Visits to physicians for oral health-related complaints in Ontario, Canada.

LaPlante, Nancy C. ; Singhal, Sonica ; Maund, Jacquie 等

Canada's national system of health insurance, Medicare, has become associated with the values of equity and solidarity. In general, universal access to health care has become a reality, specifically for physician and hospital services. Yet Canadian Medicare does not include services such as oral health care. In Canada, oral health care is primarily privately financed within a fee-for-service system delivered in private dental offices. Most Canadians pay for this care through employment-based dental insurance (62.6%) and/or through out-of-pocket expenditures (31.9%). (1) In fact, only 6% of dental expenditures in Canada stem from public programs, one of the lowest proportions among OECD (Organisation for Economic Co-operation and Development) countries. (2) As a result, access to oral health care for people in Canada largely relies on employment conditions and the ability to pay, leading to uneven and inequitable access for many in the population.

Importantly, it has been well documented that low-income and other socially disadvantaged groups show a higher prevalence of oral disease while also facing the greatest financial barriers to accessing care. (1) These oral health and access inequalities are exacerbated by the patchwork of Canadian publicly funded oral health care programs. In Ontario, Canada's most populated province, for example, there are several publicly funded programs each with its own eligibility criteria and administration, almost all focusing on at-risk children and adults receiving social assistance. A recent report from leading provincial stakeholders stressed the importance of unifying the current mix of public programming and identified the need to expand Ontario's public dental programs to reach other at-risk populations, such as low-income adults and seniors. (3) In turn, the Ontario government is now integrating all low-income children's programs into one program named Healthy Smiles Ontario, which expands eligibility to low-income children who have traditionally remained uninsured. (4) Yet despite the expansion, there remain gaps in access to dental care, and for this reason certain populations exhibit particular health-seeking behaviours.

To be sure, the costs of dental care and lack of public oral health care programs mean that some socially marginalized groups have little choice but to seek oral health care from other health providers, hoping to avoid direct costs for dental treatment. It is not surprising, then, that studies have found visits for oral health-related diagnoses in hospital emergency departments to be over-represented by adults, low-income groups, those without dental insurance and/or those who do not qualify for public dental care programs. (5,6) Similarly, visits to physician offices for oral health-related complaints are also expected. In the US, while less is known about office-based physician visits than about emergency department visits for oral health-related diagnoses, a few studies have reviewed these visits. In 2001-02, slightly more than 200 visits per 100 persons occurred in primary care offices with a principal diagnosis of diseases of the teeth and supporting structures. (7) Another study, also done in the US, reported that physicians do not have professional dental care training, so visits to medical professionals for oral health problems are inappropriate and do not provide high-quality care to those in need. (8)

In Canada, visits to physician offices for oral health-related complaints are also expected to occur, yet they have not been studied. Therefore, this study was conducted to explore the numbers and rates of visits to physicians for oral health-related diagnoses in Ontario.

METHODS

A retrospective secondary data analysis of health system utilization in Ontario was carried out for visits to physicians for oral health-related diagnoses. The target population was individuals who visited physicians and who were given a diagnosis of oral health-related issues. Data, stratified by age and sex, were extracted from IntelliHEALTH ONTARIO, which is a knowledge repository that contains clinical and administrative data collected from various sectors in the Ontario health care system. The data accessed for this study were from the Medical Services database, which contains all Ontario Health Insurance Plan (OHIP) approved billing claims submitted by providers, mainly physicians from a variety of settings. Salaried physician services, such as at some community health centres, health service organizations and academic institutions were excluded because they do not bill OHIP for the services and so their billings do not flow into the database. However, this should not affect our estimates, as salaried physicians in Ontario serve less than 1% of the provincial population. (9)

Included in a typical claim were service date, provider, patient, fee schedule code, number of services (units) and diagnostic information (not always required). The OHIP diagnostic codes 521 to 529, specifically pertaining to diseases of the oral cavity, salivary glands and jaws, were used in this study. All these codes are within the scope of a dental practice; however, diseases of the salivary glands, such as xerostomia, are also considered to be in the domain of general physicians. (10) Although ICD 10 codes were introduced in 2000, ICD 9 codes, without the decimal place, have continued to be used to define the Ontario health diagnostic codes in the Medical Services database in the IntelliHEALTH data repository. This database does not have any mechanism in place to validate the accuracy of the reason or diagnosis for patient visits, which was recognized as a primary limitation of this study. The codes included are described in Table 1.

