Christopher Okunseri, BDS, MSc, MLS, DDPHRCSE, FFDRCSI, Elaye Okunseri, MBA, MSHR, Thorpe JM, PhD., Xiang Qun, MS.

Transcription

1 Dental Health Services Research Team Christopher Okunseri, BDS, MSc, MLS, DDPHRCSE, FFDRCSI, Elaye Okunseri, MBA, MSHR, Thorpe JM, PhD., Xiang Qun, MS., Aniko Szabo, PhD

2 Research Support: National Institute of Health grant #1R15DE This presentation was not sponsored by any corporate and professional organization.

3 Disclaimer The findings shared in my presentation are that of my research team. They do not necessarily reflect Marquette University s or Marquette University School of Dentistry s position. Also, my presentation is not intended to provide specific regulatory or legal advice. To obtain such information you should consult with your company s or university s clinical and regulatory specialist, and legal counsel.

4 Opioid and Non-Opioid Prescriptions for Dental Care in U.S. Emergency Departments

5 Current Terminologies Nontraumatic Dental Conditions (NTDCs) or preventable dental conditions: Direct sequelae from one of the two most common chronic dental conditions. Ambulatory Care Sensitive Conditions (ACSCs): Conditions for which good outpatient care could potentially prevent the need for hospitalization, or for which early intervention could prevent complications or more severe disease" (AHRQ 2004)

6 Emergency Departments Critical component of our health care system. Serve as an interface between the public and health care. Act as providers of last resort for millions of under- and uninsured patients who lack adequate access to dental and medical care. Provide assessment, stabilization and referral for individuals with acute conditions and injuries.

7 Introduction Nationally, NTDC visits increased by 54% at an annual rate of 4% from 1997 to Medicaid and self-pay patients are significantly more likely to make NDTC visits. Compared to whites, racial/ethnic minorities have significantly higher odds of making NTDC visits.

8 Background Most patients with NTDCs present to emergency departments with toothache/pain. Nationally, prescription of medications for NTDC visits in EDs have increased substantially over time. Adults years old have significantly higher odds of receiving antibiotics and analgesics for NDTC visits in EDs. Whites have significantly higher odds of receiving any medication for NTDC visits at the ED.

9 Background In the short-term analgesics are critical for managing acute pain Long-term use of analgesics could mask symptoms of underlying injury or disease and create a potential for pain tolerance, substance abuse and exacerbate drugseeking behavior among addicts of analgesics.

10 Background Most studies on the prescribing practices of emergency physicians for analgesics have largely focused on medical conditions, and very little has been reported on NTDC visits in the U.S. Despite documented evidence of disparities in emergency physicians prescribing practices of pain medications for medical conditions, limited information, if any, exists on possible disparities for NTDC visits.

11 Study Objective The primary aim of this study was to examine rates and trends in the prescription of opioids, non-opioids, combinations (opioids and nonopioids) and no analgesics by U.S. emergency physicians for NTDC visits. The secondary aim was to estimate the probability of receiving a prescription for opioids, non-opioids, and a combination compared to no analgesics in EDs for NTDC visits, adjusting for available covariates.

12 Methods Study Design: Retrospective secondary data analysis. Data Source: The National Hospital Ambulatory Medical Care Survey for Data collection: Information from medical records focused on visits by patients with nontraumatic dental conditions as the primary diagnosis.

13 Methods ICD-9-CM codes used for NTDCs: (diseases of dental hard tissues of teeth) (diseases of pulp and periapical tissues) (gingival and periodontal diseases) (retained dental root) (unspecified disorder of the teeth and supporting structures) (internal structures of mouth, without broken tooth).

14 Measures Primary outcome: Proportions of visits for which a prescription of opioids, non-opioids (non-steroidal antiinflammatory drugs or acetaminophen), combinations (opioids and non-opioids), or no analgesics were provided. The NHAMCS records up to 8 medications associated with each ED visit. Analgesic prescriptions were identified by searching the Multum Lexicon codes for central nervous system agents (level 1 Lexicon code: 057) with analgesic therapeutic effects (level 2 Lexicon code: 058). Thereafter, analgesics were further classified into opioids (level 3 Lexicon codes 060, 191) and non-opioids (level 3 Lexicon codes 058, 059, , 278).

