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

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

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

Percentage of Emergency Department Visits by Primary Payer, 2012

Prior Research

2011, 1697 NTDC visits, 970 (57%) Medicaid2-week pilot of vouchers

Patients with NTDC and Medicaid or no coverage18 patients received, 10 redeemed, 2 returned

Avg voucher care cost = $318, avg ED care = $1010

2-week query of NTDC returns60 patients, 9 returned in 60 days for NTDC

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 ClinicDental Clinic

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.

Aim 3

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

$

Methods

N=318 patients presenting to RH ED with NTDC in 2015-2016

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

TABLE 1. Patient Characteristics at Baseline, Overall & by Voucher AssignmentALL (N=318) NO VOUCHER (N=188) VOUCHER ISSUED (N=130)

VARIABLE N PCT2 N PCT3 N PCT3 P-VALUEAgeMean ± SD 32.0 ± 9.6 32.1 ± 9.9 31.9 ± 9.3 0.957Min | Med | Max 18 | 30 | 67 18 | 30 | 67 18 | 30 | 60

18-29 149 46.9% 88 59.1% 61 40.9% 0.83030-44 129 40.6% 78 60.5% 51 39.5%45-67 40 12.6% 22 55.0% 18 45.0%

GenderFemale 132 41.5% 82 62.1% 50 37.9% 0.418Male 186 58.5% 106 57.0% 80 43.0%

RaceAfrican-American 164 51.6% 94 57.3% 70 42.7% 0.450Asian 4 1.3% 3 75.0% 1 25.0%Caucasian 118 37.1% 71 60.2% 47 39.8%Native American 17 5.4% 13 76.5% 4 23.5%Other/Unknown 15 4.7% 7 46.7% 8 53.3%

EthnicityNon-Hispanic 295 92.8% 177 60.0% 118 40.0% 0.276Hispanic 23 7.2% 11 47.8% 12 52.2%

Insurance StatusMedicaid 88 27.7% 51 58.0% 37 42.1% 0.800Uninsured 230 72.3% 137 59.6% 93 40.4%

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)

TABLE 2: ED Returns at 30 Days & 90 Days, by Voucher Assignment and Redemption Status

ED RETURNS (30 DAYS)

NO DENTAL VOUCHERDENTAL

VOUCHERVOUCHER

NOT REDEEMEDVOUCHER REDEEMED

N PCT1 N PCT1 P VALUE2 N PCT1 N PCT1 P VALUE3 P VALUE4 P VALUE5

0 159 84.6% 120 92.3% 0.190 60 90.9% 60 93.8% 0.185 0.042 0.0601 25 13.3% 9 6.9% 5 7.6% 4 6.3%2 3 1.6% 0 0.0% 0 0.0% 0 0.0%3 0 0.0% 0 0.0% 0 0.0% 0 0.0%4 1 0.5% 0 0.0% 0 0.0% 0 0.0%5 0 0.0% 0 0.0% 0 0.0% 0 0.0%6 0 0.0% 1 0.8% 1 1.5% 0 0.0%Total 188 100.0% 130 100.0% 66 100.0% 64 100.0%

ED RETURNS (90 DAYS)

NO DENTAL VOUCHERDENTAL

VOUCHERVOUCHER

NOT REDEEMEDVOUCHER REDEEMED

N PCT1 N PCT1 P VALUE2 N PCT1 N PCT1 P VALUE3 P VALUE4 P VALUE5

0 152 80.9% 117 90.0% 0.153 58 87.9% 59 92.2% 0.102 0.018 0.0281 29 15.4% 11 8.5% 6 9.1% 5 7.8%2 5 2.7% 1 0.8% 1 1.5% 0 0.0%3 1 0.5% 0 0.0% 0 0.0% 0 0.0%4 1 0.5% 0 0.0% 0 0.0% 0 0.0%5 0 0.0% 0 0.0% 0 0.0% 0 0.0%6 0 0.0% 0 0.0% 0 0.0% 0 0.0%7 0 0.0% 1 0.8% 1 1.5% 0 0.0%Total 188 100.0% 130 100.0% 66 100.0% 64 100.0%

