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Hospital-Based Emergency Department PEDIATRIC DENTISTRY V 36 / NO 5 SEP / OCT 14 Clinical Article OA CROSS-SECTIONAL STUDY Hospital-based Emergency Department Visits with Dental Conditions among Children in the United States: Nationwide Epidemiological Data Veerasathpurush Allareddy, BDS, MBA, MHA, MMSc, PhD1 • Romesh P. Nalliah, BDS2 • Mehedia Haque, BA3 • Hope Johnson, BS4 • Sankeerth Rampa B. Tech, MBA, MPH5 • Min Kyeong Lee, DMD6 Abstract: Purpose: To provide nationally representative estimates of hospital-based emergency department visits (ED) for dental caries, pulp and periapical lesions, gingival/periodontal lesions, and mouth cellulitis occurring among patients who were 21 years old and younger. Methods: Nationwide Emergency Department Sample (NEDS) for the year 2008 was used. All ED visits with dental conditions were included. Discharge patterns, demographics, disposition following ED visit, and hospital charges, were examined. NEDS is a uniform, stratified dataset, and can be projected to the national level. Results: A total of 215,073 ED visits with dental conditions occurred among children. These visits included diagnosis of dental caries (50 percent of visits), pulpal and periapical conditions (41 percent), gingival (15 percent) and periodontal diseases (five percent), and mouth abscess/cellulitis (three percent). Forty-two percent were covered by Medicaid, and 32 percent were uninsured. Mean charge per visit was $564, and total ED charge across the United States (US) was $104.2 million. Among those hospitalized following ED visits, total hospitalization charge across US was $162 million. Conclusions: A substantial amount of hospital resources are spent treating dental con- ditions in the ED. A total of 43 percent of ED visits were covered by Medicaid, and 32 percent were uninsured. (Pediatr Dent 2014;36:393-9) Received May 10, 2013 | Last Revision December 12, 2013 | Accepted December 12, 2013 KEYWORDS: EMERGENCY ROOM, EPIDEMIOLOGY, HOSPITAL CHARGES, MEDICAID While overall rates of dental caries are declining, the Surgeon coverage as barriers.11-14 Furthermore, treatment of these con- General’s report concludes that oral health disease and access ditions is often postponed until the problem and/or pain is to care disparities are increasing among the “poor, racial, and so severe that help is sought in a hospital emergency depart- ethnic minorities, those born outside the United States, disabled ment (ED).5-8 However, most EDs are not equipped to provide persons, and the elderly” who suffer from greater rates of lack definitive dental treatment. Moreover, the costs associated with of insurance and dental disease, including caries and perio- treating dental conditions in a hospital ED setting are much dontal disease.1 A study from the Kaiser Foundation revealed higher than the costs associated with the treatment needed to that, in 2009, 19 million, or approximately 25 percent of all prevent them.15 children in America, did not have insurance covering dental A study among adults by Cohen et al. found that fewer care.2 Davis et al. stated that fewer than half of all dentists than 60 percent of people with toothache presented to the participate in public dental insurance programs, and even those dental office for care,15 and it may be possible to expect adult who do may restrict the number served.3 parents to manage their childrens’ toothaches in similar ways. In 2012, the Affordable Care Act (ACA) mandated that, Cohen et al. reported that 20 percent of patients contacted a by 2014, all health plans are to include dental insurance for physician, and nearly 10 percent presented to the hospital ED. children. This is important, as dental caries is the most prev- Of those who sought care in a hospital ED, 80 percent sub- alent chronic childhood disease4 and can cause pain, lead to sequently went to the dentist, suggesting that the ED did not difficulty eating, and affect speech, nutrition, growth, and provide definitive treatment. In fact, Cohen et al. demonstrated overall quality of life. that 96 percent of patients who presented with a dental com- It has been well established that lack of access to dental care plaint to a hospital ED subsequently went to see a dentist. This can lead to a sequela of dental disease. These sequelae include, would suggest that the ED does not replace, but only post- but are not limited to, caries, infection and abscess, periodontal pones, the dental visit. Therefore, effective diversion programs disease, facial infections, airway involvement, and Ludwig’s that help these patients seek dental care in a dental office angina.5-10 While many of these conditions could have been (rather than a hospital ED) could reduce government costs avoided with early preventive oral health interventions, studies on health care. suggest that adults and children do not receive regular dental A national study from 1997-2000 by Lewis et al. found care, citing lack of financial resources and dental insurance that approximately 738,000 million