15 Independent Measures Age, gender, race/ethnicity (non-hispanic White, non- Hispanic Black, Hispanic, other) Payer type or expected source of payment (selfpay, Medicare, Medicaid, private insurance, other, unknown) Hospital emergency department ownership (voluntary non-profit, government (nonfederal), and proprietary) Provider type (MD, staff, other).

16 Independent Measures Hospital location (Northeast, South, Midwest, and West) Pain severity (severe, moderate, mild, none, and unknown) Location in a metropolitan statistical area (nonmetropolitan statistical area and metropolitan statistical area) Patient-stated reason for visit (dental vs. nondental).

17 Statistical Analysis Conceptual framework: ED providers have mainly 4 options for management of pain due to NTDCs: no analgesics, opioids, non-opioids, and combinations (opioids and non-opioids). Descriptive statistics and multinomial multivariate logistic regression were performed. All analyses were adjusted for the survey design.

18 Statistical Analysis Multinomial logistic regression: Estimates of the multiplicative effect of each predictor on the relative risk of an outcome category, such as receiving only an opioid prescription, to the reference category of no analgesic prescription. For example, if a patient with mild pain is 1.1 times more likely to receive an opioid-only prescription than no analgesic, and a patient with severe pain is 4.1 times more likely to receive opioid-only prescription than no analgesic, then the relative risk ratio for severe versus mild pain is 4.1/1.1=3.7

19 Statistical Analysis Multiple imputation methodology as implemented in MI and MiAnalyze SAS procedures to incorporate missing data. An alpha level of 0.05 was used throughout to denote statistical significance. All statistical analyses were performed using SAS software Version 9.2 (SAS Institute Inc, Cary, NC), with the primary model fitted using the Surveylogistic procedure.

20 Results - Descriptive Statistics A total of 4,726 records with NTDC as primary diagnosis were identified. Prescription of pain medications were as follows: Opioids 43%, non-opioids 20%, combination 12% and no analgesic 25%. 56% were white, non-hispanic Blacks 21%, and 54% were females. More than two-thirds were between ages

21 Results - Descriptive Statistics 80% of NTDC visits were in a metropolitan area. In 90% of visits an emergency department physician was seen. 25% of NTDC visits were for severe pain. Largest proportion of NTDC visits was in the Southern region (41%). 71% of NTDC visits were at voluntary nonprofit owned EDs (71%) and by self-payers.

22 Results-Descriptive Statistics Prescription of opioids increased from 32% in 1997 to 44% in 2007, peaking at 49% in 2006 (p<0.001 for trend). Prescription of combination therapy medication rose from 5% in 1997 to 13% in 2007, and was most pronounced in 2004 at 17% (p<0.001 for trend). Prescription of no analgesics decreased from 35% in 1997 to 19% in 2007 (p<0.001 for trend).

23 Proportion of Visits Where Opioids, Non-Opioids, Both (Combination of Opioids and Non-opioids) and No Analgesics Were Prescribed for NTDCs in EDs by Population Characteristics Predictor No analgesics provided Non-opioids only Opioids only Age group Both Opioids and non-opioids P-value 0-4 years 43.7 (3.9) 44.3 (4.2) 9.9 (2.6) 2.1 (1.0) < years 30.4 (2.9) 28.6 (3.1) 33.1 (3.5) 8.0 (1.5) years 20.9 (1.6) 18.4 (1.3) 47.4 (1.8) 13.2 (1.0) years 21.6 (1.6) 16.8 (1.2) 48.3 (1.7) 13.3 (1.2) years 41.4 (4.1) 11.2 (2.0) 38.7 (3.9) 8.8 (2.2) over 73 years 60.4 (7.3) 25.5 (6.8) 11.3 (5.1) 2.8 (1.6) Provider Type MD 24.9 (1.1) 19.5 (0.9) 43.9 (1.4) 11.7 (0.7) No provider 41.4 (9.6) 15.3 (7.4) 34.8 (9.2) 8.5 (5.9) Staff only 23.7 (2.9) 23.3 (3.2) 39.4 (3.5) 13.6 (2.1) MSA MSA (Metropolitan Statistical Area) 24.9 (1.3) 19.9 (1.0) 42.9 (1.4) 12.4 (0.8) Non-MSA 25.2 (2.2) 19.6 (1.9) 45.8 (3.3) 9.3 (1.3) Hospital Ownership Government, non-federal 26.4 (1.9) 22.8 (2.2) 37.9 (2.2) 12.9 (1.4) Proprietary 23.1 (2.6) 16.4 (2.1) 49.4 (3.6) 11.1 (1.9) Voluntary non-profit 24.9 (1.4) 19.6 (1.0) 43.9 (1.5) 11.6 (0.8)