TABLE 2. ED Returns at 30 Days & 90 Days, by Voucher Assignment and Redemption Status

ED RETURNS (30 DAYS)

NO DENTAL VOUCHERDENTAL

VOUCHERVOUCHER

NOT REDEEMEDVOUCHER REDEEMED

N PCT1 N PCT1 P VALUE2 N PCT1 N PCT1 P VALUE3 P VALUE4 P VALUE5

0 159 84.6% 120 92.3% 0.190 60 90.9% 60 93.8% 0.185 0.042 0.0601 25 13.3% 9 6.9% 5 7.6% 4 6.3%2 3 1.6% 0 0.0% 0 0.0% 0 0.0%3 0 0.0% 0 0.0% 0 0.0% 0 0.0%4 1 0.5% 0 0.0% 0 0.0% 0 0.0%5 0 0.0% 0 0.0% 0 0.0% 0 0.0%6 0 0.0% 1 0.8% 1 1.5% 0 0.0%Total 188 100.0% 130 100.0% 66 100.0% 64 100.0%

ED RETURNS (90 DAYS)

NO DENTAL VOUCHERDENTAL

VOUCHERVOUCHER

NOT REDEEMEDVOUCHER REDEEMED

N PCT1 N PCT1 P VALUE2 N PCT1 N PCT1 P VALUE3 P VALUE4 P VALUE5

0 152 80.9% 117 90.0% 0.153 58 87.9% 59 92.2% 0.102 0.018 0.0281 29 15.4% 11 8.5% 6 9.1% 5 7.8%2 5 2.7% 1 0.8% 1 1.5% 0 0.0%3 1 0.5% 0 0.0% 0 0.0% 0 0.0%4 1 0.5% 0 0.0% 0 0.0% 0 0.0%5 0 0.0% 0 0.0% 0 0.0% 0 0.0%6 0 0.0% 0 0.0% 0 0.0% 0 0.0%7 0 0.0% 1 0.8% 1 1.5% 0 0.0%Total 188 100.0% 130 100.0% 66 100.0% 64 100.0%

TABLE 3. Count models for number/rate of Emergency Department return visitsVARIABLE UNADJUSTED RR

(95% CI)P-VALUE ADJUSTED1 RR

(95% CI)P-VALUE

ITT, 30 DaysVoucher vs. No Voucher

0.62 (0.30-1.27) 0.190 - -

ITT, 90 DaysVoucher vs. No Voucher

0.63 (0.33-1.19) 0.153 - -

As Treated, 30 DaysRedemption vs. Unused Voucher

0.35 (0.11-1.06) 0.062 0.42 (0.14-1.28) 0.127

As Treated, 90 DaysRedemption vs.Unused Voucher

0.33 (0.12-0.89) 0.029 0.38 (0.14-1.03) 0.058

1 Adjusted for age and gender.

TABLE 4. Logistic Regression Models for Likelihood of ED Return at 30/90 Days by Voucher Assignment/Redemption Status

≥1 ED RETURN UNADJUSTED ADJUSTED1

VARIABLE N N % OR 95% CI P-VALUE OR 95% CI P-VALUETotal 318 49 15.4% - - - - - -

Intent to Treat, 30 DaysNo Voucher 188 29 15.4%

Voucher 130 10 7.7% 0.46 0.21-0.97 0.043 - - -

Intent to Treat, 90 DaysNo Voucher 188 36 19.1%

Voucher 130 13 10.0% 0.47 0.24-0.92 0.029 - - -

As Treated, 30 DaysNo Dental Clinic 254 35 13.8%Dental Voucher Redemption 64 4 6.3% 0.42 0.14-1.22 0.110 0.45 0.15-1.32 0.145

As Treated, 90 DaysNo Dental Clinic 254 44 17.3%Dental Voucher Redemption 64 5 7.8% 0.40 0.15-1.07 0.067 0.43 0.16-1.13 0.086