Data were successfully obtained for 11 fiscal years (April 1 to March 31) from 2001 to 2011. Age and sex adjustments were performed using Microsoft Excel, and IBM SPSS Statistics 19 was used to perform descriptive analysis. Crude rates were calculated by dividing the total number of events (in this case, the number of patients visiting physicians for oral health-related diagnoses) in a population by the sum of a population in a specified year, typically expressed per 100,000; this represents the actual experience of a population and should always be examined when assessing the morbidity or mortality of a population. (11) However, crude rates can be misleading when comparing across groups or over time, as the distribution of major demographic factors, such as age and sex, might differ. As a result, the rates were adjusted by both age and sex simultaneously. Also, to demonstrate any potential differences between sexes, sex-specific age-standardized rates were calculated. Further, Kendall's tau, a simple method that can be used when there are at least five time periods, was used to conduct a time trend analysis of visits over the 11-year period. (12)

Rates were stratified into three age groups, 0-19, 20-64 and 65 years and above. These age groupings were selected because currently publicly funded oral health care programs in Ontario target primarily low-income children under the age of 18 (IntelliHEALTH ONTARIO would not permit the 0-18 age grouping). As well, 65 years and older was selected as there is some very limited public programming for seniors.

Along with assessing the extent of physician visits for oral health-related diagnoses, we also wanted to understand the particular complaints for which these visits were made. Therefore, proportions of each specific code (521 to 529) were calculated overall and specifically for each age group. Finally, South Riverdale Community Health Centre Leadership Team, who oversee the licensed user of IntelliHEALTH ONTARIO, approved the data collection and analysis carried out in its organization as a collaboration with the dental researchers at the University of Toronto Faculty of Dentistry.

RESULTS

Between 2001 and 2011, approximately 208,375 visits per year were made to physicians for oral health-related diagnoses. There were an average 1,298/100,000 patient visits per year made for these diagnoses: 1,381/100,000 for women and 1,215/100,000 for men. During the period of observation, the rate of patients visiting physicians declined overall and for both men and women specifically (Figure 1). Kendall's tau correlation values confirmed these trends. Overall, there was a significant negative correlation between number of visits and time period (r = -0.745, p = 0.001). Importantly, when stratified by sex there was a stronger correlation among men (r = -0.745, p = 0.001) than women (r = -0.636, p = 0.006), which suggests that over the 11-year period of observation the reduction in the rate of visiting physicians for oral problems was greater among men than women. For each sex stratified by age group, similar trends were observed, except for males aged 20-64, among whom the rates remained almost constant over the period of observation (Table 2).

Oral health-related diagnoses by physicians were mainly made for six ICD-9 categories and, out of these six, three categories constituted three quarters of the visits (Table 3). For ages 0-19 and 65+, a large proportion of visits were made for soft tissue lesions (Figure 2). Among those aged 65+, visits for diseases of the salivary glands were also frequent as compared with other age groups; this was likely associated with xerostomia, a prevalent condition in the elderly. (13)

DISCUSSION

The study described the number of patients visiting physicians in Ontario for oral health-related complaints from 2001 to 2011, and assessed age--and sex-standardized rates for these visits. The number of people visiting physicians is arguably high--an average of over 208,000 people per year. Unfortunately, these figures cannot be compared with visits for any other services, as most are covered under the publicly funded health care system. Visits for eye care cannot be compared either, as they are not billed through the government insurance plan, even at a physician's office. Nevertheless, a study that investigated visits to the emergency department for problems related to the eye, including trauma, concluded that decisions to use the emergency department arose from not merely the urgency of the situation but also differences in insurance coverage. (11) Therefore, the current literature does not provide any contextual comparator for the findings in this article.

