Millions of Americans Lack Access to Essential Oral Health Care

Millions of Americans are not receiving needed dental care services because of "persistent and systemic" barriers that limit their access to oral health care, says a new report by the Institute of Medicine and National Research Council. To remove these barriers — which disproportionately affect children, seniors, minorities and other vulnerable populations — the report recommends changing funding and reimbursement for dental care; expanding the oral health workforce by training doctors, nurses, and other nondental professionals to recognize risk for oral diseases; and revamping regulatory, educational and administrative practices.

"The consequences of insufficient access to oral health care and resultant poor oral health — at both the individual and population levels — are far-reaching," said Frederick Rivara, Seattle Children's Guild Endowed Chair in Pediatrics at the University of Washington School of Medicine, Seattle, and chair of the committee that wrote the report. "As the nation struggles to address the larger systemic issues of access to health care, we need to ensure that oral health is recognized as a basic component of overall health."

The report says that economic, structural, geographic and cultural factors contribute to this problem. For example, approximately 33.3 million people live in areas with shortages of dental health professionals. In 2008, 4.6 million children did not obtain needed dental care because their families could not afford it. And in 2006, only 38 percent of retirees had dental coverage, which is not covered by Medicare.

Lack of regular oral health care has serious consequences, the report says, including increased risk of respiratory disease, cardiovascular disease, and diabetes, as well as inappropriate use of hospital emergency departments for preventable dental diseases.  The report offers a vision of oral health care in which prevention of oral diseases and promotion of oral health are a priority and a facet of overall health.

The uneven distribution of the dental work force, both in geographic dispersion as well as in specialization, is a long-recognized challenge, the report notes. In addition, graduating dental students report that they feel unprepared to care for older patients and those with special needs.

The report says that efforts should be made to increase recruitment and support for dental students from minority, lower-income and rural populations, as well as to boost the number of dental faculty with expertise caring for underserved and vulnerable populations. In addition, the Health Resources and Services Administration should dedicate Title VII funding to aid and expand opportunities for dental residencies in community-based settings.

These residencies should take place in geographically underserved areas and include clinical experiences with young children, individuals with special health care needs, and older adults. 

Regional System to Cool Cardiac Arrest Patients Improves Outcomes

A broad, regional system to lower the temperature of resuscitated cardiac arrest patients at a centrally located hospital improved outcomes, according to a study in Circulation: Journal of the American Heart Association. Cooling treatment, or therapeutic hypothermia, is effective yet underused, researchers said.

A network of first responders, EMS departments and more than 30 independent hospitals within 200 miles of Minneapolis and Abbott Northwestern Hospital collaborated to implement the protocol.

"We've shown that a fully integrated system of care, from EMS through hospital discharge, can provide this essential therapy to victims of out-of-hospital cardiac arrest across a broad geographic region," said Michael Mooney, M.D., the study's lead author and director of the therapeutic hypothermia program at Minneapolis Heart Institute, where the protocol was developed.

Researchers tracked 140 patients who suffered out-of-hospital cardiac arrest between February 2006 and August 2009. Although their heartbeat and circulation were restored within an hour of collapse, they remained unresponsive.

Ice packs were used to begin the cooling process, which started during initial EMS transport to the hospital and in the emergency departments of the network hospitals; 140 patients were admitted to Abbott Northwestern Hospitals for therapeutic hypothermia and re-warming — 107 of those were transferred from other hospitals.

Over three to four hours, the patients' core body temperature was lowered to about 92 degrees Fahrenheit and maintained at that temperature for about 24 hours. Over the next eight hours, physicians gradually re-warmed them to a normal temperature.
Researchers found that:

  • Among the 56 percent of patients who survived to hospital discharge, 92 percent had positive neurological scores, indicating no severe disability. Prior to the protocol, about 77 percent of similar patients had positive neurologic scores.
  • The risk of death rose 20 percent for each hour of delay between the return of spontaneous circulation and cooling.
  • Survival rates were comparable between patients who were transferred for care within the network and those who were not.

"What our data show is if you have a cardiac arrest 200 miles away or on our doorstep, the quality of the outcomes is identical," Mooney
said.

About 300,000 out-of-hospital cardiac arrests occur in the United States each year and most are fatal, according to the American Heart Association.

If a cardiac arrest patient survives the initial loss of oxygen from their arrest, they then face the destruction that unfolds after their blood flow is rapidly restored, which is devastating and often fatal.

Therapeutic hypothermia blunts the damage that can occur in the 16-hour window after bloodflow is restored. The American Heart Association and other experts recommend therapeutic hypothermia, but U.S. cardiologists have been slow to use it.

The efficiencies of the area's existing network, transfer agreements and working relationships between the EMS departments, network hospitals and the central hospital helped Mooney and his colleagues implement the protocol.

Even Privately Insured May Lack Access to Psychiatric Care

Access to outpatient psychiatric care in the Boston area, even for privately insured patients who have been referred by the emergency department, is severely limited, according to a preliminary study published as a letter to the editor in the Annals of Emergency Medicine.

"People with mental illness often can't advocate for themselves—especially in a crisis," said lead author J. Wesley Boyd, an attending psychiatrist at the Harvard-affiliated Cambridge Health Alliance. "Health insurers, through their restrictive provider networks and their low reimbursement rates for psychiatric services, have created a situation where a patient with a potentially life-threatening disorder is essentially abandoned at a time of great need."

Study personnel posed as patients insured by Blue Cross Blue Shield of Massachusetts PPO, the largest insurer in Massachusetts. They called every Blue Cross-contracted mental health facility within a 10-mile radius of downtown Boston, stating they had been evaluated in an emergency department for depression and discharged with instructions to obtain a psychiatric appointment within two weeks.

"Despite having private coverage, our simulated patients faced daunting barriers when trying to access psychiatric care," Boyd said. "How likely is it that a real patient in the grip of severe depression would persevere through so many unsuccessful attempts?"

Only 8 of the 64 facilities (12.5 percent) listed by Blue Cross as preferred providers offered appointments; only 4 (6.2 percent) offered an appointment within two weeks. According to the study, 23 percent of phone calls seeking appointments were never returned, even after a second attempt. Another common reason appointments were unavailable was that 23 percent of psychiatric providers required that the patient already be enrolled with a primary care doctor affiliated with their psychiatric facility.

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