A Randomized Controlled Trial of Emergency Department Dental Care Vouchers to Improve Care and Reduce Return Visits

Transcription

1 A Randomized Controlled Trial of Emergency Department Dental Care Vouchers to Improve Care and Reduce Return Visits Bjorn C. Westgard, Kory L. Kaye, Jeff P. Anderson, Abigail Zagar, Sandi Wewerka

2 Emergency Department Visits for Non-Traumatic Dental Conditions (NTDC) Common and increasing Costly and poorly reimbursed Palliative and not definitive Driven by modifiable factors Can be systematically reduced

3 Trends in Dental Emergency Department Visits per 1,000 Population, by Patient Age, 2006 to 2012

4 Percentage of Emergency Department Visits by Primary Payer, 2012

5 Prior Research 2011, 1697 NTDC visits, 970 (57%) Medicaid 2-week pilot of vouchers Patients with NTDC and Medicaid or no coverage 18 patients received, 10 redeemed, 2 returned Avg voucher care cost = $318, avg ED care = $ week query of NTDC returns 60 patients, 9 returned in 60 days for NTDC

6 Aim 1 To determine if distributing a voucher for free, prompt dental care decreases return rates to the emergency department after 30 and 90 days for patients without dental insurance or those covered by Medicaid dental insurance that have a visit for a non-traumatic dental condition. EMERGENCY Dental Clinic Dental Clinic

7 Aim 2 To determine if there is any reasonable ability for the treating MD to predict which patients will follow up with a dentist by utilizing their vouchers.

8 Aim 3 To compare treatment costs for visits for non-traumatic dental conditions between Regions Hospital s Emergency Department and HealthPartners Dental Clinics. $

9 Methods N=318 patients presenting to RH ED with NTDC in Uninsured or Medicaid Randomized* to voucher for timely dental care or usual care Voucher, N=130 (41%) No Voucher, N=188 (59%) *Some voucher patients left prior to receipt, classified as non-voucher Vouchers: clinic appointment and limited care subsidy Patients followed for 90 days of subsequent RH ED utilization Covariates: patient demographics, treatments in the ED

10 TABLE 1. Patient Characteristics at Baseline, Overall & by Voucher Assignment ALL (N=318) NO VOUCHER (N=188) VOUCHER ISSUED (N=130) VARIABLE N PCT 2 N PCT 3 N PCT 3 P-VALUE Age Mean ± SD 32.0 ± ± ± Min Med Max % % % % % % % % % Gender Female % % % Male % % % Race African-American % % % Asian 4 1.3% % % Caucasian % % % Native American % % % Other/Unknown % % % Ethnicity Non-Hispanic % % % Hispanic % % % Insurance Status Medicaid % % % Uninsured % % %

11 Voucher Redemption and Returns Voucher Redemption Not used = 64, Used = 64, Missing = 2 ED Returns (range 0-7) No return = 269 (85%), 1 return = 49 No associations between voucher assignment/redemption or ED returns and: Age, Gender, Race, Ethnicity, Insurance Administration of Antibiotics, Dental Block, Narcotics (In Dept or Prescription)

12 TABLE 2: ED Returns at 30 Days & 90 Days, by Voucher Assignment and Redemption Status ED RETURNS NO DENTAL VOUCHER DENTAL VOUCHER VOUCHER NOT REDEEMED VOUCHER REDEEMED (30 DAYS) N PCT 1 N PCT 1 P VALUE 2 N PCT 1 N PCT 1 P VALUE 3 P VALUE 4 P VALUE % % % % % 9 6.9% 5 7.6% 4 6.3% % 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % 1 0.8% 1 1.5% 0 0.0% Total % % % % ED RETURNS NO DENTAL VOUCHER DENTAL VOUCHER VOUCHER NOT REDEEMED VOUCHER REDEEMED (90 DAYS) N PCT 1 N PCT 1 P VALUE 2 N PCT 1 N PCT 1 P VALUE 3 P VALUE 4 P VALUE % % % % % % 6 9.1% 5 7.8% % 1 0.8% 1 1.5% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % 1 0.8% 1 1.5% 0 0.0% Total % % % %