24 Proportion of Visits Where Opioids, Non-Opioids, Both (Combination of Opioids and Non-opioids) and No Analgesics Were Prescribed for NTDCs in EDs by Population Characteristics No analgesics provided Non-opioids only Opioids only Both Opioids and non-opioids Predictor P-value Pain Severity None 62.5 (4.7) 25.9 (4.7) 10.3 (2.8) 1.2 (0.7) <.0001 Mild 32.8 (2.6) 23.6 (2.4) 37.0 (3.5) 6.5 (1.1) Moderate 21.5 (1.8) 19.5 (2.0) 46.6 (2.3) 12.4 (1.5) Severe 13.1 (1.6) 15.9 (1.5) 54.1 (2.4) 16.9 (1.6) Unknown 28.9 (1.6) 20.8 (1.4) 39.7 (1.7) 10.6 (0.9) Sex Female 25.0 (1.4) 19.1 (1.2) 43.7 (1.7) 12.2 (0.9) Male 24.9 (1.3) 20.7 (1.1) 43.1 (1.6) 11.3 (0.8) Payer type Medicaid 26.3 (1.9) 21.1 (1.6) 41.1 (2.2) 11.5 (1.2) Medicare 37.6 (3.6) 17.5 (3.0) 35.6 (3.7) 9.4 (2.2) Other 25.2 (4.2) 16.5 (3.6) 50.8 (5.0) 7.5 (2.3) Private insurance 26.4 (1.8) 21.0 (1.6) 41.6 (2.0) 11.0 (1.2) Self-pay 19.7 (1.3) 19.0 (1.4) 48.0 (2.0) 13.4 (1.0) Unknown 28.5 (4.2) 17.5 (3.0) 41.4 (4.6) 12.5 (2.1) Race/ethnicity Hispanic 24.0 (2.2) 25.9 (2.6) 37.5 (2.9) 12.7 (1.9) Non-Hispanic Black 24.8 (1.6) 23.2 (1.8) 38.8 (1.8) 13.1 (1.3) Non-Hispanic White 24.1 (1.4) 17.6 (1.0) 47.0 (1.5) 11.3 (0.8) Other 29.3 (6.0) 24.6 (5.8) 42.1 (6.8) 4.0 (2.2) Unknown ethnicity 29.0 (3.2) 18.8 (2.4) 39.6 (3.4) 12.5 (2.0)