Time to ED Return Visit by Dental Voucher Status

Time to ED Return Visit by Dental Voucher Assignment

Time to ED Return Visit by Dental Voucher Redemption

TABLE 5. Cox models for Time to First Emergency Department return visitVARIABLE UNADJUSTED RR

(95% CI)P-VALUE ADJUSTED1 RR

(95% CI)P-VALUE

ITT, 30 DaysVoucher vs. No Voucher 0.48 (0.23, 0.98) 0.044 - -

ITT, 90 DaysVoucher vs. No Voucher 0.50 (0.26, 0.93) 0.030 - -

As Treated, 30 DaysRedemption vs. No (Used) Voucher

0.43 (0.15, 1.22) 0.114 0.46 (0.16, 1.29) 0.138

As Treated, 90 DaysRedemption vs.No (Used) Voucher

0.43 (0.17, 1.08) 0.071 0.44 (0.17, 1.11) 0.082

1 Adjusted for age and gender.

TABLE 6. Accuracy of MDs in Predicting Redemption by Voucher Recipients

PREDICTION DID NOT REDEEM REDEEMED TOTAL

Will Not Use Voucher 11 4 15

Will Use Voucher 53 60 113

Total 64 64 128

Accuracy 0.555

Sensitivity 0.938

Specificity 0.172

Positive Predictive Value 0.531

Negative Predictive Value 0.733

TABLE 6. Accuracy of MDs in Predicting Redemption by Voucher Recipients

PREDICTION DID NOT REDEEM REDEEMED TOTAL

Will Not Use Voucher 11 4 15

Will Use Voucher 53 60 113

Total 64 64 128

Accuracy 0.555

Sensitivity 0.938

Specificity 0.172

Positive Predictive Value 0.531

Negative Predictive Value 0.733

Costs by voucher assignment:Total Charges

Costs by voucher assignment:Net Margin

TABLE 7. Generalized Linear Models for Emergency Department return costs

VARIABLE UNADJUSTED β(95% CI)

P-VALUE ADJUSTED1 RR(95% CI)

P-VALUE

ITT, Total ChargesVoucher vs. No Voucher 0.29 (-0.13, 0.70) 0.172 - -

As Treated, Total ChargesRedemption vs.No (Used) Voucher

0.11 (-0.49, 0.72) 0.712 0.29 (-0.35, 0.93) 0.373

ITT, Net MarginVoucher vs. No Voucher -19.07 (-46.16, 8.01) 0.168 - -

As Treated, Net MarginRedemption vs.No (Used) Voucher

-6.58 (-39.90, 26.74) 0.699 -6.89 (-40.28, 26.49) 0.686

1 Adjusted for age and gender.

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.

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

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

Limitations

Limited by extent of voucher funds to assist dental payment

Vouchers completed payment for dental visitsCost and margin data require more analysis

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 elsewhereSuch efforts show promise for improving care

and cost as part of multifaceted interventionsCost-effectiveness needs further explorationProviders are poor predictors of voucher

patient follow-up with dentistry

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THANKS

90-Day Emergency Department Returns by Voucher Assignment and Redemption

30-Day Emergency Department Returns by Voucher Assignment and Redemption

DENTAL CLINIC COSTS AMONG VOUCHER REDEEMERS

VARIABLE N NMISS MEAN SD MIN MEDIAN QRANGE MAX

Dental Clinic Cost 63 0 396.08 238.37 102 298 345 988

ED Return Charges3

Overall 312 4 239.37 839.42 0.00 0.00 0.00 7983.35

No Voucher 183 4 251.94 741.61 0.00 0.00 0.00 6346.30

Voucher 129 0 221.54 964.09 0.00 0.00 0.00 7983.35

Voucher Not Received/Used 249 4 259.55 847.98 0.00 0.00 0.00 7983.35

Voucher Redeemed 63 0 159.60 806.30 0.00 0.00 0.00 6121.60