13 TABLE 2. ED Returns at 30 Days & 90 Days, by Voucher Assignment and Redemption Status ED RETURNS NO DENTAL VOUCHER DENTAL VOUCHER VOUCHER NOT REDEEMED VOUCHER REDEEMED (30 DAYS) N PCT 1 N PCT 1 P VALUE 2 N PCT 1 N PCT 1 P VALUE 3 P VALUE 4 P VALUE % % % % % 9 6.9% 5 7.6% 4 6.3% % 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % 1 0.8% 1 1.5% 0 0.0% Total % % % % ED RETURNS NO DENTAL VOUCHER DENTAL VOUCHER VOUCHER NOT REDEEMED VOUCHER REDEEMED (90 DAYS) N PCT 1 N PCT 1 P VALUE 2 N PCT 1 N PCT 1 P VALUE 3 P VALUE 4 P VALUE % % % % % % 6 9.1% 5 7.8% % 1 0.8% 1 1.5% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % 1 0.8% 1 1.5% 0 0.0% Total % % % %

14 TABLE 3. Count models for number/rate of Emergency Department return visits VARIABLE ITT, 30 Days Voucher vs. No Voucher ITT, 90 Days Voucher vs. No Voucher As Treated, 30 Days Redemption vs. Unused Voucher As Treated, 90 Days Redemption vs. Unused Voucher UNADJUSTED RR (95% CI) P-VALUE ADJUSTED 1 RR (95% CI) P-VALUE 0.62 ( ) ( ) ( ) ( ) ( ) ( ) Adjusted for age and gender.

15 TABLE 4. Logistic Regression Models for Likelihood of ED Return at 30/90 Days by Voucher Assignment/Redemption Status 1 ED RETURN UNADJUSTED ADJUSTED 1 VARIABLE N N % OR 95% CI P-VALUE OR 95% CI P-VALUE Total % Intent to Treat, 30 Days No Voucher % Voucher % Intent to Treat, 90 Days No Voucher % Voucher % As Treated, 30 Days No Dental Clinic % Dental Voucher Redemption % As Treated, 90 Days No Dental Clinic % Dental Voucher Redemption %

16 Time to ED Return Visit by Dental Voucher Status

17 Time to ED Return Visit by Dental Voucher Assignment Time to ED Return Visit by Dental Voucher Redemption

18 TABLE 5. Cox models for Time to First Emergency Department return visit VARIABLE UNADJUSTED RR (95% CI) P-VALUE ADJUSTED 1 RR (95% CI) P-VALUE ITT, 30 Days Voucher vs. No Voucher 0.48 (0.23, 0.98) ITT, 90 Days Voucher vs. No Voucher 0.50 (0.26, 0.93) As Treated, 30 Days Redemption vs. No (Used) Voucher As Treated, 90 Days Redemption vs. No (Used) Voucher 0.43 (0.15, 1.22) (0.16, 1.29) (0.17, 1.08) (0.17, 1.11) Adjusted for age and gender.

19 TABLE 6. Accuracy of MDs in Predicting Redemption by Voucher Recipients PREDICTION DID NOT REDEEM REDEEMED TOTAL Will Not Use Voucher Will Use Voucher Total Accuracy Sensitivity Specificity Positive Predictive Value Negative Predictive Value 0.733

20 TABLE 6. Accuracy of MDs in Predicting Redemption by Voucher Recipients PREDICTION DID NOT REDEEM REDEEMED TOTAL Will Not Use Voucher Will Use Voucher Total Accuracy Sensitivity Specificity Positive Predictive Value Negative Predictive Value 0.733

21 Costs by voucher assignment: Total Charges

22 Costs by voucher assignment: Net Margin

23 TABLE 7. Generalized Linear Models for Emergency Department return costs VARIABLE UNADJUSTED β (95% CI) P-VALUE ADJUSTED 1 RR (95% CI) P-VALUE ITT, Total Charges Voucher vs. No Voucher 0.29 (-0.13, 0.70) As Treated, Total Charges Redemption vs. No (Used) Voucher 0.11 (-0.49, 0.72) (-0.35, 0.93) ITT, Net Margin Voucher vs. No Voucher (-46.16, 8.01) As Treated, Net Margin Redemption vs. No (Used) Voucher (-39.90, 26.74) (-40.28, 26.49) Adjusted for age and gender.