Over the period of observation, there was some reduction in visits to physicians for these complaints, and this was not similar between men and women. There appear to be more women visiting physicians than men. The reasons for this need to be explored in future research, but it could be speculated that the finding is due, in part, to the greater number of women than men who are working at minimum wage jobs (working poor) and who thus experience greater financial barriers to accessing dental care. (14) In Ontario, women also tend to cite cost more often than men as a reason for not seeking dental care. (15) In the US, with a dental care system similar to Canada's, more women than men report poor oral health alongside self-reports of financial hardship in accessing dental care, (16) so it may be that a low-income status for women is more strongly associated with poor access to dental care.

The differences between children, adults and seniors also need to be considered, as diagnoses are different for each age group. The number of visits appears to be increasing (as shown in Table 2) for adults and seniors with slight decreases over the years for children. It will be valuable to monitor the rate of physician visits for dental issues for different age groups, since most Ontario government-funded oral health programs focus on low-income children. With the absolute numbers of visits exceeding 208,000 per year, there is arguably a significant waste of public funds for patient care, by providers who do not have the appropriate training, skills and tools to treat and who are billing the provincial, publicly funded health insurance program for these visits. As mentioned, we acknowledge that some of the oral problems, such as diseases of the salivary glands, are not completely out of physicians' scope of practice; however, had these patients received equal opportunity to access dental care for their oral problems, a shift in patient load for such problems to dental offices could be expected. This could reduce the burden on the health care system and wait times in physicians' offices.

Between 2001 and 2011, there were 2,303,920 visits billed to OHIP by medical services for oral health conditions. The lowest OHIP fee charges are for a Minor Assessment (A001), currently billed at $21.70, and the Intermediate Assessment (A007), currently billed at $33.70; both may be used to bill for these visits. This would amount to costs ranging from $50 million to $78 million in the last 10 years. These are public funds that could have been more appropriately spent on public dental care programming to prevent and treat oral health problems. Clearly, the government needs to consider a more efficient and effective means to provide appropriate, timely and accessible oral health care for those people who are inappropriately seeking oral health care from medical providers. This evidence is a strong signal to policy-makers that they need to align policy changes with public health need. Again, these oral health needs are not being treated by the appropriate professional, and this could result in treatments that do not improve and may exacerbate the condition, as such problems tend to worsen over time. Additionally, it is reasonable to assume that some of the acute conditions present in this study could have been avoided with preventive and/or timely curative oral health care.

It also appears that more adults and seniors than children are seeking care in physician offices, again representing poor use of public funds. Redirection of these funds and new public investment in expanded public oral health care programs for low-income adults and seniors would arguably be a more effective approach to caring for the oral health needs of vulnerable populations. Ultimately, appropriate care at the right time in the right setting can be achieved through the implementation of healthy public policy.

The primary limitation for this study is that there is no means to validate the accuracy of the diagnosis in the Medical Service database that contains the OHIP billing claims of providers. As well, salaried providers, including physicians who work in community health centres, were not included in the data. The mandate of the community health centre sector is to serve the most marginalized populations, who may be more vulnerable to oral health complaints and face greater financial barriers to accessing appropriate oral health care, so the number of visits to physicians for oral health problems is likely even higher. While an economic perspective is given, a more detailed economic evaluation needs to be part of future research in this area. We also recommend that future research investigate additional socio-demographic variables that correlate with these visits as a means to target the most vulnerable. Given the differences in Ontario in how oral health care programming is administered in municipalities, regional differences should be explored.

In conclusion, this study will help to inform policy debates regarding the health care impacts of poor access to dental care. The patchwork of different programs that currently exists in Ontario, the gaps in population coverage and the unnecessary costs of incomplete care provided in physicians' offices suggest the need for public policy discussion on how to achieve a better oral health care policy for vulnerable populations.

REFERENCES

(1.) Health Canada. Summary Report on the Findings of the Oral Health Component of the Canadian Health Measures Survey 2007-2009. Available at: www.fptdwg.ca/English/e-documents.html (Accessed September 28, 2014).

(2.) Canadian Academy of Health Sciences. Improving Access to Oral Health Care for Vulnerable People Living in Canada. 2014.

(3.) Aslanyan G, Feller A, Goel V, Hawkins R, Quinonez C, Sharma P, Tetley A. Staying ahead of the curve: A unified public oral health program for Ontario? Toronto, ON: Faculty of Dentistry, University of Toronto, in partnership with the Association of Local Public Health Agencies, the Association of Ontario Health Centres, and the Ontario Association of Public Health Dentistry, 2012.