patients per year, which is less than one percent of all ED visits, resulted from a dental complaint.16 Children younger than 18 years old comprised 15 percent of these visits. Clearly, there is evidence to suggest 1 Dr. Allareddy is an associate professor, Department of Orthodontics, College of Den- tistry, The University of Iowa, Iowa City, Iowa. 2Dr. Nalliah is a senior tutor, Castle that some children with oral health conditions do not receive Society, Office of Dental Education; 3Ms. Haque and 4Johnson are dental students; and routine care in a dental office and present to the hospital ED 6Dr. Lee is an orthodontic resident, Department of Developmental Biology, all at Har- instead. vard School of Dental Medicine, Boston, Mass. 5Mr. Tech is an independent statistical The purpose of this study was to provide nationally repre- consultant, Cleveland, Ohio, USA. sentative estimates of hospital-based emergency department Correspond with Dr. Nalliah at [email protected] PEDIATRIC DENTAL CONDITIONS 393 PEDIATRIC DENTISTRY V 36 / NO 5 SEP / OCT 14 visits for dental caries, pulp and periapical lesions, gingival/ Methods periodontal lesions, and mouth cellulitis occurring among The Nationwide Emergency Department Sample (NEDS) for patients who were 21 years old and younger. the year 2008, a component database of the Healthcare Cost and Utilization Project (HCUP) family of datasets, was Table 1. DIAGNOSIS OF HOSPITAL-BASED EMERGENCY DEPARTMENT VISITS used for the current study. The HCUP is sponsored by IN CHILDREN (<21 YEARS OLD) IN THE UNITED STATES IN 2008 the Agency for Healthcare Research and Quality (AHRQ), Baltimore, Md., USA17 NEDS is a 20 percent (n=215,073) stratified representative sample of all acute care hos- Characteristic Response n (%) pitals in the United States. Each hospital drawn into Dental caries Dental caries, unspecified (521.00) 98,605 (46) the sample provides information on all hospital ED (ICD-9-CM code) Dental caries limited to enamel (521.01) 55 (<1) visits that occurred in that calendar year. Each ED Dental caries extending into dentin (521.02) 61 (<1) visit is assigned a sampling weight. These weights are Dental caries extending into pulp (521.03) 251 (<1) used to provide 100 percent representative estimates of all ED visits occurring across the United States. Arrested dental caries (521.04) DS† NEDS has been validated and is sponsored by AHRQ Odontoclasia (521.05)* DS for research purposes. Several peer-reviewed papers Dental caries of pits and fissures (521.06) 16 (<1) have been published using the NEDS dataset. NEDS Dental caries of smooth surfaces (521.07) 13 (<1) is the largest all-payer ED visits database in the Dental caries of root surfaces (521.08) 32 (<1) United States.17 Other dental caries (521.09) 8,640 (4) The NEDS dataset provides information on more Any one of above 107,663 (50) than 100 patient and hospital-related variables, includ- Diseases of pulp Pulpitis (522.0) 1,269 (<1) ing age in years, gender, payer information (Medicare, and periapical Necrosis of the pulp (522.1) 64 (<1) Medicaid, private insurance plans, uninsured, and tissues Pulp degeneration (522.2) 14 (<1) other insurance plans), and information on up to 15 (ICD-9-CM code) Abnormal hard tissue formation in pulp (522.3) DS diagnostic fields to estimate the comorbid burden and Acute apical periodontitis of pulpal origin 14,701 (7) median household income levels based on geographic (522.4) zip codes. Additionally, there is information on: dis- Periapical abscess without sinus (522.5) 71,087 (33) position status following ED visit; disposition status Chronic apical periodontitis (522.6) 64 (<1) following hospitalization as an inpatient into the Periapical abscess with sinus (522.7) 374 (<1) same hospital; weekend/day of ED visit; location of Radicular cyst (522.8) 64 (<1) patient; hospital ED charges; hospitalization charges; Other and unspecified diseases of pulp and 243 (<1) and length of stay in the hospital. Information on the periapical tissues (522.9) hospital’s geographic region (Northeast, South, Midwest, Any one of above 87,589 (41) or Western regions of the United States) and teaching Gingival diseases Acute gingivitis, plaque induced (523.00) 3,871 (2) status (metropolitan teaching, metropolitan nonteach- (ICD-9-CM code) Acute gingivitis, nonplaque induced (523.01) 467 (<1) ing, and nonmetropolitan hospitals) is also captured Chronic gingivitis, plaque induced (523.10) 28,406 (13) in this dataset. Chronic gingivitis, nonplaque induced (523.11) 376 (<1) An institutional review board exemption was ob- Gingival recession, unspecified (523.20) 31 (<1) tained from the Harvard School of Dental Medicine, Gingival recession, minimal (523.21) DS Boston, Mass., for the conduct of this study. The Gingival recession, moderate (523.22) DS NEDS dataset is publicly available data that is available Gingival recession, severe (523.23) DS for purchase from the AHRQ following the data user Gingival recession, localized (523.24) DS agreement (DUA) training.
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