic.

Orthognathic cases: what are the surgical costs?

This multicentre, retrospective, study assessed the cost, and factors influencing the cost, of combined orthodontic and surgical treatment for dentofacial deformity. The sample, from a single region in England, comprised 352 subjects treated in 11 hospital orthodontic units who underwent orthognathic surgery between 1 January 1995 and 31 March 2000. Statistical analysis of the data was undertaken using non-parametric tests (Spearman and Wilcoxon signed rank). The average total treatment cost for the tax year from 6 April 2000 to 5 April 2001 was euro6360.19, with costs ranging from euro3835.90 to euro12 150.55. The average operating theatre cost was euro2189.54 and the average inpatient care (including the cost of the intensive care unit and ward stay) was euro1455.20. Joint clinic costs comprised, on average, 10 per cent of the total cost, whereas appointments in other specialities, apart from orthodontics, comprised 2 per cent of the total costs. Differences in the observed costings between the units were unexplained but may reflect surgical difficulties, differences in clinical practice, or efficiency of patient care. These indicators need to be considered in future outcome studies for orthognathic patients.

Changes and factors associated with dentists' willingness to treat patients with severe disabilities.

OBJECTIVE: This study investigated changes in dentists' willingness to treat severely disabled patients and to understand dentists' opinions on reimbursements after the implementation of a dental care financial reward program in Taiwan. METHODS: Three hundred dentists from 29 teaching hospitals were randomly selected to answer a structured questionnaire, and 184 structured questionnaires were returned. Multiple regression analysis was used to examine the factors associated with dentists' willingness to treat severely disabled patients. RESULTS: Approximately 60% of the dentists said reimbursements for treatment of severely disabled patients were reasonable. 50.4% of dentists were willing or very willing to treat disabled patients. Seventy-nine percent dentists affected by the program had a higher willingness but 83.7% dentists said this program did not make a significant difference to their income. 52.8% of dentists agreed the program would increase the quality of dental care. The factors significantly affecting dentists' willingness included dentist's age, specialty field, perception of the program in promoting the quality of dental services, and perception of the ability to provide adequate treatments for severely disabled patients. CONCLUSIONS: The rewards program significantly increased the willingness of most hospital-base dentists to treat the severely disabled patients although the effect of incentive to their income was limited.

Measuring the cost, effectiveness, and cost-effectiveness of orthodontic care.

AIM: To determine the relative effectiveness and cost-effectiveness of orthodontic treatment per case in one "fee for item" and two different types of salaried orthodontic clinics. SUBJECTS AND METHODS: This prospective study recruited a random sample of six self-employed orthodontists (fee-for-item) and six orthodontists from both hospital and community clinics (salaried services). One hundred patients were followed to completion of orthodontic care. Questionnaires were employed to determine cost of treatment from the clinicians' and patients' points of views. Four cost-effectiveness models were developed. RESULTS: Complete records of outcome were available for 1,087 patients, but only 789 had complete data on costing. Three of the four cost-effectiveness models indicated similar rankings for the 18 clinicians. The most cost-effective service was provided by clinicians working in community clinics, followed by clinicians working in hospitals, then self-employed clinicians. The preferred cost-effective model takes into consideration the initial need and successful outcome of orthodontic treatment. CONCLUSION: Cost-effectiveness models have been developed to quantify the performance of individual clinicians working in self-employed and salaried clinics. Costs and effectiveness of the clinicians in each clinical setting show considerable variation.