(4.) Service Ontario news release. Giving more kids access to free dental care: Ontario expands Healthy Smiles Program, Ministry of Health and Long Term Care Available at: http://news.ontario.ca/mohltc/en/2014/04/giving-more-kids-access-to-free-dental-care.html (Accessed September 28, 2014).

(5.) Cohen LA, Bonito AJ, Eicheldinger C, Manski RJ, Macek MD, Edwards RR, Khanna N. Comparison of patient visits to emergency departments, physician offices, and dental offices for dental problems and injuries. J Public Health Dent 2011 Winter;71(1):13-22. PMID: 20726944. doi: 10.1111/j.1752-7325.2010.00195.x

(6.) Quinonez C, Ieraci L, Guttmann A. Potentially preventable hospital use for dental conditions: Implications for expanding dental coverage for low income populations. J Health Care Poor Underserved 2011 Aug;22(3):1048-58. PMID: 21841295. doi: 10.1353/hpu.2011.0097.

(7.) Schappert SM, Burt CW. Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States,2001-02. National Center for Health Statistics. Vital Health Stat 2006;13(159). PMID: 16471269.

(8.) Cohen LA, Manski RJ, Magder LS, Mullins CD. A Medicaid population's use of physicians' offices for dental problems. Am J Public Health 2003;93(8):1297-301. PMID: 12893618.

(9.) Glazier RH, Zagorski BM, Rayner J. Comparison of Primary Care Models in Ontario by Demographics, Case Mix and Emergency Department Use, 2008/09 to 2009/10. ICES Investigative Report. Toronto: Institute for Clinical Evaluative Sciences, 2012.

(10.) Al-Hashimi I. Xerostomia secondary to Sjogren's syndrome in the elderly: Recognition and management. Drugs Aging 2005;22(11):887-99. PMID: 16323968.

(11.) Bains N. Standardization of rates. Available at: http://www.apheo.ca/resources/indicators/Standardization%20report_NamBains_FINALMarch16.pdf (Accessed September 25, 2014).

(12.) Ely JW, Dawson JD, Lemke JH, Rosenberg J. An introduction to time-trend analysis. Infect Control Hosp Epidemiol 1997;18(4):267-74. PMID: 9131373.

(13.) Liu B, Dion MR, Jurasic MM, Gibson G, Jones JA. Xerostomia and salivary hypofunction in vulnerable elders: Prevalence and etiology. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114(1):52-60. PMID: 22727092. doi: 10.1016/j.0000.2011.11.014.

(14.) Block S. Who is working for minimum wage in Ontario? Report. Toronto: Wellesley Institute, 2013.

(15.) Ontario Agency for Health Protection and Promotion (Public Health Ontario). Report on Access to Dental Care and Oral Health Inequalities in Ontario. Toronto: Queen's Printer for Ontario, 2012.

(16.) Chi DL, Tucker-Seeley R. Gender-stratified models to examine the relationship between financial hardship and self-reported oral health for older US men and women. Am J Public Health 2013;103(8):1507-15. PMID: 23327271. doi: 10.2105/AJPH.2012.301145.

Received: October 16, 2014

Accepted: January 27, 2015

Nancy C. LaPlante, MSc, [1] Sonica Singhal, BDS, MPH, MSc, [2] Jacquie Maund, MA, [3] Carlos Quinonez, DMD, MSc, PhD, FRCDC [2]

Author Affiliations

[1.] South Riverdale Community Health Centre, Toronto, ON

[2.] Dental Public Health, University of Toronto, Toronto, ON

[3.] Association of Ontario Health Centres, Toronto, ON

Correspondence: Carlos Quinonez, Dental Public Health, University of Toronto, 521B-124 Edward St, Toronto, ON M5G 1G6, Tel: [telephone] 416-979-4908, ext. 4491, E-mail: carlos.quinonez@utoronto.ca

Acknowledgements: In-kind support from South Riverdale Community Health Centre and Association of Ontario Health Centres.

Conflict of Interest: None to declare.