25 Proportion of Visits Where Opioids, Non-Opioids, Both (Combination of Opioids and Non-opioids) and No Analgesics Were Prescribed for NTDCs in EDs by Population Characteristics No analgesics provided Non-opioids only Opioids only Both Opioids and non-opioids Predictor P-value Region Midwest 26.4 (2.9) 19.9 (1.7) 43.6 (2.7) 10.2 (1.4) Northeast 26.4 (2.0) 25.6 (2.2) 34.4 (2.1) 13.6 (1.6) South 23.1 (1.6) 19.0 (1.6) 47.5 (2.3) 10.4 (0.9) West 25.7 (2.4) 14.2 (1.9) 44.4 (3.3) 15.7 (1.9) Self-reported reason for visit Dental reason 17.9 (1.4) 17.9 (1.1) 51.7 (1.6) 12.5 (0.8) <.0001 Non-dental reason 37.2 (1.6) 23.1 (1.2) 29.2 (1.6) 10.5 (1.0) Year (3.6) 27.7 (3.3) 31.9 (4.1) 5.2 (1.8) < (5.0) 22.2 (3.7) 36.5 (4.1) 6.8 (1.9) (4.7) 16.6 (3.1) 39.8 (4.1) 10.7 (2.7) (3.1) 20.4 (2.3) 43.5 (4.1) 8.1 (1.9) (2.7) 18.4 (2.3) 47.4 (3.4) 9.9 (1.8) (3.3) 19.0 (2.5) 44.7 (3.8) 10.2 (1.4) (2.8) 18.2 (2.2) 41.5 (2.9) 11.9 (2.1) (3.1) 18.7 (2.2) 43.7 (3.2) 17.0 (2.1) (2.4) 19.5 (2.6) 45.7 (3.8) 16.4 (1.9) (2.6) 16.2 (2.1) 49.0 (3.2) 13.5 (1.8) (2.2) 23.7 (2.5) 44.4 (3.1) 13.0 (1.7)

26 Results - Unadjusted Statistics Non-Hispanic Whites were more likely to receive prescriptions for opioids (47%) than Non-Hispanic Blacks (39%), and Hispanics (38%) (p<0.0011). Non-Hispanic Blacks (23%) and Hispanics (26%) were more likely to receive a prescription for nonopioids than Non-Hispanic Whites at 18% (p<0.0011). All racial/ethnic groups received similar proportions of no analgesic prescriptions.

27 Results of Multivariate Logistic Regression Analysis Compared to NTDC visits where patients were designated as being in severe pain, those with mild and moderate pain had a significantly lower probability of receiving a prescription for either opioids or combination therapy. Compared to non-hispanic Whites, Hispanics (RR=1.41, 95% CI ) had a significantly higher probability of receiving non-opioids for NTDC visits, but that of Non-Hispanic Blacks (RR=1.17, 95% CI ) was not significant.

28 Results of Multivariate Logistic Regression Analysis Compared to non-hispanic Whites, Non-Hispanic Blacks had a lower probability (RR= 0.83, 95% CI ) of receiving opioids for NTDC visits in EDs, but this was not significant. Compared to young adults (19-33 years old), children (0-18 years old) had a significantly lower probability of receiving a prescription for opioids and combination therapy and a higher probability of receiving a prescription for non-opioids, (especially among 0-4 years old) for NTDC visits.

29 Results of Multinomial Multivariate Logistic Regression: Relative Risk of Receiving only Non-Narcotic, only Narcotic, or Both Analgesics Compared to No Analgesics Predictor Non-opioids only vs. no analgesics Adjusted Relative Risk Ratio (95% Confidence Interval) Non- opioids only p-value Opioids only vs. no analgesics Opioids only p- value Opioids and nonopioids vs. no analgesics Opioids and non- opioids p-value Provider Type MD 1.00 (ref) 1.00 (ref) 1.00 (ref) No provider 0.42 ( ) ( ) ( ) Staff only 1.15 ( ) ( ) ( ) Metropolitan Statistical Area (MSA) MSA 1.00 (ref) 1.00 (ref) 1.00 (ref) Non-MSA 1.05 ( ) ( ) ( ) Pain Severity None 0.37 ( ) ( ) < ( ) <.0001 Mild 0.71 ( ) ( ) < ( ) <.0001 Moderate 0.81 ( ) ( ) ( ) Severe 1.00 (ref) 1.00 (ref) 1.00 (ref) Unknown 0.68 ( ) ( ) < ( ) Payer type Medicaid 0.87 ( ) ( ) ( ) Medicare 0.88 ( ) ( ) ( ) Other 0.79 ( ) ( ) ( ) Private insurance 1.00 (ref) 1.00 (ref) 1.00 (ref) Self-pay 1.10 ( ) ( ) ( )