24 Aim 1: Evaluating Impact of Dental Vouchers on Return Visits Voucher Receipt (ITT) Significantly lower proportion of patients returning to the ED and longer time to first ED return. Voucher Use (As Treated) Significantly lower number of ED returns, relative to patients who did not receive or did not use a voucher.

25 Aim 2: Accuracy and Predictive Value of MD Predictions Sensitivity was very good Negative Predictive Value was fair Accuracy, Specificity, and Positive Predictive Value were poor

26 Aim 3: Costs Incurred by Voucher Assignment and Redemption No significant differences in total charge or net margin by voucher assignment (ITT) or voucher redemption (as treated) Dental clinic costs (voucher redemption) slightly higher average and much lower max than ED total costs

27 Limitations Limited by extent of voucher funds to assist dental payment Vouchers completed payment for dental visits Cost and margin data require more analysis

28 Conclusions Vouchers for prompt dental care can provide access to definitive care for NTDC and reduce ED return visits without changing ED margins Similar programs have been instituted elsewhere Such efforts show promise for improving care and cost as part of multifaceted interventions Cost-effectiveness needs further exploration Providers are poor predictors of voucher patient follow-up with dentistry

29 References Wall T, Nasseh K, Vujicic M. Financial barriers to dental care declining after a decade of steady increase. Health Policy Institute Research Brief. American Dental Association. October Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. Agency for Healthcare Research and Quality, Rockville, MD. Lewis C, Lynch H, Johnston B. Dental Complaints in emergency departments: a national perspective. Ann Emerg Med. 2003;42(1): McCormick at al. Reducing the burden of dental patients on the busy hospital emergency department. J Oral Maxillofac Surg. 2013; 71: Lee HH, Lewis CW, Saltzman B, Starks H. Visiting the emergency department for dental problems: trends in utilization, 2001 to Am J Public Health. 2012;102(11):e McCormick AP, Abubaker AO, Laskin DM, Gonzales MS, Garland S. Reducing the burden of dental patients on the busy hospital emergency department. J Oral Maxillofac Surg. 2013;71(3): Washington State Health Care Authority. Emergency Department Utilization: Update on Assumed Savings from Best Practices Implementation Singhal A, Caplan DJ, Jones MP, Momany ET, Kuthy RA, Buresh CT, Isman R, Damiano PC. Eliminating Medicaid adult dental coverage in California led to increased dental emergency visits and associated costs. Health Affairs May 1;34(5): Skinner H (Truven Health Analytics), Blanchard J (RAND), Elixhauser A (AHRQ). Trends in Emergency Department Visits, HCUP Statistical Brief #179. September Agency for Healthcare Research and Quality, Rockville, MD. Tang, N., Stein, J., Hsia, R., Maselli, J., & Gonzales, R. (2010, August 11). Trends and Characteristics of US Emergency Department Visits, Davis EE, Deinard AS, Maiga EWH. Doctor, my tooth hurts: the costs of incomplete dental care in the emergency room. Journal of Public Health Dentistry 2010; 70: Okunseri C, Pajewski NM, Jackson S, Szabo A. Wisconsin Medicaid enrollees recurrent use of emergency departments and physicians offices for treatment of nontraumatic dental conditions. The Journal of the American Dental Association 2011; 142(5): Quinonez C. Self-reported emergency room visits for dental problems. International Journal of Dental Hygiene 2011; 9: Okunseri C, Okunseri E, Thorpe JM, Xiang Q, Szabo A. Patient characteristics and trends in nontraumatic dental condition visits to emergency departments in the United States. Clinical, Cosmetic and Investigational Dentistry 2012; 4: 1-7. Ramraj CC, Quiononez CR. Emergency room visits for dental problems among working poor Canadians. Journal of Public Health Dentistry 2013; 73: Cohen LA, Manski RJ, Hooper FJ. Does the elimination of Medicaid reimbursement affect the frequency of emergency department dental visits? 1996; 127:

30 THANKS

31 90-Day Emergency Department Returns by Voucher Assignment and Redemption

32 30-Day Emergency Department Returns by Voucher Assignment and Redemption

33 DENTAL CLINIC COSTS AMONG VOUCHER REDEEMERS VARIABLE N NMISS MEAN SD MIN MEDIAN QRANGE MAX Dental Clinic Cost ED Return Charges 3 Overall No Voucher Voucher Voucher Not Received/Used Voucher Redeemed