Increased Incidence and Severity of Odontogenic Infections with Escalation in Healthcare Costs after Public Dental Benefits Restriction in Illinois

Statement of the Problem: The lack of appropriate dental care for disparate patient populations is an issue that has drawn considerable and increasing attention. As an alternative to the desirable preventative medicine paradigm, these patients instead seek emergency care in hospital or urgent care settings, and very often do not receive appropriate comprehensive treatment due to the lack of trained dental professionals and available resources, and this less than ideal treatment carries an inflated cost. On July 1, 2012, Illinois passed the SMART Act, which limited state adult dental benefits to emergency-only. This study aimed to determine if there is an increase in the number and severity of odontogenic infections in an urban hospital after restriction in public dental insurance in Illinois. Additionally, the study intends to measure the associated effect on cost to the healthcare system. 

Materials and Methods:  A retrospective review of patient records presenting for dental pain or infection at University of Illinois Hospital and Health Science System (UIHHSS) was performed. The data was collected using dental infection-related ICD-9 codes. Data analysis compared three patient cohorts, each over an 18 month time period. Cohort 1 (7/1/09-12/31/10) and cohort 2 (1/1/11-6/30/12) occurred prior to the SMART Act, and cohort 3 (7/1/12-12/31/13) occurred after. The variables collected included age, gender, insurance status, OMS consultation, radiographic studies, treatment type, treatment location, number of hospital admission days, and inpatient care level. Additionally, actual UIHHSS charges were used to calculate an average cost per patient based on the above variables and a cost comparison was performed across the three cohorts.  

Methods of Data Analysis: A chi square test was performed to compare age and insurance status across cohorts. The variables noted above were compared across the three cohorts. Cohort 1 and 2 were compared to cohort 3 individually. Additionally, actual UIHHSS charges were used to calculate an average cost per patient based on the above variables and a cost comparison was performed across the three cohorts. Cohort 1 and 2 were compared to cohort 3 individually as well.   

Results: 9,665 patient encounters were identified and 1,859 (19%) met inclusion criteria. There was no statistically significant difference between the three cohorts for age (p=0.45) or insurance status (P=0.34). Comparing cohort 3 to cohort 1, patient encounters increased 85%, ED visits increased 94% OMS consults increased 72%, I&Ds increased 115%, number of inpatient days increased 97%, ICU days increased 346%. Comparing cohort 3 to cohort 2, patient encounters increased 48%, ED visits increased 48%, OMS consults increased 91%, I&Ds increased 100%, number of inpatient days increased 128%, ICU days increased 76%. There was an 88% and 77% increase in total cost in cohort 3 compared to cohorts 1 and 2, respectively.

Outcome Data: The outcome variables were the number of infections, the severity of the infection, and the overall cost of treatment. 

Conclusions:  After limitation of public dental benefits, a substantial increase in both the number and severity of odontogenic infections was seen at UIHHSS. Additionally, there was a considerably increased financial burden on the healthcare system. These findings illustrate the negative public health and economic implications of limiting basic dental coverage to emergency-only treatment.

References:

1. Nazir Ahmad, DDS, A. Omar Abubaker, DMD, PhD, Daniel M. Laskin, DDS, MS, and David Steffen, DrPH, MSNx: The Financial Burden of Hospitalization Associated With Odontogenic Infections. J Oral Maxillofac Surg 71: 656-658, 2013.
2. Martha Neely, DMD, Judith A. Jones, DDS, DScD, MPH, Sharron Rich, MPH, Lillelenny Santana Gutierrez, DMD, and Pushkar Mehra, BDS, DMD:  Effects of Cuts in Medicaid on Dental-Related Visits and Costs at a Safety-Net Hospital. American Journal of Public Health. June 2014, Vol 104, No. 6.