30 Results of Multinomial Multivariate Logistic Regression: Relative Risk of Receiving only Non-Narcotic, only Narcotic, or Both Analgesics Compared to No Analgesics Predictor Non-opioids only vs. no analgesics Adjusted Relative Risk Ratio (95% Confidence Interval) Opioids only vs. Opioids only p- no analgesics value Non- opioids only p-value Opioids and nonopioids vs. no analgesics Opioids and non- opioids p-value Region Midwest 0.78 ( ) ( ) ( ) Northeast 1.00 (ref) 1.00 (ref) 1.00 (ref) South 0.85 ( ) ( ) ( ) West 0.56 ( ) ( ) ( ) Age group 0-4 years 1.78 ( ) ( ) < ( ) years 1.26 ( ) ( ) ( ) years 1.00 (ref) 1.00 (ref) 1.00 (ref) years 0.92 ( ) ( ) ( ) years 0.39 ( ) ( ) ( ) Over 73 years 0.75 ( ) ( ) ( ) Hospital Ownership Government, non ( ) ( ) ( ) Federal Proprietary 0.97 ( ) ( ) ( ) Voluntary non-profit 1.00 (ref) 1.00 (ref) 1.00 (ref)

31 Results of Multinomial Multivariate Logistic Regression: Relative Risk of Receiving only Non-Narcotic, only Narcotic, or Both Analgesics Compared to No Analgesics Adjusted Relative Risk Ratio (95% Confidence Interval) Predictor Non-opioids only vs. no analgesics Non- opioids only p-value Opioids only vs. no analgesics Opioids only p- value Opioids and non- opioids vs. no analgesics Opioids and non- opioids p-value Year 1.04 ( ) ( ) ( ) Race / Ethnicity Hispanic 1.41 ( ) ( ) ( ) Non-Hispanic 1.17 ( ) ( ) ( ) Black Non-Hispanic 1.00 (ref) 1.00 (ref) 1.00 (ref) White Other 1.10 ( ) ( ) ( ) Sex Female 0.95 ( ) ( ) ( ) Male 1.00 (ref) 1.00 (ref) 1.00 (ref) Self-reported Reason for visit Dental reason 1.00 (ref) 1.00 (ref) 1.00 (ref) Non-dental reason 0.64 ( ) ( ) < ( ) <. 0001

32 Limitations No information on quantity of opioids or nonopioids prescribed for each NTDC visit to ED. No information on whether patients requested opioids or non-opioids at NTDC visits. We are unable to determine whether the prescriptions for these medications were actually filled or the drugs taken.

33 Limitations Classification of race/ethnicity was determined by hospital interviewers based on their perceptions. The proportion of missing data on pain categorization. Potential exists for coding errors or misclassification of data collected.

34 Conclusions Nationally, we identified a substantial increase in the rates of prescription of opioids for NTDC visits in EDs over time. Opioids were prescribed in 1 out of every 2 NTDC visits. Non-opioids were prescribed in 1 out of every 5 NTDC visits.

35 Conclusions Combination therapy was prescribed in 1 out of every 10 NTDC visits. No analgesics were prescribed in 1 out of every 4 NTDC visits. No substantial racial/ethnic disparities found in ED physicians prescribing practices for opioids, but there was a significant association for non-opioids among Hispanics only.

36 Implications of ED Use for NTDCs Provides temporary care without the option for continuity of care. Public policy, workforce and program concerns with associated cost implications. Inappropriate and continuous use of EDs for NTDC visits may contribute to overcrowding and increased waiting times. Improved training for ED physicians on dental pain management.

37 Potential Solutions Different intervention strategies are required to reduce ED use for NTDCs given the population mix. Targeted distribution of dental providers to areas of high need. Establishment of after hours clinics staffed by dental healthcare providers. Improved use of electronic health records and case management.

38 THANKS FOR LISTENING

39 Future Opioid Prescribing Educational Opportunities May 2013 Opioid Prescribing Webinar TBA June 16-21, 2013 University of Utah School on Alcoholism and Other Drug Dependencies Sept , 2013 American Dental Association Conference on Dentist Health and Well-Being/Opioid Education Track For more information contact Alison Siwek at