Table 1. ICD-9 codes for oral health-related diagnoses

ICD-9 Code   Major disease group

521          Diseases of hard tissues of teeth
522          Diseases of pulp and periapical tissues
523          Gingival and periodontal diseases
524          Dentofacial anomalies, including
               malocclusion
525          Other diseases and conditions of the
               teeth and supporting structures
526          Diseases of the jaws
527          Diseases of the salivary glands
528          Diseases of the oral soft tissues
               excluding lesions specific for
               gingiva and tongue
529          Diseases and other conditions of the tongue

Source: Medical Service, Ontario Ministry of Health and Long-Term
Care, IntelliHEALTH ONTARIO Data, last refreshed April 2014.

Table 2. Number of visits to physicians per 100,000 for oral
health-related complaints, by age and sex: 2001
to 2011

Year   Sex      0-19     20-64    65       Sex-specific
                years    years    +years   age
                                           standardized

2001   Female   1438.3   1445.6   1346.7   1431
       Male     1379.7   1191.6   1173.2   1229
2002   Female   1444     1459.8   1324.4   1438
       Male     1372.1   1193.6   1184.5   1230.9
2003   Female   1394     1415.1   1270.8   1390.9
       Male     1341     1169.3   1169.8   1206.6
2004   Female   1457.6   1444.4   1301.6   1428.3
       Male     1392.1   1191.5   1169.5   1231.4
2005   Female   1380     1443.7   1297.4   1409.3
       Male     1313.8   1201.9   1218     1228.8
2006   Female   1372     1436     1219.8   1392.2
       Male     1301     1218.7   1165.3   1227.8
2007   Female   1317.6   1415.7   1218.7   1366.5
       Male     1274.7   1205.9   1155.2   1212.5
2008   Female   1322.4   1399.9   1205.2   1355.8
       Male     1288.2   1201.8   1134.7   1209.6
2009   Female   1246.5   1367.2   1198.8   1316.6
       Male     1230.2   1191     1139     1191
2010   Female   1287.2   1374.1   1198.7   1330.4
       Male     1255.2   1192     1155.1   1199.7
2011   Female   1283     1381.4   1223.1   1337.4
       Male     1242.8   1198.8   1139.7   1198.7

Source: Medical Service, Ontario Ministry of Health and Long-Term
Care, IntelliHEALTH ONTARIO Data, last refreshed April 2014.

Table 3. Proportion of visits to physicians by ICD-9 code

ICD 9: Diseases of the oral cavity,        Proportion
salivary glands and jaws

525: Other diseases of the teeth and         33.20%
supporting structures

521: Diseases of hard tissues                23.60%

528: Diseases of the oral soft tissues       18.10%
excluding lesions specific for gingiva
and tongue

527: Diseases of the salivary glands         9.20%

524: Dental facial anomalies, including      8.60%
malocclusion

523: Gingival and periodontal diseases       7.20%

Other                                        0.10%

Source: Medical Service, Ontario Ministry of Health and Long-Term
Care, IntelliHEALTH ONTARIO Data, last refreshed April 2014.

Figure 1. Physician visits per 100,000 for oral health-related
complaints in Ontario: 2001-2011
Medical Service, Ontario Ministry of Health and
Long-Term Care, IntelliHEALTH ONTARIO Data, last
refreshed April 2014.

       Female *   Male *   Age--and
                           sex-standardized

2001   1431       1229     1329
2002   1438       1231     1334
2003   1391       1207     1298
2004   1428       1231     1329
2005   1409       1229     1318
2006   1392       1228     1309
2007   1367       1213     1289
2008   1356       1210     1282
2009   1317       1191     1253
2010   1330       1200     1265
2011   1337       1199     1267

Note: Table made from line graph.

Figure 2. Oral health-related diagnoses by age group
Medical Service, Ontario Ministry of Health and Long-Term
Care, IntelliHEALTH ONTARIO Data, last refreshed
April 2014.
                                 0-19   20-64   65+

528: Diseases of the oral soft   23%    15%     23%
tissues excluding lesions
specific for gingiva and
tongue

527: Diseases of the salivary     3%     9%     19%
glands

525: Other diseases of the       37%    34%     23%
teeth and supporting
structures

524: Dental facial anomalies,     5%    10%      8%
including malocclusion

523: Gingival and periodontal     5%     7%     10%
diseases

521: Diseases of hard tissues    27%    24%     17%

Note: Table made from bar graph.